Different measures of alcohol use as predictors of DSM-5 alcohol use disorder among adolescents - A cohort study from Sweden

BACKGROUND AND AIMS

This study addresses a significant gap in existing research by investigating the longitudinal relationship between various measures of alcohol use and the development of alcohol use disorders (AUDs) in a cohort of Swedish adolescents.

METHODS

A prospective longitudinal survey was conducted on 3999 adolescents in Sweden who were in 9th grade in 2017 and were followed up in 2019. Baseline assessments included lifetime alcohol use, recent use (past 30 days), risky drinking (AUDIT-C), and heavy episodic drinking (HED). Follow-up assessments comprised eleven items measuring DSM-5 AUD criteria. The study explores prospective associations between these diverse alcohol use measures and the occurrence of AUD, while also calculating population attributable fractions (PAF).

FINDINGS

The proportion of alcohol consumers who met the criteria for AUD at follow-up was 31.8%. All baseline measures of alcohol use exhibited associations with subsequent AUD. Notably, the HED group demonstrated the highest prevalence of AUD at 51.4% (p<.001). However, when calculating PAFs, any lifetime alcohol use emerged as the most substantial contributor, accounting for 10.8% of all subsequent AUD cases.

CONCLUSIONS

This study underscores that alcohol use during mid-adolescence heightens the risk of developing AUD in late adolescence. Among the various measures, heavy episodic drinking presents the highest risk for later AUD. From a public health perspective, preventing any alcohol use emerges as the most effective strategy to mitigate the population-level burden of disease of AUD.

Associations Between Cannabis Use and Mental Distress in Young People: A Longitudinal Study

PURPOSE

Despite a large number of studies on the relation between cannabis use and mental distress in adolescence, results are inconclusive regarding the nature of this association. The aim of the present study is to expand this body of research by analyzing the within-person association between changes in cannabis use and changes in mental distress among young people.

METHODS

We used longitudinal data from a national sample of young people in Norway. The cohort was assessed in 1992 (T1), 1994 (T2), 1999 (T3), and 2005 (T4). The cumulative response rate was 60%. Respondents who participated in all four waves, aged 11-18 years at T1 (N = 1,988) were analyzed. Within-person association between changes in cannabis use and changes in mental distress in terms of symptoms of depression, anxiety, suicidal ideation, and deliberate self-harm were estimated by applying fixed-effects modeling.

RESULTS

For males, an increase in cannabis use from no use to more than 10 times/year was significantly associated with increased risk for anxiety (relative risk [RR]: 1.72, p = .009), depressed mood (RR: 1.49, p < .001), and suicidal ideation (RR: 3.43, p = .012). For females, the corresponding increase in cannabis use yielded an increased risk for anxiety (RR: 1.38, p = .023) and suicidal ideation (RR: 2.47, p = .002).

DISCUSSION

Increased cannabis use during adolescence and young adulthood seem to increase the risk for symptoms of mental distress. Although the associations appear to be more pronounced among males, it was only for depression that there was a statistically significant gender difference in the association.

The impact of the COVID-19 pandemic on mortality in Sweden-Did it differ across socioeconomic groups?

The characterization of the socioeconomic profile of COVID-19 mortality is limited. Likewise, the mapping of potential indirect adverse outcomes of the pandemic, such as suicide and alcohol abuse, along socioeconomic lines is still meagre. The main aim of this paper is to (i) depict SES-differences in COVID-19 mortality, and (ii) to assess the impact of the COVID-19 pandemic on suicide and alcohol mortality across socioeconomic groups. We used Swedish monthly data spanning the period January 2016-December 2021. We chose education as indicator of socioeconomic status (SES). The following causes of deaths were included in the analysis: COVID-19, all-cause mortality excluding COVID-19, suicide and a composite index of alcohol-specific deaths. SARIMA-modelling was used to assess the impact of the pandemic on suicide and alcohol-specific mortality. Two alternative measures of the pandemic were used: (1) a dummy that was coded 1 during the pandemic (March 2020 and onwards), and 0 otherwise, and (2) the Oxford COVID-19 Government Response Tracker's Stringency Index. There was a marked SES-gradient in COVID-19 mortality in the working-age population (25-64) which was larger than for other causes of death. A SES-gradient was also found in the old-age population, but this gradient did not differ from the gradient for other causes of death. The outcome from the SARIMA time-series analyses suggested that the pandemic did not have any impact on suicide or alcohol-specific mortality in any of the educational and gender groups.

The public-private decision for alcohol retail systems: Examining the economic, health, and social impacts of alternative systems in Finland

Background: Organising alcohol retail systems with more or less public ownership has implications for health and the economy. The aim of the present study was to estimate the economic, health, and social impacts of alcohol use in Finland in 2018 (baseline), and in two alternative scenarios in which current partial public ownership of alcohol retail sales is either increased or fully privatised. Methods: Baseline alcohol-attributable harms and costs were estimated across five categories of death, disability, and criminal justice. Two alternate alcohol retail systems were defined as privately owned stores selling: (1) only low strength alcoholic beverages (public ownership scenario, similar to Sweden); or (2) all beverages (private ownership scenario). Policy analyses were conducted to estimate changes in alcohol use per capita. Health and economic impacts were modelled using administrative data and epidemiological modelling. Results: In Finland in 2018, alcohol use was estimated to be responsible for €1.51 billion (95% Uncertainty Estimates: €1.43 billion, €1.58 billion) in social cost, 3,846 deaths, and 270,652 criminal justice events. In the public ownership scenario, it was estimated that alcohol use would decline by 15.8% (11.8%, 19.7%) and social cost by €384.3 million (€189.5 million, €559.2 million). Full privatisation was associated with an increase in alcohol use of 9.0% (6.2%, 11.8%) and an increase in social cost of €289.7 million (€140.8 million, €439.5 million). Conclusion: The outcome from applying a novel analytical approach suggests that more public ownership of the alcohol retail system may lead to significant decreases in alcohol-caused death, disability, crime, and social costs. Conversely, full privatisation of the ownership model would lead to increased harm and costs.

