Author reply to technical comment

Reply to the Letter to the Editor of J. G. Heckmann

Publication Date: 21.09.2014
Swiss Med Wkly. 2014;144:w14029

Simon Marmet, Jürgen Rehm, Gerhard Gmel

Please find the affiliations for this article in the PDF.

A long way from anecdotal evidence to quantification

The methodology used in the latter article is based on the Comparative Risk Assessment (CRA) of the Global Burden of Disease (GBD) 2010 study [3], which can be considered as the current standard for estimating alcohol-attributable mortality. This methodology and particularly the association between risk factors and diseases is in a constant flux as new evidence becomes available [4]. Often, the association between a specific disease and alcohol is known for a while but the causality and strength of the causal association is not established. One more recent example would be tuberculosis [4], which was not included in earlier Global Burden of Disease (GBD) estimates, but has been included in the recent GBD 2010 study and our estimates. The GBD sets very strict criteria when a health condition is causally attributed to a risk factor, such as biological mechanism, temporality (cause precedes the effect), consistency across studies and the estimated effect size [5]. A typical example for non-inclusion is depression for which a link to alcohol is well known [6], but it is still difficult to determine whether a depression is a consequence of alcohol consumption or alcohol is used as a self-medication for depression. Thus, it has not yet been possible to quantify the effect size for alcohol-attributable depression and it was therefore not included in GBD and in our estimates.

As for ischemic stroke, we agree that heavy drinking occasions can trigger this condition, as shown in a recent systematic review [7]. In this respect, the aetiology of ischemic stroke is similar to ischemic heart disease, where irregular heavy drinking occasions have been shown to be related to increased mortality in overall light to moderate drinkers [8, 9]. However, we are not aware of any systematic review or meta-analysis which would combine the impact of both dimensions of average consumption and irregular heavy drinking occasions, so it was decided in the CRA of the GBD to model ischemic stroke based on the meta-analysis for average drinking only [10].

The concept of Halloween Stroke is broadly similar to the long known holiday heart syndrome [11] for ischemic heart disease due to its higher incidence rates after holidays and weekends. The excess occurrence of myocardial infarctions and strokes on Mondays and sometimes Saturdays have already been given different labels such as Monday blues or weekend warrior phenomenon [12].

To conclude, there is very likely a causal relationship between heavy irregular drinking on weekends or holidays and stroke on the following day(s), but its quantification has not been achieved yet. Whether this will be labelled Monday stroke, Holiday stroke, or Halloween stroke in the future is subject to debate and will be determined by scientific consensus. We are, however, not in favour of a label that refers to a single particular holiday which is popular as a drinking event mainly in the US.


Correspondence: Simon Marmet, lic.phil., Addiction Switzerland, Av. Louis-Ruchonnet 14, CH-1003 Lausanne, Switzerland, Smarmet[at]addictionsuisse.chLetter to the Editor:


  1 Heckmann JG. Letter to the editor concerning: “Alcohol-attributable mortality in Switzerland in 2011 – age-specific causes of death and impact of heavy versus non-heavy drinking”. Swiss Med Wkly. 2014;144:w14028.

  2 Marmet S, Rehm J, Gmel G, Frick H, Gmel G. Alcohol-attributable mortality in Switzerland in 2011 – Age-specific causes of death and impact of heavy versus non-heavy drinking. Swiss Med Wkly. 2014;144:w13947.

  3 Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2224–60.

  4 Rehm J, Borges G, Gmel G, Graham K, Grant B, Parry C, et al. The comparative risk assessment for alcohol as part of the Global Burden of Disease 2010 Study: What changed from the last study? Int J Alcohol Drug Res. 2013;2(1):1–5.

  5 Rehm J, Baliunas D, Borges GLG, Graham K, Irving H, Kehoe T, et al. The relation between different dimensions of alcohol consumption and burden of disease: An overview. Addiction. 2010;105(5):817–43.

  6 Boden JM, Fergusson DM. Alcohol and depression. Addiction. 2011;106(5):906–14.

  7 Guiraud V, Amor MB, Mas J-L, Touze E. Triggers of ischemic stroke: A systematic review. Stroke. 2010;41(11):2669–77.

  8 Roerecke M, Rehm J. Irregular heavy drinking occasions and risk of ischemic heart disease: A systematic review and meta-analysis. Am J Epidemiol. 2010;171(6):633–44.

  9 Gerlich MG, Kramer A, Gmel G, Maggiorini M, Luscher TF, Rickli H, et al. Patterns of alcohol consumption and acute myocardial infarction: A case-crossover analysis. Eur Addic Res. 2009;15(3):143–9.

10 Patra J, Taylor B, Irving H, Roerecke M, Baliunas D, Mohapatra S, et al. Alcohol consumption and the risk of morbidity and mortality for different stroke types – A systematic review and meta-analysis. BMC Pub Health. 2010;10:258.

11 Ettinger PO, Wu CF, De La Cruz C, Jr., Weisse AB, Ahmed SS, Regan TJ. Arrhythmias and the "Holiday Heart": Alcohol-associated cardiac rhythm disorders. Am Heart J. 1978;95(5):555–62.

12 Reavey M, Saner H, Paccaud F, Marques-Vidal P. Exploring the periodicity of cardiovascular events in Switzerland: Variation in deaths and hospitalizations across seasons, day of the week and hour of the day. Int J Cardiol. 2013;168(3):2195–200.

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