Burden of alcohol use disorder, alcohol-related liver disease, and alcohol-related liver cancer: Editorial on “Global epidemiology of alcohol-related liver disease, liver cancer, and alcohol use disorder, 2000–2021

Article information

Clin Mol Hepatol. 2025;31(2):654-657

Publication date (electronic) : 2025 February 10

doi : https://doi.org/10.3350/cmh.2025.0133

Youxin Wang^1,2, Noriko Oza^1,3, Jazleen Leo¹, Ashok Choudhury⁴, Daniel Q. Huang^,1,5

¹Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore

²Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China

³Liver Center, Saga University Hospital, Saga, Japan

⁴Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India

⁵Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore

Corresponding author : Daniel Q. Huang Division of Gastroenterology and Hepatology, Department of Medicine, National University Health System, Tower Block Level 10, 1E Kent Ridge Road, Singapore 119228, Singapore Tel: +65-6772-4354, Fax: +65-6775-1518, E-mail: daniel_huang@nus.edu.sg

Editor: Han Ah Lee, Chung-Ang University College of Medicine, Korea

Received 2025 February 5; Accepted 2025 February 6.

Heavy alcohol consumption is a major contributor to the global burden of disease, affecting millions of individuals worldwide. Chronic and excessive alcohol use is associated with a broad spectrum of adverse health outcomes, including the development of alcohol use disorder (AUD) and alcohol-related liver disease (ALD) [1]. These conditions contribute substantially to premature mortality and diminished quality of life [2]. Moreover, alcohol consumption is a leading risk factor for the development of alcohol-attributable primary liver cancer, such as hepatocellular carcinoma (HCC), further compounding its global health impact [3,4]. The burden of alcohol-related diseases extends across diverse regions, populations, and socio-economic strata [5]. AUD, a chronic relapsing condition characterized by impaired control over alcohol consumption, leads to severe physiological, psychological, and social impairments [6]. Similarly, ALD encompasses a continuum of liver pathologies, ranging from simple steatosis to alcohol-associated hepatitis, fibrosis, cirrhosis, and HCC [7,8]. The synergistic interplay between these conditions amplifies the public health challenges posed by alcohol consumption. The global trends in alcohol consumption and its related diseases have shifted over the past two decades, reflecting changes in societal behaviors, alcohol policies, and healthcare advancements [9]. Despite growing recognition of these issues, comprehensive assessments of the global burden of AUD, ALD, and alcohol-attributable liver cancer remain limited. Quantifying the disease burden over time is essential for understanding epidemiological patterns, informing evidence-based interventions, and guiding policy decisions [10].

A recent study published in Clinical and Molecular Hepatology by Danpanichkul and colleagues [11] provides a comprehensive analysis of trends in AUD, ALD, and alcohol-attributable primary liver cancer from 2000 to 2021. The study estimated 111.12 million cases of AUD, 3.02 million cases of ALD, and 132,030 cases of alcohol-attributable liver cancer in 2021. Between 2000 and 2021, the estimated prevalence of AUD increased by 14.66%, ALD by 38.68%, and alcohol-attributable primary liver cancer by 94.12%. Although the age-standardized prevalence rate (ASPR) for alcohol-attributable liver cancer increased (annual percent change, APC 0.59%), ASPRs for ALD (APC –0.71%) and AUD (APC –0.90%) declined during the same period. The disconnect between the rising prevalence compared to the age-standardized prevalence rate is likely related to population growth and ageing. Alarmingly, there was a rise in the prevalence, incidence, and death rates of ALD and liver cancer among women. Notably, age-standardized death rates remained stable for alcohol-related liver cancer, but declined for AUD and ALD. Geographic disparities were evident, with countries in lower socio-demographic index (SDI) categories exhibiting higher age-standardized death rates (ASDRs) for ALD. This pattern reflects the compounded effects of limited healthcare access, inadequate screening, and disparities in treatment availability. Conversely, high SDI countries, despite lower ASDRs, demonstrated rising alcohol consumption and related harms among certain subpopulations. The study’s utilization of the Global Burden of Disease (GBD) framework introduces several limitations that warrant discussion. Underreporting and misclassification of AUD, and ALD, particularly in low- and middle-income countries, remain significant challenges. Studies suggest that stigma, insufficient diagnostic infrastructure, and a lack of awareness contribute to substantial underestimation of the true burden of ALD and AUD [12]. Populations with limited healthcare access are less likely to receive formal diagnoses, further skewing prevalence data. The exclusive use of ICD-10 codes, as opposed to the more comprehensive DSM-5 criteria, may result in cases with AUD missed [13]. Another limitation pertains to the single-cause attribution approach employed by the GBD framework, which restricts the analysis of co-morbidities and interactive risk factors, such as the interplay between metabolic dysfunction and ALD or the synergistic effects of alcohol with chronic viral hepatitis. For example, it has been shown that alcohol consumption exacerbates the progression of metabolic dysfunction-associated steatotic liver disease in individuals with the metabolic syndrome, highlighting the need for a more integrated understanding of multi-factorial risks [14,15]. Moreover, during the COVID-19 pandemic, disruptions to healthcare services and increased alcohol consumption exacerbated reporting inaccuracies, with self-reported alcohol use and liver health data further compromised by stigma and recall bias [16]. Addressing these gaps in data accuracy and methodological rigor is critical for improving future global burden estimates.