The association between population drinking and ischemic heart disease mortality in educational groups

A large number of observational studies have found a J-shaped relationship between alcohol intake and ischemic heart disease (IHD) risk. However, some studies suggest that the alleged cardio-protective effect may be an artifact in the way that the elevated risk for abstainers is due to self-selection on risk factors for IHD. The aim of this paper is to estimate the association between alcohol and IHD-mortality on the basis of aggregate time-series data, where the problem with selection effects is not present. In addition, we will analyze SES-specific mortality to investigate whether there is any socio-economic gradient in the relationship at issue. SES was measured by educational level. We used IHD-mortality in three educational groups as outcome. Per capita alcohol consumption was proxied by Systembolaget's alcohol sales (litres of alcohol 100% per capita 15+). Swedish quarterly data on mortality and alcohol consumption spanned the period 1991Q1-2020Q4. We applied SARIMA time-series analysis. Survey data were used to construct an indicator of heavy SES-specific episodic drinking. The estimated association between per capita consumption and IHD-mortality was positive and statistically significant in the two groups with primary and secondary education, but not in the group with postsecondary education. The association was significantly stronger the lower the educational group. Although the associations were generally stronger for males than for females, these differences were not statistically significant (P > 0.05). Our findings suggest that the detrimental impact of per capita consumption on IHD-mortality was stronger the lower the educational group.

Is there a link between all-cause mortality and economic fluctuations?

Background: All-cause mortality is a global indicator of the overall health of the population, and its relation to the macro economy is thus of vital interest. The main aim was to estimate the short-term and the long-term impact of macroeconomic change on all-cause mortality. Variations in the unemployment rate were used as indicator of temporary fluctuations in the economy. Methods: We used time-series data for 21 OECD countries spanning the period 1960-2018. We used four outcomes: total mortality (0+), infant mortality (<1), mortality in the age-group 20-64, and old-age mortality (65+). Data on GDP/capita were obtained from the Maddison Project. Unemployment data (% unemployed in the work force) were sourced from Eurostat. We applied error correction modelling to estimate the short-term and the long-term impact of macroeconomic change on all-cause mortality. Results: We found that increases in unemployment were statistically significantly associated with decreases in all mortality outcomes except old-age mortality. Increases in GDP were associated with significant lowering long-term effects on mortality. Conclusions: Our findings, based on data from predominantly affluent countries, suggest that an increase in unemployment leads to a decrease in all-cause mortality. However, economic growth, as indicated by increased GDP, has a long-term protective health impact as indexed by lowered mortality.

Drinking and acquisition of unrecorded alcohol across educational groups in Sweden

INTRODUCTION

It is estimated that 18.5% of total alcohol consumption in Sweden in 2018 was unrecorded. However, little is known about the socio-economic profile of consumers of unrecorded alcohol. The aim of this study was to elucidate this issue by analysing data from a unique Swedish national repeated cross-sectional alcohol use survey.

METHODS

Individual-level information on alcohol consumption and socio-economic status (SES) for the years 2013-2018 was retrieved from the Monitoring Project; a nationally representative monthly alcohol use survey. The analytical sample comprised 64 375 respondents aged 25-74 years. SES was measured by educational level. We used three educational groups: (i) low (<10 years); (ii) intermediate (10-12 years); and (iii) high (13+ years). We included indicators of the following sources of unrecorded alcohol consumption: travellers' import, smuggled alcohol, home production, internet and illicit home-distilling. We estimated adjusted SES-specific means of the various forms of unrecorded consumption. The means were adjusted for the effects of age, sex and region.

RESULTS

There were no significant educational differences in the total of unrecorded alcohol consumption; the same holds true for home-production and internet. However, with respect to smuggled and home-distilling, a statistically significant educational gradient was observed with the lowest educational group scoring approximately four times higher than the highest.

DISCUSSION AND CONCLUSIONS

Our findings suggest that there are no differences across educational groups in the consumption of unrecorded alcohol as a whole. However, consumption of smuggled alcohol and illicitly distilled spirits is elevated in the low educational group.

Is the theory of collectivity of drinking cultures valid across educational groups?

Introduction

To explore whether Skog's theory of collectivity of drinking cultures is valid across groups with different socioeconomic position (SEP).

Methods

Individual‐level information on alcohol consumption and SEP for the years 2004–2014 were retrieved from the Monitoring Project; a nationally representative monthly alcohol use survey. The analytical sample consisted of 162 369 respondents aged 25–79 years. SEP was measured by education level. Alcohol use was measured by yearly volume of consumption and frequency of heavy episodic drinking (HED). Respondents were divided into six SEP‐groups based on their education level and sex. Mean yearly volume consumption and prevalence of monthly HED was calculated for each group and graphically plotted against the overall mean volume of consumption.

Results

The yearly changes in overall mean consumption during the study period reflected a collective shift in drinking across groups with basic, intermediate and high education. There were also indications that changes in overall mean consumption reflected collective shifts in the prevalence of HED across the SEP‐groups. Moreover, while the magnitude of the associations for both average volume and HED differed somewhat in strength across the SEP‐groups, they were clearly in the same, positive, direction.

Discussion and Conclusions

Our findings add support for including a socioeconomic dimension to Skog's theory of collectivity of drinking cultures. Future studies should replicate our analyses on cases and periods with more tangible changes in the price and availability of alcohol.

The Link Between Alcohol Sales and Alcohol-Related Harm in Finland, 1995-2016

OBJECTIVE

A key assumption in Finnish alcohol policy is that the officially registered alcohol consumption (i.e., alcohol sales) is closely related to alcohol-related harm. During the last two decades, a sizable part of total alcohol consumption, however, comprises unrecorded consumption, which may potentially make alcohol sales less powerful as a predictor of alcohol-related harm. This article thus aims to estimate the relationship between alcohol sales and alcohol-related harm on the basis of more recent Finnish time-series data.

METHOD

Data on alcohol sales (liters of 100% alcohol/capita age 15 years and older) were obtained from the National Institute for Health and Welfare in Finland. As indicators of harm, we used police-reported assaults and three forms of mortality: alcohol-specific mortality, accidents, and suicide. Quarterly data on mortality and alcohol sales spanned the period 1995-2016, and data on police-reported offenses covered the period 1990-2016. Data were analyzed by SARIMA (Seasonal Autoregressive Integrated Moving Average) modeling.

