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Alcohol Consumption and 15 Causes of Fatal Injuries: A Systematic Review and Meta-Analysis

      Introduction

      The proportion of fatal nontraffic injuries that involve high levels of alcohol use or alcohol intoxication was assessed by cause of injury to generate alcohol-attributable fractions. Updated alcohol-attributable fractions can contribute to improved estimates of the public health impact of excessive alcohol use.

      Methods

      Peer-reviewed and gray literature for 1995–2019 on 15 causes of fatal nontraffic injuries in the U.S., Canada, or Mexico were systematically reviewed, and state data systems were queried for available estimates of fatalities with recorded blood alcohol concentration levels and proportions of decedents with blood alcohol concentrations ≥0.10 g/dL by cause of injury. For each injury cause, alcohol-attributable fractions across studies were synthesized by meta-analysis of single proportions using generalized linear mixed models.

      Results

      In total, 60 published studies and 40 additional population-level data points from 6 state data systems were included. The meta-analyzed alcohol-attributable fractions by cause of injury are as follows: air-space transport (0.03), aspiration (0.24), child maltreatment (0.09), drowning (0.31), fall injuries (0.37), fire injuries (0.34), firearm injuries (0.24), homicide (0.29), hypothermia (0.29), motor vehicle nontraffic crashes (0.42), occupational and machine injuries (0.08), other road vehicle crashes (railroad trespasser injuries) (0.63), poisoning (not alcohol) (0.20), suicide (0.21), and water transport (0.27), yielding an overall median alcohol-attributable fraction of 0.27.

      Discussion

      Excessive alcohol use is associated with substantial proportions of violent and nonviolent injury deaths. These findings can improve the data used for estimating alcohol-attributable injury deaths and inform the planning and implementation of evidence-based strategies (e.g., increasing alcohol taxes, regulating alcohol outlet density) to prevent them.

      INTRODUCTION

      Excessive alcohol use is a leading cause of preventable death in the U.S.
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      and was responsible for an average of >95,000 deaths each year during 2011–2015.
      • Esser MB
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      Deaths and years of potential life lost from excessive alcohol use - United States, 2011-2015.
      It is a risk factor for both unintentional and intentional injuries.

      Cherpitel CJ, Borges G, Giesbrecht N, Monteiro M, Stockwell T. Prevention of alcohol-related injuries in the Americas: from evidence to policy action. Washington, DC: Pan-American Health Organization, WHO. https://iris.paho.org/bitstream/handle/10665.2/6085/Prevention%20of%20alcohol-related%202013.pdf?sequence=1&isAllowed=y. Published 2013. Accessed May 5, 2022.

      Binge drinking (i.e., the consumption of 4 or more drinks for women or 5 or more drinks for men on an occasion or in about a 2-hour period, which generally raises one's blood alcohol concentration [BAC] level to 0.08 g/dL or higher) is associated with an increase in the likelihood of fatal injuries.
      • Esser MB
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      Deaths and years of potential life lost from excessive alcohol use - United States, 2011-2015.
      ,
      • Li G
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      Drinking behavior in relation to cause of death among U.S. adults.
      Nearly one seventh of U.S. high-school students reported binge drinking in 2019,
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      Prescription opioid misuse and use of alcohol and other substances among high school students - Youth Risk Behavior Survey, United States, 2019.
      as did one sixth of adults in 2018, and 25% of adults did so at least weekly.
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      Binge drinking among adults, by select characteristics and state - United States, 2018.
      Alcohol-attributable fractions (AAFs) measure the contribution of alcohol use to a given health outcome or cause of death and are important for estimating alcohol-related morbidity and mortality. Direct estimates of AAFs (i.e., the proportion of persons dying from a particular alcohol-attributable condition that had a BAC above a specified level) are often used to measure the contribution of alcohol to acute causes of death, such as injuries. With approximately 10,000 deaths from alcohol-impaired driving recorded each year, AAFs for fatal motor vehicle crashes are well monitored in the U.S. relative to those of other causes of alcohol-related injuries, and such data are accessible from the Fatality Analysis Reporting System.

      Fatal analysis reporting system. U.S. Department of Transportation, National Highway Transportation Safety Administration. https://www.nhtsa.gov/research-data/fatality-analysis-reporting-system-fars. Updated March 9, 2022. Accessed May 5, 2022.

      Earlier reviews have examined the role of alcohol use in fatal injuries.
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      Fatal nontraffic injuries involving alcohol: a metaanalysis.
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      The quantification of drug-caused mortality and morbidity in Australia.
      However, limited current data are available on alcohol involvement in fatal nontraffic injuries, and more are needed to improve the estimates of the public health burden of excessive alcohol use. The most recent meta-analysis on alcohol involvement in fatal nontraffic injuries in the U.S. was published >20 years ago using data from medical examiner reports from 1975 to 1995.
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      Fatal nontraffic injuries involving alcohol: a metaanalysis.
      Given the increases in binge drinking and alcohol-related emergency department visits since then,
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      findings from earlier studies may no longer reflect the current situation. For example, binge drinking is a risk factor for other substance use,
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      Use of alcohol at the same time as benzodiazepines or opioids can increase the risk of a fatal overdose.
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      With the rise in drug overdose deaths,

      Understanding the epidemic. Centers for Disease Control and Prevention. https://www.cdc.gov/drugoverdose/epidemic/index.html. Updated 2021. Accessed April 9, 2021.

      the extent to which high levels of alcohol are involved in fatal drug overdoses and other poisonings may have changed since earlier reviews.
      The purpose of this systematic review and meta-analysis is to assess the proportion of fatal nontraffic injuries that involve high levels of alcohol (BAC ≥0.10 g/dL or indications of alcohol intoxication) by cause of injury. The results from this meta-analysis can improve the data used for estimating alcohol-attributable deaths from nontraffic injuries, such as in data systems that rely on AAFs (e.g., the Centers for Disease Control and Prevention's [CDC] Alcohol-Related Disease Impact [ARDI] application). The findings from this study could also inform the planning and implementation of evidence-based population-level strategies

      The Guide to Community Preventive Services: excessive alcohol consumption. Community Preventive Services Task Force. https://www.thecommunityguide.org/topic/excessive-alcohol-consumption. Accessed May 5, 2022.

      to reduce binge drinking and associated injuries and deaths.

      METHODS

      A total of 15 mutually exclusive acute causes of death from alcohol-attributable nontraffic-related injuries were included in this systematic review and meta-analysis: air-space transport, aspiration, child maltreatment, drowning, poisoning (not alcohol), fall injuries, fire injuries, firearm injuries, homicide, hypothermia, motor vehicle nontraffic crashes, other road vehicle crashes, occupational and machine injuries, suicide, and water transport. These categories align with the acute causes of death from partially alcohol-attributable nontraffic-related injuries that are used in CDC's ARDI application

      Alcohol Related Disease Impact (ARDI) application. Centers for Disease Control and Prevention. http://www.cdc.gov/ARDI. Updated July, 2020. Accessed April 28, 2021.

      and are identified primarily by the International Classification of Diseases, Ninth Revision and ICD-10 codes (Appendix 1, available online). Deaths from homicide or suicide are characterized as intentional injuries. Deaths from child maltreatment included unintentional and intentional injuries. All other causes of death included only unintentional injuries.
      The CDC's ARDI application is a comprehensive tool for estimating state and national alcohol-attributable deaths and years of potential life lost for nearly 60 causes of alcohol-related death. Data on alcohol-related deaths from chronic conditions were not included in this study nor were injuries that are fully alcohol attributable (e.g., alcohol poisoning). Fully alcohol-attributable deaths (AAF=1.0) are those that would not occur in the absence of alcohol; therefore, no estimation is required. Because annual AAFs for fatal motor vehicle traffic crashes are available from the Fatality Analysis Reporting System,

      National Highway Traffic Safety Administration. Traffic safety Facts 2018 annual report: A compilation of motor vehicle crash data. Washington, DC. U.S. Department of Transportation, National Center for Statistics and Analysis. https://crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/812981. Published 2020. Accessed June 3, 2021.

      they are not estimated in this meta-analysis, although they are included in ARDI. PRISMA guidelines were followed.
      • Moher D
      • Liberati A
      • Tetzlaff J
      • Altman DG
      • Group PRISMA
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      This study involved secondary analyses of deidentified data; therefore, IRB oversight was not required.

