Alcohol-related acute medical reviews in an acute hospital before and immediately after the introduction of minimum unit pricing

Background

Methods

Results

Conclusion

A long-brewing crisis: The historical antecedents of major alcohol policy change in Ireland

INTRODUCTION

The Public Health (Alcohol) Act 2018 in Ireland has been hailed as a world-leading package of alcohol policy reforms. Existing studies have identified the events that led to alcohol emerging onto the high-level policy agenda in Ireland, particularly after 2009. Using policy feedback theory, this study specifically investigates the political consequences of accumulating alcohol-related health and social harms for processes of policy change prior to 2009.

METHODS

The study traces the development of alcohol policy in Ireland over the past three decades. It draws on primary documents, secondary literature and interviews with public health advocates, medical doctors, public health experts and key decision-makers.

RESULTS

The study documents a decades-long struggle to have alcohol recognised as a public health issue in Ireland. We identify 2008/2009 as the key turning point, where policy conditions decisively shifted in a public health direction. We show how insufficient institutional authority and the accumulation of the effects of earlier policy failures helped foster this dynamic. These two factors elevated the visibility of alcohol-related harm for key stakeholders, helping spur greater demand for major policy change.

DISCUSSION AND CONCLUSIONS

Not acting on the population health harms caused by alcohol can produce significant societal costs, particularly when consumption is rising, and entail subsequent political consequences. Understanding of innovations in alcohol policy decision making requires an appreciation of the historical context, including earlier policy failures.

Comparison of different approaches for estimating age-specific alcohol-attributable mortality: The cases of France and Finland

Background

Accurate estimates of the impact of alcohol on overall and age-specific mortality are crucial for formulating health policies. However, different approaches to estimating alcohol-attributable mortality provide different results, and a detailed comparison of age-specific estimates is missing.

Methods

Using data on cause of death, alcohol consumption, and relative risks of mortality at different consumption levels, we compare eight estimates of sex- and age-specific alcohol-attributable mortality in France (2010) and Finland (2013): five estimates using cause-of-death approaches (with one accounting for contributory causes), and three estimates using attributable fraction (AF) approaches.

Results

AF-related approaches and the approach based on alcohol-related underlying and contributory causes of death provided estimates of alcohol-attributable mortality that were twice as high as the estimates found using underlying cause-of-death approaches in both countries and sexes. The differences across the methods were greatest among older age groups An inverse U-shape in age-specific alcohol-attributable mortality (peaking at around age 65) was observed for cause-of-death approaches, with this shape being more pronounced in Finland. AF-related approaches resulted in different estimates at older ages: i.e., mortality was found to increase with age in France; whereas in Finland mortality estimates depended on the underlying assumptions regarding the effects of alcohol consumption on cardiovascular mortality.

Conclusions

While the most detailed approaches (i.e., the AF-related approach and the approach that includes underlying and contributory causes) are theoretically able to provide more accurate estimates of alcohol-attributable mortality, they–especially the AF approaches- depend heavily on data availability and quality. To enhance the reliability of alcohol-attributable mortality estimates, data quality for older age groups needs to be improved.

Is problem alcohol use being detected and treated in Irish general practice?

BACKGROUND

The pattern of alcohol consumption in Ireland has serious societal and health consequences. General practice is well placed to screen for problem alcohol use and to carry out brief interventions. The aims of this study were to investigate the prevalence of documentation of problem alcohol use in patient records in Irish general practice, and to describe the documentation of its diagnosis and treatment.

METHODS

General practitioners (GPs) affiliated with an Irish medical school were invited to participate in the study. One hundred patients were randomly selected from each participating practice using the practice software and the clinical records were reviewed for evidence of problem alcohol use. The following was recorded: patient demographics, whether problem alcohol use was documented, whether they had an intervention, a psychotropic medication or if a referral was made. Descriptive statistics and an estimate of the prevalence were calculated using SPSS and SAS software.

RESULTS

Seventy one percent of the practices participated (n = 40), generating a sample of 3, 845 active patients. Only 57 patients (1.5%, 95% confidence interval 1 to 2%) were identified as having problem alcohol use in the previous two years. 29 (51%) of those with documented problem alcohol use were referred to other specialist services. 28 (49%) received a psychological intervention. 40 (70%) were prescribed psychotropic medications.

