Alcoholism and correlates of mortality. Implications for epidemiology

The alcohol harm paradox and tooth loss among Brazilian older adults

OBJECTIVE

To investigate whether the association between alcohol consumption and tooth loss is modified across socioeconomic positions (SEPs) in Brazilian older adults.

METHODS

We conducted a secondary analysis using data of The Brazilian Longitudinal Study of Ageing (ELSI-Brazil 2015-2016). Effect Measure Modification (EMM) analyses using multivariable Poisson regression models tested whether the association between heavy drinking and lack of functional dentition (FD) varies in magnitude and direction according to levels of Household Wealth index (HWI) and educational attainment, assessed by the Relative Excess Risk due to Interaction (RERI). Sensitivity analyses using lifetime exposure to alcohol were performed.

RESULTS

The analytical sample comprised 8078 participants. Heavy drinkers living in low-wealth households and with lower education presented 7% (95% CI: 1.01-1.14) and 36% (95% CI: 1.28-1.44) higher prevalence of lack of FD, respectively, than their counterparts, and super-additive associations were detected [RERI for HWI: 0.12 (95% CI: 0.02-0.21); RERI for educational attainment: 0.20 (95% CI: 0.09-0.30)]. The associations were also super-additive in the sensitivity analyses when controlling for abstainer reference group bias.

CONCLUSION

We suggest that alcohol consumption disproportionately impacts the prevalence of tooth loss in Brazilian older adults from lower SEP groups.

Causal mechanisms proposed for the alcohol harm paradox-a systematic review

BACKGROUND AND AIMS

The alcohol harm paradox (AHP) posits that disadvantaged groups suffer from higher rates of alcohol-related harm compared with advantaged groups, despite reporting similar or lower levels of consumption on average. The causes of this relationship remain unclear. This study aimed to identify explanations proposed for the AHP. Secondary aims were to review the existing evidence for those explanations and investigate whether authors linked explanations to one another.

METHODS

This was a systematic review. We searched MEDLINE (1946-January 2021), EMBASE (1974-January 2021) and PsycINFO (1967-January 2021), supplemented with manual searching of grey literature. Included papers either explored the causes of the AHP or investigated the relationship between alcohol consumption, alcohol-related harm and socio-economic position. Papers were set in Organization for Economic Cooperation and Development high-income countries. Explanations extracted for analysis could be evidenced in the empirical results or suggested by researchers in their narrative. Inductive thematic analysis was applied to group explanations.

RESULTS

Seventy-nine papers met the inclusion criteria and initial coding revealed that these papers contained 41 distinct explanations for the AHP. Following inductive thematic analysis, these explanations were grouped into 16 themes within six broad domains: individual, life-style, contextual, disadvantage, upstream and artefactual. Explanations related to risk behaviours, which fitted within the life-style domain, were the most frequently proposed (n = 51) and analysed (n = 21).

CONCLUSIONS

While there are many potential explanations for the alcohol harm paradox, most research focuses on risk behaviours while other explanations lack empirical testing.

Socio-economic differences in all-cause mortality in people with alcohol use disorder: a prospective cohort study

BACKGROUND AND AIMS

While alcohol-attributable mortality rates are higher in low socio-economic status (SES) groups, less is known about SES differences in all-cause mortality in alcohol use disorder (AUD). The aim of this study was to explore whether there are SES differences in people with AUD, regarding (i) treatment admission, (ii) all-cause mortality risk and (iii) relative mortality risk.

DESIGN AND SETTING

A prospective cohort study in Norway, follow-up period from 2009-10 to 2013. Data on SES and mortality were obtained through linkages to national registries, using national unique ID numbers.

PARTICIPANTS

AUD patients (age 20+) admitted to treatment in 2009-10 (n = 11 726) and age and gender frequency-matched controls from the general population (n = 12 055).

MEASUREMENTS

The SES indicator was education level (low, intermediate and high). Mortality was calculated as deaths per 1000 person-years during the 4-year observation period.

FINDINGS

Admission to AUD treatment was elevated in the low compared with the high SES categories (OR = 3.31, 95% CI = 3.09, 3.55). Among AUD patients, mortality risk was elevated in the low SES category (HR = 1.23, 95% CI = 1.04, 1.45). Relative mortality risk from AUD was significantly higher in the high SES (HR = 8.65, 95% CI = 6.16, 12.14) compared with the low SES categories (HR = 3.29, 95% CI = 2.61, 4.15).

CONCLUSION

Admission to treatment for alcohol use disorders in Norway appears to decrease with increasing socio-economic status, and relative mortality risk from alcohol use disorder appears to increase with increasing socio-economic status.

