Mats Ramstedt

Mortality and population drinking: a review of the literature

The aim of this review was to review research addressing the relationship between population drinking and health, particularly mortality. The review is based primarily on articles published in international journals after 1994 to February 2005, identified via Medline. The method used in most studies is time-series analysis based on autoregressive intergrated moving average (ARIMA) modelling. The outcome measures covered included the following mortality indicators: mortality from liver cirrhosis and other alcohol-related diseases, accident mortality, suicide, homicide, ischaemic heart disease (IHD) mortality and all-cause mortality. The study countries included most of the EU member states as of 1995 (14 countries), Canada and the United States. For Eastern Europe there was only scanty evidence. The study period was in most cases the post-war period. There was a statistically significant relationship between per capita consumption and mortality from liver cirrhosis and other alcohol-related diseases in all countries. In about half the countries, there was a significant relationship between consumption, on one hand, and mortality from accidents and homicide as well as all-cause mortality on the other hand. A link between alcohol and suicide was found in all regions except for mid- and southern Europe. There was no systematic link between consumption and IHD mortality. Overall, a 1-litre increase in per capita consumption was associated with a stronger effect in northern Europe and Canada than in mid- and southern Europe. Research during the past decade has strengthened the notion of a relationship between population drinking and alcohol-related harm. At the same time, the marked regional variation in the magnitude of this relationship suggests the importance of drinking patterns for modifying the impact of alcohol. By and large, there was little evidence for any cardioprotective effect at the population level. It is a challenge for future research to reconcile this outcome with the findings from observational studies, most of which suggest a protective effect of moderate drinking.

The societal cost of alcohol consumption: an estimation of the economic and human cost including health effects in Sweden, 2002

This article estimates the societal cost of alcohol consumption in Sweden in 2002, as well as the effects on health and quality of life. The estimation includes direct costs, indirect costs and intangible costs. Relevant cost-of-illness methods are applied using the human capital method and prevalence-based estimates, as suggested in existing international guidelines, allowing cautious comparison with prior studies. The results show that the net cost (i.e. including protective effects of alcohol consumption) is 20.3 billion Swedish kronor (SEK) and the gross cost (counting only detrimental effects) is 29.4 billon (0.9 and 1.3% of GDP). Alcohol consumption is estimated to cause a net loss of 121,800 QALYs. The results are within the range found in prior studies, although at the low end. A large number of sensitivity analyses are performed, indicating a sensitivity range of 50%.

Explaining change and stasis in alcohol consumption

The term ‘saturation’ has often been used when alcohol consumption in a region stays the same despite there having been reason to expect an increase, e.g. after a decrease of taxation. However, the term ‘saturation’ has been used only descriptively, and in different ways. We therefore propose a wider-ranging framework for understanding and explaining trends in alcohol consumption, illustrating the operation of the factors with historical or contemporary examples. In the framework, we include not only taxes and other alcohol controls, but also situational and other norms on drinking and intoxication, competing responsibilities and attractions that demand or favour sobriety, structural changes, external influences and the range of societal or cultural responses to alcohol problems.

Alcohol-Related Mortality in 15 European Countries in the Postwar Period

The aim of this paper isto assess postwar differences and trends inalcohol-related mortality in the currentEuropean Union (minus Luxembourg plus Norway)on the basis of liver cirrhosis mortality anddeaths with explicit mention of alcohol,primarily alcohol dependence, alcohol psychosisand alcohol poisoning (AAA). The questionof the extent to which these indicators arecomparable across Western European countries isalso addressed. A marked north-south gradientwas found for cirrhosis mortality, with thehighest rates revealed in Southern Europe andthe lowest in Northern Europe. However, thisgradient weakened with the passage of time andthe initially quite substantial regionaldifferences declined during the latter part ofthe study period. Explicitly alcohol-relatedmortality (AAA), on the other hand, showed areverse cross-national pattern with the highestrates in the north and the lowest in the south.A positive cross-national relationship wasobserved between cirrhosis and per capitaconsumption but this match was not improved bycombining cirrhosis with explicitlyalcohol-related causes. Nevertheless, withinSouthern, Central and Northern Europeancountries the relationship between per capitaconsumption and AAA-mortality was positive. Itis concluded that cirrhosis mortality is usefulfor making rough national comparisons in aWestern European context whereas the validityof explicitly alcohol-related mortality isquestionable. Cultural differences in recordingpractices and drinking patterns are discussedas possible determinants of geographicaldifferences in AAA-mortality.