CONCLUSION

This is the first large scale study of patient records in general practice in Ireland looking at documentation of screening and treatment of problem alcohol use. It highlights the current lack of documentation of alcohol problems and the need to re-inforce positive attitudes among GPs in relation to preventive work.

Impact of level and patterns of alcohol drinking on coronary heart disease and stroke burden in Argentina

BACKGROUND

Deaths from cardiovascular disease (CVD), including coronary heart disease (CHD) and stroke are expected to increase in Latin America. Moderate and regular alcohol consumption confers cardiovascular protection, while binge drinking increases risk. We estimated the effects of alcohol use on the number of annual CHD and stroke deaths and disability-adjusted life years (DALYs) in Argentina.

METHODS

Alcohol use data were obtained from a nationally representative survey (EnPreCosp 2011), and etiological effect sizes from meta-analyses of epidemiological studies. Cause-specific mortality rates were from the vital registration system.

RESULTS

There were 291,475 deaths in 2010 including 24,893 deaths from CHD and 15,717 from stroke. 62.7% of men and 38.7% of women reported drinking alcohol in the past year. All heavy drinkers (i.e. women who drank >20g/day and men who drank >40g/day of alcohol) met the definition of binge drinking and therefore did not benefit from cardioprotective effects. Alcohol drinking prevented 1,424 CHD deaths per year but caused 935 deaths from stroke (121 ischemic and 814 hemorrhagic), leading to 448 CVD deaths prevented (58.3% in men). Alcohol use was estimated to save 85,772 DALYs from CHD, but was responsible for 52,171 lost from stroke.

CONCLUSIONS

In Argentina, the cardioprotective effect of regular and moderate alcohol drinking is slightly larger than the harmful impact of binge drinking on CVD. However, considering global deleterious effects of alcohol in public health, policies to reduce binge drinking should be enforced, especially for young people. Studies are still needed to elucidate effects on cardiovascular health.

Potential Impact of Minimum Unit Pricing for Alcohol in Ireland: Evidence from the National Alcohol Diary Survey

AIM

One of the main provisions of the Irish Public Health (Alcohol) Bill is the introduction of a minimum unit price (MUP) for alcohol in Ireland, set at €1.00/standard drink. We sought to identify who will be most affected by the introduction of a MUP, examining the relationship between harmful alcohol consumption, personal income, place of purchase and price paid for alcohol.

METHOD

A nationally representative survey of 3187 respondents aged 18-75 years, completing a diary of their previous week's alcohol consumption. The primary outcome was purchasing alcohol at <€1.00/standard drink; secondary outcome was purchasing alcohol at <€1.00/standard drink off-sales. Primary exposures were harmful alcohol consumption (AUDIT-C > 5), low personal annual income (<€20,000) and place of purchase (off- or- on-sales).

RESULTS

One in seven respondents (14%) spent <€1.00/standard drink, with a median spend of 0.78/standard drink. High-risk drinkers (OR 1.56, 95% CI 1.09-2.23), men (OR 1.95, 95% CI 1.43-2.66), people on low income (OR 1.64, 95% CI 1.20-2.23) and those purchasing alcohol off-sales (OR 21.9, 95% CI 12.5-38.1) were most likely to report purchasing alcohol at <€1.00/standard drink. Forty-four per cent of alcohol consumed was purchased off-sales. Of those purchasing off-sales, 30% bought cheap alcohol. High-risk drinkers, men and those on low income were most likely to report paying < €1.00/standard drink off-sales.

CONCLUSION

Heavy drinkers, men and those on low income seek out the cheapest alcohol. The introduction of a MUP in Ireland is likely to target those suffering the greatest harm, and reduce alcohol-attributable mortality in Ireland. Further prospective studies are needed to monitor consumption trends and associated harms following the introduction of minimum unit pricing of alcohol.

The importance of age groups in estimates of alcohol-attributable mortality: impact on trends in Switzerland between 1997 and 2011

BACKGROUND AND AIMS

Monitoring trends of alcohol-attributable mortality is an integral part of the global strategy to reduce the harmful use of alcohol. However, mortality estimates based on different age ranges come to different conclusions. This study examined the impact of including different age ranges in terms of directions of trends of alcohol-attributable mortality during 14 years in Switzerland.

