NCHS Data Brief ■ No. 383 ■ October 2020

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics

Rates of Alcohol-induced Deaths Among Adults Aged 25 and 

Over in Urban and Rural Areas: United States, 2000–2018

Merianne Rose Spencer, M.P.H., Sally C. Curtin, M.A., and Holly Hedegaard, M.D.

Key findings

Data from the National 

Vital Statistics System, 

Mortality

● Age-adjusted rates of 

alcohol-induced deaths among 

adults aged 25 and over were 

stable from 2000 to 2006, 

then increased 43% from 

10.7 per 100,000 in 2006 to 

15.3 in 2018. 

● For both males and females, 

alcohol-induced death rates 

increased at a greater rate 

between 2000 and 2018 in rural 

compared with urban areas. 

● Among males, the rate 

of alcohol-induced deaths 

was highest in large central 

metro areas in 2000 (21.3); 

by 2018, rates in medium 

(25.1) and small metro 

(25.9), micropolitan (26.7), 

and noncore (25.3) areas 

were highest. 

● Among females, the rate 

of alcohol-induced deaths in 

noncore areas (4.4) was among 

the lowest in 2000; by 2018, 

rates in noncore areas had more 

than doubled (9.9). 

Excessive alcohol consumption is a well-known risk factor for mortality and 

has been causally linked to many diseases, conditions and injuries, including 

alcohol-attributable cancer, liver cirrhosis, and alcohol poisonings (1). 

Alcohol-induced deaths, or deaths from dependent and nondependent use of 

alcohol, as well as accidental poisoning by alcohol (2), have been increasing 

in the United States since 1999 with differences by sex, age, urban–rural 

classification, and other demographic characteristics (3,4). This Data Brief 

focuses on alcohol-induced deaths among adults aged 25 and over, which 

account for more than 99% of the alcohol-induced deaths in the United States. 

The report presents trends from 2000 through 2018 by sex and urbanization 

level of county of residence.

Rates for alcohol-induced deaths among persons aged 25 

and over increased from 2000 through 2018. 

Figure 1. Age-adjusted rates of alcohol-induced deaths among persons aged 25 and over: 

United States, 2000–2018

1Stable trend from 2000 to 2005; significant increasing trend from 2005 through 2018, with different rates of change over time; 

p < 0.05. 2Stable trend from 2000 to 2006; significant increasing trend from 2006 through 2018, with different rates of change over time; 

p < 0.05. 3Significant increasing trend from 2000 through 2018, with different rates of change over time; p < 0.05.

NOTES: Age-adjusted death rates were calculated using the direct method and the 2000 U.S. standard population. 

Alcohol-induced deaths include International Classification of Diseases, 10th Revision, or ICD–10 codes E24.4, F10, G31.2, 

G62.1, G72.1, I42.6, K29.2, K70, K85.2, K86.0, R78.0, X45, X65, and Y15. Alcohol-induced causes exclude unintentional injuries, 

homicides, and other causes indirectly related to alcohol use, as well as newborn deaths associated with maternal alcohol use. 

Access data table for Figure 1 at: https://www.cdc.gov/nchs/data/databriefs/db383-tables-508.pdf#1. 

SOURCE: National Vital Statistics System, Mortality (NVSS-M). 

25

Male1

Female3

Total2

15

20

10

5

0

Deaths per 100,000 standard population

2000 2002 2004 2006 2008 2010 2012 2014 2016 2018

NCHS reports can be downloaded from: https://www.cdc.gov/nchs/products/index.htm.
NCHS Data Brief ■ No. 383 ■ October 2020

■  2  ■

● Age-adjusted rates of alcohol-induced deaths among all persons aged 25 and over were 

stable from 2000 to 2006 at about 10.7 per 100,000, then increased 43% to 15.3 in 2018 

(Figure 1). 

● For males aged 25 and over, rates were stable from 2000 to 2005, then increased 34% from 

2005 through 2018, from 16.9 to 22.6. 

● For females aged 25 and over, rates increased 76% from 2000 through 2018, from 4.9 to 8.6. 

● For each year, rates of alcohol-induced deaths for males aged 25 and over were higher than 

for females.

The difference in alcohol-induced death rates between urban and rural 

areas was greater in 2018 than in 2000 for both males and females aged 

25 and over. 

● Among males aged 25 and over, rates in urban areas were stable from 2000 to 2005, then 

increased 32% from 16.8 in 2005 to 22.1 in 2018. Rates in rural areas increased 51% 

throughout the period from 17.3 in 2000 to 26.1 in 2018 (Figure 2).

