Kimmo Herttua

Changes in Alcohol-Related Mortality and its Socioeconomic Differences After a Large Reduction in Alcohol Prices: A Natural Experiment Based on Register Data

The authors examined the effect of a large reduction in the price of alcohol in Finland in 2004 on alcohol-related mortality by age and socioeconomic group. For this register-based study of Finns aged >or=15 years, data on independent variables were extracted from the employment statistics of Statistics Finland. Mortality follow-up was carried out for 2001-2003 (before the price reduction) and 2004-2005 (after). Alcohol-related causes were defined using both underlying and contributory causes of death. Alcohol-related mortality increased by 16% among men and by 31% among women; 82% of the increase was due to chronic causes, particularly liver diseases. The increase in absolute terms was largest among men aged 55-59 years and women aged 50-54 years. Among persons aged 30-59 years, it was biggest among the unemployed or early-age pensioners and those with low education, social class, or income. The relative differences in change between the education and social class subgroups were small. The employed and persons aged <35 years did not suffer from increased alcohol-related mortality during the 2 years after the change. These results imply that a large reduction in the price of alcohol led to substantial increases in alcohol-related mortality, particularly among the less privileged, and in chronic diseases associated with heavy drinking.

An evaluation of the impact of a large reduction in alcohol prices on alcohol-related and all-cause mortality: time series analysis of a population-based natural experiment

BACKGROUNDnWe examined the effect of a large reduction in the price of alcohol that occurred in Finland in 2004 on alcohol-related and all-cause mortality, and mortality due to cardiovascular diseases (CVDs) from which alcohol-attributable cases were excluded.nnnMETHODSnTime series intervention analysis modelling was applied to the monthly aggregations of deaths in Finland for the period 1996-2006 to assess the impact of the reduction in alcohol prices. Alcohol-related mortality was defined using information on both underlying and contributory causes of death. Analyses were carried out for men and women aged 15-39, 40-49, 50-69 and >69 years.nnnRESULTSnAlcohol-related deaths increased in men aged 40-49 years, and in men and women aged 50-69 years, after the price reduction when trends and seasonal variation were taken into account: the mean rate of alcohol-related mortality increased by 17% [95% confidence interval (CI) 1.5, 33.7], 14% (95% CI 1.1, 28.0) and 40% (95% CI) 7.1, 81.7), respectively, which implies 2.5, 2.9 and 1.6 additional monthly deaths per 100,000 person-years following the price reduction. In contrast to alcohol-related mortality, CVD and all-cause mortality decreased: among men and women aged >69 years a decrease of 7 and 10%, respectively, in CVD mortality implied 19 and 25 fewer monthly deaths per 100,000 person-years, and a decrease of 7 and 14%, respectively, in all-cause mortality similarly implied 42 and 69 fewer monthly deaths.nnnCONCLUSIONnThese results obtained from the time series analyses suggest that the reduction in alcohol prices led to an increase in alcohol-related mortality, except in persons <40 years of age. However, it appears that beneficial effects in older age, when CVD deaths are prevalent, counter-balance these adverse effects, at least to some extent.

Adherence to antihypertensive therapy prior to the first presentation of stroke in hypertensive adults: population-based study

AIMSnAntihypertensive drug therapy is a major strategy of stroke prevention among hypertensive patients. The aim of this study was to estimate the excess risk of stroke associated with non-adherence to antihypertensive drug therapy among hypertensive patients.nnnMETHODS AND RESULTSnWe conducted a population-based study using records from Finnish national registers for 1 January 1995 to 31 December 2007. Of the 73 527 hypertensive patients aged 30 years or older and without pre-existing stroke or cardiovascular disease, 2144 died from stroke and 24 560 were hospitalized due to stroke during the follow-up. At the 2- and 10-year follow-up after the start of continuous antihypertensive medication, non-adherent patients had 3.81 [95% confidence interval (CI) 2.85-5.10] and 3.01 (95% CI: 2.37-3.83) times higher odds of stroke death when compared with the adherent patients. The corresponding odds ratio (OR) for stroke hospitalization was 2.74 (95% CI: 2.35-3.20) at Year 2 and 1.71 (95% CI: 1.49-1.96) at Year 10. In the stroke-event year, the ORs were higher, 5.68 (95% CI: 5.05-6.39) for stroke death and 1.87 (95% CI: 1.72-2.03) for hospitalization. Among those using agents acting on the renin-angiotensin system combined with diuretics or β-blockers, these ORs were 7.49 (95% CI: 5.62-9.98) and 3.91 (95% CI: 3.23-4.75), respectively. The associations between non-adherence and stroke followed a dose-response pattern--the poorer the adherence, the greater the risk of death and hospitalization due to stroke.nnnCONCLUSIONnThese data suggest that poor adherence to antihypertensive therapy substantially increases near- and long-term risk of stroke among hypertensive patients.