METHOD

Alcohol-attributable mortality was estimated at four time-points between 1997 and 2011 using the Global Burden of Disease 2010 methodology. Estimates were obtained for two age groups: 15-64 years and the total adult population (15 years and older).

RESULTS

Alcohol-attributable mortality among 15-64-year-olds decreased [1997: 1334 deaths, confidence interval (CI) = 1237-1432; 2011: 1019 deaths, CI = 964-1073; trend per year odds ratio (OR) = 0.99, P < 0.001]. In contrast, alcohol-attributable mortality among those 65 and older increased in the same time-period (1997: 581 deaths, CI = -196 to 1357; 2011: 1664 deaths, CI = 957-2372; OR = 1.07, P< 0.001), resulting in an overall increase of alcohol-attributable mortality for 15+ year-olds (1997: 1915 deaths, CI = 1133-2697; 2011: 2683, CI = 1973-3393; OR = 1.02, P < 0.001). The main shift in trends was due to changes in the mixture (e.g. hypertension, ischaemic heart disease) of cardiovascular diseases over time among those 65+ years old.

CONCLUSIONS

Trends in alcohol-attributable mortality may yield qualitatively different results based on the upper age limit for deaths set for these estimates. Global trends of alcohol-attributable mortality between 1997 and 2011 were influenced heavily by changes in the mixture of deaths across cardiovascular diseases. Trends for alcohol-attributable mortality and cross-country comparisons should be reported separately for 15-64 and 65+ year-olds.

Surveillance of US Death Rates from Chronic Diseases Related to Excessive Alcohol Use

AIMS

To assess the utility of multiple-cause (MC) death records for surveillance of US mortality rates from chronic causes related to excessive alcohol use.

METHODS

The Alcohol-Related Disease Impact (ARDI) resource produced estimates of the population 'alcohol attributable fraction' (AAF) due to excessive drinking for each alcohol-related (AAF > 0%) cause of death, and used AAFs to estimate numbers of alcohol-related deaths from alcohol-related underlying causes (UC) in adults age 20-64 and 65+ years in 2006-2010. For surveillance, this study used MC death file to identify individual deaths (2006-2010) with an 'alcohol-induced' cause (AAF = 100%) anywhere on the certificate, and to obtain US rates of premature death (ages 15-64 and 65-74 years) for 1999-2012.

RESULTS

Using the selected MC records, numbers of deaths from alcohol-related chronic UC (2006-2010) were 81% of ARDI estimates for age 20-64, but only 40% for 65+ years. The MC records identified substantial numbers of deaths from causes (e.g. certain infectious diseases) not included as alcohol-related in ARDI, but included in surveillance of premature death rates for chronic UC. Also, premature death rates for chronic alcohol-induced causes using only the UC (as in routine mortality statistics) were only about half the rates based on MC; all rates increased in recent years but some reached statistical significance only by using MC.

CONCLUSIONS

Using MC records underestimated total US deaths from alcohol-related chronic causes as the UC, but enhanced surveillance of rates for premature deaths involving chronic causes that may be related to excessive alcohol use.

Children's awareness of alcohol sponsorship of sport in Ireland: Munster Rugby and the 2008 European Rugby Cup

OBJECTIVES

Examined children's awareness of sport sponsorship in Ireland, focussing on the 2008 European Rugby Cup win by Munster Rugby.

METHODS

Following the Munster Rugby win in 2008, a cross-sectional sample of 1,175 children (7-13 years) in 11 National Schools in Ireland were asked which company sponsored "the cup that Munster won" and were then asked to name the product made by that company.

RESULTS

Significantly higher level of awareness of the sponsor by children in Munster (69.9 %) to those outside Munster (21.5 %). No significant difference in the level of awareness of their product (alcohol) by location (inside Munster 75.9 %, outside Munster 83.6 %).

CONCLUSIONS

These findings support the view for an immediate introduction of legislation banning the sponsorship of sport.