Self-help groups reduce mortality risk: a 5-year follow-up study of alcoholics in the Tokyo metropolitan area

The present study aimed to determine whether alcoholics who attend self-help groups experience fewer deaths than those who do not. Subjects were patients from the Alcoholism Treatment Program (ATP) of Matsuzawa hospital. A cohort of alcoholic patients recruited into a prospective study was followed from April 1994 to March 1999. A total of 469 alcoholic patients met the International Classification of Diseases (10th edition) criteria for alcohol dependency. Of these, 94 patients refused to participate in the study, leaving a total of 375 participants. After discharge from the ATP and a complete explanation of the present study, subjects decided whether to attend a self-help group (SHG) or not. The SHG comprised 208 subjects, and the non-self-help group (NSHG) comprised 167 subjects. Outcomes were evaluated with regard to death during follow-up for a mean of 2.4 years. Death was ascertained through the records of the Setagaya Department of Health and Welfare center, Matsuzawa hospital and other hospitals, and through personal contact with informants, relatives, and significant others of subjects. Deaths were confirmed for 47 NSHG subjects and only five SHG subjects. NSHG displayed a significantly decreased cumulative survival compared with SHG (P < 0.0001). Cox proportion hazard analysis was used to examine variables that may help to predict mortality among alcoholics. Alcoholics who attended self-help groups differed from those who did not, with regard to mortality experience. Attending a self-help group represented the most important predictor of prognosis for alcoholics.

Lymphocyte DNA alteration by sub-chronic ethanol intake in alcohol-preferring rats

BACKGROUND

Excessive alcohol consumption has been correlated with a higher susceptibility to infections among humans. Chromosome aberrations and other parameters have been suggested as useful biomarkers in assessing genetic damage due to ethanol intake.

METHODS

Genetically selected alcohol-preferring rats were given water, 10% ethanol and water or 10% ethanol alone for 3 months as fluid to drink. Food was available ad libitum for the entire period. At the end of the sub-chronic treatment their blood and liver were collected. All blood cells were counted and both lymphocytes and hepatocytes of all three groups were tested with the Comet assay to determine whether any DNA damage had occurred.

RESULTS

Only lymphocytes showed DNA damage, with differences among groups. The group that had only ethanol to drink showed greater lymphocyte DNA damage than the ethanol/water and water alone groups. On the other hand, hepatocyte DNA did not show any signs of damage.

CONCLUSIONS

Ten weeks of sub-chronic ethanol treatment produces small but significant damage to lymphocytes but not to hepatocytes, a result which confirms the observations of previous authors, and extends them even to a strain of rats genetically selected for high ethanol intake.

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 unspecialized 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.

Cultural aspects of alcohol use (Part 2)

This is the second of a two‐part article on cultural aspects of alcohol use. Part I introduced the primary and secondary characteristics of culture and the current information on drinking patterns of selected ethnocultural groups. Part 2 includes other selected primary and secondary characteristics of culture such as age, gender, religious affiliation, education, socioeconomic status, and sexual orientation. The article concludes with measures whose effectiveness has been questionable in promoting responsible alcohol use and includes some proven and new recommendations.

A 60-year follow-up of alcoholic men

AIMS

To study the course of male alcohol abuse from age 20 to age 70-80 years.

DESIGN

A prospective multi-disciplinary follow-up of two community cohorts of adolescent males from 1940 until the present.

SETTING AND PARTICIPANTS

Two hundred and sixty-eight former Harvard undergraduates (college sample) and 456 non-delinquent, socially disadvantaged Boston adolescents (core city sample).

MEASUREMENTS

Since adolescence these cohorts have been followed by repeated interview, questionnaires and physical examination. The college cohort has been followed until age 80 and the younger core city cohort until age 70. DSM-III criteria were used to ascertain alcohol abuse and alcohol dependence. At some point during their lives, 54 (20%) of the college men and 140 (31%) of the core city men met criteria for alcohol abuse. Outcome categories were mortality, continued alcohol abuse and stable remission.

FINDINGS AND CONCLUSIONS

These socially divergent cohorts resembled each other in four respects. First, by age 70 chronic alcohol dependence was rare; this was due both to death and to stable abstinence. By age 70, 54% of the 72 successfully followed alcohol-dependent core city men had died, 32% were abstinent, 1% were controlled drinkers and only 12% were known to be still abusing alcohol. By age 70, 58% of the 19 successfully followed college alcohol-dependent men had died, 21% were abstinent, 10.5% were controlled drinkers and only 10.5% were known to be still abusing alcohol. Secondly, in both samples alcohol abuse could persist for decades without remission, death or progression to dependence. Thirdly, among both samples prior alcohol dependence and AA attendance were the two best predictors of sustained abstinence. Fourthly, few life-time symptoms of alcohol abuse were the best predictor of sustained return to controlled-drinking.