The impact of a large reduction in the price of alcohol on area differences in interpersonal violence: a natural experiment based on aggregate data

Background: This paper examines the effect of a drastic reduction in the price of alcohol that occurred in Finland in 2004 on interpersonal violence in the Helsinki Metropolitan Area, and how these changes varied at the small-area level. Methods: This study comprised 86 administrative tracts from the Helsinki Metropolitan Area. Data pertaining to the social structure of the tracts and interpersonal violence were collected from archival sources in the cities and the police in 2002–2005, and analysed using regression analysis. Results: Interpersonal violence rates did not increase after a large reduction in alcohol prices and an increase in consumption. For domestic violence, the rate even decreased. There was a significant relationship between measures of social disadvantage and interpersonal violence. A low educational level and a high outmigration level were the most salient factors. The differences in impact of the reduction in alcohol prices on interpersonal violence between high-, intermediate- and low-status areas were small. Conclusions: It would appear that a radical reduction in the price of alcohol and an increase in consumption do not necessarily lead to detrimental consequences in interpersonal violence or to an adverse development in areas of social disadvantage.

Living alone and alcohol-related mortality: a population-based cohort study from Finland.

Kimmo Herttua and colleagues showed that living alone is associated with a substantially increased risk of alcohol-related mortality, irrespective of gender, socioeconomic status, or cause of death, and that this effect was exacerbated after a price reduction in alcohol in 2004.

The effects of a large reduction in alcohol prices on hospitalizations related to alcohol: a population-based natural experiment

AIMSnFinland experienced a large reduction in alcohol prices in 2004 due to in the lowering of alcohol taxes by about one-third and the abolition of duty-free allowances for travellers from the European Union. We examined the effects of these changes on alcohol-related hospitalizations.nnnDESIGN AND PARTICIPANTSnTime-series intervention analyses of monthly aggregations of hospitalization for acute and chronic causes among men and women aged 15-39, 40-49, 50-69 and more than 69 years.nnnSETTINGnFinland, 1996-2006.nnnFINDINGSnAfter the price reduction the chronic hospitalization rate for men increased among those below age 70 years. It was largest among those aged 50-69 years: 22%, which implies an increase of 18.0 monthly hospitalizations per 100,000 person-years, and there was an 11% and 16% (11.5 and 4.8 monthly hospitalizations) increase among those aged 40-49 and 15-39, respectively. Among the women the rate increased by 23% (4.0 monthly hospitalizations) in the 50-69-year-olds, and decreased in the under-40s. The increase in all the population groups was due mainly to an increase in mental and behavioural disorders due to alcohol. Acute hospitalizations increased by 17% and 20% (6.2 and 7.0 per month) among men aged 40-49 and 50-69 years, respectively, and by 38% among women aged 50-69 years (2.3 per month).nnnCONCLUSIONSnThe results, obtained in a natural experimental setting when trends and seasonal variation had been taken into account, suggest that the reduction in alcohol prices led to increases in alcohol-related hospitalization in certain population groups, mainly among 50-69-year-olds, in Finland.

Poor Adherence to Statin and Antihypertensive Therapies as Risk Factors for Fatal Stroke.

BACKGROUNDnPoor adherence to medication regimens is common, potentially contributing to the occurrence of related disease.nnnOBJECTIVESnThe authors sought to assess the risk of fatal stroke associated with nonadherence to statin and/or antihypertensive therapy.nnnMETHODSnWe conducted a population-based study using electronic medical and prescription records from Finnish national registers in 1995 to 2007. Of the 58,266 hypercholesterolemia patients age 30+ years without pre-existing stroke or cardiovascular disease, 532 patients died of stroke (cases), and 57,734 remained free of incident stroke (controls) during the mean follow-up of 5.5 years. We captured year-by-year adherence to statin and antihypertensive therapy in both study groups and estimated the excess risk of stroke death associated with nonadherence.nnnRESULTSnIn all hypercholesterolemia patients, the adjusted odds ratio for stroke death for nonadherent compared with adherent statin users was 1.35 (95% confidence interval [CI] 1.04 to 1.74) 4 years before and 2.04 (95% CI: 1.72 to 2.43) at the year of stroke death or the end of the follow-up. In hypercholesterolemia patients with hypertension, relative to those who adhered to statins and antihypertensive therapy, the odds ratio at the year of stroke death was 7.43 (95% CI: 5.22 to 10.59) for those nonadherent both to statin and antihypertensive therapy, 1.82 (95% CI: 1.43 to 2.33) for those non-adherent toxa0statin but adherent to antihypertensive therapy, and 1.30 (95% CI: 0.53 to 3.20) for those adherent to statin, but nonadherent to antihypertensive, therapy.nnnCONCLUSIONSnIndividuals with hypercholesterolemia and hypertension who fail to take their prescribed statinxa0andxa0antihypertensive medication experience a substantially increased risk of fatal stroke. The risk is lower ifxa0thexa0patient is adherent to either one of these therapies.