      Search Strategy

      For each of the 15 causes of fatal nontraffic injuries, published studies in peer-reviewed journals, government reports (e.g., medical examiners’ reports), and other gray literature were systematically reviewed to identify studies, reports, and data systems that independently assessed alcohol involvement. Boolean algorithms were submitted to literature search engines that index relevant published studies, including PubMed, ScienceDirect, Web of Science, Cochrane Central, Embase, SCOPUS, CINAHL, Google Scholar, and Epistomonikos. Gray literature was also searched to capture data from sources that might not otherwise be available in the peer-reviewed literature (Appendix 2, available online),
      • Paez A.
      Gray literature: an important resource in systematic reviews.
      including proceedings of professional association meetings, coroners’ and medical examiners’ reports, and U.S. federal and state government and Canadian reports.
      State health surveillance systems, vital death records, and medical examiner/coroner offices have traditionally been the primary sources of data underlying fatal injury AAFs. Therefore, between January 2020 and August 2020, emails were sent to health departments or medical examiner government offices in 20 states that have centralized medical examiner systems or an epidemiologist working on alcohol. Each was provided with a table specifying the 15 causes of fatal injuries and the cause-specific ICD-10 codes. Recent 5 years of data were requested to calculate the number of fatalities with a valid BAC test result and the number of decedents with BAC ≥0.10 g/dL, by cause of injury.
      An iterative, snowball search strategy was employed,
      • Greenhalgh T
      • Peacock R.
      Effectiveness and efficiency of search methods in systematic reviews of complex evidence: audit of primary sources.
      scanning reference lists and authors’ names of primary sources identified as well as citations to studies ascertained through Web of Science to ensure literature saturation. This approach can be particularly effective in systematic reviews of multidisciplinary areas such as alcohol involvement in fatal injuries because primary sources may reference other reports with relevant data or additional literature from other fields. The International Classification of Diseases, Ninth Revision and ICD-10 codes from CDC's ARDI application were used to identify literature on the 15 types of injuries.

      Alcohol-related ICD codes. Centers for Disease Control and Prevention. https://www.cdc.gov/alcohol/ardi/alcohol-related-icd-codes.html. Updated 2020. Accessed April 28, 2021.

      Systematic reviews were conducted from October 2019 through October 2020. Appendix 2 (available online) contains the details of the search strategy.
      Inclusion criteria consisted of studies and reports on any of the 15 causes of fatal nontraffic injuries published from 1995 through 2019 or data from state systems during this period; involving human subjects; based in the U.S., Canada, or Mexico; and written in English. The search started with 1995, being the final year of reports included in the previous comprehensive meta-analysis on alcohol-related nontraffic injuries.
      • Smith GS
      • Branas CC
      • Miller TR.
      Fatal nontraffic injuries involving alcohol: a metaanalysis.
      Studies were primarily sought that reported direct AAF estimates or included data to directly assess AAFs (i.e., the proportion of persons that died of a particular injury with BAC ≥0.10 g/dL at the time of injury among those who had a valid BAC test). In other words, AAF is an estimate of the percentage of deaths that are attributed to alcohol. Consistent with CDC's ARDI application, 0.10 g/dL was used as the threshold for determining alcohol involvement instead of 0.08 g/dL (a common threshold level for acute intoxication). Injury fatalities can be due to many nonalcohol-related factors, and the higher BAC threshold provides a greater level of assurance for a death being attributable to alcohol.
      • Smith GS
      • Branas CC
      • Miller TR.
      Fatal nontraffic injuries involving alcohol: a metaanalysis.
      ,

      ARDI methods. Centers for Disease Control and Prevention. https://www.cdc.gov/alcohol/ardi/methods.html. Updated 2020. Accessed April 28, 2021.

      Alcohol measurements from tissues other than blood were not included because of limited comparability with more common BAC measures.
      • Smith GS
      • Branas CC
      • Miller TR.
      Fatal nontraffic injuries involving alcohol: a metaanalysis.
      BAC measurements are typically, although not always, obtained during injury death investigations conducted by medical examiners, coroners, or other government officials (e.g., forensic toxicology laboratories). These measurements are often included in state and local health surveillance and vital death records systems. Studies in which the AAF was equal to zero were included if selection bias was not suspected. A minimum sample size of at least 5 decedents with BAC test results per cause of death was required for inclusion.
      Upon completion of comprehensive full-text reviews, minimal studies with suitable BAC data were identified for 7 fatal injury causes (aspiration, child maltreatment, fall injuries, homicide, hypothermia, occupational and machine injuries, and other road vehicle crashes). Therefore, the inclusion criteria were broadened for these to include descriptions of alcohol intoxication that would approximate BAC ≥0.10 g/dL (i.e., alcohol intoxication, alcohol impaired, inebriated, under the influence, drunk, or alcohol was a factor). This broader approach aligns with the seminal English and Holman meta-analysis on alcohol and numerous related outcomes.
      • English DR
      • Holman CDJ
      • Milne E
      • et al.
      and Health. XXX
      The quantification of drug-caused mortality and morbidity in Australia.
      Because our study reports AAFs by cause of injury, AAFs for the 7 causes mentioned earlier can be viewed separately from AAFs for the other causes. Appendix 1 (available online) provides further details on study inclusion by cause of death.
      All citations identified in the systematic literature reviews were compiled and managed in an EndNote reference management database after initial screening for eligibility by a bibliographic research librarian (NW) on the basis of cause of injury, location, and presence of BAC information. Before data abstraction, 2 investigators closely examined the full-text reports for specificity and linkage of BAC information with fatal injuries, minimum sample size requirements, the remaining eligibility criteria, and any redundancies among reports. Each eligible source was compared with the remaining reports with respect to dates, places of data collection, and populations sampled to exclude duplicates. When the same underlying data were reported by >1 source, the source with the largest number of decedents was included.
      Data abstraction forms were developed to collect the following information from each published report: report information (e.g., data source type, funding source); study eligibility (e.g., causes of death, BAC or alcohol intoxication data); study setting; population characteristics; methodology, including study design, sampling frame, selection criteria, fatal injury data sources, and BAC sources and timing; effect size, including the numbers of decedents, BAC tests, BAC test results ≥0.10 g/dL, and missing or unreported BAC tests; and risk of bias assessment.
      The risk of bias assessment for individual studies was adapted from the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

      Schünemann H, Brożek J, Guyatt G, Oxman A. Grade handbook. https://gdt.gradepro.org/app/handbook/handbook.html. Updated October 2013. Accessed May 5, 2022.

      The GRADE approach uses specific evaluation criteria to identify the subset of studies likely to yield the most accurate approximation of the effect size of alcohol on each cause of death. It allows for optimal objectivity and clear communication of any subjective judgments. Consistent with this approach, 2 primary investigators with formal epidemiologic training and experience evaluating quality and risk of bias in research (HRA and CMC) independently performed data abstraction and evaluation. Discrepancies were adjudicated by a third epidemiologist investigator (MES), and any remaining issues were discussed and resolved among all investigators before analysis. Calibration exercises were held using clear instructions with explicit evaluation criteria, and a structured approach was employed to ensure transparency.
      The potential study-level biases (selection bias, imprecision, missing data, external validity, and reporting bias) relevant to measures of direct AAF estimates (i.e., incidence and proportions) for fatal nontraffic injuries were evaluated following the PRISMA statement and GRADE recommendations.
      • Moher D
      • Liberati A
      • Tetzlaff J
      • Altman DG
      • Group PRISMA
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      ,
      • Guyatt GH
      • Oxman AD
      • Vist GE
      • et al.
      GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.
      Evaluation of nonpeer-reviewed data considered internal consistency, reliability, and face validity of the sources. The risk of bias score was increased by 1 point for each type of bias judged to potentially influence the accuracy or precision of the AAF significantly. Points were summed for an overall rating of each study. Published studies that met inclusion criteria were selected for analysis if they had a risk of bias score not >3. In the absence of suitably defined data, emails were sent to authors of 8 potentially eligible studies requesting clarification of reported BAC data or other important missing information or to resolve observed inconsistencies.
      Data abstracted included the numerator and denominator of the study-level AAF for each cause of death. The numerator was defined as the number of deaths where the decedent (or offender in homicide and child maltreatment cases) either had BAC ≥0.10 g/dL or was reported to be alcohol intoxicated. The denominator was defined as the number of deaths where the decedent (or offender) had either a valid BAC test result or a descriptive indication of alcohol involvement. For each cause of death, AAFs across studies were synthesized by meta-analysis of single proportions using generalized linear mixed models. Generalized linear mixed model was used rather than alternative methods (e.g., standard inverse variance methods such as Freeman‒Tukey double arcsine transformation) because it avoids potential problems with back transformations by considering the binomial structure of AAF data.
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      was calculated to quantify the percentage of total variance contributed by between-study variance. The meta-analyzed AAFs were derived from the random-effects model, regardless of study heterogeneity. The analysis was conducted using the meta and metafor packages
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      A sensitivity analysis was conducted by analyzing U.S.-only data to assess whether results were biased by the inclusion of data from Canadian studies for 6 causes of death (i.e., aspiration, drowning, hypothermia, occupational and machine injuries, suicide, and water transport).