RESULTS

A positive and significant association between alcohol sales and all harm indicators was found. A 1-L increase in alcohol sales per capita was associated with a 20% increase in alcohol-specific mortality, a 12% increase in assaults, and a 5%-6% increase in accidents and suicide. These estimates are in line with earlier findings estimated on data for the period when unrecorded alcohol consumption was less common in Finland.

CONCLUSIONS

The results provide support for a continued strong relationship between alcohol sales and alcohol-related harm in Finland. Policy measures aimed at lowering alcohol sales were supported from these results.

The link between per capita alcohol consumption and alcohol-related harm in educational groups

INTRODUCTION AND AIMS

Research based on individual-level data suggests that the same amount of alcohol yields more harm in low-socioeconomic status (SES) groups than in high-SES groups. Little is known whether the effect of changes in population-level alcohol consumption on harm rates differs by SES-groups. The aim of this study was to elucidate this issue by estimating the association between per capita alcohol consumption and SES-specific rates of alcohol-related mortality.

DESIGN AND METHODS

Per capita alcohol consumption was proxied by Systembolaget's alcohol sales (litres 100% alcohol per capita 15+). Quarterly data on mortality and alcohol consumption spanned the period 1991Q1-2017Q4. We used two outcomes: (i) alcohol-specific mortality (deaths with an explicit alcohol diagnosis); and (ii) violent deaths. SES was measured by education. We used three educational groups: (i) low (<10 years); (ii): intermediate (10-12 years); and (iii) high (13+ years). We applied error correction modelling to estimate the association between alcohol and alcohol-specific mortality, and seasonal autoregressive integrated moving average-modelling to estimate the association between alcohol and violent deaths.

RESULTS

The estimated associations between per capita consumption and the two outcomes were positive and statistically significant in the two groups with low and intermediate education, but not in the high education group. There was a significant gradient in the level of association between alcohol consumption and alcohol-related harm by educational group; the association was stronger the lower the educational group.

DISCUSSION AND CONCLUSIONS

Our findings suggest that the association between per capita consumption and alcohol-related harm was stronger the lower the educational group.

Is there a link between cardiovascular mortality and economic fluctuations?

Background: Unemployment might affect several risk factors of cardiovascular disease (CVD), which is the leading cause of death globally. The characterisation of the relation between these two phenomena is thus of great significance from a public-health perspective. The main aim of this study was to estimate the association between the unemployment rate and mortality from CVD and from coronary heart disease (CHD). Additional aims were (a) to assess whether the associations are modified by the degree of unemployment protection; (b) to determine the impact of GDP on heart-disease mortality; and (c) to assess the impact of the Great Recession in this context. Methods: We used time-series data for 32 countries spanning the period 1960-2015. We applied two alternative modelling strategies: (a) error correction modelling, provided that the data were co-integrated; and (b) first-difference modelling in the absence of co-integration. Separate models were estimated for each of five welfare state regimes with different levels of unemployment protection. We also performed country-specific ARIMA-analyses. Results: Because the data did not prove to be co-integrated, we applied first-difference modelling. The estimated effect of unemployment and GDP on CVD as well as CHD was statistically insignificant across age and sex groups and across the various welfare state regimes. An interaction term capturing the possible excess effect of unemployment during the Great Recession was also statistically insignificant. Conclusions: Our findings, based on data from predominantly affluent countries, suggest that heart-disease mortality does not respond to economic fluctuations.

Effects of Local Alcohol Prevention Initiatives in Swedish Municipalities, 2006-2014

Background: Several components of the Swedish alcohol policy, e.g., pricing and availability, weakened when Sweden joined the EU in 1995. To counteract the possible negative effects of this, emphasis was placed on the local level as an important arena of alcohol prevention. Thus, considerable efforts were made to strengthen alcohol prevention in Swedish municipalities. Objectives: The aim of this study was to examine whether local alcohol prevention reduced consumption and alcohol-related harm in Swedish municipalities. Methods: Alcohol prevention was monitored using a composite measure called the Alcohol Prevention Magnitude Measure (APMM), with subcategories of staff and budget, inspections and licenses, policy, activities, and cooperation. APMM and its categories were analysed in relation to alcohol consumption and harm over time, 2006-2014. A fixed effects model was used with 63% (N=182, consumption) and 71% (N=207, harm) of 290 Swedish municipalities, respectively, included in the analyses. Results: The main results suggest that when APMM increases with 1 percent, the alcohol-related mortality decreases with 0.26 percent, controlled for changes in population size, median income, unemployment, and post-secondary education. In light of this result, the estimated effect of APMM on alcohol consumption (sales) is small (0.02 percent decrease); possible explanations for this are discussed in the article. Conclusion: The overall results indicate that local alcohol prevention initiatives in Sweden have reduced some forms of alcohol-related harm, not least alcohol-related mortality, during the period 2006-2014. Further studies are needed to assess the generalizability of the present study.

Estimating the public health impact of disbanding a government alcohol monopoly: application of new methods to the case of Sweden

BACKGROUND

Government alcohol monopolies were created in North America and Scandinavia to limit health and social problems. The Swedish monopoly, Systembolaget, reports to a health ministry and controls the sale of all alcoholic beverages with > 3.5% alcohol/volume for off-premise consumption, within a public health mandate. Elsewhere, alcohol monopolies are being dismantled with evidence of increased consumption and harms. We describe innovative modelling techniques to estimate health outcomes in scenarios involving Systembolaget being replaced by 1) privately owned liquor stores, or 2) alcohol sales in grocery stores. The methods employed can be applied in other jurisdictions and for other policy changes.

METHODS

Impacts of the privatisation scenarios on pricing, outlet density, trading hours, advertising and marketing were estimated based on Swedish expert opinion and published evidence. Systematic reviews were conducted to estimate impacts on alcohol consumption in each scenario. Two methods were applied to estimate harm impacts: (i) alcohol attributable morbidity and mortality were estimated utilising the International Model of Alcohol Harms and Policies (InterMAHP); (ii) ARIMA methods to estimate the relationship between per capita alcohol consumption and specific types of alcohol-related mortality and crime.

