Alcoholic Liver Cirrhosis, More than a Simple Hepatic Disease—A Brief Review of the Risk Factors Associated with Alcohol Abuse

Highlights

• Media exposure contributes to the influence on social alcoholic norms. Advertisements for alcoholic products mainly affects the young population, thus increasing their alcohol consumption.
• Alcohol may be used as a coping mechanism for stressful and traumatic situations.

Abstract

Liver cirrhosis is a significant public health problem, being an important cause of mortality and morbidity, responsible for approximately 1.8% of the total number of deaths in Europe. Chronic alcohol consumption is the most common cause of liver cirrhosis in developed countries. Europe has the highest level of alcohol consumption among all the global World Health Organisation (WHO) regions. In this paper, we briefly review major factors leading to excessive alcohol consumption in order to draw attention to the fact that alcoholic liver cirrhosis is more than a simple liver disease, and if those risk/causal factors can be prevented, the incidence of this disease could be reduced greatly. Although excessive alcohol consumption is regarded as the cause of alcoholic liver cirrhosis, the etiology is complex, involving multiple factors that act in synchrony, and which, if prevented, could greatly reduce the incidence of this disease. Children of addicts are likely to develop an alcohol-related mental disorder; however, there is no “gene for alcoholism”.

Introduction

Chronic alcohol consumption and related liver diseases are the common causes of liver cirrhosis in most developed countries. Abusive alcohol consumption results from a variety of factors that differ across individuals but that may augment one another.

Liver cirrhosis is the final stage in the progression of chronic hepatic disease, that is morphologically defined as a pathologically diffused process that affects the structure and the architecture of the liver through fibrosis and nodular transformation, which ultimately leads to hepatic failure. Liver cirrhosis represents a significant public health problem, being a significant cause of mortality and morbidity. Its prevalence among the general population is difficult to specify as it is affected by modifiable risk factors such as chronic alcohol consumption, chronic viral hepatitis, and being overweight. In 2010, liver cirrhosis was the 23rd cause of death worldwide, accounting for 31 million deaths [1,2]. The World Health Organization (WHO) shows that 1.8% of the deaths in Europe (about 700,000 people) occur due to liver cirrhosis.

The primary etiology of liver cirrhosis is twofold: chronic alcohol consumption and chronic viral hepatitis [3,4]. Chronic alcohol consumption is a common cause of liver cirrhosis in most developed countries. Europe has the highest level of alcohol consumption of all the global WHO regions [5].

Discussions

The concern related to chronic alcohol consumption

Alcohol, in its various forms, concentrations, flavors, but with the same type of effects, is the most widely used drug in the world, having the advantage of legality and, in particular, of unconditional acceptance by most societies. The effects of alcohol (tonic, sedative, aphrodisiac) have been known for thousands of years, and the relationship with liver disease for over 200 years.

The excessive consumption of alcohol is responsible for 3.3 million deaths signifying roughly 6% of all global deaths [6]. In 2015, in the USA, 47% of liver disease deaths were due to chronic alcohol consumption [7], and of all cirrhotic deaths in 2013, 47.9 % were alcohol-related [8]. In Europe, 41% of liver-related deaths are due to alcohol- induced hepatic disease, Romania being the country with the highest such death rate in Europe, most of which are alcohol-related.

The amount of alcohol considered dangerous, risky, or problematic has not been clearly defined. According to some reports, it is at a level of 12g/day. For practical reasons, the consumption of fewer than two servings of alcohol (each portion of about 10 grams of pure alcohol) per day for women and three servings for men is considered the safety limit. Consumption above this level is considered harmful [24].

Abusive alcohol consumption - causes, risk factors

Identifying the cause that leads to the occurrence of abusive alcohol consumption is difficult. No single set of circumstances or factors is responsible, but rather a variety of factors that differ across individuals appear to act together. It is clear, however, that any person is susceptible to alcohol abuse independent of age, gender, ethnicity, body type, and personal beliefs; nevertheless, predicting abusive alcohol consumption is challenging. Furthermore, for some individuals, the manifestations develop rapidly and aggressively [9], while for others it may take years for the signs to appear.

I. Biological factors

Research on alcohol consumption and dependence indicates that genetic factors play a role in developing alcoholism and account for approximately half of the risk for alcohol use disorder. Several genes associated with alcohol dependence (ADH1B and ALDH2) can be transferred from generation to generation, thus making children of addicts more likely to develop an alcohol- related mental disorder [10].

Family history of chronic alcohol consumption is not sufficient to demonstrate that genetic factors contribute solely to alcohol use disorder in offspring; however, adoption studies show that alcoholism in adopted children correlates more strongly with the biological parents than with adoptive parents. However, it should be stressed that, while genetic differences affect the risk, there is no "gene for alcoholism," and environmental and social factors weigh heavily in the development of alcoholism [11].