The Irish drinking habits of 2002—Drinking and drinking‐related harm in a European comparative perspective

Aims: To examine drinking habits and experiences of adverse consequences of drinking among men and women in Ireland 2002 and to compare some results with earlier European studies using similar data and methods. Methods: Data on self‐reported drinking habits and experiences of alcohol‐related problems were obtained from a general population survey undertaken in 2002. Two approaches were used: (1) cross‐tabulations of drinking habits and the experience of adverse consequences in various demographic groups (2) logistic regressions predicting the likelihood of experiencing problems. Results: Self‐reported alcohol consumption confirms statistics on alcohol sales; a lot of alcohol is consumed in Ireland today despite a large fraction of abstainers in the population. Binge drinking is very common, and, out of 100 drinking events, 58 end up in binge drinking for men and 30 for women. Irish drinkers also experience harmful drinking‐related consequences to a larger extent than in other western European countries. Both volume of drinking and binge drinking affect the likelihood of experiencing most alcohol‐related harms. Conclusions: Drinkers in Ireland drink more than in other western European countries and many have risky drinking habits that lead to adverse consequences. It will be an important challenge to find preventive measures that can reduce these problems in Ireland.

Alcohol and suicide at the population level : the Canadian experience

Studies suggest that the population level link between alcohol and suicide differs across countries and between men and women. The aim of this paper was to estimate the relationship between alcohol consumption and suicide in Canada and to put the results in a comparative perspective. The relationship was elucidated for whole Canada, different provinces and also separately for men and women. The total suicide rate in Canada increased significantly by around 4% as alcohol consumption increased by one litre per capita, suggesting that approximately 25 - 30% of Canadian suicides were related to alcohol. The relationship was stronger for women than for men. A significant effect was found in all provinces except from Quebec, but the overall regional variation was not statistically significant. In an international perspective, the relationship for women was somewhat weaker than in Sweden and Norway, but larger than in Finland, the United States and Southern European countries. For men, the association was similar to what is found in the United States and Finland, weaker than in Sweden, Norway and Russia but stronger than in Southern European countries. The results only partly support the idea that intoxication frequency explains national differences in this relationship. Possible explanations for the stronger association among women are also discussed.

Alcohol and fatal accidents in the United States--a time series analysis for 1950-2002.

AIMS To estimate the association between per capita alcohol consumption and fatal accidents in the United States and to compare the outcome with findings from Europe and Canada. DATA AND METHOD Yearly data on fatal accidents by gender and age were analysed in relation to per capita alcohol consumption for 1950-2002 using the Box-Jenkins technique for time series analysis. FINDINGS A 1-L increase in per capita consumption was on average followed by 4.4 male deaths per 100,000 inhabitants, but had no significant effect on female accident mortality. Regarding specific categories of accidents, the effect on fatal motor vehicle accidents accounted for a large part of the overall effect for men and was also significant for women. With respect to fatal falling accidents and other accidents, the only significant effects were found among young males. As concerns women, the association with per capita consumption in the US was weak in comparison with Canada and Europe. The US effect estimate for overall male accidents was however equally strong as in Northern Europe (5.2) or Canada (5.9), and stronger than that found in Central and Southern Europe (2.1 and 1.6, respectively). With respect to alcohol and fatal motor vehicle accidents, the association for men of 3.2 was stronger than in Europe and more similar to the Canadian finding (3.6). CONCLUSIONS Per capita alcohol consumption has at least partly been an explanation for the development of male fatal accidents and particularly motor vehicle accident rates in the post-war United States. High traffic density and relatively high legal limits for drunken driving blood alcohol concentration (BAC) are suggested to explain the strong association found between alcohol and fatal motor vehicle accidents. The results also suggest that a reduction in per capita consumption would have its most preventive impact on fatal accidents among younger males.

Fluctuations in male ischaemic heart disease mortality in Russia 1959-1998: assessing the importance of alcohol.