RESULTS

Replacing government stores with private liquor stores (Scenario 1) led to a 20.0% (95% CI, 15.3-24.7) increase in per capita consumption. Replacement with grocery stores (Scenario 2) led to a 31.2% (25.1-37.3%) increase. With InterMAHP there were 763 or + 47% (35-59%) and 1234 or + 76% (60-92%) more deaths per year, for Scenarios 1 and 2 respectively. With ARIMA, there were 850 (334-1444) more deaths per year in Scenario 1 and 1418 more in Scenario 2 (543-2505). InterMAHP also estimated 10,859 or + 29% (22-34%) and 16,118 or + 42% (35-49%) additional hospital stays per year respectively.

CONCLUSIONS

There would be substantial adverse consequences for public health and safety were Systembolaget to be privatised. We demonstrate a new combined approach for estimating the impact of alcohol policies on consumption and, using two alternative methods, alcohol-attributable harm. This approach could be readily adapted to other policies and settings. We note the limitation that some significant sources of uncertainty in the estimates of harm impacts were not modelled.

Extended opening hours at nightclubs in Visby: An evaluation of a trial in the summer of 2014

Background and aims:

During 10 weeks in the summer 2014 opening hours in nightclubs in Visby (Sweden) were extended by 1 hour, postponing the permitted closing time from 2 to 3 a.m. A number of preventive efforts such as Responsible Server Training, and an intensified cooperation between the police and the nightclubs were strengthened in connection with the trial. The aim of this study was to evaluate the impact of this trial on police-reported violence.

Data and methods:

To estimate the effect of the trial on violence, we compared the violence rate during the intervention period (week 24–week 33, 2014) with the violence rate in the corresponding period in Visby in 2010–2013. The intervention period thus comprised 10 weeks, and the pre-intervention period 40 weeks. As outcome measure we chose police-reported assaults that had occurred at night (midnight–6 a.m.). As control series we used assaults daytime (6 a.m.–midnight). The intervention effect was estimated with the method of “difference in differences” (DiD). Interviews with key informants provided the study with an explanatory context for the trial outcomes.

Results:

The intervention effect was strongly statistically significant with a reduction of 3.336 reported assaults at night per week compared to the pre-intervention period. This represents a decrease of 71%.

Conclusion:

The trial with an extension of opening hours at nightclubs in Visby was followed by a reduction in police-reported violence. This unexpected outcome is likely to be the result of (i) the simultaneous strengthening of efficient preventive measures, and (ii) a decreased congestion in the streets resulting from increased spread in closing hours.

The Link Between Per Capita Alcohol Consumption and Alcohol-Related Harm in Sweden, 1987-2015

OBJECTIVE

Recent studies have suggested a weakening of the relationship between population drinking and harm in Sweden. The aim of the present article was to estimate this association on the basis of more recent Swedish time-series data.

METHOD

The Swedish state monopoly's (Systembolaget) alcohol sales were used as a proxy for population drinking, expressed in liters 100% alcohol per capita ages 15 and older. As indicators of harm we used mortality (cirrhosis mortality, accidents, and suicide), police-reported assaults, and drink driving. Quarterly data on mortality and alcohol consumption spanned the period 1987Q1-2015Q1, and the data on police-reported offenses covered the period 1995Q1-2015Q1. Data were analyzed by applying the technique of seasonal autoregressive integrated moving average (SARIMA) modeling.

RESULTS

We found a positive and statistically significant association between population drinking and all harm indicators. A 1 L increase in per capita consumption was associated with a 19% increase in cirrhosis mortality and a 17% increase in drink driving. The effects on the other harm rates were estimated to be between 11% and 13%. These estimates are in line with earlier findings except the estimate for cirrhosis, which was weaker and now similar to findings for other countries.

CONCLUSIONS

The results provide continuing support for a strong relationship between population drinking and alcohol-related harm in Sweden. Policy measures aimed at lowering the level of drinking gained support from these results.

Effects on Alcohol Consumption and Alcohol Related Harm of a Community-Based Prevention Intervention With National Support in Sweden

BACKGROUND

In order to strengthen local alcohol prevention work in Sweden the Swedish government has for the past almost 15 years commissioned the Public Health Agency of Sweden to initiate a series of community-based alcohol prevention projects. The latest of these, labeled local development with ambitions (LUMA), included 25 municipalities in Sweden.

OBJECTIVES

Aim of this study is to examine if LUMA municipalities that received financial support, with requirements, increased local alcohol prevention and if alcohol consumption and harm declined.

METHODS

Twenty-five Swedish municipalities that received financial support aiming to strengthen local alcohol preventing activities (intervention group) were compared to municipalities that did not receive such support (control group, N = 224), before, during, and after the intervention period. Two composite measures of policy and activity were created and used. The composite activity measure includes seven activity indicators and the composite policy measure includes six policy indicators. Harm measures have been selected based on several recommended indicators for monitoring alcohol, tobacco, and other drugs in Sweden. A fixed effects model was used to analyze data.

RESULTS

The results reveal that prevention activities increased and several alcohol-related harm indicators were reduced in intervention municipalities (LUMA) compared with in control municipalities.

CONCLUSIONS

It seems as if financial support, combined with specific requirements and support from the regional and national level, can stimulate local alcohol prevention activities and have a significant effect on alcohol consumption and alcohol-related harm. Similar evaluations in other countries would be of great value for assessing the generalizability of findings.

Social Class and Alcohol Use by Youth: Different Drinking Behaviors, Different Associations?

OBJECTIVE

Low socioeconomic status (SES) is related to hazardous alcohol use in adults, and the association seems to be stronger for more deviant and harmful drinking behaviors. We examined whether a similar pattern was present among adolescents.

METHOD

Data stem from a Norwegian school survey of 14- to 17-year-olds (n = 12,966; response rate in participating schools: 86%). Parental education (high/ middle vs. low) was our main SES indicator. The outcomes comprised lifetime and past-year drinking and intoxication, and past-year symptoms of excessive drinking. We used Poisson regression to estimate relative risks (RR) and post-estimation Wald F tests to compare coefficient estimates.