      RESULTS

      The data in this meta-analysis were sourced from a total of 60 published studies (Figure 1) and 6 state data and surveillance systems (Colorado, Michigan, Minnesota, North Carolina, Utah, and Virginia) that provided data for 40 AAF estimates. Overall, data were included from 28 U.S. states, 5 national-level U.S. studies, and 6 Canadian studies. Characteristics of individual data sources, including study-level AAFs used for calculating the meta-analyzed AAFs, are presented in Table 1.

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      • Smith GS
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      • Hadley JA
      • et al.
      Drinking and recreational boating fatalities: a population-based case-control study.

      Barss P. Boating immersion and trauma deaths in Canada: 18 years of research. Ontario, Canada: Transport Canada and the Canadian Red Cross Society. https://www.redcross.ca/crc/documents/3-3-4_2011_boating_fnl.pdf. Published 2011. Accessed May 5, 2022.

      • Pelletier A.
      Deaths among railroad trespassers. The role of alcohol in fatal injuries.

      North American Management. Rail Trespasser Fatalities: Demographic and Behavioral Profiles. Washington, DC: U.S. Department of Transportation, Federal Railroad Administration. https://railroads.dot.gov/sites/fra.dot.gov/files/fra_net/3315/RailTrespasserFatalitiesDemograph62013.pdf. Published 2013. Accessed June 3, 2021.

      Centers for Disease Control and Prevention (CDC)
      Injuries among railroad trespassers–Georgia, 1990-1996.
      The number of original data sources included in the meta-analyses varied by cause of death, ranging from 2 for fall injuries to 19 for suicide (Figure 2). Risk of bias total scores were similar between investigators and reflected a low risk of bias within and across the included studies (Table 1

      Botch SR, Johnson RD. Toxicological findings of pilots involved in aviation accidents operated under Title 14 CFR, Part 135. Washington, DC: Office of Aerospace Medicine, Federal Aviation Administration. https://apps.dtic.mil/sti/pdfs/ADA506749.pdf. Published 2009. Accessed May 5, 2022.

      Botch SR, Johnson RD. Alcohol-related aviation accidents involving pilots with previous alcohol offenses. Washington, DC: Office of Aerospace Medicine, Federal Aviation Administration. https://libraryonline.erau.edu/online-full-text/faa-aviation-medicine-reports/AM08-22.pdf. Published 2008. Accessed May 5, 2022.

      • Li G
      • Hooten EG
      • Baker SP
      • Butts JD.
      Alcohol in aviation-related fatalities: North Carolina, 1985-1994.
      • Boghossian E
      • Tambuscio S
      • Sauvageau A.
      Nonchemical suffocation deaths in forensic setting: a 6-year retrospective study of environmental suffocation, smothering, choking, and traumatic/positional asphyxia.

      Colorado child fatality prevention system data dashboard. Colorado Department of Public Health and Environment. https://cohealthviz.dphe.state.co.us/t/PSDVIP-MHPPUBLIC/views/CFPSDashboardFinalLocal/Story1?iframeSizedToWindow=true&:embed=y&:showAppBanner=false&:display_count=no&:showVizHome=no. Accessed May 5, 2022.

      • Parks SE
      • Mirchandani G
      • Rodriguez S
      • Hellsten J.
      History of maltreatment among unintentional injury deaths: analyses of Texas child fatality review data, 2005-2007.

      South Carolina State Child Fatality Advisory Committee. State fiscal year 2019 report. Columbia, SC: South Carolina State Child Fatality Advisory Committee. https://scfacsc.files.wordpress.com/2020/02/2019-scfac-annual-report-final.pdf. Published February 2020. Accessed April 12, 2021.

      • Okuda T
      • Wang Z
      • Lapan S
      • Fowler DR.
      Bathtub drowning: an 11-year retrospective study in the state of Maryland.
      • Cummings P
      • Quan L.
      Trends in unintentional drowning: the role of alcohol and medical care.
      • Browne ML
      • Lewis-Michl EL
      • Stark AD.
      Unintentional drownings among New York State residents, 1988-1994.
      Canadian Red Cross Society
      Drownings and other water-related injuries in Canada: 10 years of research, Module 1 overview.
      • Lincoln JM
      • Perkins R
      • Melton F
      • Conway GA.
      Drowning in Alaskan waters.
      • Levine B
      • Moore KA
      • Fowler D.
      Interaction between carbon monoxide and ethanol in fire fatalities.

      Tridata Corporation. Establishing a Relationship Between Alcohol and Casualties of Fire. Arlington, VA: Federal Emergency Management Agency, United States Fire Administration National Fire Data Center. https://www.sustainable-design.ie/fire/alcoholfire.pdf. Published October 1999. Accessed May 5, 2022.

      U.S. Department of Homeland Security/Federal Emergency Management Agency. Case study: contribution of alcohol to fire fatalities in Minnesota. Topical Fire Research Series. Vol. 3-Issue 4. Washington, DC: U.S. Department of Homeland Security/Federal Emergency Management Agency. https://nfa.usfa.fema.gov/downloads/pdf/statistics/v3i4.pdf. July 2003. Accessed May 5, 2022.

      • McGwin Jr, G
      • Chapman V
      • Rousculp M
      • Robison J
      • Fine P.
      The epidemiology of fire-related deaths in Alabama, 1992‒1997.
      • Marshall SW
      • Runyan CW
      • Bangdiwala SI
      • Linzer MA
      • Sacks JJ
      • Butts JD.
      Fatal residential fires: who dies and who survives?.
      • Cherry D
      • Runyan C
      • Butts J.
      A population based study of unintentional firearm fatalities.
      • Collins KA.
      Adolescent Russian roulette deaths.
      • Shields LB
      • Hunsaker 3rd, JC
      • Stewart DM.
      Russian roulette and risk-taking behavior: a medical examiner study.
      • Spunt B
      • Brownstein HH
      • Crimmins SM
      • Langley S
      • Spanjol K.
      Alcohol-related homicides committed by women.
      • Spunt B
      • Brownstein H
      • Goldstein P
      • Fendrich M
      • Liberty HJ.
      Drug use by homicide offenders.
      • Banks L
      • Crandall C
      • Sklar D
      • Bauer M.
      A comparison of intimate partner homicide to intimate partner homicide-suicide: one hundred and twenty-four New Mexico cases.

      Greenfeld LA. Alcohol and crime: an analysis of national data on the prevalence of alcohol involvement in crime. Washington, DC. U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics. https://bjs.ojp.gov/content/pub/pdf/ac.pdf. Published 1998. Accessed May 5, 2022.

      • Koutsavlis AT
      • Kosatsky T.
      Environmental-temperature injury in a Canadian metropolis.
      • Hall AJ
      • Bixler D
      • Helmkamp JC
      • Kraner JC
      • Kaplan JA.
      Fatal all-terrain vehicle crashes: injury types and alcohol use.

      Fatality summary, annual reports and crash reporting, all-terrain vehicle crash incident reports. Wisconsin Department of Natural Resources. https://dnr.wisconsin.gov/topic/ATV/CrashInfo. Accessed May 5, 2022.

      Fatality summary, annual reports and crash reporting, recreational vehicle incident reports. Wisconsin Department of Natural Resources. https://dnr.wisconsin.gov/topic/snowmobile/CrashInfo. Accessed May 5, 2022.

