Predicting the Impact of Alcohol Taxation Increases on Mortality-A Comparison of Different Estimation Techniques

Alcohol, No Ordinary Commodity: policy implications for Canada

Alcohol is a favorite psychoactive substance of Canadians. It is also a leading risk factor for death and disability, playing a causal role in a broad spectrum of health and social issues. Alcohol: No Ordinary Commodity is a collaborative, integrative review of the scientific literature. This paper describes the epidemiology of alcohol use and current state of alcohol policy in Canada, best practices in policy identified by the third edition of Alcohol: No Ordinary Commodity, and the implications for the development of effective alcohol policy in Canada. Best practices - strongly supported by the evidence, highly effective in reducing harm, and relatively low-cost to implement - have been identified. Measures that control affordability, limit availability, and restrict marketing would reduce population levels of alcohol consumption and the burden of disease attributable to it.

Trends of alcohol-attributable deaths in Lithuania 2001-2021: epidemiology and policy conclusions

BACKGROUND

Lithuania, a Baltic country in the European Union, can be characterized by high alcohol consumption and attributable burden. The aim of this contribution is to estimate the mortality burden due to alcohol use for the past two decades based on different relative risk functions, identify trends, and analyse the associations of alcohol-attributable burden with alcohol control policies and life expectancy.

METHODS

The standard methodology used by the World Health Organization for estimating alcohol-attributable mortality was employed to generate mortality rates for alcohol-attributable mortality, standardized for Lithuania's 2021 population distribution. Joinpoint analysis, T-tests, correlations, and regression analyses including meta-regressions were used to describe trends and associations.

RESULTS

Age-standardized alcohol-attributable mortality was high in Lithuania during the two decades between 2001 and 2021, irrespective of which relative risks were used for the estimates. Overall, there was a downward trend, mainly in males, which was associated with four years of intensive implementation of alcohol control policies in 2008, 2009, 2017, and 2018. For the remaining years, the rates of alcohol-attributable mortality were stagnant. Among males, the correlations between alcohol-attributable mortality and life expectancy were 0.90 and 0.76 for Russian and global relative risks respectively, and regression analyses indicated a significant association between changes in alcohol-attributable mortality and life expectancy, after controlling for gross domestic product.

CONCLUSIONS

Male mortality and life expectancy in Lithuania were closely linked to alcohol-attributable mortality and markedly associated with strong alcohol control policies. Further implementation of such policies is predicted to lead to further improvements in life expectancy.

Impact of the WHO "best buys" for alcohol policy on consumption and health in the Baltic countries and Poland 2000-2020

Alcohol use is a major risk factor for burden of disease. This narrative review aims to document the effects of major alcohol control policies, in particular taxation increases and availability restrictions in the three Baltic countries (Estonia, Latvia, and Lithuania) between 2000 and 2020. These measures have been successful in curbing alcohol sales, in general without increasing consumption of alcoholic beverages from unrecorded sources; although for more recent changes this may have been partly due to the COVID-19 pandemic. Moreover, findings from time-series analyses suggest improved health, measured as reductions in all-cause and alcohol-attributable mortality, as well as narrowing absolute mortality inequalities between lower and higher educated groups. For most outcomes, there were sex differences observed, with alcohol control policies more strongly affecting males. In contrast to this successful path, alcohol control policies were mostly dismantled in the neighbouring country of Poland, resulting in a rising death toll due to liver cirrhosis and other alcohol-attributable deaths. The natural experiment in this region of high-income European countries with high consumption levels highlights the importance of effective alcohol control policies for improving population health.