The findings underscore the urgent need for early detection and integrated management of alcohol-related conditions, particularly given the observed gender-specific and geographic disparities. The rising prevalence of ALD among women highlights a critical gap in prevention and treatment strategies. Recent research indicates that women are more susceptible to alcohol-induced liver injury due to physiological differences, including alcohol metabolism and hormonal influences on liver inflammation [17]. During the COVID-19 pandemic, alcohol consumption among women increased disproportionately, driven by stress, caregiving responsibilities, and mental health challenges. Consequently, gender-sensitive approaches, including targeted public health messaging, alcohol screening programs, and access to supportive services, are essential to mitigate these trends [18]. Routine alcohol screening in primary care settings has proven effective for the early identification of AUD and ALD but remains inconsistently implemented, particularly in resource-limited regions. Integrating liver health assessments, such as transient elastography or non-invasive fibrosis scores, into routine care could facilitate earlier diagnosis and prevent progression to cirrhosis or liver cancer [19]. In high-risk regions with elevated ASDRs, healthcare systems must prioritize capacity building and resource allocation to strengthen diagnostic and treatment services. For example, task-shifting models, where non-specialist health workers are trained to provide basic liver care, have been effective in resource-limited settings. Telemedicine is another promising avenue to bridge gaps in care. Recent studies have demonstrated the feasibility of telehealth platforms in delivering alcohol counseling and liver disease management, particularly during the COVID-19 pandemic [20].

From a public health perspective, robust alcohol control policies are essential to reducing the burden of alcohol-related liver disease. Evidence-based strategies, including taxation, advertising restrictions, and limiting alcohol availability, have demonstrated some encouraging results in curbing consumption and related harms [21,22]. However, such measures must be paired with culturally appropriate public health campaigns that promote awareness, address stigma, and encourage health-seeking behaviors. For instance, community-based programs in low-SDI countries have successfully reduced harmful drinking behaviors by combining education with accessible treatment options [23]. Equitable access to prevention and treatment services is paramount to addressing disparities in alcohol-related outcomes. Strengthening healthcare infrastructure, investing in workforce training, and integrating alcohol management into primary care can significantly improve outcomes in under-resourced areas. Collaborative efforts involving governments, non-governmental organizations, and international agencies are essential to achieve sustainable progress in reducing the burden of alcohol-related liver disease globally [22].

Metabolic comorbidities including alcohol, obesity, and type 2 diabetes are likely to play a role in increasing morbidity and mortality in people with AUD and ALD [24]. Alcohol control policies have a substantial impact on mortality from cirrhosis and HCC [25]. The burden due to viral hepatitis is in the decline because of vaccination, antiviral therapy, and public welfare initiatives contributing to the prevention of hepatic decompensation and liver cancer [26]. As many people with AUD and ALD are unemployed, dependent on welfare, and lack social support, improving social support programs may be helpful in serving this population. The World Health Organization Sustainable Development Goal health target 3.5 aims to strengthen the prevention and treatment of substance abuse, including harmful alcohol use [27]. Addressing the growing prevalence of alcohol-related liver disease requires a multifaceted approach that integrates early clinical detection, comprehensive care models, evidence-based public health strategies, and policy interventions tailored to diverse populations. By adopting such an approach, the global health community can make meaningful progress in reducing the societal and economic toll of alcohol consumption.