      • Landen MG
      • Middaugh J
      • Dannenberg AL.
      Injuries associated with snowmobiles, Alaska, 1993‒1994.
      • West R
      • Shkrum MJ
      • Young JG.
      Commercial logging fatalities in Ontario, 1986-1991.
      • Foster CA
      • Dissanaike SD.
      Prevalence and consequences of positive blood alcohol levels among patients injured at work.
      • Davis GG
      • Brissie RM.
      A review of crane deaths in Jefferson County, Alabama.
      • Fullerton L
      • Olson L
      • Crandall C
      • Sklar D
      • Zumwalt R.
      Occupational injury mortality in New Mexico.
      • Lucas DL
      • Lincoln JM.
      Fatal falls overboard on commercial fishing vessels in Alaska.
      • Przepyszny LM
      • Jenkins AJ.
      The prevalence of drugs in carbon monoxide-related deaths: a retrospective study, 2000-2003.
      • Moolenaar RL
      • Etzel RA
      • Parrish RG.
      Unintentional deaths from carbon monoxide poisoning in New Mexico, 1980 to 1988. A comparison of medical examiner and national mortality data.
      • Levine B
      • Green D
      • Smialek JE.
      The role of ethanol in heroin deaths.
      • Weinberger LE
      • Sreenivasan S
      • Sathyavagiswaran L
      • Markowitz E.
      Child and adolescent suicide in a large, urban area: psychological, demographic, and situational factors.
      • Lewis RJ
      • Johnson RD
      • Whinnery JE
      • Forster EM.
      Aircraft-assisted pilot suicides in the United States, 1993–2002.
      • San Nicolas AC
      • Lemos NP.
      Toxicology findings in cases of hanging in the City and County of San Francisco over the 3-year period from 2011 to 2013.
      • Bullock MJ
      • Diniz D.
      Suffocation using plastic bags: a retrospective study of suicides in Ontario, Canada.
      • Davis LG.
      Suicidal drowning in South Florida.
      • Wolford-Clevenger C
      • McCleskey B
      • Cropsey KC.
      RSA/ISBRA Abstracts.
      • Cherpitel CJ.
      Regional differences in alcohol and fatal injury: a comparison of data from two county coroners.
      • Fisher LB
      • Overholser JC
      • Dieter L.
      Methods of committing suicide among 2,347 people in Ohio.
      • Branas CC
      • Richmond TS
      • Ten Have TR
      • Wiebe DJ
      Acute alcohol consumption, alcohol outlets, and gun suicide.
      • Kaplan MS
      • McFarland BH
      • Huguet N
      • et al.
      Acute alcohol intoxication and suicide: a gender-stratified analysis of the National Violent Death Reporting System.
      • Shields LB
      • Hunsaker DM
      • Hunsaker 3rd, JC
      • Ward MK.
      Toxicologic findings in suicide: a 10-year retrospective review of Kentucky medical examiner cases.
      • Conner KR
      • Lathrop S
      • Caetano R
      • Silenzio V
      • Nolte KB.
      Blood alcohol concentrations in suicide and motor vehicle crash decedents ages 18 to 54.

      Boating resources. Recreational boating reports. New York State Office of Parks, Recreation & Historic Preservation. https://parks.ny.gov/recreation/boating/resources.aspx. Accessed May 5, 2022.

      Fatality summary, annual reports and crash reporting, boat crash incident reports. Wisconsin Department of Natural Resources. https://dnr.wisconsin.gov/Topic/Boat/CrashInfo. Accessed May 5, 2022.

      • Browne ML
      • Lewis-Michl EL
      • Stark AD.
      Watercraft-related drownings among New York State residents, 1988-1994.
      • Smith GS
      • Keyl PM
      • Hadley JA
      • et al.
      Drinking and recreational boating fatalities: a population-based case-control study.

      Barss P. Boating immersion and trauma deaths in Canada: 18 years of research. Ontario, Canada: Transport Canada and the Canadian Red Cross Society. https://www.redcross.ca/crc/documents/3-3-4_2011_boating_fnl.pdf. Published 2011. Accessed May 5, 2022.

      • Pelletier A.
      Deaths among railroad trespassers. The role of alcohol in fatal injuries.

      North American Management. Rail Trespasser Fatalities: Demographic and Behavioral Profiles. Washington, DC: U.S. Department of Transportation, Federal Railroad Administration. https://railroads.dot.gov/sites/fra.dot.gov/files/fra_net/3315/RailTrespasserFatalitiesDemograph62013.pdf. Published 2013. Accessed June 3, 2021.

      Centers for Disease Control and Prevention (CDC)
      Injuries among railroad trespassers–Georgia, 1990-1996.
      ).
      Figure 1
      Figure 1Flowchart of selection of studies for inclusion in the meta-analysis.
      Figure 2
      Figure 2Meta-analysis of AAFs for 15 causes of fatal nontraffic injuries.
      an: the total number of studies and data from states included for a given cause of fatal injury.
      bBAC ≥0.10 g/dL: the number of deaths where the involved decedent (or offender in homicide and child maltreatment cases) had BAC ≥0.10 g/dL or were reported to be alcohol intoxicated.
      cTested: the number of deaths where the involved decedent (or offender in homicide and child maltreatment cases) had either valid BAC test results or valid measures of alcohol involvement.
      dI²: a statistic that describes the percentage of variation across studies that is because of heterogeneity rather than chance.
      AAF, alcohol-attributable fraction; BAC, blood alcohol concentration.
      Table 1Study Characteristics and Risk of Bias Scores for 15 Causes of Fatal Nontraffic Injuries
      Studies by cause of deathDates of injuriesGeographical locationBAC ≥0.10g/dLBAC tests (n)Alcohol-attributable fractionRisk of bias score
      State data systems were not assigned a risk of bias score.
      Air-space transport
      Botch and Johnson (2009)

      Botch SR, Johnson RD. Toxicological findings of pilots involved in aviation accidents operated under Title 14 CFR, Part 135. Washington, DC: Office of Aerospace Medicine, Federal Aviation Administration. https://apps.dtic.mil/sti/pdfs/ADA506749.pdf. Published 2009. Accessed May 5, 2022.

      ,
      Cases are from separate, nonoverlapping samples in Botch et al. reports.
      1997–2007U.S.11390.012
      Botch and Johnson (2008)

      Botch SR, Johnson RD. Alcohol-related aviation accidents involving pilots with previous alcohol offenses. Washington, DC: Office of Aerospace Medicine, Federal Aviation Administration. https://libraryonline.erau.edu/online-full-text/faa-aviation-medicine-reports/AM08-22.pdf. Published 2008. Accessed May 5, 2022.

      ,
      Cases are from separate, nonoverlapping samples in Botch et al. reports.
      2000–2007U.S.82150.042
      Li et al. (1998)
      • Li G
      • Hooten EG
      • Baker SP
      • Butts JD.
      Alcohol in aviation-related fatalities: North Carolina, 1985-1994.
      1985–1994North Carolina41010.042
      Virginia data system2014–2018Virginia0170.00NA
      Utah data system2014–2018Utah0130.00NA
      Aspiration
      Boghossian et al. (2010)
      • Boghossian E
      • Tambuscio S
      • Sauvageau A.
      Nonchemical suffocation deaths in forensic setting: a 6-year retrospective study of environmental suffocation, smothering, choking, and traumatic/positional asphyxia.
      ,
      Data were based on descriptive reports of alcohol intoxication, drunkenness, or alcohol being a factor involved in the fatalities.
      2000–2005Quebec, Canada2110.181
      Virginia data system2014–2018Virginia4500.08NA
      Utah data system2014–2018Utah5260.19NA
      North Carolina data system2014–2019North Carolina15210.71NA
      Child maltreatment
      Colorado CFPS (2021)

      Colorado child fatality prevention system data dashboard. Colorado Department of Public Health and Environment. https://cohealthviz.dphe.state.co.us/t/PSDVIP-MHPPUBLIC/views/CFPSDashboardFinalLocal/Story1?iframeSizedToWindow=true&:embed=y&:showAppBanner=false&:display_count=no&:showVizHome=no. Accessed May 5, 2022.

