National trends and disparities in alcoholic liver disease mortality, United States, 1999-2024

Alcoholic Liver Disease (ALD) is a leading and rising cause of liver-related mortality in the United States; estimates spanning the COVID-19 era are needed. We analyzed adult ALD deaths (1999-2024) using the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database. Age-adjusted mortality rates were standardized to the 2000 U.S. population. Trends were evaluated with Joinpoint regression to estimate annual percent change and average annual percent change (AAPC). Analyses were stratified by sex, age, race/ethnicity, state, Census region, and 2013 urbanization (available through 2020). ALD mortality increased overall, surged from 2018 to 2021, and partially declined thereafter. Men consistently had higher mortality, whereas women showed faster proportional increases during growth periods. The steepest pandemic-era annual percent changes occurred in younger adults, especially ages 25 to 34. Racial/ethnic patterns were heterogeneous, with disproportionate burdens among Hispanic and non-Hispanic (NH) White populations and improvement among NH Black individuals. Regional and state heterogeneity was marked: several Midwestern and Western states clustered in higher-burden quantiles, the Northeast generally had lower Age-adjusted mortality rates, and nonmetropolitan counties showed steeper late-period increases than metropolitan areas (through 2020). These temporal and geographic patterns were consistent across sensitivity displays and aligned with subgroup findings reported in recent literature. Subgroup analysis by ALD subtype showed that alcoholic cirrhosis of the liver (K70.3) accounted for approximately 80% of ALD deaths and exhibited the steepest increase. United States ALD mortality rose over the past quarter century, accelerated during the pandemic, and remains uneven by sex, age, race/ethnicity, region, and urbanization. Alcohol policies, early detection, expanded treatment, and timely hepatology care, especially in rural and high-burden areas, are warranted; state variability warrants action.