● From 2007 through 2018, rates for males in rural areas were significantly higher than rates 

in urban areas. 

Figure 2. Age-adjusted rates of alcohol-induced deaths among persons aged 25 and over, by sex and urban–rural 

classification: United States, 2000–2018

1Significant increasing trend from 2000 through 2018, with different rates of change over time; p < 0.05. 2Rates in rural areas were higher than in urban areas from 2007 through 2018; p < 0.05. 3Stable trend from 2000 to 2005; significant increasing trend from 2005 through 2018, with different rates of change over time; p < 0.05. 4Rates in rural areas were higher than in urban areas from 2011 through 2018; p < 0.05. 5Stable trend from 2000 to 2007; significant increasing trend from 2007 through 2018; p < 0.05.

NOTES: Age-adjusted death rates were calculated using the direct method and the 2000 U.S. standard population. Alcohol-induced deaths include International 

Classification of Diseases, 10th Revision, or ICD–10 codes E24.4, F10, G31.2, G62.1, G72.1, I42.6, K29.2, K70, K85.2, K86.0, R78.0, X45, X65, and Y15. 

Alcohol-induced causes exclude unintentional injuries, homicides, and other causes indirectly related to alcohol use, as well as newborn deaths associated with 

maternal alcohol use. Access data table for Figure 2 at: https://www.cdc.gov/nchs/data/databriefs/db383-tables-508.pdf#2.

SOURCE: National Vital Statistics System, Mortality (NVSS-M). Deaths per 100,000 standard population25

30

15

20

10

5

0

2000 2002 2004 2006 2008 2010 2012 2014 2016 2018

Rural, male1,2

Urban, male3

Rural, female1,4

Urban, female5
NCHS Data Brief ■ No. 383 ■ October 2020

■  3  ■

● Among females aged 25 and over, rates in urban areas were stable from 2000 to 2007, then 

increased 57% from 5.3 in 2007 to 8.3 in 2018. Rates in rural areas more than doubled 

throughout the period from 4.6 in 2000 to 10.2 in 2018.

● From 2011 through 2018, rates for females in rural areas were significantly higher than in 

urban areas. 

In 2000, the highest rates of alcohol-induced deaths among males aged 25 

and over occurred in the most urban areas, while in 2018, the highest rates 

occurred in medium metro, small metro, and rural areas. 

● In 2000, the highest rate for males was in large central metro counties (21.3) and lowest in 

large fringe metro areas (12.9); rates in medium metro (18.0), small metro (17.0), and rural 

areas (17.8 in micropolitan and 16.7 in noncore areas) were similar (Figure 3). 

● In 2018, the pattern of rates by urbanicity changed from 2000, with the highest rates in 

medium metro (25.1), small metro (25.9), micropolitan (26.7), and noncore (25.3) areas.

● Rates of alcohol-induced deaths for males aged 25 and over were higher in 2018 than in 

2000 for every urbanization level. 

Figure 3. Age-adjusted rates of alcohol-induced deaths among males aged 25 and over, by urbanization level: 

United States, 2000 and 2018

1Rates for all urbanicity groups in 2018 are significantly higher than rates in 2000, p < 0.05. 2Rate is significantly higher than rates for all other urbanicity groups in 2000, p < 0.05. 3Rate is significantly lower than rates for all other urbanicity groups, p < 0.05. 4Rate is significantly higher than the rates for large central metro and large fringe metro groups, p < 0.05.

NOTES: Age-adjusted death rates were calculated using the direct method and the 2000 U.S. standard population. Alcohol-induced deaths include International 

Classification of Diseases, 10th Revision, or ICD–10 codes E24.4, F10, G31.2, G62.1, G72.1, I42.6, K29.2, K70, K85.2, K86.0, R78.0, X45, X65, and Y15. 

Alcohol-induced causes exclude unintentional injuries, homicides, and other causes indirectly related to alcohol use, as well as newborn deaths associated with 

maternal alcohol use. Urbanization level is based on the Office of Management and Budget’s February 2013 delineation of metropolitan statistical areas (MSA), in 

which each MSA must have at least one urbanized area of at least 50,000 inhabitants. Areas with fewer than 50,000 inhabitants are grouped into the rural 

category. Categories are presented from most urban (large central metro) to least urban (small metro) and from rural (micropolitan) to most rural (noncore). Access 

data table for Figure 3 at: https://www.cdc.gov/nchs/data/databriefs/db383-tables-508.pdf#3. 

