Alcohol misuse accounted for 35,823 deaths in 2017, an increase of nearly 46 percent over almost two decades, according to a Washington Examiner analysis of mortality data.

The data , which come from the Centers for Disease Control and Prevention, show that alcohol-related deaths have climbed steadily from the 19,469 deaths recorded in 1999. Deaths from misusing alcohol did not decline at any time since that period, and they included not only alcohol poisonings but also alcoholic liver disease and cirrhosis. They do not include deaths from accidents people have while they are drinking, because in these instances, the cause of death would be drowning, a car accident, or a fall.

Deaths from such heavy drinking patterns are contributing to the lower life expectancy trend that has been observed in the U.S. in recent years, an issue compounded by opioid overdose deaths and suicides. These alcohol deaths are still lower than those caused by opioids such as heroin, which were responsible for 47,600 deaths in 2017, and suicides, which accounted for 47,173 deaths. When combined with deaths from accidents where people have been drinking, however, they climb to 88,000 deaths a year, federal reports show.

“I consider alcohol the elephant in the room when it comes to the drug abuse issues that have been surfacing,” said Dr. George Koob, director of the National Institute on Alcohol Abuse and Alcoholism.

The latest data assembled by the Washington Examiner, obtained through the CDC’s Wide-ranging OnLine Data for Epidemiologic Research, adds to recent studies on mortality by the CDC.

It's unclear what is behind the factors driving lower life expectancy. Scholars have dubbed the phenomenon “deaths of despair,” noting mortality is rising particularly among whites in rural areas who have no more than a high school education. Princeton economists and spouses Anne Case and Angus Deaton have raised the possibility that deaths are tied to mental health issues, economic uncertainty, and physical pain.

The data pulled from the CDC show that alcohol deaths were highest among people between the ages of 50 to 64 and that men were more than twice as likely to die from alcohol misuse than women were. The number of deaths among whites were significantly higher than any other race, but rates of death were highest among American Indians or Alaska Natives.

In recent years, the statistics show that alcoholic liver disease has been primarily responsible for the increases in chronic liver disease and cirrhosis, according to the CDC. But with alcohol poisoning data, sometimes opioids or another drug such as Valium are also involved as contributing to the death, even though alcohol is considered the underlying factor, the CDC has said .

“The population is aging; people are taking more pills, but they don’t know you can’t drink on top of these pills, which becomes a lethal combination,” Koob said.

The latest information comes amid positive outcomes on alcohol in other areas. Additional federal data show underage drinking has reached record lows and that alcohol use disorders have been declining since 2002 among all age groups . Alcohol-impaired driving fatalities now account for 29 percent of overall driving deaths, the lowest percentage since 1982 .

But studies on mortality have caught the attention of public health officials domestically and globally. There is widespread disagreement about how to reverse the trend of deaths tied to alcohol, in part because it is a legal product that many people consume in moderate amounts. U.S. dietary guidelines say that moderate drinking for those of legal drinking age can be part of a healthy diet, which means up to one drink per day for women and two drinks per day for men.

“One of the challenges is that we in our institute are dealing with a legal drug that is everywhere, where 70 percent of Americans participate in drinking at one time or another, and most don’t have a problem,” Koob said. “That fact alone is a real challenge for our institute. We have to be careful about not exaggerating one side or another.”

The World Health Organization has urged countries to implement alcohol restrictions including marketing bans, tax increases, and reducing where or when alcohol can be sold. Koob pointed to a recent report from the surgeon general suggesting communities could consider such policies to curb addiction.

“It’s pretty well-established that if you increase the cost of alcohol it decreases consumption, and if you decrease availability in any manner, shape, or form it will decrease consumption,” he said.

The alcohol industry opposes these types of restrictions and instead supports other approaches to tackling problem drinking that wouldn’t affect people who consume only moderately. They note that prohibitions on alcohol have worsened the issue in the past and that small businesses would be damaged by certain proposals.

“The important thing is that people separate problem drinkers, heavy drinkers, and binge drinkers from moderate and social drinkers,” said Jackson Shedelbower, spokesman for the American Beverage Institute, a trade group that represents restaurants.

The group supports the use of ignition airlocks devices or Breathalyzers in cars for those with high blood alcohol content and repeat offenders. They also support a 24/7 sobriety program , in which people with alcohol problems must take a breath test to show they are sober.

The Distilled Spirits Council supports CDC guidance that directs more doctors to talk to their patients about their drinking patterns.

“A physician can rapidly assess whether a patient is drinking alcohol as part of an overall healthy lifestyle, or if counseling is needed, just by asking a few questions during a routine exam,” Lisa Hawkins, spokeswoman for the Distilled Spirits Council, said in an email. “Research shows these brief discussions, held in a healthcare setting, can help individuals moderate their alcohol consumption or abstain altogether.”

Some states are tightening access to alcohol. A law set to go into effect in Utah Dec. 30 would reduce the legal blood alcohol limit from 0.08 to 0.05, a move pushed by the National Transportation Safety Board. The guidelines equate to one glass of wine for a 120-pound woman, and have also been considered in New York, Washington state, Hawaii, and Delaware. Though the proposals didn’t advanced, they’re expected to be re-introduced next year.

The U.S. overall has been trending in the opposite direction, with state lawmakers saying alcohol laws need to be modernized. Indiana, for instance, started selling alcohol on Sundays, and Pennsylvania now allows wine and beer to be sold in grocery stores.