The Socioeconomic Differences in Alcohol-Related Harm and the Effects of Alcohol Prices on Them: A Summary of Evidence from Finland

AIMSnWe make a case study of Finland to study the connections between socioeconomic status, alcohol use, related harm and possibilities for intervention by means of alcohol pricing.nnnMETHODSnA review of Finnish studies on the topic.nnnRESULTSnThe socioeconomic differences in severe alcohol-related harm were great, and in the past two decades, these differences have widened. Alcohol-related mortality has also strongly contributed to both the level and widening of socioeconomic differences in life expectancy. Both in 2004, when alcohol prices were abruptly cut, and in the longer term with more gradual changes in lowest prices of alcohol, the lowest socioeconomic groups were most affected in absolute-but not so clearly in relative-terms, particularly among men. However, these effects are sometimes weak, not fully consistent by gender and across different measures of harm.nnnCONCLUSIONSnThe large and increasing socioeconomic differences in alcohol-related harm in Finland underline the importance of reducing these differences. The finding that particularly among men the impact of reduced alcohol prices on health has often in absolute terms been the greatest in the lower socioeconomic groups suggests that policies aimed at keeping the price of alcoholic beverages high may help to both minimize the overall level of alcohol-related health problems and to reduce absolute inequalities.

Minimum Prices for Alcohol and Educational Disparities in Alcohol-related Mortality

Background: Minimum price of alcohol is one of the proposed set of alcohol policies in many high-income countries. However, the extent to which alcohol-related harm is associated with minimum prices across socioeconomic groups is not known. Methods: Using Finnish national registers in 1988–2007, we investigated, by means of time-series analysis, the association between minimum prices for alcohol overall, as well as for various types of alcoholic beverages, and alcohol-related mortality, among men and women ages 30–79 years across three educational groups. We defined quarterly aggregations of alcohol-related deaths, based on a sample including 80% of all deaths, in accordance with information on both underlying and contributory causes of death. Results: About 62,500 persons died from alcohol-related causes during the 20-year follow-up. The alcohol-related mortality rate was more than threefold higher among those with a basic education than among those with a tertiary education. Among men with a basic education, an increase of 1% in the minimum price of alcohol was associated with a decrease of 0.03% (95% confidence interval = 0.01, 0.04%) in deaths per 100,000 person-years. Changes in the minimum prices of distilled spirits, intermediate products, and strong beer were also associated with changes in the opposite direction among men with a basic education and among women with a secondary education, whereas among the most highly educated there were no associations between the minimum prices of any beverages and mortality. Moreover, we found no evidence of an association between lower minimum prices for wine and higher rates of alcohol-related mortality in any of the population sub-groups. Conclusions: The results reveal associations between higher minimum prices and lower alcohol-related mortality among men with a basic education and women with a secondary education for all beverage types except wine.

Educational inequalities in hospitalization attributable to alcohol: a population-based longitudinal study of changes during the period 2000–07

AIMSnTo estimate the relative risk of hospitalization from alcohol-related causes among men and women in Finland across different educational categories, and to determine whether these differentials changed following a large reduction in alcohol prices in 2004.nnnDESIGN AND MEASUREMENTSnA register-based longitudinal study of hospitalizations. We used repeated-measures analysis to estimate alcohol-attributable hospitalization rates and assessed effects of the reduction in alcohol prices by comparing two 4-year periods (2000-03 and 2004-07).nnnSETTINGnFinland.nnnPARTICIPANTSnA representative sample of the residents of Finland aged 30-79 years in the period 2000-07 (n = 470,627).nnnFINDINGSnThere was a clear gradient across educational levels in alcohol-attributable hospitalizations: the incidence rate ratios among men and women with basic education were 1.70 [95% confidence interval (CI) = 1.32, 2.20] and 1.96 (95% CI = 1.36, 2.84), respectively, compared with those with upper-tertiary education. After allowing for the long-term trend, there were no significant changes between the two follow-up periods either among men with an upper tertiary education or among women in any educational level, whereas the rate increased by 21% (95% CI = 5, 41), 16% (95% CI = 6, 27) and 10% (95% CI = 2, 18), respectively, among men with a lower tertiary, secondary and basic education. However, these differences in changes were not statistically significant.nnnCONCLUSIONSnLower-level education is associated with a substantially increased risk of alcohol-related hospitalization among men and women in Finland, even when adjusted for age, economic activity and income. The results do not provide strong evidence that the 2004 price reduction had differential effects by education.