SOURCE: National Vital Statistics System, Mortality (NVSS-M). Deaths per 100,000 standard population

Urban Rural Urban Rural

2000 20181

Large 

central

metro

Large

fringe

metro

Medium

metro

Small

metro

NoncoreMicropolitanLarge 

central

metro

Large

fringe

metro

Medium

metro

Small

metro

NoncoreMicropolitan

25

30

15

20

10

5

0

221.3

312.9

18.0 17.0 17.8 16.7

22.8

317.5

425.1 425.9 426.7 425.3
NCHS Data Brief ■ No. 383 ■ October 2020

■  4  ■

In 2000, the highest rates of alcohol-induced deaths among females aged 

25 and over occurred in the most urban areas, while in 2018, the highest 

rates occurred in medium metro, small metro, and rural areas. 

● In 2000, the rate of alcohol-induced mortality among females was highest in large central 

metro counties (5.6). Rates were lowest in large fringe metro (4.1) and noncore (4.4) 

counties; the rates for noncore, small metro (5.0), and micropolitan (4.7) counties were 

statistically similar (Figure 4).

● In 2018, rates for females were higher in medium metro (9.6), small metro (10.9), 

micropolitan (10.5), and noncore (9.9) areas than in large central metro (8.0) and large 

fringe metro areas. The lowest rates for females occurred in large fringe metro areas (6.9). 

● Rates of alcohol-induced deaths for females aged 25 and over were higher in 2018 than in 

2000 for every urbanization level.

Figure 4. Age-adjusted rates of alcohol-induced deaths among females aged 25 and over, by urbanization level: 

United States, 2000 and 2018

1Rates for all urbanicity groups in 2018 are significantly higher than rates in 2000, p < 0.05. 2Rate is significantly higher than rates for all other urbanicity groups in 2000, p < 0.05. 3Rate is significantly lower than rates for all other urbanicity groups except for noncore, p < 0.05. 4Rate is significantly lower than rates for all other urbanicity groups, p < 0.05. 5Rate is significantly higher than the rates for large central metro and large fringe metro, p < 0.05.

NOTES: Age-adjusted death rates were calculated using the direct method and the 2000 U.S. standard population. Alcohol-induced deaths include International 

Classification of Diseases, 10th Revision, or ICD–10 codes E24.4, F10, G31.2, G62.1, G72.1, I42.6, K29.2, K70, K85.2, K86.0, R78.0, X45, X65, and Y15. 

Alcohol-induced causes exclude unintentional injuries, homicides, and other causes indirectly related to alcohol use, as well as newborn deaths associated with 

maternal alcohol use. Urbanization level is based on the Office of Management and Budget’s February 2013 delineation of metropolitan statistical areas (MSA), in 

which each MSA must have at least one urbanized area of at least 50,000 inhabitants. Areas with fewer than 50,000 inhabitants are grouped into the rural 

category. Categories are presented from most urban (large central metro) to least urban (small metro) and from rural (micropolitan) to most rural (noncore). Access 

data table for Figure 4 at: https://www.cdc.gov/nchs/data/databriefs/db383-tables-508.pdf#4. 

SOURCE: National Vital Statistics System, Mortality (NVSS-M). Deaths per 100,000 standard population

Urban Urban

2000 20181

Rural Rural

Large 

central

metro

Large

fringe

metro

Medium

metro

Small

metro

NoncoreMicropolitanLarge 

central

metro

Large

fringe

metro

Medium

metro

Small

metro

NoncoreMicropolitan

10

12

6

8

4

2

0

25.6

34.1

5.2 5.0 4.7 4.4

8.0

46.9

59.6

510.9 510.5 59.9
NCHS Data Brief ■ No. 383 ■ October 2020

■  5  ■

Summary

This report describes trends in rates of alcohol-induced deaths among adults aged 25 and over 

from 2000 through 2018, with a focus on differences by sex and urbanization level of the 

decedent’s county of residence. Rates overall and rates for males and females increased over 

the period. While rates were higher for males than females for each year, the rate of change was 

greater for females, resulting in a narrowing of the differences between male and female rates. In 

2000, the rate for males was 3.6 times the rate for females (17.5 and 4.9, respectively); in 2018, 

the rate for males was 2.6 times the rate for females (22.6 and 8.6, respectively). 

