Liver diseases related to health behaviors are emerging as the most common causes of chronic liver disease and cirrhosis world-wide. Harmful alcohol use can culminate in different manifestations of liver disease from steatosis to a severe acute steatohepatitis, cirrhosis and liver cancer. Historically, alcoholic hepatitis, alcoholic liver disease and alcoholism were the terms used to describe alcohol-related liver conditions and the disorder associated with their development, respectively. These terms, we now realize, are hugely stigmatizing. Stigma has a major impact on liver diseases, leading to discrimination, reduction in healthcare-seeking behaviour, and reduced allocation of resources, which all result in poor clinical outcomes [1]. With the rise in recent years of alcohol as a major cause of liver-related morbidity and mortality, there is need for the hepatology community to change its terminology; this statement is intended to be an important first step in advancing a non-stigmatizing, person-centric approach.
The transition away from the use of alcoholic is already well-underway, with more than 500 publications since 2018 utilizing “alcohol-associated” or “alcohol-related” as alternatives to alcoholic. This is gratifying, but to assist further in bringing uniformity to the published research and review articles on the topic of alcohol and liver disease, there is agreement on banning the term “alcoholic” from our medical lexicon and instead using “alcohol-associated” or “alcohol-related”. Both convey the desired qualities of being non-stigmatizing and establish alcohol as the key determinant of the liver condition. There should be agreement on the acronyms used – with use of ALD (alcohol-associated or alcohol-related liver disease) and AH (alcohol-associated or alcohol-related hepatitis). This may make literature searches that include both older and newer papers more straightforward. The NIAAA (National Institutes of Health Alcohol and Addiction Division) favours the term “alcohol-associated” and this is the term adopted by AASLD [2]. In European institutions the term “alcohol related”, as suggested in the EASL guideline from 2019, has been adopted [3]. Liver societies play a key role in shaping clinical care, research and public policy. With this responsibility in mind, we suggest the following terminology be adopted widely (Table 1).
Additionally, we endorse a “person-first” approach rather than condition-first approach. Specifically, we recommend describing “an individual with alcohol-associated cirrhosis” rather than “alcohol-associated cirrhotic”. Utilizing people-first language when describing individuals with medical conditions has been a widely accepted norm, with recent emphasis on persons with obesity (rather than obese persons). Looking forward, we would encourage journal editors, conference organizers, researchers and educators to adopt this person-first language.
Finally, as clinicians and researchers, we must acknowledge that in addition to using the “right terms”, there is a need to create the “right environment” for persons with alcohol use disorder and liver disease to receive care. This requires that clinicians as well as their support staff and research coordinators receive education regarding alcohol use disorder and can interact with persons with alcohol use disorder in an unbiased and non-stigmatizing manner. Provision of a supportive clinical and research environment is critical if we are to be effective in improving the lives of persons with ALD.
The AASLD, ALEH, APASL, and EASL condemn the use of stigmatizing language, images, attitudes, and policies related to alcohol use disorder and associated liver diseases and are united in our commitment to harmonize terms and the desire to advance clinical care and research by removing stigmatizing terminology.
FundingFunding was provided by American Association for the Study of Liver Diseases (AASLD), Latin American Association for the Study of the Liver (ALEH), European Association for the Study of the Liver (EASL), and Asian Pacific Association for the Study of the Liver (APASL). Norah A. Terrault received institutional grants from the National Institutes of Health.
Declaration of interestsNorah A. Terrault consults for Moderna. She received institutional grants from GSK, Genentech-Roche, Helio Health, Gilead, and Durect. She has other interests in CCO and Simply Speaking. AK has served as speaker for Novo Nordisk, Norgine, Siemens and Nordic Bioscience and participated in advisory boards for Norgine, Siemens, Resalis Therapeutics, Boehringer Ingelheim and Novo Nordisk, all outside the submitted work. Research support; Norgine, Siemens, Nordic Bioscience, Astra, Echosense. Consulting Takeda, Resalis Therapeutics, Zealand Pharma, Novo Nordisk, Boehringer Ingelheim. Board member and co-founder Evido.
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Authors' contributionsNorah A. Terrault, MD, MPH Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, CA; Graciela Castro-Narro, MD, MSc, Gastroenterology Department, National Institute of Medical Sciences and Nutrition, Mexico City, Mexico; Aleksander Krag, MD Department of Hepatology, Odense University Hospital, Odense, Denmark. Shuichiro Shiina MD, PhD, Department of Gastroenterological Imaging and Interventional Oncology, Juntendo University, Tokyo, Japan.
AcknowledgmentsThe authors would like to thank the Society Governing Boards for their contributions.
This article is being co-published by Journal of Hepatology, Hepatology, Hepatology International and Annals of Hepatology. Minor differences in style may appear in each publication, but the article is substantially the same in each journal.