Reducing alcohol use through alcohol control policies in the general population and population subgroups: a systematic review and meta-analysis

We estimate the effects of alcohol taxation, minimum unit pricing (MUP), and restricted temporal availability on overall alcohol consumption and review their differential impact across sociodemographic groups. Web of Science, Medline, PsycInfo, Embase, and EconLit were searched on 08/12/2022 and 09/26/2022 for studies on newly introduced or changed alcohol policies published between 2000 and 2022 (Prospero registration: CRD42022339791). We combined data using random-effects meta-analyses. Risk of bias was assessed using the Newcastle-Ottawa Scale. Of 1887 reports, 36 were eligible. Doubling alcohol taxes or introducing MUP (Int$ 0.90/10 g of pure alcohol) reduced consumption by 10% (for taxation: 95% prediction intervals [PI]: -18.5%, -1.2%; for MUP: 95% PI: -28.2%, 5.8%), restricting alcohol sales by one day a week reduced consumption by 3.6% (95% PI: -7.2%, -0.1%). Substantial between-study heterogeneity contributes to high levels of uncertainty and must be considered in interpretation. Pricing policies resulted in greater consumption changes among low-income alcohol users, while results were inconclusive for other socioeconomic indicators, gender, and racial and ethnic groups. Research is needed on the differential impact of alcohol policies, particularly for groups bearing a disproportionate alcohol-attributable health burden.

Funding

Research reported in this publication was supported by the National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health under Award Number R01AA028009.

Alcohol control policies reduce all-cause mortality in Baltic Countries and Poland between 2001 and 2020

Alcohol consumption in the Baltic countries and Poland is among the highest globally, causing high all-cause mortality rates. Contrary to Poland, the Baltic countries have adopted many alcohol control policies, including the World Health Organization (WHO) "best buys". The aim of this study was to evaluate the impact of these policies, which were implemented between 2001 and 2020, on all-cause mortality. Monthly mortality data for men and women aged 20+ years of age in Estonia, Latvia, Lithuania, and Poland were analysed for 2001 to 2020. A total of 19 alcohol control policies, fulfilling an a-priori defined definition, were implemented between 2001 and 2020 in the countries of interest, and 18 of them could be tested. Interrupted time-series analyses were conducted by employing a generalized additive mixed model (GAMM) for men and women separately. The age-standardized all-cause mortality rate was lowest in Poland and highest in Latvia and had decreased in all countries over the time period. Taxation increases and availability restrictions had short-term effects in all countries, on average reducing the age-standardized all-cause mortality rate among men significantly (a reduction of 2.31% (95% CI 0.71%, 3.93%; p = 0.0045)). All-cause mortality rates among women were not significantly reduced (a reduction of 1.09% (95% CI - 0.02%, 2.20%; p = 0.0554)). In conclusion, the alcohol control policies implemented between 2001 and 2020 reduced all-cause mortality among men 20+ years of age in Baltic countries and Poland, and thus, the practice should be continued.

Classifying alcohol control policies enacted between 2000 and 2020 in Poland and the Baltic countries to model potential impact

AIMS

The study's aim is to identify and classify the most important alcohol control policies in the Baltic countries (Estonia, Latvia and Lithuania) and Poland between 2000 and 2020.

METHODS

Policy analysis of Baltic countries and Poland, predicting potential policy impact on alcohol consumption, all-cause mortality and alcohol-attributable hospitalizations was discussed.

RESULTS

All Baltic countries implemented stringent availability restrictions on off-premises trading hours and different degrees of taxation increases to reduce the affordability of alcoholic beverages, as well as various degrees of bans on alcohol marketing. In contrast, Poland implemented few excise taxation increases or availability restrictions and, in fact, reduced stipulations on prior marketing bans.

CONCLUSIONS

This classification of alcohol control policies in the Baltic countries and Poland provides a basis for future modeling of the impact of implementing effective alcohol control policies (Baltic countries), as well as the effects of loosening such policies (Poland).

Reduction of Alcoholic Strength: Does It Matter for Public Health?

In this work, reduction of alcoholic strength was discussed as a means to reduce consumption and alcohol-attributable harm. Statistical modelling was conducted to (1) estimate its potential for the largest six Western and Central European countries (France, Germany, Italy, Poland, Spain, UK); (2) calculate the increase in taxation necessary to reach this potential, and (3) estimate the mortality gains achieved with the introduction of no- or low-alcohol beverages in the UK and Spain. The high public health potential of reducing alcoholic strength was demonstrated via modelling a scenario in which the strength of all beverages was reduced by 10%, which would avert thousands of deaths in these six European countries per year. However, methods by which to achieve these gains were not clear, as the alcohol industry has shown no inclination toward reductions in the alcoholic strength of beer, wine, or spirits via a reformulation on a large scale. The increase of excise taxation to achieve the public health gains of such a reduction would result in markedly increasing prices-a situation unlikely to be implemented in Europe. Finally, the introduction of beer and wine with an alcoholic strength below 0.5% led to some substitutions of higher-strength beverages, but did not show a marked public health impact. New taxation initiatives to achieve the potential of a reduction of alcoholic strength will need to be implemented.