INTRODUCTION AND AIMS The decline in cardiovascular mortality in Russia following the Soviet anti-alcohol campaign of 1985-1988 and the subsequent increase when these extreme alcohol controls were repealed suggested that alcohol consumption is responsible for a substantial number of ischaemic heart disease (IHD) deaths in Russia. To examine whether a similar conclusion can be drawn on the basis of a time-series analysis covering a longer time period, namely 1959-1998. DESIGN AND METHODS Using ARIMA time-series analysis, the male IHD mortality rates from 1959 to 1998 were analysed in relation to three indicators of alcohol consumption: estimated per capita consumption, mortality from liver cirrhosis and alcohol poisonings. Cigarette sales and lung cancer mortality were used as indicators of smoking. RESULTS Each indicator of alcohol consumption had positive and statistically significant relationships with male IHD mortality in bivariate autoregressive integrated moving average models. The association was stronger in models predicting changes in premature male IHD mortality (30-54 years). At least one alcohol indicator was significantly related to IHD mortality in multivariate models, and in the case of premature IHD mortality, both mortality indicators were significant. DISCUSSION AND CONCLUSIONS The results provide additional empirical evidence supporting alcohols conceivable negative effects on IHD in Russia and the idea that binge drinking could be the mechanism through which this effect is mediated. There were no signs of any protective effects from alcohol among Russian men.

How much alcohol do you buy? A comparison of self-reported alcohol purchases with actual sales

BACKGROUND Unrecorded alcohol has increased in the Nordic countries during recent years, above all in terms of cross-border trade. This implies that trends and levels of per capita consumption would look different without estimates of this source of alcohol, estimates that in Sweden and other countries are made through surveys. AIM The overall aim is to analyse the validity of Swedish survey estimates of alcohol bought in the cross-border trade and possibly to develop weights that can be applied to such estimates. DATA AND METHOD The analysis consists of comparing self-reported purchases of spirits, wine, cider/alcopops and beer at retail monopoly (Systembolaget) during 2008 (n = 18,000) with actual sales during the same period overall and monthly. FINDINGS Of the recorded amount of purchases at Systembolaget, 87% was reported in the survey, compared with the 40-60% usually found for self-reported consumption. Significant differences across beverages were revealed, showing a lower coverage rate for beer and spirits and a higher coverage rate for wine and cider. Changes in purchases of all beverages were captured fairly well, at least changes taking place from one month to another. CONCLUSIONS Self-reported alcohol purchases achieve a higher coverage rate than found typically in studies based on self-reported use of alcohol. If adjustments are to be made to correct for underreporting in self-reported data on alcohol purchases, different weights should be applied to different beverages. Furthermore, at least major changes in how much alcohol is purchased in the population can be monitored using well-designed population surveys.

Changes in alcohol-related harm in Sweden after increasing alcohol import quotas and a Danish tax decrease—an interrupted time-series analysis for 2000–2007

Background Denmark decreased its tax on spirits by 45% on 1 October 2003. Shortly thereafter, on 1 January 2004, Sweden increased its import quotas of privately imported alcohol, allowing travellers to bring in much larger amounts of alcohol from other European Union countries. Although these changes were assumed to increase alcohol-related harm in Sweden, particularly among people living close to Denmark, analyses based on survey data collected before and after these changes have not supported this assumption. The present article tests whether alcohol-related harm in southern Sweden was affected by these changes by analysing other indicators of alcohol-related harm, e.g. harm recorded in different kinds of registers. Methods Interrupted time-series analysis was performed with monthly data on cases of hospitalization due to acute alcohol poisoning, number of reported violent assaults and drunk driving for the years 2000–07 in southern Sweden using the northern parts of Sweden as a control and additionally controlling for two earlier major changes in quotas. Results The findings were not consistent with respect to whether alcohol-related harm increased in southern Sweden after the decrease in Danish spirits tax and the increase in Swedish alcohol import quotas. On the one hand, an increase in acute alcohol poisonings was found, particularly in the 50–69 years age group, on the other hand, no increase was found in violent assaults and drunk driving. Conclusions The present results raise important questions about the association between changes in availability and alcohol-related harms. More research using other methodological approaches and data is needed to obtain a comprehensive picture of what actually happened in southern Sweden.