      ,
      Data were based on descriptive reports of alcohol intoxication, drunkenness, or alcohol being a factor involved in the fatalities.
      2009–2018Colorado414520.092
      Parks et al. (2011)
      • Parks SE
      • Mirchandani G
      • Rodriguez S
      • Hellsten J.
      History of maltreatment among unintentional injury deaths: analyses of Texas child fatality review data, 2005-2007.
      ,
      Data were based on descriptive reports of alcohol intoxication, drunkenness, or alcohol being a factor involved in the fatalities.
      2005–2007Texas252600.101
      South Carolina SCFAC (2019)

      South Carolina State Child Fatality Advisory Committee. State fiscal year 2019 report. Columbia, SC: South Carolina State Child Fatality Advisory Committee. https://scfacsc.files.wordpress.com/2020/02/2019-scfac-annual-report-final.pdf. Published February 2020. Accessed April 12, 2021.

      ,
      Data were based on descriptive reports of alcohol intoxication, drunkenness, or alcohol being a factor involved in the fatalities.
      7/1/2018 – 6/30/2019South Carolina151450.102
      Drowning
      Okuda et al. (2015)
      • Okuda T
      • Wang Z
      • Lapan S
      • Fowler DR.
      Bathtub drowning: an 11-year retrospective study in the state of Maryland.
      2003–2013Maryland8570.142
      Cummings and Quan (1999)
      • Cummings P
      • Quan L.
      Trends in unintentional drowning: the role of alcohol and medical care.
      1975–1995King County, Washington913040.302
      Browne et al. (2003)
      • Browne ML
      • Lewis-Michl EL
      • Stark AD.
      Unintentional drownings among New York State residents, 1988-1994.
      1988–1994New York581780.332
      Canadian Red Cross society (2006)
      Canadian Red Cross Society
      Drownings and other water-related injuries in Canada: 10 years of research, Module 1 overview.
      1991–2000Canada5831,5000.390
      Lincoln et al. (1996)
      • Lincoln JM
      • Perkins R
      • Melton F
      • Conway GA.
      Drowning in Alaskan waters.
      1988–1992Alaska941860.513
      Utah data system2014–2018Utah111300.08NA
      Virginia data system2014–2018Virginia833460.24NA
      Minnesota data system2014–2018Minnesota491360.36NA
      North Carolina data system2014–2019North Carolina1312300.57NA
      Fall injuries
      Virginia data system2014–2018Virginia897600.12NA
      North Carolina data system2014–2019North Carolina1161590.73NA
      Fire injuries
      Levine et al. (2001)
      • Levine B
      • Moore KA
      • Fowler D.
      Interaction between carbon monoxide and ethanol in fire fatalities.
      3-year period before 2001Maryland451960.231
      Tridata Corporation (1999)

      Tridata Corporation. Establishing a Relationship Between Alcohol and Casualties of Fire. Arlington, VA: Federal Emergency Management Agency, United States Fire Administration National Fire Data Center. https://www.sustainable-design.ie/fire/alcoholfire.pdf. Published October 1999. Accessed May 5, 2022.

      1993–1996Minnesota672550.262
      U.S. Fire administration (2003)

      U.S. Department of Homeland Security/Federal Emergency Management Agency. Case study: contribution of alcohol to fire fatalities in Minnesota. Topical Fire Research Series. Vol. 3-Issue 4. Washington, DC: U.S. Department of Homeland Security/Federal Emergency Management Agency. https://nfa.usfa.fema.gov/downloads/pdf/statistics/v3i4.pdf. July 2003. Accessed May 5, 2022.

      1996–2002Minnesota1133740.300
      McGwin et al. (2000)
      • McGwin Jr, G
      • Chapman V
      • Rousculp M
      • Robison J
      • Fine P.
      The epidemiology of fire-related deaths in Alabama, 1992‒1997.
      1992–1997Alabama1142470.462
      Marshall et al. (1998)
      • Marshall SW
      • Runyan CW
      • Bangdiwala SI
      • Linzer MA
      • Sacks JJ
      • Butts JD.
      Fatal residential fires: who dies and who survives?.
      2/1/1988 – 1/31/1989North Carolina691300.530
      Utah data system2014–2018Utah5400.12NA
      Virginia data system2014–2018Virginia513380.15NA
      North Carolina data system2014–2019North Carolina801000.80NA
      Firearm injuries
      Cherry et al. (2001)
      • Cherry D
      • Runyan C
      • Butts J.
      A population based study of unintentional firearm fatalities.
      1985–1994North Carolina553510.160
      Collins (2010)
      • Collins KA.
      Adolescent Russian roulette deaths.
      1987–2006South Carolina270.292
      Shields et al. (2008)
      • Shields LB
      • Hunsaker 3rd, JC
      • Stewart DM.
      Russian roulette and risk-taking behavior: a medical examiner study.
      1993–2002Kentucky10200.503
      Minnesota data system2015–2018Minnesota1170.06NA
      Virginia data system2014–2018Virginia7670.10NA
      Colorado data system2014–2018Colorado10420.24NA
      Utah data system2014–2018Utah9300.30NA
      North Carolina data system2014–2019North Carolina11190.58NA
      Homicide
      Spunt et al. (1998)
      • Spunt B
      • Brownstein HH
      • Crimmins SM
      • Langley S
      • Spanjol K.
      Alcohol-related homicides committed by women.
      ,
      Data were based on descriptive reports of alcohol intoxication, drunkenness, or alcohol being a factor involved in the fatalities.
      Cases are from separate, nonoverlapping samples in Botch et al. reports.
      1992–1993New York411810.232
      Spunt et al. (1995)
      • Spunt B
      • Brownstein H
      • Goldstein P
      • Fendrich M
      • Liberty HJ.
      Drug use by homicide offenders.
      ,
      Data were based on descriptive reports of alcohol intoxication, drunkenness, or alcohol being a factor involved in the fatalities.
      1984New York862690.322
      Banks et al. (2008)
      • Banks L
      • Crandall C
      • Sklar D
      • Bauer M.
      A comparison of intimate partner homicide to intimate partner homicide-suicide: one hundred and twenty-four New Mexico cases.
      1993–2002New Mexico12370.322
      Greenfeld (1998)

      Greenfeld LA. Alcohol and crime: an analysis of national data on the prevalence of alcohol involvement in crime. Washington, DC. U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics. https://bjs.ojp.gov/content/pub/pdf/ac.pdf. Published 1998. Accessed May 5, 2022.

      1996U.S.651730.382
      Utah data system2014–2018Utah6390.15NA
      Hypothermia
      Koutsavlis and Kosatsky (2003)
      • Koutsavlis AT
      • Kosatsky T.
      Environmental-temperature injury in a Canadian metropolis.
      ,
      Data were based on descriptive reports of alcohol intoxication, drunkenness, or alcohol being a factor involved in the fatalities.
      1994–1998Montreal Island and Ile-Bizard,

      Quebec, Canada
      3120.252
      Utah data system2014–2018Utah13550.24NA
      Virginia data system2014–2018Virginia261010.26NA
      North Carolina data system2014–2019North Carolina11210.52NA
      Motor vehicle nontraffic crashes
      Minnesota DNR (2002–2010)2002–2010Minnesota441660.271
      Hall et al. (2009)
      • Hall AJ
      • Bixler D
      • Helmkamp JC
      • Kraner JC
      • Kaplan JA.
      Fatal all-terrain vehicle crashes: injury types and alcohol use.
      2004–2006West Virginia23520.441
      Wisconsin DNR (2002–2020)

      Fatality summary, annual reports and crash reporting, all-terrain vehicle crash incident reports. Wisconsin Department of Natural Resources. https://dnr.wisconsin.gov/topic/ATV/CrashInfo. Accessed May 5, 2022.

      ,
      Cases are from separate, nonoverlapping samples (including snowmobiles and all-terrain vehicles) in the Wisconsin Department of Natural Resources motor vehicle nontraffic crash reports.
      2002–2020Wisconsin1182450.481
      Minnesota DNR (2001–2015)2001–2015Minnesota811650.491
      Wisconsin DNR (2001–2020)

      Fatality summary, annual reports and crash reporting, recreational vehicle incident reports. Wisconsin Department of Natural Resources. https://dnr.wisconsin.gov/topic/snowmobile/CrashInfo. Accessed May 5, 2022.