RESULTS

Parental education was related inversely to the lifetime measures of drinking and intoxication among all students but the 17-year-olds. The impact on any intoxication episodes was significantly stronger than that on any alcohol use only among the 14-year-olds (RR = 1.79, 95% CI [1.31, 2.43] vs. RR = 1.21, 95% CI [0.98, 1.49]) (p < .001). Among past-year drinkers at all ages (14-17 years; n = 7,796), the differential impact of low parental education was particularly large with respect to the frequency of intoxication (RR = 1.68, 95% CI [1.39, 2.02]) compared with the frequency of drinking (RR = 1.42, 95% CI [1.24, 1.62]) (p < .001) and frequent symptoms of excessive drinking (RR = 1.80, 95% CI [1.47, 2.20]) compared with any symptoms (RR = 1.07, 95% CI [1.01, 1.14]) (p < .001). A similar but somewhat less clear pattern emerged when using an alternative indicator for low parental SES.

CONCLUSIONS

Parents' social standing was inversely related to alcohol use by youth and related more strongly so to more deviant and harmful drinking behaviors.

Alcohol Consumption and the Physical Availability of Take-Away Alcohol: Systematic Reviews and Meta-Analyses of the Days and Hours of Sale and Outlet Density

OBJECTIVE

Systematic reviews and meta-analyses were completed studying the effect of changes in the physical availability of take-away alcohol on per capita alcohol consumption. Previous reviews examining this topic have not focused on off-premise outlets where take-away alcohol is sold and have not completed meta-analyses.

METHOD

Systematic reviews were conducted separately for policies affecting the temporal availability (days and hours of sale) and spatial availability (outlet density) of take-away alcohol. Studies were included up to December 2015. Quality criteria were used to select articles that studied the effect of changes in these policies on alcohol consumption with a focus on natural experiments. Random-effects meta-analyses were applied to produce the estimated effect of an additional day of sale on total and beverage-specific consumption.

RESULTS

Separate systematic reviews identified seven studies regarding days and hours of sale and four studies regarding density. The majority of articles included in these systematic reviews, for days/hours of sale (7/7) and outlet density (3/4), concluded that restricting the physical availability of take-away alcohol reduces per capita alcohol consumption. Meta-analyses studying the effect of adding one additional day of sale found that this was associated with per capita consumption increases of 3.4% (95% CI [2.7, 4.1]) for total alcohol, 5.3% (95% CI [3.2, 7.4]) for beer, 2.6% (95% CI [1.8, 3.5]) for wine, and 2.6% (95% CI [2.1, 3.2]) for spirits. The small number of included studies regarding hours of sale and density precluded meta-analysis.

CONCLUSIONS

The results of this study suggest that decreasing the physical availability of take-away alcohol will decrease per capita consumption. As decreasing per capita consumption has been shown to reduce alcohol-related harm, restricting the physical availability of take-away alcohol would be expected to result in improvements to public health.

No effects of increased alcohol availability during adolescence on alcohol-related morbidity and mortality during four decades: a natural experiment

BACKGROUND

A strict high legal age limit for alcohol purchases decreases adolescents' access to alcohol, but little is known about long-term health effects. The aim was to estimate the effect of increased alcohol availability during adolescence on alcohol-related morbidity and mortality.

METHODS

A nationwide register-based study using data from a natural experiment setting. In two regions of Sweden, strong beer (4.5%-5.6% alcohol by volume) became temporarily available for purchase in grocery stores for individuals 16 years or older (instead of 21) in 1967/1968. The intervention group was defined as all individuals living in the intervention area when they were 14-20 years old (n=72 110). The remaining Swedish counties excluding bordering counties, without the policy change, were used as the control group (n=456 224). The outcomes of alcohol-related morbidity and mortality were collected from the Hospital Discharge Register and Cause of Death Register, in which average follow-up times were 38 years and 41 years, respectively. HRs with 95% CIs were obtained by Cox regression analysis.

RESULTS

In the fully adjusted model, no clear evidence of an association between increased alcohol availability during adolescence and alcohol-related morbidity (HR: 0.99, 95% CI 0.96 to 1.02) or mortality (HR: 1.02, 95% CI 0.95 to 1.10) was found.

CONCLUSION

The initial elevated risk of alcohol-related morbidity and mortality later in life among adolescents exposed to increased access to strong beer in Sweden vanished when a regional measure population density of locality was included in the model, which is important to consider in future research.

Drinking trajectories of at-risk groups: Does the theory of the collectivity of drinking apply?

INTRODUCTION AND AIMS

Alcohol consumption among Swedish adolescents has halved during the last decade. We aim to: (i) investigate whether the overall decrease in drinking may conceal an underlying heterogeneity in drinking trajectories across at-risk groups that differ with respect to risk for drinking and; (ii) assess to what degree alcohol-related harm has responded to this decrease.

DESIGN AND METHODS

Data were obtained from the nationally representative annual school survey of alcohol and drug habits among Swedish ninth-grade students covering the period 2000-2012 (n ≈ 5000/year). Respondents were divided into five at-risk groups ranging from low to high based on their relative ranking on a risk scale for drinking. Alcohol consumption was measured by beverage-specific quantity and frequency items summarised into a measure of overall drinking in litres of 100% alcohol per year. Alcohol-related harm was measured by eight items asking about whether the respondent had experienced various alcohol-related negative consequences.

RESULTS

Drinking and alcohol-related harm decreased in all five at-risk groups. There was a marked relation between the overall consumption and the mean consumption in each of the five at-risk groups. Self-reported alcohol-related harm decreased during the study period to an extent that was expected from the decrease in alcohol consumption.

DISCUSSION AND CONCLUSIONS

Alcohol consumption among Swedish youth has declined in five groups that were delineated based on their relative ranking on a risk factor index. The findings are consistent with Skog's theory of the collectivity of drinking behaviour. [Norström T, Raninen J. Drinking trajectories of at-risk groups: Does the theory of the collectivity of drinking apply?.

