After Decades of Damage and a Pandemic Spike, Where Does Alcohol-Associated Liver Disease Stand?

Over the past two decades, alcohol-associated liver disease (ALD) has trended upward, with a sharp increase during the COVID-19 pandemic and disproportionate mortality increases among women, young adults, and American Indian and Alaska Native people.¹

Recent data point to the first decline in US alcohol use since the pandemic, although drinking remains above 2018 levels and heavy drinking continues to rise among adults aged 50 to 64.² Against that changing backdrop, hepatologists point to important differences in ALD burden by age, sex, race and ethnicity, and coexisting metabolic risk.

From 1999 to 2022, the ALD death rate nearly doubled, rising from 6.71 to 12.53 per 100,000, according to a study published in JAMA Network Open.¹ In total, 436,814 ALD deaths were recorded over that period.¹ An important distinction is that during this time, ALD deaths increased faster in women than in men, an average of 4.29% vs 2.50% per year.¹

"There are groups of populations in the US who are disproportionately affected by alcohol-associated liver disease, and that includes women, younger people, and Native Americans," said Stevan Gonzalez, in an interview with HCPLive. "There are groups that we have to be careful about because they have had a significant increase in alcohol-associated liver disease that's more than in the past."

From 2000 to 2023, the age-adjusted death rate from alcohol-related cirrhosis rose 72.2% overall, from 4.3 to 7.4 per 100,000, according to the National Institute on Alcohol Abuse and Alcoholism (NIAAA).³ In 2024, alcohol-associated cirrhosis was the most common primary diagnosis among adult liver transplant recipients in the US.⁴

A Clear Trigger: The COVID-19 Pandemic

"Alcohol-associated liver disease was actually increasing at a gradual pace in the United States, and then in 2020 we just saw this upward shift where a significant increase occurred, and it coincided directly with the COVID-19 pandemic," Gonzalez told HCPLive. "What's concerning is that was in 2020, but that has persisted."

For about a decade before 2020, ALD was already rising:

• The age-adjusted alcohol-related cirrhosis death rate rose from 4.3 per 100,000 in 2000 to 6.1 in 2018.³
• Among adults aged 25 to 34, the rate more than doubled, from 0.7 to 1.8 per 100,000.³
• Liver transplant waitlisting for ALD among adults <40 rose 4-fold from 2003 to 2018.⁵

The increase in ALD predated the pandemic, but the pace accelerated around the pandemic period:

• The alcohol-related cirrhosis death rate rose from 6.4 per 100,000 in 2019 to 7.8 in 2020, the largest single-year increase since 2000, and reached 8.7 in 2021.³
• The ALD death rate rose 8.94% per year from 2018 to 2022.¹
• Among adults aged 25 to 44, ALD mortality increased an average of 4.23% per year from 1999 to 2022.¹

Alcohol-associated hepatitis was also already increasing among younger adults before COVID-19.

"Alcohol-associated hepatitis in young adults was rising well before 2020, and the pandemic accelerated a trend rather than creating one," Brian Lee told HCPLive.

US Alcohol Use Fell for the First Time Since the Pandemic, but Remains Above 2018 Levels

New data from a study led by Brian Lee point to a decline in drinking after 2022, and separate mortality data show alcohol-related cirrhosis deaths have eased since 2021. However, neither measure has returned to its 2018 level.

The study analyzed National Health Interview Survey data from 114,352 US adults from 2018 to 2024:²

• From 2022 to 2024, any alcohol use fell nearly 2% and heavy drinking fell >8%, the first confirmed decline since the pandemic.²
• Gen Z adults had the largest drop in any alcohol use (>5%), and millennials had the largest drop in heavy drinking (17%).²
• Both measures remain above 2018 levels.²

The study defined heavy drinking using NIAAA criteria: ≥15 drinks per week or ≥5 drinks on any day for men, and ≥8 drinks per week or ≥4 drinks on any day for women.²

"The decline occurred largely independent of clear clinical intervention as far as we know," Brian Lee said.

While it’s unclear what’s leading the decline, the drop in drinking isn't the only sign of easing. Mortality data show a similar pattern: after peaking in 2021, alcohol-related cirrhosis death rates fell in both 2022 and 2023:

• The age-adjusted alcohol-related cirrhosis death rate fell from 8.7 per 100,000 in 2021 to 7.4 in 2023.³
• From 2022 to 2023 alone, the crude alcohol-related cirrhosis death rate fell 7.8%, and total cirrhosis deaths fell by 2,409.³
• In 2024, the age-adjusted death rate from chronic liver disease and cirrhosis of all causes fell 2.3%, from 13.0 to 12.7 per 100,000.⁶

"It looks like there's hopefully a decline, looking at the most recent statistics of mortality associated with alcohol-associated liver disease, but that was definitely a trigger," Gonzalez said.