      ,
      Cases are from separate, nonoverlapping samples (including snowmobiles and all-terrain vehicles) in the Wisconsin Department of Natural Resources motor vehicle nontraffic crash reports.
      2001–2020Wisconsin2063430.601
      Landen et al. (1999)
      • Landen MG
      • Middaugh J
      • Dannenberg AL.
      Injuries associated with snowmobiles, Alaska, 1993‒1994.
      1990–1994Alaska11170.652
      Utah data system2014–2018Utah5480.10NA
      Occupational and machine injuries
      West et al. (1996)
      • West R
      • Shkrum MJ
      • Young JG.
      Commercial logging fatalities in Ontario, 1986-1991.
      1986–1991Ontario, Canada0240.003
      Foster and Dissanaike (2014)
      • Foster CA
      • Dissanaike SD.
      Prevalence and consequences of positive blood alcohol levels among patients injured at work.
      2007–2011Texas0110.003
      Davis and Brissie (2000)
      • Davis GG
      • Brissie RM.
      A review of crane deaths in Jefferson County, Alabama.
      1981–1996Jefferson County, Alabama0100.002
      Fullerton et al. (1995)
      • Fullerton L
      • Olson L
      • Crandall C
      • Sklar D
      • Zumwalt R.
      Occupational injury mortality in New Mexico.
      1980–1991New Mexico294490.061
      Lucas and Lincoln (2007)
      • Lucas DL
      • Lincoln JM.
      Fatal falls overboard on commercial fishing vessels in Alaska.
      ,
      Data were based on descriptive reports of alcohol intoxication, drunkenness, or alcohol being a factor involved in the fatalities.
      1990–2005Alaska14710.202
      Utah data system2014–2018Utah150.20NA
      North Carolina data system2014–2019North Carolina370.43NA
      Other road vehicle crashes (railroad trespasser injuries)
      North American Management (2013)

      North American Management. Rail Trespasser Fatalities: Demographic and Behavioral Profiles. Washington, DC: U.S. Department of Transportation, Federal Railroad Administration. https://railroads.dot.gov/sites/fra.dot.gov/files/fra_net/3315/RailTrespasserFatalitiesDemograph62013.pdf. Published 2013. Accessed June 3, 2021.

      ,
      Data were based on descriptive reports of alcohol intoxication, drunkenness, or alcohol being a factor involved in the fatalities.
      2005–2010U.S.4709400.501
      CDC (1999)
      Centers for Disease Control and Prevention (CDC)
      Injuries among railroad trespassers–Georgia, 1990-1996.
      1990–1996Georgia40780.512
      Pelletier (1997)
      • Pelletier A.
      Deaths among railroad trespassers. The role of alcohol in fatal injuries.
      1990–1994North Carolina1001250.801
      North Carolina data system2014–2019North Carolina33480.69NA
      Poisoning (not alcohol)
      Przepyszny and Jenkins (2007)
      • Przepyszny LM
      • Jenkins AJ.
      The prevalence of drugs in carbon monoxide-related deaths: a retrospective study, 2000-2003.
      2000–2003Cuyahoga County, Ohio19840.231
      Moolenaar et al. (1995)
      • Moolenaar RL
      • Etzel RA
      • Parrish RG.
      Unintentional deaths from carbon monoxide poisoning in New Mexico, 1980 to 1988. A comparison of medical examiner and national mortality data.
      1980–1988New Mexico17740.232
      Levine et al. (1995)
      • Levine B
      • Green D
      • Smialek JE.
      The role of ethanol in heroin deaths.
      A12-month period before 1995Maryland481190.402
      Utah data system2014–2018Utah1701,7190.10NA
      Michigan data system2017–2018Michigan4754,0810.12NA
      Virginia data system2014–2018Virginia6685,5760.12NA
      Minnesota data system2019Minnesota605000.12NA
      North Carolina data system2014–2019North Carolina1,1262,3880.47NA
      Suicide
      Weinberger et al. (2001)
      • Weinberger LE
      • Sreenivasan S
      • Sathyavagiswaran L
      • Markowitz E.
      Child and adolescent suicide in a large, urban area: psychological, demographic, and situational factors.
      1996–1997Los Angeles county, California1460.023
      Lewis et al. (2007)
      • Lewis RJ
      • Johnson RD
      • Whinnery JE
      • Forster EM.
      Aircraft-assisted pilot suicides in the United States, 1993–2002.
      1993–2002U.S.0140.002
      San Nicolas and Lemos (2015)
      • San Nicolas AC
      • Lemos NP.
      Toxicology findings in cases of hanging in the City and County of San Francisco over the 3-year period from 2011 to 2013.
      2011–2013San Francisco county, California141020.141
      Bullock and Diniz (2000)
      • Bullock MJ
      • Diniz D.
      Suffocation using plastic bags: a retrospective study of suicides in Ontario, Canada.
      1993–1997Ontario, Canada11770.142
      Davis (1999)
      • Davis LG.
      Suicidal drowning in South Florida.
      1994–1998Broward County, Florida4240.172
      Wolford-Clevenger et al. (2020)
      • Wolford-Clevenger C
      • McCleskey B
      • Cropsey KC.
      RSA/ISBRA Abstracts.
      2013–2019Jefferson County, Alabama754470.171
      Cherpitel (1996)
      • Cherpitel CJ.
      Regional differences in alcohol and fatal injury: a comparison of data from two county coroners.
      12/1987–11/1988 and 02/1992–01/1993Contra Costa county, California and hinds county, Mississippi171010.171
      Fisher et al. (2015)
      • Fisher LB
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      1994–2008Cuyohoga County, Ohio3802,1780.171
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      2003–2006Philadelphia, Pennsylvania241230.202
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      2003–200916 states
      States included were Alaska, Colorado, Georgia, Kentucky, Maryland, Massachusetts, New Jersey, New Mexico, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina, Utah, Virginia, and Wisconsin. BAC, blood alcohol concentration; CFPS, Child Fatality Prevention System; DNR, Department of Natural Resources; NA, not applicable; OPRHP, Office of Parks, Recreation and Historic Preservation; SCFAC, State Child Fatality Advisory Committee.
      7,77739,5790.200
      Shields et al. (2006, 2008)
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      1993–2002Kentucky6562,7020.240
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      2000–2003Cuyohoga County, Ohio8310.261
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      2012New Mexico882240.393
      Utah data system2014–2017Utah4852,4160.20NA
      Virginia data system2014–2018Virginia4932,4170.20NA
      Minnesota data system2015–2018Minnesota5882,4900.24NA
      Colorado data system2014–2018Colorado1,0384,2210.25NA
      Michigan data system2014–2018Michigan9623,6450.26NA
      North Carolina data system2014–2019North Carolina1,2491,8860.66NA
      Water transport
      New York State OPRHP (2013–2019)

      Boating resources. Recreational boating reports. New York State Office of Parks, Recreation & Historic Preservation. https://parks.ny.gov/recreation/boating/resources.aspx. Accessed May 5, 2022.

      2013–2019New York14830.172
      Wisconsin DNR (2004–2018)

      Fatality summary, annual reports and crash reporting, boat crash incident reports. Wisconsin Department of Natural Resources. https://dnr.wisconsin.gov/Topic/Boat/CrashInfo. Accessed May 5, 2022.

      2004–2018Wisconsin371700.221
      Browne et al. (2003)
      • Browne ML
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      • Stark AD.
      Watercraft-related drownings among New York State residents, 1988-1994.
      1988–1994New York18730.252
      Smith et al. (2001)
      • Smith GS
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      Drinking and recreational boating fatalities: a population-based case-control study.
      1990–1998Maryland and North Carolina602210.271
      Barss (2011)

      Barss P. Boating immersion and trauma deaths in Canada: 18 years of research. Ontario, Canada: Transport Canada and the Canadian Red Cross Society. https://www.redcross.ca/crc/documents/3-3-4_2011_boating_fnl.pdf. Published 2011. Accessed May 5, 2022.