Social inequality in youth violence: The role of heavy episodic drinking

INTRODUCTION AND AIMS

Alcohol use is an important risk factor for violence, and violent behaviour is more prevalent in lower socioeconomic status (SES) groups. The aim of this study was to examine whether the SES difference in youth violence can be explained by differential exposure to-and/or differential vulnerability to-heavy episodic drinking (HED). In the latter case, effect modification by impulsivity could be assumed.

DESIGN AND METHODS

We analysed cross-sectional data from a school survey of 15- to 17-year-olds in Norway (n = 9853). We employed two measures of low-SES group. Associations between SES, HED and violence were estimated by Poisson regressions, applying a residual centring procedure to test effect modification.

RESULTS

Violent behaviour frequency, HED frequency and impulsivity scores were all elevated in the low-SES group. The SES difference in violent behaviour was significantly reduced when adjusting for HED. The stronger association between HED and violence in the low, compared with the medium-SES/high-SES group, was modified when accounting for impulsivity. Sensitivity analyses suggested robust findings.

DISCUSSION AND CONCLUSIONS

The findings lend support to both the differential exposure hypothesis and to the differential vulnerability hypothesis as well as the hypothesis of an enhancing effect of impulsivity on the HED-violence association. The SES difference in youth violence can be accounted for by: (i) an elevated prevalence of HED in low-SES groups; and (ii) a stronger than average link between HED and violence in low-SES groups due to their higher than average impulsivity score. [Norström T, Rossow I, Pape H. Social inequality in youth violence: The role of heavy episodic drinking. Drug Alcohol Rev 2017;00:000-000].

Adolescent drinking-a touch of social class?

AIMS

To estimate whether parental socio-economic status (SES) is associated with adolescent drinking, and the degree to which a possible association may be accounted for by various parental factors.

DESIGN AND SETTING

Cross-sectional Norwegian school survey from 2006 (response rate: 86%).

PARTICIPANTS

Students aged 13-14 years (n = 5797), 15-16 years (n = 6613) and 17-18 years (n = 5351), of whom 51% were girls.

MEASUREMENTS

Parents' education was our main SES indicator, and we distinguished between low (7%) and middle/high (93%) educational level. The outcomes comprised past-year drinking and intoxication. We also applied measures on general parenting, parents' alcohol-related permissiveness and parental intoxication. The main analyses were conducted using Poisson regression.

FINDINGS

Parents' education had no statistically significant impact on alcohol use among the 17-18-year-olds, while 13-16-year-olds with low educated parents had an elevated relative risk (RR) of both drinking [RR = 1.21, 95% confidence interval (CI) = 1.13-1.29] and intoxication (RR = 1.32, 95% CI = 1.21-1.44). The RRs became statistically insignificant when including all the parental factors as covariates in the regression models. Among adolescents who had consumed alcohol, low parental education was related to more frequent drinking (RR = 1.24, 95% CI = 1.11-1.38) and intoxication episodes (RR = 1.42, 95% CI = 1.22-1.66). Again, the RRs became statistically insignificant when we accounted for all the parental factors. This pattern was replicated when we applied an alternative indicator for low parental SES.

CONCLUSIONS

Adolescent drinking in Norway appears to be related inversely to parents' social standing. The elevated risk of low socio-economic status vanishes when general parenting, alcohol-related parental permissiveness and parents' drinking are accounted for.

Unregistered alcohol consumption and alcohol-related harm in Sweden, 2001–2005

Background and Aim

During recent years unregistered alcohol consumption has increased markedly in Sweden, and the market share of the State Monopoly (Systembolaget) has decreased. The sales through Systembolaget are regulated by strict rules. Further, previous research suggests that the intake of unregistered alcohol is associated with a more risky drinking pattern. We test the hypothesis that the larger the market share of Systembolaget, the lower the prevalence of alcohol-related harm. We also address a related issue, namely whether alcohol-related harm responds differently to different components of total alcohol consumption (registered and various forms of unregistered).

Data and Method

Data on consumption of various forms of unregistered alcohol consumption were obtained from monthly surveys. Registered consumption was gauged by sales data from Systembolaget. The harm indicators included two alcohol-related crime indicators (police-reported assaults and drink driving offences), and two indicators on admission to treatment for alcohol-related diagnoses. The montly data were aggregated into quarterly observations separately for southern Sweden, mid-Sweden and northern Sweden. The study period was Q1 2001- Q4 2005. In addition to regional analyses, the data were analyzed by means of time-series analyses (ARIMA-models).

Findings

The findings did not suggest that a high market share for Systembolaget would be associated with lower rates of alcohol-related harm. As to the effects of the various components of total consumption on harm, there was no systematic pattern implying that any specific component would carry a greater risk than any other – most of the estimates were insignificant. However, all harm indicators responded significantly to the comprehensive consumption indicator (including unregistered consumption as well as Systembolaget's sales), suggesting that total consumption still matters.

The price elasticity for alcohol in Sweden 1984–2003

■ Aims

The article addresses the following research questions: (i) How strong is the price elasticity for beer, wine and spirits? (ii) How rapid is the effect of a price change? (iii) Is the price elasticity stable across time and space? (iv) Does an increase in price give a corresponding effect as a decrease?

■ Methods & Data

The sales data cover Systembolaget's retail sales of beer, wine and spirits for the period from January 1984 to March 2004. The price indexes are based on weighted baskets deflated by a consumer price index. Most of the analyses were performed on quarterly data. The data were analysed using the Box-Jenkins technique for time series analysis.

■ Results

The price elasticities—as estimated from quarterly data—were statistically significant for all beverages; –0.8 for beer, –0.6 for wine and and –1 for spirits. Similar estimates were obtained from monthly data, suggesting a fast consumer response to price changes. The elasticity for beer was weaker during the period 1995–2004 (-0.6) than during the period 1984–1994 (-1.4), but it was no different in southern Sweden than in the remainder of the country. An increase in the price of spirits seems to affect sales as much as a price decrease, that is, the price effect seems to be symmetric. Finally, the results indicated that since 1995 sales of beer and wine increased more, and spirits sales less, than predicted from the development in prices.