Still, the 2023 alcohol-related cirrhosis death rate remains above its 2018 level of 6.1 per 100,000, and drinking remains above 2018 levels.²˒³

The recent population-level decline also does not mean the burden is changing equally across groups. Sex-specific, metabolic, genetic, and social factors may help explain why ALD risk and outcomes differ across populations.

Women: A Step Down From a Large Step Up

Women cut heavy drinking more than men from 2022 to 2024 (9% vs 7.7%), but experts say their ALD reflects decades of rising intake and greater biological vulnerability.²

According to Brian Lee, heavy drinking among women remains about 13% above 2018 and is now slightly more prevalent among women than men in the survey, because the heavy drinking thresholds are lower for women.

"The reduction from 2022 to 2024 is real but it's a recent step down from a large step up," he said. "Women develop fibrosis at lower cumulative exposure, they progress faster once it's established, and the increase in women's drinking predated the pandemic by at least a decade. So the liver disease we're seeing in women now reflects fifteen or twenty years of rising intake."

Women's physiology may partly explain these disproportionate impacts.

"We know that women are generally smaller and have decreased total body water and higher body fat percentage, which causes higher concentrations of alcohol in the blood stream compared to men who ingest the same amount of alcohol," Frances Lee told HCPLive.

Taken together, these differences mean similar levels of alcohol intake may not translate to the same biological exposure or liver risk in women and men, an important consideration when clinicians assess alcohol history and cumulative exposure.

Frances Lee added that the effects of hormone levels and menopausal status on ALD progression remain understudied, a point she discussed in a previous interview with HCPLive.

Alcohol-related cirrhosis deaths in women tell a similar story:

• From 2000 to 2023, the alcohol-related cirrhosis death rate rose 125% in women vs 51.2% in men.³
• Beginning in 2011, nearly a decade before the pandemic, the ALD death rate among women rose 8.32% per year through 2022.¹
• The alcohol-related cirrhosis death rate in women peaked at 5.5 per 100,000 in 2021 and fell to 4.8 in 2023, still above 3.7 in 2018.³
• Men's alcohol-related cirrhosis death rates remain greater overall: 10.2 vs 4.8 per 100,000 in 2023.³

"Two years of modest decline won't change that trajectory quickly," Brian Lee said.

Alcohol-Associated Hepatitis Hospitalizations in Young Adults Surpassed Older Adults by 2020

ALD-related hospitalizations increased particularly rapidly among young adults from 2016 to 2022, and while younger generations are now drinking less, alcohol-related cirrhosis deaths in this group remain above 2018 levels.

Hospital data from 2016 to 2022 show the shift:

• ALD hospitalizations among adults aged 20 to 49 rose from 106.5 to 144.7 per 100,000, or 4.48% per year, vs 1.78% per year among older adults.⁷
• By 2020, alcohol-associated hepatitis hospitalization rates were greater in younger adults than in older adults (65.6 vs 61.3 per 100,000).⁷
• Older adults still had greater ALD hospitalization rates overall in 2022 (295.0 vs 144.7 per 100,000).⁷

Among adults aged 25 to 34:

• The alcohol-related cirrhosis death rate nearly doubled, from 1.8 per 100,000 in 2018 to 3.4 in 2021, then eased to 3.0 in 2023.³
• In 2023, 80.3% of cirrhosis deaths in this age group were alcohol related, the highest share of any age group.³
• Among women aged 25 to 34, the rate rose from 2.3 in 2022 to 2.5 in 2023, an exception to the overall decline.³

Frances Lee pointed to metabolic and genetic factors that may help explain the trend. She noted that "with the increasing incidence of diabetes, obesity, and other features of metabolic syndrome, especially in younger patients, the more likely we are to see clinical disease."

Genetics may also play a role. "We are also increasingly aware of the genetic changes that may increase one's risk of developing liver disease, whether that be from PNPLA3 polymorphisms or otherwise," Frances Lee said. "Genetic polymorphisms may elucidate why younger patients are developing liver disease, especially with the progression of metabolic disease and alcohol intake."

In a UK Biobank cohort study, participants with obesity and excessive alcohol intake who were homozygous carriers of the PNPLA3 I148M variant had a 17.52-fold greater risk of cirrhosis than participants without obesity or excessive drinking who did not carry the variant (adjusted hazard ratio [aHR], 17.52; 95% CI, 12.84-23.90).⁸

Together, the findings illustrate why younger age alone may not capture liver disease risk. Alcohol exposure may occur alongside metabolic and genetic risk factors, making the broader risk profile relevant even in younger patients.