      1991–2008Canada5651,9230.291
      Virginia data system2014–2018Virginia370.43NA
      Minnesota data system2014–2018Minnesota20450.44NA
      a State data systems were not assigned a risk of bias score.
      b Cases are from separate, nonoverlapping samples in Botch et al. reports.
      c Data were based on descriptive reports of alcohol intoxication, drunkenness, or alcohol being a factor involved in the fatalities.
      d Cases are from separate, nonoverlapping samples (including snowmobiles and all-terrain vehicles) in the Wisconsin Department of Natural Resources motor vehicle nontraffic crash reports.
      e States included were Alaska, Colorado, Georgia, Kentucky, Maryland, Massachusetts, New Jersey, New Mexico, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina, Utah, Virginia, and Wisconsin.BAC, blood alcohol concentration; CFPS, Child Fatality Prevention System; DNR, Department of Natural Resources; NA, not applicable; OPRHP, Office of Parks, Recreation and Historic Preservation; SCFAC, State Child Fatality Advisory Committee.
      The meta-analysis results for the 15 causes of fatal nontraffic injuries are summarized in Figure 2, including AAFs and associated 95% CIs. In alphabetical order, the AAFs were air-space transport (0.03), aspiration (0.24), child maltreatment (0.09), drowning (0.31), fall injuries (0.37), fire injuries (0.34), firearm injuries (0.24), homicide (0.29), hypothermia (0.29), motor vehicle nontraffic crashes (0.42), occupational and machine injuries (0.08), other road vehicle crashes (railroad trespasser injuries) (0.63), poisoning (not alcohol) (0.20), suicide (0.21), and water transport (0.27). The AAF for each cause of death can be interpreted as the percentage of deaths attributable to alcohol among those with known BAC levels or intoxication status. For example, 24% of 553 firearm injury deaths with known BAC levels were attributable to alcohol. Overall, cause-specific analyses yielded a median AAF of 0.27. Study heterogeneity, based on I2, varied by cause of death, ranging from 0% for air-space transport and child maltreatment to 100% for fall injuries and poisoning (not alcohol) (Appendix 3, available online). In sensitivity analysis, no statistically significant differences (based on overlapping 95% CIs) were observed between AAFs derived with and without the inclusion of Canadian data (Appendix 4, available online).

      DISCUSSION

      This study is the most current and comprehensive systematic review and meta-analysis assessing involvement of excessive alcohol use in deaths from 15 causes of fatal nontraffic injuries. The study shows that excessive drinking was associated with more than one quarter of violent and nonviolent injury deaths. For example, the findings show that almost 1 in 4 unintentional firearm injury deaths, 1 in 3 homicides, 1 in 5 poisonings (not alcohol), and 1 in 5 suicides involved alcohol, with a BAC ≥0.10 g/dL or a descriptive indication of alcohol intoxication. The mechanisms by which excessive drinking might lead to these deaths could include the effects of alcohol and impaired brain function resulting in poor judgment; slow decision making and reaction time; reduced perception and response to hazards; loss of balance and motor skills; and through behavioral effects, such as increased risk taking, reduced inhibitions, reduced processing of communications, and increased aggression.
      • Hingson R
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      • Lunetta P
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      The role of alcohol in injury deaths.
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      • Collins JJ
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      Epidemiology of alcohol-related violence.
      Some effects of alcohol, including impairment in judgment and motor dysfunction, are apparent at BAC levels <0.10 g/dL.
      • Koob GF
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      • Le Moal M.
      Alcohol.
      AAF estimates were determined in this study using the direct method, which is based on the proportion of deaths from a given cause of injury due to alcohol. This method has advantages compared with approaches for estimating alcohol-related injury fatalities that are not based on individual causes of death. For example, applying continuous distributions that consider the prevalence of alcohol use and the RR of dying from a given injury to the estimated number of deaths from that injury generally involves aggregating alcohol-attributable injuries into broad categories (e.g., road injuries, other unintentional injuries, intentional injuries).
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      This is because limited cause-specific data are available to inform risk functions. Others have indicated that a systematic review of data from medical examiners' and coroners’ reports on the contribution of alcohol to injury deaths, such as those used in this study, might be more accurate than estimates generated from continuous risk functions.
      • Chrystoja BR
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      A systematic comparison of the global comparative risk assessments for alcohol.
      Unlike other studies on alcohol-related homicides that rely on BAC among victims, a strength of this study is that it uniquely considered alcohol intoxication among homicide offenders.
      • Naimi TS
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      • Cooper SE
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      Alcohol involvement in homicide victimization in the United States.
      Offender BACs for homicides and child maltreatment are typically not collected by state data and surveillance systems. Sources of homicide and maltreatment data in this study used either offender BAC or alternatively observer or self-reports of alcohol intoxication among offenders.
      Most of the poisoning (not alcohol) deaths in this study were from drug overdose fatalities that involved a BAC ≥0.10 g/dL. However, the AAF of 0.20 may underestimate the role of alcohol in drug overdose deaths because alcohol can contribute to overdoses at low levels, particularly when combined with substances such as opioids or benzodiazepines.
      • Singh AK.
      Alcohol interaction with cocaine, methamphetamine, opioids, nicotine, cannabis, and γ-hydroxybutyric acid.
      ,
      • Dasgupta A.
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      Nevertheless, binge drinking is associated with the use of other substances and increases the risk of concurrently misusing prescription drugs, which increases the chance of overdose.
      • Esser MB
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      • Evans ME.
      Binge drinking, other substance use, and concurrent use in the U.S., 2016-2018.

      Limitations

      This meta-analysis has limitations. The contribution of alcohol to mortality is generally underestimated in studies, in part owing to incomplete alcohol use documentation in death certificates.
      • White AM
      • Castle IP
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      Using death certificates to explore changes in alcohol-related mortality in the United States, 1999 to 2017.
      ,
      • Castle IJ
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      • Hingson RW
      • White AM.
      State variation in underreporting of alcohol involvement on death certificates: motor vehicle traffic crash fatalities as an example.
      Alcohol testing rates among decedents vary by decedents’ characteristics (e.g., race/ethnicity), cause of death, and state of residence.
      • Castle IJ
      • Yi HY
      • Hingson RW
      • White AM.
      State variation in underreporting of alcohol involvement on death certificates: motor vehicle traffic crash fatalities as an example.
      ,
      • Greene N
      • Tomedi LE
      • Cox ME
      • Mello E
      • Esser MB.
      Alcohol testing and alcohol involvement among violent deaths by state, 2014-2016.
      State-level data in this study were from 28 states, including 6 state surveillance systems. Additional states did not provide data from their surveillance systems for reasons provided such as labor intensiveness and insufficient resources during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease 2019 [COVID-19]) pandemic. The inclusion of data from only some state data systems potentially introduces biases in the AAFs owing to socioeconomic, demographic, policy environment, or social norm differences among states regarding drinking.
      Because AAFs in this meta-analysis were calculated as a percentage among decedents tested for alcohol, the estimates might be high if decedents who were not tested for alcohol had consistently lower BAC levels. Testing rates, procedures for conducting postmortem BAC tests, and timing of alcohol testing (relative to both the time since alcohol was consumed and time after death) likely varied across states,
      • Greene N
      • Tomedi LE
      • Cox ME
      • Mello E
      • Esser MB.
      Alcohol testing and alcohol involvement among violent deaths by state, 2014-2016.
      although most potential systematic biases in BAC testing (e.g., lag between death and BAC test) likely led to conservative AAF estimates.
      • Chrystoja BR
      • Rehm J
      • Manthey J
      • Probst C
      • Wettlaufer A
      • Shield KD.
      A systematic comparison of the global comparative risk assessments for alcohol.
      ,
      • Greene N
      • Esser MB
      • Vesselinov R
      • Auman KM
      • Kerns TJ
      • Lauerman MH.
      Variability in antemortem and postmortem blood alcohol concentration levels among fatally injured adults.
      ,
      • Thomas M
      • Riemann B
      • Jones J.
      Epidemiology of alcohol and drug screening among pedestrian fatalities in the United States, 2014-2016.
      Postmortem BACs used to estimate ante mortem drinking can vary in either direction relative to ante mortem BACs.
      • Greene N
      • Tomedi LE
      • Cox ME
      • Mello E
      • Esser MB.
      Alcohol testing and alcohol involvement among violent deaths by state, 2014-2016.
      ,
      • Greene N
      • Esser MB
      • Vesselinov R
      • Auman KM
      • Kerns TJ
      • Lauerman MH.
      Variability in antemortem and postmortem blood alcohol concentration levels among fatally injured adults.
      ,
      • Quintas MJ
      • Costa P
      • Melo P
      • Castro A
      • Franco JM
      • Teixeira HM.
      Postmortem in vitro ethanol production-It could be more common than we think!.
      Variability exists in AAFs from individual sources within causes of death. Some relatively extreme values might have contributed to the nonstatistically significant differences observed between random-effects and fixed-effect estimates for certain causes. These could also be partially explained by factors such as differences in alcohol use by sex, age, race/ethnicity, or location. However, sufficient data were not available to estimate AAFs by decedents’ characteristics, and observed variation in AAFs by location across individual sources improves generalizability.
      The sensitivity analyses suggest that biases did not result from inclusion of Canadian data, although the AAFs in this meta-analysis might not reflect those that would be obtained from meta-analyses of exclusively Canadian data. The U.S. and Canada are comparable on several indicators of population-level alcohol consumption (e.g., per capita alcohol consumption, prevalence of heavy episodic drinking),
      WHO
      Global status report on alcohol and health 2018.
      although they may differ in other relevant aspects (e.g., implementation and enforcement of alcohol control policies). These AAFs also might not be generalizable to Mexico because only studies in English were searched.
      There were some limitations because of the data available for certain causes of death. Deaths from poisonings have the potential for misclassification of intent (suicide versus unintentional) and for unobserved heterogeneity.
      • Rockett IRH
      • Caine ED
      • Connery HS
      • et al.
      Unrecognised self-injury mortality (SIM) trends among racial/ethnic minorities and women in the USA.
      For deaths from homicide and child maltreatment, BAC data among offenders are potentially limited because the offenders are often not apprehended immediately at the time of injury. Given the sensitive nature of child maltreatment deaths, further data on alcohol involvement in these deaths may be discovered from restricted sources, such as the National Child Death Review Case Reporting System.
      For fall injuries, the AAF estimate was based on the data of >900 decedents, although high study heterogeneity between the 2 data sources and the wide 95% CIs suggest some uncertainty around the estimate. The extent to which excessive alcohol use contributes to deaths from falls might vary by age group. More data pertaining to the age distribution of decedents would be needed to differentially estimate alcohol-related falls among younger and older people. Nevertheless, falls contribute to a substantial number of deaths each year, especially among older adults,

