Pia Mäkelä

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.

Binge drinking and depressive symptoms: a 5-year population-based cohort study

BACKGROUND Only few prospective population studies have been able so far to investigate depression and drinking patterns in detail. Therefore, little is known about what aspect of alcohol consumption best predicts symptoms of depression in the general population. PARTICIPANTS AND DESIGN In this prospective population-based two-wave cohort study, a cohort of alcohol-drinking men and women (n = 15 926) were followed-up after 5 years. A postal questionnaire was sent in 1998 (response proportion 40%) and again in 2003 (response proportion 80% of the baseline participants) to Finnish adults aged 20-54 years at baseline. MEASUREMENTS Alcohol consumption was measured by average intake (g/week) and by measures of binge drinking (intoxications, hangovers and alcohol-induced pass-outs). Depressive symptoms were assessed with the 21-item Beck Depression Inventory. In addition, information from hospital discharge register for depression and alcohol abuse were linked to the data. FINDINGS This study found a positive association between baseline binge drinking and depressive symptoms 5 years later. Adjustment for several possible confounders attenuated the observed relationships only slightly, suggesting that binge drinking contributes independently to the occurrence of depressive symptoms. Binge drinking was related to symptoms of depression independently of average intake. CONCLUSIONS This study supports the hypothesis that heavy drinking, and in particular a binge pattern involving intoxications, hangovers or pass-outs, produces depressive symptoms in the general population. The frequency of hangovers was the best predictor for depressive symptoms.

Episodic heavy drinking in four Nordic countries: a comparative survey.

AIMS The purpose of this study was to compare the phenomenon of episodic heavy drinking (binge drinking) and its different indicators in the Nordic countries. DESIGN A comparative survey of four Nordic countries. SETTING Telephone interviews in Denmark, 1997; Finland, 1996; Norway, 1996; and Sweden 1996-97. PARTICIPANTS Random samples of men and women aged 19-71 years. MEASUREMENTS Episodic heavy drinking was measured by the frequency of subjective intoxication, of drinking six or more drinks at a time (6+), and of negative consequences (mainly hangover symptoms). Additionally, annual consumption and measures of intake per occasion were used. FINDINGS Annual consumption, overall frequency of drinking and frequency of drinking 6+ were highest in Denmark and lowest in Norway. Frequency of subjectively defined intoxication was highest in Finland. There it was clearly higher than the frequency of drinking 6+, whereas in Denmark the contrary was observed. Finnish and Norwegian men and Danish women reported the largest quantities drunk per occasion. Results on 6+ frequency and the prevalence of negative consequences, with annual consumption held constant, suggest that Danes have the least concentrated drinking pattern. With annual consumption held constant, Norwegians report as high a frequency of intoxication, as do Finns. CONCLUSIONS The relations between subjective and more objective measures of episodic heavy drinking vary considerably between the Nordic countries. The results suggest that the definition, acceptability and experience of intoxication vary even when a set of relatively homogeneous countries are compared.

Inequalities in Alcohol-Related Mortality in 17 European Countries : A Retrospective Analysis of Mortality Registers.

Background Socioeconomic inequalities in alcohol-related mortality have been documented in several European countries, but it is unknown whether the magnitude of these inequalities differs between countries and whether these inequalities increase or decrease over time. Methods and Findings We collected and harmonized data on mortality from four alcohol-related causes (alcoholic psychosis, dependence, and abuse; alcoholic cardiomyopathy; alcoholic liver cirrhosis; and accidental poisoning by alcohol) by age, sex, education level, and occupational class in 20 European populations from 17 different countries, both for a recent period and for previous points in time, using data from mortality registers. Mortality was age-standardized using the European Standard Population, and measures for both relative and absolute inequality between low and high socioeconomic groups (as measured by educational level and occupational class) were calculated. Rates of alcohol-related mortality are higher in lower educational and occupational groups in all countries. Both relative and absolute inequalities are largest in Eastern Europe, and Finland and Denmark also have very large absolute inequalities in alcohol-related mortality. For example, for educational inequality among Finnish men, the relative index of inequality is 3.6 (95% CI 3.3–4.0) and the slope index of inequality is 112.5 (95% CI 106.2–118.8) deaths per 100,000 person-years. Over time, the relative inequality in alcohol-related mortality has increased in many countries, but the main change is a strong rise of absolute inequality in several countries in Eastern Europe (Hungary, Lithuania, Estonia) and Northern Europe (Finland, Denmark) because of a rapid rise in alcohol-related mortality in lower socioeconomic groups. In some of these countries, alcohol-related causes now account for 10% or more of the socioeconomic inequality in total mortality. Because our study relies on routinely collected underlying causes of death, it is likely that our results underestimate the true extent of the problem. Conclusions Alcohol-related conditions play an important role in generating inequalities in total mortality in many European countries. Countering increases in alcohol-related mortality in lower socioeconomic groups is essential for reducing inequalities in mortality. Studies of why such increases have not occurred in countries like France, Switzerland, Spain, and Italy can help in developing evidence-based policies in other European countries.

Income differences in life expectancy: the changing contribution of harmful consumption of alcohol and smoking.