Still, there may be reason for cautious optimism. Younger adults drove the recent decline in drinking: from 2022 to 2024, any alcohol use among Gen Z adults fell >5%, and heavy drinking among millennials fell 17%.²

"Acute alcohol-associated hepatitis in young adults is hopefully near its peak if their drinking stays down," Brian Lee said.

American Indian and Alaska Native People Face the Highest ALD Death Rates

American Indian and Alaska Native people had the highest ALD mortality rate among the racial and ethnic groups examined in the JAMA Network Open analysis, increasing from 25.21 to 46.75 deaths per 100,000 from 1999 to 2022.¹

Earlier research found that in 2020, the mean age-adjusted ALD mortality rate among American Indian and Alaska Native people in states with available data was nearly 6 times that of White people (68.5 vs 11.7 per 100,000).⁹ A 2024 review of studies on racial and ethnic disparities in ALD found this group had the highest pooled mortality rate of any racial or ethnic group, but noted that the population remains "understudied with regard to ALD epidemiology and the mechanisms behind the disproportionate mortality."¹⁰

The authors pointed to possible contributors, including genetics, drinking patterns, social determinants of health such as income and access to care, and provider bias and diagnostic delays.¹⁰

These disparities mean alcohol exposure alone cannot explain differences in ALD outcomes. Access to care, timely diagnosis, and other social and clinical factors may also shape which patients develop advanced disease or experience ALD-related mortality.¹⁰

Why ALD May Be Worse Than It Looks

The numbers may undercount ALD, and experts say metabolic disease may be raising the harm associated with alcohol use.

Part of that undercount may come from binge drinking going unrecognized. Research Frances Lee presented at Digestive Disease Week (DDW) 2026, which analyzed National Health and Nutrition Examination Survey (NHANES) data from 2017 to 2023 for 5093 participants with steatotic liver disease, found that metabolic dysfunction and alcohol-associated liver disease (MetALD) and ALD carried 2.58-fold and 4.55-fold greater odds of advanced fibrosis, respectively, than metabolic dysfunction-associated steatotic liver disease (MASLD).¹¹

"Our study shows that many patients categorized as MASLD or metALD were participating in binge alcohol intake between twice a week to twice a month," Frances Lee said. "Physicians may also not be asking about binge alcohol intake, further reducing awareness of the harms of binge drinking."

For clinicians, the findings underscore that metabolic liver disease and clinically relevant alcohol exposure can coexist. Asking about drinking patterns, including episodes of binge drinking rather than average consumption alone, may provide information that is missed when alcohol history is treated as a simple yes-or-no distinction.

Additionally, stigma may make it difficult for patients to open up about their drinking, and it can affect how alcohol-related deaths are counted. NIAAA notes that alcohol may be omitted from some cirrhosis death certificates, including when certifiers seek to protect families, potentially contributing to undercounting of alcohol-related deaths.³ From 2000 to 2023, 43.6% to 54.3% of cirrhosis deaths were coded as alcohol related, depending on the year.³

"We know that the word 'alcoholic' comes with stigma, and in using 'alcohol-associated liver disease' or 'alcohol use disorder,' patients may feel that they are seen for more than just their addiction and open to creating a therapeutic relationship with their healthcare provider," Frances Lee said.

Metabolic factors may also modify alcohol-related liver disease risk. Brian Lee's earlier research examined how alcohol and cardiometabolic risk factors together relate to liver disease.¹²

"The finding in that work was that the per-drink harm to the liver has been rising, and the best explanation is that heavy drinkers now carry obesity, diabetes, and hypertension at rates they didn't twenty years ago," Brian Lee said. "Alcohol and metabolic dysfunction aren't additive in the liver, they're multiplicative."

Heavy Drinking Rises Among Adults 50 to 64

While drinking fell overall, one group moved in the other direction. Heavy drinking among adults aged 50 to 64 rose >36% from 2018 to 2024, and any drinking in that group rose nearly 4%.²

"Heavy drinking among ages 50-64 is up by more than a third since 2018, a concerning trend because this age group faces some of the greatest risks of harm from alcohol, including cirrhosis and alcohol-related cancers," Brian Lee said in a statement.

Will Alcohol-Associated Liver Disease Keep Falling? Questions That Remain

Because liver damage builds over years, it may take time before recent changes in drinking show up in liver disease data. Whether the post-2021 decline in alcohol-related cirrhosis mortality continues, and which patients clinicians are most likely to see next, remain open questions.

Part 2 of this series will look at where ALD is headed and what clinicians can do now.

Editor's note: Frances Lee does not report any relevant disclosures. Gonzalez reports relevant disclosures with Mallinckrodt Pharmaceuticals, Salix, AbbVie, Gilead, and others. Brian Lee reports consulting for Gilead Sciences, Novo Nordisk, GlaxoSmithKline, Altimmune, Bausch Health, and others.

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