      Wonder CDC. Centers for Disease Control and Prevention. https://wonder.cdc.gov. Updated 2020. Accessed April 28, 2021.

      and a linear association has been documented between the amount of alcohol consumed and the risk of fall injuries.
      • Taylor B
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      • Kanteres F
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      The more you drink, the harder you fall: a systematic review and meta-analysis of how acute alcohol consumption and injury or collision risk increase together.
      Fatal injuries from other road vehicle crashes involve pedestrians or occupants who collide with or fall from pedal cycles, other nonmotor vehicles, or railway trains; however, the available studies of alcohol involvement in these deaths pertained solely to scenarios involving railroad trespassers (i.e., persons on railroad property whose presence was prohibited or unlawful). One of these studies documented that alcohol intoxication was the most frequently reported factor associated with these deaths,
      • Pelletier A.
      Deaths among railroad trespassers. The role of alcohol in fatal injuries.
      as when people walk across railroad tracks while being intoxicated.

      North American Management. Rail Trespasser Fatalities: Demographic and Behavioral Profiles. Washington, DC: U.S. Department of Transportation, Federal Railroad Administration. https://railroads.dot.gov/sites/fra.dot.gov/files/fra_net/3315/RailTrespasserFatalitiesDemograph62013.pdf. Published 2013. Accessed June 3, 2021.

      ,
      Centers for Disease Control and Prevention (CDC)
      Injuries among railroad trespassers–Georgia, 1990-1996.
      The AAF for these circumstances might not be applicable to different situations of other road vehicle crash deaths.
      Available data regarding air-space transport were limited to pilot fatalities. Data reported in one of the studies on aviation-related crashes suggests that the number of aviation passenger deaths per crash did not differ between crashes involving and not involving alcohol.
      • Li G
      • Baker SP
      • Lamb MW
      • Qiang Y
      • McCarthy ML.
      Characteristics of alcohol-related fatal general aviation crashes.
      The AAF for this cause of death may therefore be appropriate for estimating the total number of alcohol-attributable deaths among persons who die from air-space transport injuries.
      Despite these limitations, the findings in this meta-analysis have public health implications. Effective population-level approaches for preventing excessive drinking include those recommended by the Community Preventive Services Task Force, such as strategies to decrease the availability of and access to alcohol or to increase alcohol prices.
      • Middleton JC
      • Hahn RA
      • Kuzara JL
      • et al.
      Effectiveness of policies maintaining or restricting days of alcohol sales on excessive alcohol consumption and related harms.
      • Campbell CA
      • Hahn RA
      • Elder R
      • et al.
      The effectiveness of limiting alcohol outlet density as a means of reducing excessive alcohol consumption and alcohol-related harms.
      • Elder RW
      • Lawrence B
      • Ferguson A
      • et al.
      The effectiveness of tax policy interventions for reducing excessive alcohol consumption and related harms.
      In addition to reducing the number and concentration of alcohol outlets, having dram shop liability laws to hold retailers accountable for harms incurred by service to intoxicated or underage patrons could also reduce alcohol-attributable injury deaths.
      • Campbell CA
      • Hahn RA
      • Elder R
      • et al.
      The effectiveness of limiting alcohol outlet density as a means of reducing excessive alcohol consumption and alcohol-related harms.
      ,
      • Rammohan V
      • Hahn RA
      • Elder R
      • et al.
      Effects of dram shop liability and enhanced overservice law enforcement initiatives on excessive alcohol consumption and related harms: two community guide systematic reviews.
      These population-level alcohol policies have been found to be associated with reductions in several causes of death, including homicides,
      • Naimi TS
      • Xuan Z
      • Coleman SM
      • et al.
      Alcohol policies and alcohol-involved homicide victimization in the United States.
      suicides,
      • Coleman SM
      • Lira MC
      • Blanchette J
      • Heeren TC
      • Naimi TS.
      Alcohol policies, firearm policies, and suicide in the United States: a lagged cross-sectional study.
      and pedestrian injuries.
      • Nesoff ED
      • Milam AJ
      • Branas CC
      • Martins SS
      • Knowlton AR
      • Furr-Holden DM.
      Alcohol outlets, neighborhood retail environments, and pedestrian injury risk.
      Screening and brief interventions to reduce excessive alcohol use might also reduce alcohol-related injuries if delivered face to face in clinical settings or using electronic devices in a variety of settings (e.g., healthcare facilities, universities, workplaces).
      • O'Connor EA
      • Perdue LA
      • Senger CA
      • et al.
      Screening and behavioral counseling interventions to reduce unhealthy alcohol use in adolescents and adults: updated evidence report and systematic review for the U.S. Preventive Services Task Force.
      ,
      • Tansil KA
      • Esser MB
      • Sandhu P
      • et al.
      Alcohol electronic screening and brief intervention: a Community Guide systematic review.

      CONCLUSIONS

      The results of this meta-analysis show that a median of 27% of fatalities from nontraffic injuries are attributable to excessive alcohol use, which is a preventable risk behavior. The updated AAFs in this meta-analysis are fundamental for improving the estimates of alcohol-attributable deaths (as in CDC's ARDI application) and for calculating the economic burden of excessive drinking. Such data are essential for establishing public health priorities. Future research would benefit from more routine and widespread data collection on alcohol involvement in nontraffic fatal injuries, particularly those where previous investigation has been lacking. Our findings underscore the importance of implementing and enforcing evidence-based strategies for preventing excessive drinking and designing and encouraging safer community environments.

      ACKNOWLEDGMENTS

      The authors thank the Colorado Department of Public Health and Environment, Michigan Department of Health and Human Services, Minnesota Department of Health, North Carolina Office of the Chief Medical Examiner, Utah Department of Health, and Virginia Office of the Chief Medical Examiner for state-level fatality and blood alcohol concentration data.
      The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention (CDC).
      This study was supported by CDC of HHS, as part of a financial assistance award totaling $219,325.27 with 100% funded by CDC/HHS.
      No financial disclosures were reported by the authors of this paper.

      CRediT AUTHOR STATEMENT

      Marissa B. Esser: Conceptualization, Writing - review and editing. Megan E. Slater: Methodology, Investigation, Writing - review and editing. Young-Hee Yoon: Methodology, Investigation. Chiung M. Chen: Formal analysis, Methodology, Investigation, Writing - review and editing. Hillel R. Alpert: Investigation, Methodology, Writing - original draft, Writing - review and editing. Nancy Winstanley: Investigation.

      Appendix. SUPPLEMENTAL MATERIAL

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