Thor Norström

The role of welfare state principles and generosity in social policy programmes for public health: an international comparative study

BACKGROUND Many important social determinants of health are also the focus for social policies. Welfare states contribute to the resources available for their citizens through cash transfer programmes and subsidised services. Although all rich nations have welfare programmes, there are clear cross-national differences with respect to their design and generosity. These differences are evident in national variations in poverty rates, especially among children and elderly people. We investigated to what extent variations in family and pension policies are linked to infant mortality and old-age excess mortality. METHODS Infant mortality rates and old-age excess mortality rates were analysed in relation to social policy characteristics and generosity. We did pooled cross-sectional time-series analyses of 18 OECD (Organisation for Economic Co-operation and Development) countries during the period 1970-2000 for family policies and 1950-2000 for pension policies. FINDINGS Increased generosity in family policies that support dual-earner families is linked with lower infant mortality rates, whereas the generosity in family policies that support more traditional families with gainfully employed men and homemaking women is not. An increase by one percentage point in dual-earner support lowers infant mortality by 0.04 deaths per 1000 births. Generosity in basic security type of pensions is linked to lower old-age excess mortality, whereas the generosity of earnings-related income security pensions is not. An increase by one percentage point in basic security pensions is associated with a decrease in the old age excess mortality by 0.02 for men as well as for women. INTERPRETATION The ways in which social policies are designed, as well as their generosity, are important for health because of the increase in resources that social policies entail. Hence, social policies are of major importance for how we can tackle the social determinants of health.

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.

Alcohol and mortality: methodological and analytical issues in aggregate analyses.

This supplement includes a collection of papers that aim at estimating the relationship between per capita alcohol consumption and various forms of mortality, including mortality from liver cirrhosis, accidents, suicide, homicide, ischaemic heart disease, and total mortality. The papers apply a uniform methodological protocol, and they are all based on time series data covering the post-war period in the present EU countries and Norway. In this paper we discuss various methodological and analytical issues that are common to these papers. We argue that analysis of time series data is the most feasible approach for assessing the aggregate health consequences of changes in population drinking. We further discuss how aggregate data may also be useful for judging the plausibility of individual-level relationships, particularly those prone to be confounded by selection effects. The aggregation of linear and curvilinear risk curves is treated as well as various methods for dealing with the time-lag problem. With regard to estimation techniques we find country specific analyses preferable to pooled cross-sectional/time series models since the latter incorporate the dubious element of geographical co-variation, and conceal potentially interesting variations in alcohol effects. The approach taken in the papers at hand is instead to pool the country specific results into three groups of countries that represent different drinking cultures; traditional wine countries of southern Europe, beer countries of central Europe and the British Isles and spirits countries of northern Europe. The findings of the papers reinforce the central tenet of the public health perspective that overall consumption is an important determinant of alcohol-related harm rates. However, there is a variation across country groups in alcohol effects, particularly those on violent deaths, that indicates the potential importance of drinking patterns. There is no support for the notion that increases in per capita consumption have any cardioprotective effects at the population level.

The impact of small changes in bar closing hours on violence. The Norwegian experience from 18 cities

Aims To estimate the effect on violence of small changes in closing hours for on-premise alcohol sales, and to assess whether a possible effect is symmetrical. Design, setting, and participants A quasi-experimental design drawing on data from 18 Norwegian cities that have changed (extended or restricted) the closing hours for on-premise alcohol sales. All changes were ≤ 2 hours. Measurements Closing hours were measured in terms of the latest permitted hour of on-premise trading, ranging from 1 a.m. to 3 a.m. The outcome measure comprised police-reported assaults that occurred in the city centre between 10 p.m. and 5 a.m. at weekends. Assaults outside the city centre during the same time window should not be affected by changes in closing hours but function as a proxy for potential confounders, and was thus included as a control variable. The data spanned the period Q1 2000–Q3 2010, yielding 774 observations. Findings Outcomes from main analyses suggested that each 1-hour extension of closing hours was associated with a statistically significant increase of 4.8 assaults (95% CI 2.60, 6.99) per 100 000 inhabitants per quarter (i.e. an increase of about 16%). Findings indicate that the effect is symmetrical. These findings were consistent across three different modelling techniques. Conclusion In Norway, each additional 1-hour extension to the opening times of premises selling alcohol is associated with a 16% increase in violent crime.

The Great Recession, unemployment and suicide

Background How have suicide rates responded to the marked increase in unemployment spurred by the Great Recession? Our paper puts this issue into a wider perspective by assessing (1) whether the unemployment-suicide link is modified by the degree of unemployment protection, and (2) whether the effect on suicide of the present crisis differs from the effects of previous economic downturns. Methods We analysed the unemployment-suicide link using time-series data for 30 countries spanning the period 1960–2012. Separate fixed-effects models were estimated for each of five welfare state regimes with different levels of unemployment protection (Eastern, Southern, Anglo-Saxon, Bismarckian and Scandinavian). We included an interaction term to capture the possible excess effect of unemployment during the Great Recession. Results The largest unemployment increases occurred in the welfare state regimes with the least generous unemployment protection. The unemployment effect on male suicides was statistically significant in all welfare regimes, except the Scandinavian one. The effect on female suicides was significant only in the eastern European country group. There was a significant gradient in the effects, being stronger the less generous the unemployment protection. The interaction term capturing the possible excess effect of unemployment during the financial crisis was not significant. Conclusions Our findings suggest that the more generous the unemployment protection the weaker the detrimental impact on suicide of the increasing unemployment during the Great Recession.