■ Conclusions

The study confirms previous findings that the demand of alcoholic beverages is responsive to changes in price; however, price is not the sole factor that drives the trends in sales. The reduced elasticity for beer may be due to the marked drop in beer prices.

Beverage specific effects on suicide

Thor Norström & Ingeborg Rossow: Beverage specific effects on suicide

The authors analyze the relationship between suicide and beverage specific indicators of alcohol sales in Norway and Sweden. The data comprised aggregate time series for Norway (1918–1994) and Sweden (1948–1994). The suicide indicator was the number of male suicides per 100,000 inhabitants (15+). The beverage specific indicators were sales of beer, spirits and wine (liters 100 % ethanol per inhabitant, 15+). The beverage specific effects on suicide were estimated by means of ARIMA-models. For Norway as well as Sweden, there was a statistically significant relationship between suicide on the one hand, and sales of beer (in Sweden retail sales only) and spirits on the other. A common finding in the two countries was the absence of any effect of wine sales. A tentative interpretation of the findings is that spirits and beer sales are markers of the prevalence of an important risk group for suicide, i.e., heavy drinkers. The fact that beer seems to be of greater importance in this context in Norway – which might be attributable to differences between the two countries in the availability of this beverage – is a reminder of how culturally bounded the findings are.

Alkoholkonsumtionens mörkertal i Sverige 1960–1994

The aim of the study was to estimate the trend in unregistered alcohol consumption in Sweden during the period 1960–1994. The estimation was based on the discrepancy between the observed trend in alcohol related harms (alcohol-related mortality, assault, homicide, and drunk driving) and the trend expected from registered alcohol sales. The impact of alcohol sales on these indicators were estimated by means of ARIMA-analyses, and then the error term series was calculated for each indicator, meaning the difference between the observed and the expected trends in harm rates. A factor analysis of the four error-term series yielded one single factor which was interpreted as the unregistered alcohol consumption. According to the outcome this would have increased linearly by about 80% during the study period. Some comparisons are made with other data; for example it is noted that the trend in travelling abroad reasonably matches the trend in estimated unregistered consumption.

Alcohol Consumption as a Risk Factor for Suicidal Behavior: A Systematic Review of Associations at the Individual and at the Population Level

The objective of this study was to provide an updated review of the magnitude of the relationship between alcohol use and suicidal behaviour at the individual and the population level. Systematic literature searches retrieved 14 reviews of individual level studies and 16 primary population level studies. Alcohol abuse and alcohol intoxication are often present in suicidal behaviour; risk of suicide is elevated in alcohol abusers and increasing population drinking tends to be associated with increase in suicide rates. Estimated magnitude of the relationship differs for men and women and it varies at the population level across cultures with different drinking pattern. These variations probably reflect gender differences and cultural variation in drinking behavior generally. Empirical evidence for a causal relationship is still urgently needed.

Short-term and long-term effects of GDP on traffic deaths in 18 OECD countries, 1960-2011

BACKGROUND

Research suggests that increases in gross domestic product (GDP) lead to increases in traffic deaths plausibly due to the increased road traffic induced by an expanding economy. However, there also seems to exist a long-term effect of economic growth that is manifested in improved traffic safety and reduced rates of traffic deaths. Previous studies focus on either the short-term, procyclical effect, or the long-term, protective effect. The aim of the present study is to estimate the short-term and long-term effects jointly in order to assess the net impact of GDP on traffic mortality.

METHODS

We extracted traffic death rates for the period 1960-2011 from the WHO Mortality Database for 18 OECD countries. Data on GDP/capita were obtained from the Maddison Project. We performed error correction modelling to estimate the short-term and long-term effects of GDP on the traffic death rates.

RESULTS

The estimates from the error correction modelling for the entire study period suggested that a one-unit increase (US$1000) in GDP/capita yields an instantaneous short-term increase in the traffic death rate by 0.58 (p<0.001), and a long-term decrease equal to -1.59 (p<0.001). However, period-specific analyses revealed a structural break implying that the procyclical effect outweighs the protective effect in the period prior to 1976, whereas the reverse is true for the period 1976-2011.

CONCLUSIONS

An increase in GDP leads to an immediate increase in traffic deaths. However, after the mid-1970s this short-term effect is more than outweighed by a markedly stronger protective long-term effect, whereas the reverse is true for the period before the mid-1970s.

The Relationship Between Different Survey Measures of Health in an Elderly Population

Health surveys directed to the oldest old are becoming more and more common. There are many ways to measure health status but they have not always been adequately tested on the oldest old. This study analyzes interrelations among various health measures obtained through interviews and assessments. The analysis is based on a Swedish sample of 421 noninstitutionalized persons aged 75 years and older. First, a list of symptoms and complaints was analyzed, which yielded five factors: pains in the limbs, mental problems, stomach problems, heart problems, and respiratory problems. Next, two measures of global health—one self-rated and one nurse-rated—were regressed on these five illness factors. The self-rating seems the more global of the measures in that it was affected by a larger range of illness factors. Some research implications of the results are discussed.

Alcohol Consumption and All-Cause Mortality in the United States, 1950–2002

The aim of the study was to estimate the relationship between per capita alcohol consumption and male all-cause mortality in the United States (U.S.) for the period 1950–2002. Alcohol sales (in litres of 100% alcohol) were used as proxy for per capita consumption. The data were analyzed using the Box-Jenkins technique. Two models were estimated, one including only female mortality as a control, the other including in addition cigarette sales. The first model yielded a significant alcohol effect that implied a 2.8% (p < 0.001) increase in mortality given a 1-litre increase in consumption. This estimate coincides with those obtained for Canada, northern Europe and Russia in previous research but is stronger than estimates for southern Europe. When cigarette sales were included in the model, the alcohol effect was almost halved but still statistically significant. The results indicate that population drinking is of great importance for public health.

Associations between emotional distress and heavy drinking among young people: A longitudinal study

INTRODUCTION AND AIMS

This study adds to the meagre body of longitudinal research on the link between emotional distress and alcohol use among young people. We address the following research questions: Are symptoms of anxiety and depressed mood likely to be causally related to heavy episodic drinking (HED)? Does the association change as individuals move from adolescence to early adulthood?