Increased mortality among previously apprehended drunken and drugged drivers

Most studies in the field of impaired driving have focused on the hazards imposed on society by the impaired drivers, whereas little attention has been paid to the future outcome of the drivers. The aim of the study was to identify mortality rates and causes of death among drunken and drugged drivers during the years after apprehension. Prospective cohort study on apprehended drunken and drugged drivers, follow-up period: 7.5 years, outcome variable: death. Apprehended drivers 20-39 years old who provided samples positive for alcohol (n=2531) or drugs other than alcohol (n=918) constituting the total national samples of these two driver categories in 1992. The mortality rate among male drunken drivers was higher than in an age-matched Norwegian population (standardised mortality ratio, SMR=3.7 (95% Cl 2.9-4.7). The SMR for drugged drivers was 18.1 (14.9-21.8) for men and 27.9 (14.4-48.8) for women. In a subgroup of male drugged drivers using heroin, SMR was 39.8 (28.8-53.6). The dominant causes of death among drunken and drugged drivers were drug poisoning/overdose, accidents and suicide. Apprehension for drunken or drugged driving and subsequent analytical verification, is an indicator of increased risk of future premature death in the age group 20-39 years, particularly for drugged drivers. To our knowledge this is a new finding, and studies to confirm it should be carried out in other countries. If verified, the results should lead to the consideration of new public health approaches towards apprehended impaired drivers.

Alcohol abuse and mortality: a 40-year prospective study of Norwegian conscripts

The availability of a 40-yr prospective study of more than 40,000 Norwegian men born in 1932-33 constituted the point of departure for assessing excess mortality in alcohol abusers as well as proportions of premature deaths in men attributable to alcohol abuse. The conscripts were medically examined at the military screening, alcohol abuse was categorized for those registered as admitted to alcohol treatment units over a 35-yr period from 1951 to 1987, and these data were further linked to the national death register in 1991. A total of 4468 men died before the age of 60 (10.8% of the sample). Alcohol abusers were found to have an overall excess mortality of 3.3, increasing with age. The cumulative risk of death before the age of 60 yr was estimated to 0.405 for the alcohol abusers, and at least 6.7% of all deaths before the age of 60 could be attributed to alcohol abuse. Presence of chronic diseases at conscription did not confound the estimates of excess mortality in alcohol abusers, neither was any significant interaction between chronic diseases at conscription and later alcohol abuse found with respect to mortality. The most prevalent causes of death in the total sample were, in descending order, cardiovascular diseases, malignant tumors, and accidents. The relative risks for alcohol abusers of death from accidents,cardiovascular diseases, and malignant tumors were estimated as 3.2, 2.5, and 1.8, respectively.

Mortality in men with drinking problems: a 20-year follow-up

This study presents mortality data from a 20-year follow-up of 99 married men with drinking problems. Forty-four of the sample had died and death certificates were obtained on 43. Cause of death was classified according to the Ninth Revision of the International Classification of Diseases. Most of the mortality excess was in the 45-54 year age group. The observed/expected mortality ratio was 3.64 for the group as a whole, 2.93 for the moderately dependent group and 4.41 for the severely dependent group. The commonest causes of death were carcinoma of the bronchus and diseases of the circulatory system. Cause of death was analysed in terms of years of life lost. The number of years of life lost per death was highest for injury and poisoning. Only four of the 43 death certificates obtained mentioned "chronic alcoholism".

Mortality rates and predictors of mortality among late-middle-aged and older substance abuse patients

This study describes mortality rates and predictors of mortality among late-middle-aged and older (55+) substance abuse inpatients (n = 21,139) in Department of Veterans Affairs (VA) Medical Centers in the 4 years after an index episode of care. A total of 24% of the patients died; this mortality rate was 2.64 times higher than expected. Predictors of earlier mortality included older age and nonmarried status, alcohol psychosis and organic brain disorder diagnoses, and several medical diagnoses, including neoplasms, liver cirrhosis, respiratory, endocrine and metabolic, and blood system disorders. Three proxy indicators of illness severity also predicted mortality: more prior inpatient and outpatient medical care and an index episode in an extended care unit. In contrast, more prior outpatient mental health care and remitted status predicted lower mortality. These diagnostic and treatment indicators can be used to identify patients at heightened risk for premature mortality. Moreover, they show that intensive mental health aftercare and remission of substance abuse may delay mortality, even among older patients who have longstanding substance abuse problems.