Alcohol, suppressed anger and violence

AIMS Is alcohol related causally to violence, and if so, is the effect of drinking contingent on suppressed anger such that it is strongest among individuals who are highly inclined to withhold angry feelings? We addressed these questions by analysing panel data using a method that diminishes the effects of confounding factors. DESIGN We analysed data on heavy episodic drinking and violent behaviour from the second (1994) and third (1999) waves of the Young in Norway Longitudinal Study (n = 2697; response rate: 67%). The first difference method was applied to estimate the association between these behaviours, implying that changes in the frequency of violence were regressed on changes in the frequency of drinking. Hence, the effects of time-invariant confounders were eliminated. Analyses were conducted for the whole sample, and for groups scoring low, medium and high on a short version of the STAXI anger suppression scale. FINDINGS Changes in drinking were related positively and significantly to changes in violent behaviour, but the alcohol effect varied with the level of suppressed anger: it was strongest in the high-anger group (elasticity estimate = 0.053, P = 0.011) and weakest (and insignificant) in the low-anger group (elasticity estimate = 0.004, P = 0.806). CONCLUSIONS Alcohol use may be related causally to violence, but the effect of drinking is confined to individuals who are inclined to suppress their angry feelings.

The declining trend in Swedish youth drinking: collectivity or polarization?

AIMS Alcohol consumption among youth in Sweden has declined markedly during the last decade. This study aims to tackle the following research questions: (i) how is the decrease in drinking distributed across consumption categories; and (ii) is the pattern of change in consumption consistent with Skogs theory of the collectivity of drinking behaviour? DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS We analysed data from the nationally representative annual school survey of alcohol and drug habits among Swedish 9th-grade students (aged 15-16 years) covering the period 2000-12 (n ≈ 5000/year). Respondents were divided into seven drinking groups based on their relative ranking on consumption, which was measured by beverage-specific quantity and frequency items summarized into a measure of overall drinking in litres of 100% alcohol per year. In addition, the mean number of heavy episodic drinking occasions (HED) was computed for each drinking group. FINDINGS The decline in consumption among Swedish youth was mirrored in all seven drinking groups, although the relative decrease was smaller for heavy drinkers (top 5%) than for light drinkers (below the median). Among the top 5%, the average annual decrease was 2% (P = 0.027), while the corresponding figure for light drinkers was 28.9% (P < 0.001). The reverse pattern was true when looking at the absolute decrease. The decrease among the top 5% accounted for 26.1% of the decrease in mean consumption during the study period, whereas the light drinkers accounted for 2.9%. There was a marked relation between overall consumption, on one hand, and mean consumption and HED, on the other hand, in each of the seven drinking groups. CONCLUSION The marked decrease in youth drinking in Sweden that occurred during the period 2000-12 was manifest at all consumption levels. The findings are consistent with Skogs theory of the collectivity of drinking behaviour.

Social Class, Drinking and Alcohol-related Mortality

The main purpose of this study is to investigate the magnitude of class differences in the distribution of alcohol consumption in Sweden, and to assess whether this is compatible with the observed pattern in class-specific mortality. The emphasis is put on analyses of survey data from 1990, but we also provide an overview of earlier published data. The findings suggest that, over the past 20-30 years, there has been an equalization, or even reversal, between social strata in the average consumption of alcohol, such that the consumption level for manual laborers is now at parity with, or possibly exceeds, the level for non-manual employees. This shift may also have been accompanied by a shift in the dispersion: the 1990 survey data indicate that the consumption distribution for the manual laborers is more skewed than that for the non-manual employees, while no such tendency was detected in the early data. Calculations demonstrated that this difference in dispersion may well account for the elevated rate of alcohol-related mortality among manual laborers. The results are finally discussed as a case of deviation from the general rule of collective change in consumption.

Per capita alcohol consumption and sickness absence in Norway

BACKGROUND There is only one previous study addressing the relationship between population drinking and sickness absence. That study, based on Swedish time-series data, showed a statistically significant relationship between per capita alcohol consumption and the male sickness absence rate. Estimates suggested that a 1-l increase in consumption was associated with a 13% increase in sickness absence among men. In the present study, we aim at replicating and expanding the Swedish study on the basis of data for Norway. METHODS The outcome measure comprised annual data for Norway on registered sickness absence for manual employees covering the period 1957-2001. The unemployment rate was included as a control, as this factor may be correlated with alcohol as well as sickness absence. Alcohol consumption was gauged by sales of alcohol (total and beverage specific by beer, spirits and wine) per inhabitant 15 years and above. The data were analysed using the Box-Jenkins method for time-series analysis. RESULTS The results suggested that a 1-l increase in total consumption was associated with a 13% increase in sickness absence among men (P < 0.05). This corresponds to an elasticity coefficient equal to 0.62. The alcohol effect was not significant for women. Unemployment was negatively associated with the outcome for men as well as for women (P < 0.05). In the beverage-specific analyses, spirits were statistically significant for men (P < 0.05), but not beer and wine. CONCLUSION The present findings strengthen the conclusion from the Swedish study, that sickness absence may be added to the list of indicators of alcohol-related harm.

Changes in Alcohol-Related Harm after Alcohol Policy Changes in Denmark

Objectives: This paper examines changes in alcohol-related harm in Denmark between 2003 and 2005 after changes in alcohol policies were introduced between 2003 and 2005. Methods: Interrupted time series analysis was performed with data on violent assaults and hospitalisations for acute alcohol intoxication from 2003 through 2005. Results: A 26% increase in the number of acute alcohol intoxication hospitalisations among people aged 15 years and younger was detected after the tax reduction on spirits. No significant increase in violent assaults and acute intoxication among adults was found. Conclusions: Even modest alcohol price policies can affect more vulnerable population sub-groups such as under-age youth. Policy makers should consider such consequences when forming economic policies that also have public health implications.