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Effectiveness in Disease and Injury Prevention County Data on Alcohol-Related Mortality -- United States

Although estimates of alcohol-related mortality (ARM) have been determined for the United States and selected states (1-6), the magnitude of ARM has not been well defined for smaller geographic areas. To provide additional geographically specific data, the Alcohol Epidemiologic Data System of the National Institute on Alcohol Abuse and Alcoholism recently released a reference manual for ARM in U.S. counties (County Alcohol Problem Indicators (7)). The manual provides information for 3107 counties for 1979-1985 using both underlying and multiple cause-of-death information. This report summarizes data sources, methods, and applications for the manual.

Data sources for the report included vital statistics from CDC's National Center for Health Statistics, population estimates from the Bureau of the Census, and estimates of alcohol-attributable fractions (AAFs) from the research literature. AAFs are estimates of the proportion of deaths from disease or injury diagnoses that are causally linked to alcohol use or misuse (4,7,8). Alcohol-related deaths were identified from death certificates based on the International Classification of Diseases, Ninth Revision (ICD-9) (9).

Data provided for each county include average death rates per 100,000 population for the following diseases and injuries: alcoholic psychoses (ICD-9 code 291), alcohol dependence syndrome (303, 265.2, 357.5, 425.5, and 535.3), nondependent abuse of alcohol (305.0), cirrhosis (571 and 572.3), alcohol poisoning (790.3 and E860), motor-vehicle crashes (E810-E825), suicide (E950-E958), and homicide (E960-E969). Application of AAFs to deaths from these diseases and injuries enabled estimation of ARM for each county. Estimates of ARM caused by alcohol-related diseases were also calculated based on multiple cause-of-death data. County rank within state and percentile rank within the United States based on these estimates and rates are provided. The number of alcohol-related disease deaths, based on multiple cause-of-death records, yields estimates of ARM that are 69% higher than those based on underlying cause only for the same diseases. These increases varied by disease and were less for cirrhosis (50%) and substantially more for alcohol dependence syndrome (150%). Because counties often have small populations with few alcohol-related deaths in any given year, population and mortality data for 5 years (1979, 1980, and 1983-1985) were averaged to develop more stable annual county death rates. (Continued on page 561)

The manual compares ARM across counties within a state and throughout the United States. Counties in the lowest U.S. percentile rank averaged fewer than five deaths that mention an alcohol-related disease per 100,000 persons, and counties in the highest percentile rank averaged more than 55 deaths per 100,000.

Determining the percentile rank of each county can assist in ranking metropolitan areas that overlap state boundaries, such as the tristate metropolitan area that includes New York City and parts of Connecticut and New Jersey. Based on U.S. percentile ranks, New York City (comprising the Bronx, Brooklyn, Manhattan, Queens, and Staten Island) and New Jersey's Essex and Hudson counties ranked in the highest 10% of U.S. counties for ARM (Figure 1).

Reported by: MF Caces, PhD, FS Stinson, PhD, SD Elliott, PhD, Alcohol Epidemiologic Data System, CSR, Inc, Washington, DC. JM Shultz, PhD, Dept of Epidemiology and Public Health, Univ of Miami School of Medicine, Miami, Florida. JA Noble, Div of Biometry and Epidemiology, National Institute on Alcohol Abuse and Alcoholism, Alcohol, Drug Abuse, and Mental Health Administration.

Editorial Note

Editorial Note:

The estimates presented in County Alcohol Problem Indicators use mortality data that are routinely collected at the county level. The alcohol-related conditions used in this analysis are based on a subset of specific causes of death for which AAFs are available, thereby producing conservative estimates of ARM (a national average of 54,000-83,000 deaths per year for 1979-1985). Other approaches to estimating ARM have used more comprehensive sets of diagnoses, resulting in less conservative definitions of AAF and producing larger estimates (e.g., 105,000 deaths in 1987 (4)).

Mortality data are a readily available and routinely measured indicator that permit analysis at the county level. These data, in conjunction with other county-level characteristics, can be used by state and local program planners and other health officials in assessing community service requirements for prevention and treatment services for alcohol-related disease. For example, the Iowa Department of Public Health used county rankings of ARM to develop a comprehensive state plan for substance abuse for 1986-1987 (10). These data can also be used to monitor local conditions relevant to prevention efforts identified in the year 2000 health objectives (11).

County Alcohol Problem Indicators is available from the Alcohol Epidemiologic Data System, c/o CSR, Inc., 1400 Eye Street, NW, Suite 600, Washington, DC 20005.


  1. Harwood HJ, Napolitano DM, Kristiansen RL, Collins JF. Economic costs to society of alcohol and drug abuse, and mental illness, 1980. Research Triangle Park, North Carolina: Research Triangle Institute, 1984.

2. Ravenholt RT. Addiction mortality in the United States, 1980: tobacco, alcohol, and other substances. Population and Development Review 1984;10.4:697-724.

3. Rice DP, Kelman S, Miller LS, Denmeyer S. The economic costs of alcohol and drug abuse and mental illness: 1985. San Francisco: Institute of Health and Aging, University of California, 1990; DHHS publication no. (ADM)90-1694.

4. CDC. Alcohol-related mortality and years of potential life lost--United States, 1987. MMWR 1990;39:173-8.

5. Parker DL, Shultz JM, Gertz L, Berkelman R, Remington PL. The social and economic cost of alcohol abuse in Minnesota, 1983. Am J Public Health 1987;77:982-6.

6. CDC. Alcohol-related disease impact--Wisconsin, 1988. MMWR 1990;39:178-80,185-7.

7. National Institute on Alcohol Abuse and Alcoholism. County problem indicators, 1979-1985: U.S. alcohol epidemiologic data reference manual. 3rd ed. Vol 3. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, 1991; publication no. (ADM)91-1740.

8. Roizen J. Estimating alcohol involvement in serious events. In: National Institute on Alcohol Abuse and Alcoholism. Alcohol consumption and related problems. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, 1982:179-219. (Alcohol and health monograph no. 1).

9. World Health Organization. Manual of the international statistical classification of diseases, injuries, and causes of death. 2 vols. Geneva, Switzerland: World Health Organization, 1978. 10. Iowa Department of Public Health. Iowa comprehensive state plan for substance abuse, 1986-1987. Des Moines, Iowa: Iowa Department of Public Health, Division of Substance Abuse, 1986. 11. Public Health Service. Healthy people 2000. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; publication no. (PHS)91-50213.

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