Estimation of usual occasion-based individual drinking patterns using diary survey data

BACKGROUND

In order to successfully address excessive alcohol consumption it is essential to have a means of measuring the drinking patterns of a nation. Owing to the multi-dimensional nature of drinking patterns, usual survey methods have their limitations. The aim of this study was to make use of extremely detailed diary survey data to demonstrate a method of combining different survey measures of drinking in order to reduce these limitations.

METHODS

Data for 1724 respondents of the 2000/01 National Diet and Nutrition Survey was used to obtain a drinking occasion dataset, by plotting the respondent's blood alcohol content over time. Drinking frequency, level and variation measures were chosen to characterise drinking behaviour and usual behaviour was estimated via statistical methods.

RESULTS

Complex patterns in drinking behaviour were observed amongst population subgroups using the chosen consumption measures. The predicted drinking distribution combines diary data equivalent coverage with a more accurate proportion of non-drinkers.

CONCLUSIONS

This statistical analysis provides a means of obtaining average consumption measures from diary data and thus reducing the main limitation of this type of data for many applications. We hope that this will facilitate the use of such data in a wide range of applications such as risk modelling, especially for acute harms, and burden of disease studies.

Undergraduate medical education in substance use in Ireland: a review of the literature and discussion paper

BACKGROUND

Medical complications of substance use are a considerable cause of morbidity and the role of the physician in the care of such problems has consistently been demonstrated. Appropriate knowledge and skills are necessary to carry out this role.

AIMS

To review the literature on training undergraduate medical students in identifying and managing substance misuse and to discuss the implications of this literature for Irish medical education.

METHODS

A search of the literature was performed using keywords; "substance-related disorders", "undergraduate" and "curriculum". All abstracts were reviewed and the full text of relevant abstracts was studied and references reviewed for further articles.

RESULTS

Despite an increase in prevalence of the problem of drug and alcohol use in Ireland and the UK, this has not been reflected in undergraduate medical curricula. In the UK, minimal time is devoted to formal teaching of medical undergraduates in the area of substance misuse and many doctors do not have the appropriate knowledge, skills, attitudes and confidence to treat patients with such problems. In Ireland, no data has reported formal undergraduate teaching hours in the area of drug and alcohol misuse. Internationally, substance abuse curricula have been developed and implemented in medical schools in the United States and Australia.

CONCLUSION

While substance misuse is increasing in prevalence, this is not reflected in the composition of medical curricula, especially in Ireland. International best practice whereby undergraduate curricula that adequately address substance misuse and related issues are systematically developed and implemented, is recommended for adoption by Irish medical schools.

Decline in age of drinking onset in Ireland, gender and per capita alcohol consumption

AIMS

We sought to examine the fall in age of first drinking in Ireland and to determine whether there were gender differences. We also aimed to determine whether there was a relationship between the per capita alcohol consumption evident when people entered later adolescence and their age of drinking onset.

METHODS

Information on age of first drinking was based on retrospective recall of 9832 interviewees from the pooled samples obtained from two population surveys. We examined the change in age of first drinking, by birth cohort and by gender, utilizing survival analysis. We utilized Pearson's correlation to explore the relationship between median age of first drinking within each birth cohort and the mean per capita alcohol consumption when that birth cohort was aged 16 years.

RESULTS

The average age of first drinking fell steadily and significantly across birth cohorts from the late 1930s to the early 1990s. This change was significantly greater in females. Per capita alcohol consumption was very highly negatively correlated with the median age at which each birth cohort commenced drinking (r = -0.96, P < 0.001).

CONCLUSION

The prevailing level of drinking in society at the point when young people enter later adolescence is very closely associated with the age at which they commence drinking. Per capita consumption may be contributing to the changes in age of onset of drinking and/or both may share a similar set of determinants. In light of this apparent relationship, it is possible that efforts to reduce per capita alcohol consumption may also reduce underage drinking.