From 2000 through 2018, greater percentage increases in the rates occurred in rural areas 

compared with urban areas overall, for both males and females. In more recent years, rates of 

alcohol-induced deaths were higher in rural areas than urban areas; by 2018, rates were 18% 

higher for males and 23% higher for females in rural compared with urban areas. Rates increased 

between 2000 and 2018 for all urbanization level groups among males and females. Among 

males, the rate in large central metro areas was highest in 2000 whereas the rate in large fringe 

metro areas (suburban) was lowest. Similar to men, rates were highest in large central metro 

areas among females in 2000; however, rates in noncore areas were lowest, along with large 

fringe metro areas. By 2018, rates for small metro, medium metro, and rural areas were higher 

than for large central metro and fringe metro areas among both males and females, with greater 

magnitudes of change among women (i.e., rates more than doubled in small metro, micropolitan, 

and noncore areas). 

Definitions

Alcohol-induced deaths: Deaths from dependent and nondependent use of alcohol, as well as 

accidental poisoning by alcohol (2). These deaths include underlying International Classification 

of Diseases, 10th Revision, or ICD–10 cause-of-death codes E24.4, F10, G31.2, G62.1, G72.1, 

I42.6, K29.2, K70, K85.2, K86.0, R78.0, X45, X65, and Y15 (2,5). The definition of alcoholinduced deaths differs from the definition of 100% alcohol-attributable causes of death listed in 

the Alcohol-Related Diseases Impact (ARDI) application (6). The rates of alcohol-attributable 

deaths based on ARDI may be higher because it draws from a broader list of underlying and 

multiple-cause-of-death codes than deaths with an alcohol-induced cause of death. 

Urbanization level: Urbanization level of the decedent’s county of residence was categorized 

using the 2013 NCHS Urban–Rural Classification Scheme for Counties (7). In this scheme, 

counties are classified into six urbanization levels based primarily on metropolitan–

nonmetropolitan status and population distribution. Metropolitan (urban) counties include 

large central counties, the fringes of large counties (suburbs), medium counties, and small 

counties. Nonmetropolitan (rural) counties include micropolitan statistical areas and noncore 

areas, including open countryside, rural towns (populations of less than 2,500), and areas with 

populations of 2,500–49,999 that are not part of larger labor market areas.
NCHS Data Brief ■ No. 383 ■ October 2020

■  6  ■

Data source and methods

The National Vital Statistics System multiple-cause-of-death mortality data from 2000–2018 

(7) were used to examine alcohol-induced deaths among adults. In each year of the study period 

(2000–2018), 99% of alcohol-induced deaths occurred among those aged 25 and over; therefore, 

this report focuses on that population.

Alcohol-induced deaths are classified using the International Classification of Diseases, 

10th Revision, or ICD–10 underlying cause-of-death codes (5): E24.4, alcohol-induced 

pseudo-Cushing’s syndrome; F10, mental and behavioral disorders due to alcohol use; G31.2, 

degeneration of nervous system due to alcohol; G62.1, alcoholic polyneuropathy; G72.1, 

alcoholic myopathy; I42.6, alcoholic cardiomyopathy; K29.2, alcoholic gastritis; K70, alcoholic 

liver disease; K85.2, alcohol-induced acute pancreatitis; K86.0, alcohol-induced chronic 

pancreatitis; R78.0, finding of alcohol in blood; X45, accidental poisoning by and exposure 

to alcohol; X65, intentional self-poisoning by and exposure to alcohol; Y15, poisoning by 

and exposure to alcohol, undetermined intent. Alcohol-induced causes exclude unintentional 

injuries, homicides, and other causes indirectly related to alcohol use, as well as newborn deaths 

associated with maternal alcohol use. This case definition for alcohol-induced deaths is consistent 

with reports of annual alcohol-induced mortality rates by NCHS as well as other publications 

describing alcohol-induced trends in mortality data (2–4).

Age-adjusted death rates were calculated using the direct method and adjusted to the 2000 

standard population (2). Trends in age-adjusted death rates were evaluated using the Joinpoint 

Regression Program (Version 4.7.0.0) (9). Joinpoint software fitted weighted least-squares 

regression models to the rates on the log transform scale. The permutation tests for model 

(number of joinpoints) significance were set at an overall alpha level of 0.05 (9). Pairwise 

comparisons of rates (e.g., age-adjusted rates for males compared with females) were conducted 

using the z test with an alpha level of 0.05 (9).