DESIGN AND METHODS

Data stemmed from a national sample of young people in Norway that was assessed in 1992 (T1; mean age = 14.9 years), 1994 (T2), 1999 (T3) and 2005 (T4) (response rate: 60%, n = 2171). We applied fixed-effects modelling, implying that intra-individual changes in the frequency of HED were regressed on intra-individual changes in emotional distress. Hence, confounding due to stable underlying influences was eliminated. Self-perceived loneliness was included as a time-varying covariate.

RESULTS

Emotional distress was unrelated to HED in adolescence (T1 to T2). In the transition from adolescence to early adulthood (T2 to T3), changes in depressiveness were positively and independently associated with changes in HED, whereas changes symptoms of anxiety were not. A similar pattern emerged in early adulthood (T3 to T4).

DISCUSSION AND CONCLUSIONS

The potential causal relationship between emotional distress and heavy drinking did not manifest itself in adolescence, but increased symptoms of depressiveness were related to more frequent HED in subsequent periods of life. Hence, this study provides conditional support to the notion that emotional distress and HED may be causally related and indicates that the association among young people may be specific to depressiveness.

Is there a link between per capita alcohol consumption and youth drinking? A time-series analysis for Sweden in 1972-2012

AIMS

To estimate the relationship between per capita alcohol consumption and youth drinking in Sweden during the last 40 years and to estimate the relationship between female and male youth drinking during the 40-year study period.

DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS

Per capita alcohol consumption was proxied by official sales data, supplemented by data on unrecorded consumption. Youth consumption was measured by a question on heavy episodic drinking (HED) included in an annual school survey of alcohol and drug habits among Swedish 9th -grade students (15-16 years of age). The annual samples comprise approximately 5000 individuals (with roughly equal numbers of boys and girls) with response rates in the range 80-93%. The study spans the period 1972-2012. Autoregressive integrated moving average (ARIMA) time-series analysis was used to estimate the relation between per-capita alcohol consumption and youth drinking. Ocular inspection of the time-series data suggested a stronger synchronization between the two series in the early period, before the mid-1990s, than in the later period, indicating a structural shift in the relation at issue. We therefore conducted period specific time-series analyses with 1995 as the year of division.

RESULTS

There was a statistically significant relation between per capita alcohol consumption and HED among youth for 1972-94. A 1% increase in per capita alcohol consumption was associated with an increase in HED of 1.52% (P = 0.008). The estimate for 1995-2012 (0.12) was well below statistical significance (P = 0.580). The estimated elasticity of the association between boys' and girls' HED during 1972-94 was close to unity (0.98, P < 0.001), suggesting proportional changes in boys' and girls' drinking. When controlling for per capita consumption, the association was halved (to 0.55) but still significant in table 3 (P = 0.045).

CONCLUSIONS

Adult and youth drinking in Sweden were synchronized closely during the two last decades of the 20th century, but youth drinking developed an independent trajectory shortly before 2000.

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.

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 Skog's 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 Skog's theory of the collectivity of drinking behaviour.

Heavy episodic drinking and deliberate self-harm in young people: a longitudinal cohort study

AIM

To assess the association between heavy episodic drinking (HED) and deliberate self-harm (DSH) in young people in Norway.

DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS

We analysed data on past-year HED and DSH from the second (1994) and third (1999) waves of the Young in Norway Longitudinal Study (cumulative response rate: 68.1%, n = 2647). Associations between HED and DSH were obtained as odds ratios and population-attributable fractions (PAF) applying fixed-effects modelling, which eliminates the effects of time-invariant confounders.

FINDINGS

An increase in HED was associated with an increase in risk of DSH (OR = 1.64, P = 0.013), after controlling for time-varying confounders. The estimated PAF was 28% from fixed-effects modelling and 51% from conventional modelling.

CONCLUSION

Data on Norwegian youths show a statistically significant association between heavy episodic drinking and deliberate self-harm.

Cannabis use and violence: Is there a link?

Background: While several studies suggest that cannabis users are at increased risk of interpersonal violence, it is not clear to what extent the association is causal. Our paper aims to assess the association between cannabis use and violence by using a method that diminishes the risk of confounding. Methods: We analysed data on cannabis use and violent behaviour from the second (1994) and third (1999) waves of the Young in Norway Longitudinal Study (cumulative response rate: 68.1%, n = 2681). We applied fixed-effects modelling to estimate the association between these behaviours, implying that changes in the frequency of violence were regressed on changes in the frequency of cannabis use. The effects of time-invariant confounders were hence eliminated. In addition, we included two time-varying covariates. Results: The elasticity estimate implies that a 10% increase in cannabis use frequency is associated with a 0.4% increase in frequency of violence ( p=.024). Conclusions: Analyses of panel data on Norwegian youths reveals a statistically significant association between cannabis use and violence.

Alcohol consumption and liver disease in Australia: a time series analysis of the period 1935-2006

AIMS

The aim of the study was to examine for Australia whether the link between population alcohol consumption and liver disease mortality varies over time, using 71 years of data.

METHODS

Overall and gender-specific rates of liver disease mortality were analysed in relation to total alcohol consumption as well as for different beverage types by using autoregressive integrated moving average (ARIMA) time series methods. Separate models were developed for the entire time period and for two sub-periods (1935-1975, 1976-2006).

RESULTS

A 1-l increase in adult per capita consumption of pure alcohol led to a rise of ∼10% in overall liver disease mortality rates and a 11 and 9% increase in female and male liver disease mortality, respectively. The strength of the relationship between per capita consumption and liver disease mortality diminished over time. Spirits consumption was found to be the main driving factor in liver mortality rates between 1935 and 1975, while beer consumption was found to be the most significant predictor in liver diseases in the last three decades. In a comparative perspective, the effect of per capita alcohol consumption on liver disease in Australia is similar to the USA, Southern and Eastern Europe countries, but weaker than in Canada and western European countries.

CONCLUSION

An increase in per capita alcohol consumption in Australia is likely to lead to an increase in liver disease. Changes in the most important beverage over the study period suggest substantial shifts in drinking patterns and preferences among the heaviest Australian drinkers.