Risk factors for suicide and undetermined death among in-patient alcoholics in Scotland

Approximately 32,000 patients, representing all those discharged alive from inpatient psychiatric care for alcoholism in Scottish hospitals between 1974 and 1983, were traced for up to 10 years by means of a national record-linkage study in order to ascertain the frequency of suicide and undetermined deaths. The cumulative mortality from these causes was 1.17% at 5 years and 2.01% at 10 years. Several risk factors were investigated, using survival analysis techniques. Sex, age, social class (males only) and marital status were not found to be useful predictors, but the different secondary diagnoses recorded at discharge were associated with major variations in outcome. Attention is drawn to the prognostic importance of a secondary diagnosis of both affective disorders and personality disorders, and some implications of the findings are noted concerning attempts to construct population models linking alcoholism, demographic characteristics and suicide.

Changes in suicide rates after reductions in alcohol consumption and problems in Ontario, 1975-1983

In this paper the relationships among suicide rates in Ontario for males, females and the total population, alcohol consumption, and other alcohol-related problems are examined for the period 1963-1983. Suicide rates, like other alcohol-related problems, were strongly correlated with per capita consumption over the total period. However, during the recent period of stabilization in consumption (1975-83), the correlations were markedly reduced and substantial differences in trends for males and females were observed. The contribution to these diverging trends of such factors as increased treatment of alcohol abuse, rising unemployment, and reduced use of tranquilizing drugs is discussed.

Mortality among alcoholics discharged from a Japanese hospital

A study of mortality among alcoholics was carried out involving patients discharged from the alcoholic ward of a Hamamatsu University-affiliated hospital from 1972 to 1984 (1021 patients). The average age at death was 48.4 years. The causes of death were divided into three groups; 'diseases', 'accidents', 'suicide and homicide', accounting for 73.5%, 10.5% and 7.3% of 257 deaths, respectively. Death rates per 1000 persons for the years at risk were compared with the expected rates for the general population. Briefly, the death rates for patients were more than 10 times as large as those in the general population. Our results showed that liver cirrhosis and heart failure ranked high among the causes of death in alcoholics. Among patients who died, only 3.1% were total abstainers after discharge from hospital, which was an extremely low proportion in comparison with the average cross-total abstinence rate of 25.8% among patients after discharge.

Mortality and illness in male alcoholics: an 8-year follow-up

An 8-year follow-up was conducted on a group of male alcoholics. Their mortality and illness records were examined. The number of observed deaths is 4.7 times that expected. The excess deaths appear to be due to causes frequently associated with alcoholism. Patient characteristics predictive of mortality are presented. Inpatient stays in general hospitals, for reasons other than alcoholism, totaled almost four times the duration expected. The relationships between drinking patterns and hospitalizations are studied. Clinical tests, which show improvement in response to abstinence, are suggested as positive reinforcers for patients in alcoholism treatment.

Mortality of patients dependent on benzodiazepines

For patients dependent on benzodiazepines alone, or in combination with alcohol and/or other legal and illegal drugs, observed mortality rates were compared with the average population, and, in cases of isolated benzodiazepine dependence, also with a control group of non-dependent patients chosen to match each dependent not only in sex and date of birth, but also in pre-existing psychiatric illness besides dependence. For patients with an isolated benzodiazepine dependence, the mortality rate was increased, when compared with the average population, by a ratio of observed to expected numbers of deaths of about 3. However, this mortality rate did not differ from that of the control group (non-dependent patients with comparable psychiatric illnesses). For patients combining benzodiazepines with alcohol among other addictive drugs, and for patients combining benzodiazepines with illegal drugs among other addictive substances, the ratio of observed to excepted numbers of deaths was 6.2 resp. 21, thus corresponding well with other studies on mortality rates associated with alcoholism and dependence on illegal drugs. We conclude that our study does not give evidence of higher risk of early death correlated with dependence on benzodiazepines alone. However, it confirms the well-known fact of increased mortality rates in patients with psychiatric illnesses, especially with dependence on alcohol or illegal drugs.

Assessing needs of alcohol-related services: a social indicators approach

In an effort to assess alcoholism service needs, the social indicators technique was employed. Data on 15 relevant indicators were collected. A three-step analysis was performed. First, cluster/multiple discriminant analyses were conducted to obtain scores reflecting the clustering of cases. Second, factor analysis was employed to derive scores spanning the space covered by the 15 variables. Third, results of both strategies were combined to obtain an overall need index score for each area.

Differential mortality among alcoholics by sample site

In a sample of 1,289 alcoholics from four clinical sites, the overall mortality rate after five to eight years of observation was 22.0 per cent, 3.1 times the expected rate. Patients from the medical and surgical services of a general hospital suffered 4.0 times the rate of expected mortality and died most often of medical causes associated with alcoholism. Patients of the public alcoholism ward had a mortality rate 3.3 times the expected rate and died of causes often associated with low social class. Private psychiatric patients had a mortality rate 2.3 times the expected rate, and psychiatric outpatients had an excess mortality ratio of 2.1. Sample site must be considered as a variable in the study of mortality among alcoholics.