Background: Social differences in mortality have increased in high-income countries, but the causes of these changes remain unclear. We quantify the contribution of alcohol and smoking to trends in income differences in life expectancy from 1988 through 2007 in Finland. Methods: An 11% sample from the population registration data of Finns 25 years and older was linked with an 80% oversample of death records. Alcohol-attributable mortality was based on underlying and contributory causes of death on individual death certificates and smoking-attributable mortality on an indirect method that used lung cancer mortality as an indicator for the impact of smoking on mortality. Results: Alcohol- and smoking-attributable deaths reduced life expectancy by about 4.5 years among men. Alcohol-attributable mortality increased and smoking-attributable mortality decreased over the period 1988–2007, leaving the joint contribution stable. Among women, the contribution of these risk factors to life expectancy over the same period increased from 0.7 to 1.2 years. In 2003–2007, life expectancy differentials between the lowest and highest income quintile were 11.4 years (men) and 6.3 years (women). In the absence of alcohol and smoking, these differences would have been 60% less for men and 36% less for women. Life expectancy differentials increased rapidly over the study period; without alcohol and smoking, the increase would have been 69% less among men and 85% less among women. Conclusions: Alcohol and smoking have a major influence on income differences in mortality and, with the exception of smoking among men, their contribution is increasing. Without alcohol and smoking, there would have been little change in life expectancy differentials.

What underlies the high alcohol related mortality of the disadvantaged: high morbidity or poor survival?

Study objective: To investigate whether the large socioeconomic differences in alcohol related mortality can be explained by differences in morbidity or differences in survival. Design: Register linkage study. A nationwide hospital discharge register was linked to population censuses for socioeconomic data and to the cause of death register for mortality follow up. Setting: Finland. Participants: Men and women aged 15 years and older discharged from hospitals with an alcohol related diagnosis in 1991–1996. Measurements: Mortality hazard up to the end of 1997 by socioeconomic category was estimated with Cox’s regression model. Main results: Socioeconomic differences in alcohol related hospitalisation rates were almost as large as those that have been observed for alcohol related mortality. For example, the rate ratio among male unspecialised workers for any alcohol related hospitalisations was 3.6 as compared with upper white collar workers; among women the rate ratio was 2.7. Depending on gender, age, hospitalisation diagnosis, and cause of death, survival after discharge either showed no socioeconomic differences or it was worse among better off groups. Conclusions: The study suggests that differences in survival after hospitalisation do not cause the high socioeconomic differences in alcohol related mortality.

Age, period and cohort analysis of light and binge drinking in Finland, 1968-2008

AIMS To analyse the effects of age, period and cohort (APC) on light and binge drinking in the general population of Finland over the past 40 years. METHODS All analyses were based on six Drinking Habits Surveys between 1968 and 2008 of representative samples of the Finnish population aged between 15 and 69 (n = 16,400). The number of drinking occasions per year involving 1-2 drinks (light) and 4+ or 6+ drinks (binges) was used as a dependent variable in APC modelling. Descriptive cohort profiles and negative binomial models were used to assess the effects of APC. RESULTS Descriptive cohort profiles differed for light and binge drinking. No substantial differences were found across cohort profiles for light drinking, while APC modelling predicted declining cohort and increasing period effects. Differences between cohorts were found for binge drinking, with predictions of slightly declining or increasing period and increasing cohort effects. CONCLUSIONS Light drinking has increased over time for each cohort, with no substantial differences between cohort profiles. Binge drinking has increased with more recent cohorts and there are distinct differences between cohort profiles, especially among women.

Alcohol-related discussions in health care a population view

AIMS The present study aimed to evaluate the frequency and the target group of alcohol screening and brief interventions in health-care settings and how well this level of activity reflects public opinion. DESIGN A general population survey. SETTING AND PARTICIPANTS A random sample of Finns aged 15-69 years with a 74% response rate (n = 2725). MEASUREMENTS Frequency counts were used to evaluate the level of activity. Logistic regression models were used to examine which groups were asked and advised about alcohol use and which groups considered it useful. FINDINGS More than 90% had positive attitudes towards being asked about their alcohol use. Of those who had been in contact with health care (n = 2062) in the 12 months before the survey, 33.3% had been asked about their alcohol use, being most often men, young, heavy drinkers and those of high socio-economic status. Thirty-seven per cent of those who had been asked were given advice, being most often heavy drinkers and those with a normal body mass index. However, 50% of heavy drinkers who had been asked about their alcohol use had not been advised about it. Of those who had been advised, 71.9% considered it useful, especially older subjects, and also including heavy episodic drinkers, although less than others. CONCLUSIONS In Finland, the frequency of health-care professionals asking and giving advice on alcohol is relatively low. However, public opinion towards these discussions is positive. Our results encourage the support and uptake of systematic screenings and brief interventions in health-care settings.

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.

Alcohol-related mortality during an economic boom and recession

Alcohol-related mortality accounts for a considerable proportion of premature mortality in Finland. The end of the 1980s saw a rapid economic boom, followed by a severe recession in the 1990s. In this study, Finnish individual-level cause of death data for 1987–1995 are used to examine how alcohol-related mortality developed during this period and whether the development was similar in subgroups of the population by age, sex and socioeconomic status. A total of 6% of all deaths in the data were alcohol-related. Alcohol-related mortality increased during the economic boom and decreased slightly during the recession. Among men, the relative changes in alcohol-related mortality were largest in the youngest age group, while among women there was no systematic pattern. People with a low socioeconomic status tended to have more negative development of alcohol-related mortality, with a stronger than average increase during the economic boom and with a smaller than average decrease during the recession.