II. Psychological factors

The human psyche is characterized by diversity in the capacity to cope and adapt to stressful and traumatic situations [12,13]. Alcohol often serves as a means of escape, providing a source of temporary relief. Common psychiatric disorders associated with alcohol abuse are anxiety disorders, depression, bipolar disorder, and schizophrenia. Alcohol, in turn, leads to the occurrence of clinical manifestations that mimic psychiatric disorders, thus creating a vicious cycle [14].

III. Social factors

Alcohol consumption varies according to gender, ethnicity, social, and cultural environment. Throughout the world, men consume more alcohol than women, whereas women in more developed countries consume more alcohol than women in developing countries. Among racial and ethnic groups, Caucasians report the highest use of alcohol among those 12 or older [7].

At the population level, research has documented the relationship between social determinants and health, in particular, alcohol consumption epidemiology, a social capital theory suggesting that social networks and connections influence health. In the context of alcohol consumption, individuals are located in the microsystem (their home, work environment, and school environment), which is also included in the wider community. Macroeconomic factors, such as exposure to advertising, can influence attitudes and norms of family and colleagues, ultimately affecting individual attitudes and behaviors [15].

III. A. Advertising, marketing and social media

Media exposure influences social norms about alcohol through advertising, product placements, and stories from a wide range of sources, including films, television, social networks, and other forms of entertainment. Although alcohol sales and marketing are highly regulated, people are exposed to a wide variety of alcohol and alcoholic beverages through the media.

The alcohol industry uses targeted, sophisticated marketing strategies that focus on different demographic groups, such as youth, gender, ethnic minorities, and socio- cultural groups, strategies that can lead to the development of positive beliefs about alcohol consumption and the creation and expansion of environments where alcohol consumption is acceptable and encouraged [16,17]. Studies have found that advertisements for alcoholic products particularly affect the young population, thus increasing their alcohol consumption [16,17].

Since the introduction of flavoured alcoholic beverages, the alcohol industry has been preoccupied with marketing techniques targeting young people in general, and young women, in particular, which has led to an increase in alcohol consumption in the female population. Although the alcohol industry claims that its marketing strategies target young adults who are at the legal age of drinking alcohol, products such as flavoured alcoholic drinks remain attractive to even younger people [18].

III. B. Discrimination

Discrimination is seen as a critical social stressor that can have life-threatening effects, including increased alcohol consumption, which is used as a coping mechanism. Several studies have revealed a strong association between alcohol consumption and minorities who are subject to racial discrimination: Asian, Hispanic, and African Americans [19].

Another group that may pose a particular risk to alcohol problems arising from their experiences of discrimination are those in the Lesbian, Gay, Bisexual, and Transgender (LGBT) community who face high levels of discrimination related to their sexual orientation and gender identification. More than two-thirds of the adult LGBT population face discrimination, and people who reported discrimination based on race, sex, and sexual orientation were almost four times more likely to use alcohol and other substances [20].

III. C. The community

The research literature about community influences on alcohol consumption focuses on environmental issues such as where people live, their access to buying alcohol, and the support for drinking alcohol. Children living in an environment with easy access to alcohol and exposure to alcohol consumption by parents and neighbours are at increased risk for alcohol consumption disorder in adulthood. For example, living in a disadvantaged neighbourhood characterized by poor construction, inferior sewage system, and limited access to drinking water increases the risk of alcohol abuse compared to those who live in a better-constructed environment [21].

III. D. Cultural Norms

Cultural norms and habits are potent predictors for both occasional and chronic alcohol abuse. In terms of race and ethnicity, African Americans and Latin Americans report more conservative attitudes towards alcohol consumption compared to white people. Asians have one of the lowest rates of alcohol consumption compared to other racial groups, especially when they accept and respect their ethnic identity. Ethnic identity can promote stronger family and traditional values, which are associated with lower alcohol consumption [15].

III. E. Family and peers’ influence

Among the strongest influences on young people's drinking behaviour are the people within their family and peer network. Adolescents from families where parents are accustomed to consuming high amounts of alcohol have a much higher risk of alcohol abuse. However, the influence of the family on the alcohol consumption of teens diminishes with time, with increasing influence of various social groups, including college/faculty, work, friends, etc. [22,23]. Young people who are closely attached to their families, who share the family’s negative attitudes towards alcohol consumption, and who have strong parental monitoring are less susceptible to drinking high amounts of alcohol.

Conclusions

Although excessive alcohol consumption is regarded as the cause of alcoholic liver cirrhosis, the etiology is complex, involving multiple factors that act in synchrony, and which, if prevented, could greatly reduce the incidence of this disease.

Minorities who are subject to discrimination (racial, sexual orientation) and people living in disadvantaged neighborhoods are at significant risk of developing alcohol use disorders. Descendents of families where parents are acustomed to consuming high amounts of alcohol have the highest risk of alcohol abuse.