Prevalence of oral mucosal abnormalities in addiction treatment centre residents in Southern Ireland

This study examines the prevalence of oral mucosal lesions and conditions among Irish addiction treatment centre residents and explores the feasibility and acceptability of a targeted oral cancer screening programme for such individuals. Four alcohol addiction treatment centres were visited periodically over a 12-month period. Two hundred and twenty residents (78% of 283 targeted) were interviewed regarding their alcohol, tobacco and drug habits (type, quantity, duration), and attitudes to dental care. Comprehensive oral examinations were performed. All potentially sinister soft tissue lesions/symptoms were referred for further investigation. Data analysis utilised SPSS-18. Ten participants who denied a history of alcohol/drug addiction were excluded from the main study. Remaining 210 participants comprised 148 males (70%) and 62 females (30%), ranging from 18 to 73 years of age, (mean 37.65; S.D. 13.82); 60% were under 40. High rates of tobacco and alcohol usage were recorded, 53% reported dual addiction (drug+alcohol), 44% alcohol only, 3% drug only. The prevalence of mucosal abnormalities was 29% with 84 mucosal abnormalities/symptoms detected in 61 subjects, comprising 28 extra-oral lesions/symptoms and 56 intra-oral lesions. Residents with mucosal abnormalities were significantly older (mean 41.8 years; S.D. 14.3) than those without such lesions (mean 35.95; S.D. 13.3), (p<0.05). Highest prevalences were noted for candidiasis (3.8%), facial scaring/laceration (3.8%), intra-oral lumps/swellings (2.9%), lymphadenopathy (2.9%) and hoarseness (1.9%). Four red areas suggestive of erythroplasia and two leukoplakic lesions were detected. Study addresses the paucity of data on the prevalence of oral mucosal lesions in addicted persons in Southern Ireland. Thirteen extra-oral lesions/symptoms and 19 intra-oral lesions were potentially significant. Despite the relatively poor follow-up compliance rate (33%), two premalignant lesions were confirmed in the main study group, yielding a detection rate of 0.9%. Results suggest that an oral cancer screening programme targeted at individuals in addiction treatment centres may provide a feasible way to access persons with a history of tobacco and alcohol abuse. A high rate of untreated disease and emergency only attendance was seen in this study suggesting a lack of engagement with GDP services. Opportunistic screening in primary care is therefore unlikely to capture this cohort. Inclusion of oral cancer screening in the routine medical examination given to residents of addiction treatment centres may provide an efficient and effective way to detect potentially malignant lesions in these high-risk individuals.

Estimating alcohol-related premature mortality in San Francisco: use of population-attributable fractions from the global burden of disease study

BACKGROUND

In recent years, national and global mortality data have been characterized in terms of well-established risk factors. In this regard, alcohol consumption has been called the third leading "actual cause of death" (modifiable behavioral risk factor) in the United States, after tobacco use and the combination of poor diet and physical inactivity. Globally and in various regions of the world, alcohol use has been established as a leading contributor to the overall burden of disease and as a major determinant of health disparities, but, to our knowledge, no one has characterized alcohol-related harm in such broad terms at the local level. We asked how alcohol-related premature mortality in San Francisco, measured in years of life lost (YLLs), compares with other well-known causes of premature mortality, such as ischemic heart disease or HIV/AIDS.

METHODS

We applied sex- and cause-specific population-attributable fractions (PAFs) of years of life lost (YLLs) from the Global Burden of Disease Study to 17 comparable outcomes among San Francisco males and females during 2004-2007. We did this in three ways: Method 1 assumed that all San Franciscans drink like populations in developed economies. These estimates were limited to alcohol-related harm. Method 2 modified these estimates by including several beneficial effects. Method 3 assumed that Latino and Asian San Franciscans drink alcohol like populations in the global regions related to their ethnicity.

RESULTS

By any of these three methods, alcohol-related premature mortality accounts for roughly a tenth of all YLLs among males. Alcohol-related YLLs among males are comparable to YLLs for leading causes such as ischemic heart disease and HIV/AIDS, in some instances exceeding them. Latino and black males bear a disproportionate burden of harm. Among females, for whom estimates differed more by method and were smaller than those for males, alcohol-related YLLs are comparable to leading causes which rank somewhere between fifth and fourteenth.

CONCLUSIONS

Alcohol consumption is a major contributor to premature mortality in San Francisco, especially among males. Interventions to avert alcohol-related harm in San Francisco should be taken at the population level and deserve the same attention that is given to other major risk factors, such as smoking or obesity.