About the authors

Merianne Rose Spencer is with the National Center for Health Statistics (NCHS), Division of 

Analysis and Epidemiology. Sally C. Curtin is with NCHS, Division of Vital Statistics. Holly 

Hedegaard is with NCHS, Division of Analysis and Epidemiology.
NCHS Data Brief ■ No. 383 ■ October 2020

■  7  ■

References

1. Rehm J, Shield KD. Global alcohol-attributable deaths from cancer, liver cirrhosis, and injury 

in 2010. Alcohol Res 35(2):174–83. 2013.

2. Kochanek KD, Murphy SL, Xu JQ, Arias E. Deaths: Final data for 2017. National Vital 

Statistics Reports; vol 68 no 9. Hyattsville, MD: National Center for Health Statistics. 2019. 

Available from: https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_09-508.pdf. 

3. Spillane S, Shiels MS, Best AF, Haozous EA, Withrow DR, Chen Y, et al. Trends in alcoholinduced deaths in the United States, 2000–2016. JAMA Netw Open 3(2):e1921451. 2020. 

Available from: https://jamanetwork.com/journals/jamanetworkopen/article-abstract/2761545. 

4. Curtin SC, Spencer MR. QuickStats: Rate of alcohol-induced deaths among persons aged 

≥ 25 years, by age group—National Vital Statistics System, 1999–2017. MMWR Morb Mortal 

Wkly Rep 68(33):734. 2019.

5. World Health Organization. International statistical classification of diseases and related 

health problems, 10th revision (ICD–10). 2008 ed. Geneva, Switzerland. 2009. 

6. Centers for Disease Control and Prevention. Alcohol and public health: Alcohol-related 

disease impact (ARDI) home. 2020. Available from: https://www.cdc.gov/alcohol/ardi/alcoholrelated-icd-codes.html.

7. Ingram DD, Franco SJ. 2013 NCHS urban–rural classification scheme for counties. National 

Center for Health Statistics. Vital Health Stat 2(166). 2014. Available from: https://www.cdc.gov/

nchs/data/series/sr_02/sr02_166.pdf.

8. National Center for Health Statistics. CDC WONDER: About underlying cause of death, 

1999–2018. 2020. Available from: https://wonder.cdc.gov/ucd-icd10.html. 

9. National Cancer Institute. Joinpoint Regression Program (Version 4.7.0.0) [computer 

software]. 2019.
NCHS Data Brief ■ No. 383 ■ October 2020

Keywords: urban–rural • trends • health disparities • National Vital Statistics 

System-Mortality (NVSS-M)

Suggested citation

Spencer MR, Curtin SC, Hedegaard H. 

Rates of alcohol-induced deaths among 

adults aged 25 and over in rural and urban 

areas: United States, 2000–2018. NCHS 

Data Brief, no 383. Hyattsville, MD: 

National Center for Health Statistics. 2020.

Copyright information

All material appearing in this report is in 

the public domain and may be reproduced 

or copied without permission; citation as to 

source, however, is appreciated.

National Center for Health 

Statistics

Brian C. Moyer, Ph.D., Director

Amy M. Branum, Ph.D., Acting Associate 

Director for Science

Division of Analysis and Epidemiology 

Irma E. Arispe, Ph.D., Director

Kevin C. Heslin, Ph.D., Associate Director for 

Science

Division of Vital Statistics

Steven Schwartz, Ph.D., Director

Isabelle Horon, Dr.P.H., Acting Associate Director 

for Science

For e-mail updates on NCHS publication 

releases, subscribe online at: 

https://www.cdc.gov/nchs/email-updates.htm.

For questions or general information

about NCHS:

Tel: 1–800–CDC–INFO (1–800–232–4636)

TTY: 1–888–232–6348

Internet: https://www.cdc.gov/nchs

Online request form: https://www.cdc.gov/info

ISSN 1941–4927 Print ed.

ISSN 1941–4935 Online ed.

CS320066 

U.S. DEPARTMENT OF

HEALTH & HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics

3311 Toledo Road, Room 4551, MS P08

Hyattsville, MD 20782–2064

OFFICIAL BUSINESS 

PENALTY FOR PRIVATE USE, $300

For more NCHS Data Briefs, visit:

https://www.cdc.gov/nchs/products/databriefs.htm.

FIRST CLASS MAIL 

POSTAGE & FEES PAID 

CDC/NCHS

PERMIT NO. G-284