Educational disparities in alcohol‐related liver disease mortality in the 21st century: Beyond deaths of despair?

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Abstract
Background: Deaths from alcohol‐related liver disease and associated conditions (ALD+), a major driver of alcohol‐attributable mortality in the United States, are rising more rapidly than per capita alcohol consumption. These trends may stem from a broader “deaths of despair” epidemic disproportionately affecting those without a college degree. However, how ALD+ mortality trends vary by educational attainment remains underexplored. To address this, we analyzed ALD+ mortality from 2001 to 2020, focusing on disparities across educational and demographic subgroups. Methods: We analyzed US mortality trends for adults 25 and older using a repeated cross‐sectional dataset combining death records for ALD+ with population data from the American Community Survey. We examined differences in mortality trends by age, sex, race/ethnicity, and educational attainment (college degree or not). Trends were modeled using logistic regression with age as a covariate and quadratic time terms. Outcomes included proportional change in mortality (odds ratios for 2020 vs. 2001), modeled age‐adjusted death rates for 2001 and 2020, and absolute change in death rate (Δ). Results: Between 2001 and 2020, the ALD+ death rate increased by 63% (OR = 1.63; 95% CI: 1.55, 1.72), from 8.8 to 16.6 deaths per 100,000. Increases were greater among individuals without a college degree compared to those with a college degree (Δ = 12.7 vs. 2.4 per 100,000). Disparities by education widened across nearly all demographic groups. Conclusion: Disparities in ALD+ mortality by educational attainment widened substantially between 2001 and 2020. Findings are partially consistent with the “deaths of despair” framework that initially focused on mortality among middle‐aged non‐Hispanic Whites but also reveal widening disparities in other demographic groups. Increased alcohol consumption alone is unlikely to fully explain these trends. Identification of social, behavioral, and medical factors contributing to increasing ALD+ deaths will shed light on opportunities for intervention focused on factors beyond alcohol consumption.
Funding Information
  • National Institutes of Health (K23AR079035 (SCG))
  • National Institutes of Health (NIH‐K08DA061258)
  • National Institutes of Health (NIH‐K23DA053433 (JKB))

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