Are restrictions in sales hours of alcohol associated with fewer emergency room visits in Lithuania? An interrupted time-series analysis

INTRODUCTION

On 1 January 2018, an amendment to the alcohol control law was introduced in Lithuania which, among other changes, reduced trading hours for alcoholic beverages by 4 h for weekdays and Saturdays, and by 9 h for Sundays. The objective of the current study was to quantify the potential association of this law with the numbers and types of emergency room (ER) visits in Lithuania, in general and specifically for Sundays, for all ER visits, for injury-related ER visits and specifically for alcohol poisoning as a 100% alcohol-attributable cause.

METHODS

Sex-stratified time-series analysis-based models for the period 2016-2019 were used to test for associations and for potential alternative explanations (e.g., the increase in minimum legal drinking age, which occurred at the same time).

RESULTS

Overall, while the reduction in sales hours for both sexes was associated with slight increases in all types and in injury-related ER visits on a weekly basis, the association with ER visits for alcohol poisoning was in the opposite direction for men in all models. Specifically, among men, it was associated with an approximate decrease of 20% of alcohol poisoning-related ER visits on Sundays and an approximate decrease of 12% of alcohol poisoning-related ER visits for all seven weekdays.

DISCUSSION AND CONCLUSIONS

As predicted, restrictions on availability were associated with marked reductions in ER visits for alcohol poisoning in men. However, contrary to expectations, there were no overall reductions in overall ER visits, nor reductions in injury-related ER visits.

The impact of alcohol taxation increase on all-cause mortality inequalities in Lithuania: an interrupted time series analysis

BACKGROUND

Taxation increases which reduce the affordability of alcohol are expected to reduce mortality inequalities. A recent taxation increase in Lithuania offers the unique possibility to test this hypothesis.

METHODS

Census-linked mortality data between 2011 and 2019 were used to calculate monthly sex- and education-stratified age-standardized mortality rates for the population aged 40 to 70 years. As primary outcome, we analysed the difference in age-standardized all-cause mortality rates between the population of lowest versus highest educational achievement. The impact of the 2017 taxation increase was evaluated using interrupted time series analyses. To identify whether changes in alcohol use can explain the observed effects on all-cause mortality, the education-based mortality differences were then decomposed into n = 16 cause-of-death groupings.

RESULTS

Between 2012 and 2019, education-based all-cause mortality inequalities in Lithuania declined by 18% among men and by 14% among women. Following the alcohol taxation increase, we found a pronounced yet temporary reduction of mortality inequalities among Lithuanian men (- 13%). Subsequent decomposition analyses suggest that the reduction in mortality inequalities between lower and higher educated men was mainly driven by narrowing mortality differences in injuries and infectious diseases.

CONCLUSIONS

A marked increase in alcohol excise taxation was associated with a decrease in mortality inequalities among Lithuanian men. More pronounced reductions in deaths from injuries and infectious diseases among lower as compared to higher educated groups could be the result of differential changes in alcohol use in these populations.

Do alcohol control policies have the predicted effects on consumption? An analysis of the Baltic countries and Poland 2000-2020

BACKGROUND

Many population-based alcohol control policies are postulated to work via changes in adult alcohol per capita consumption (APC). However, since APC is usually assessed on a yearly basis, often there are not enough data to conduct interrupted time-series or other controlled analyses. The current dataset, with 21 years of observation from four countries (Estonia, Latvia, Lithuania, and Poland), had sufficient power to test for average effects and potential interactions of the World Health Organization's (WHO) three "best buys" for alcohol control: taxation increases leading to a decrease in affordability; reduced availability (via a decrease in opening hours of at least 20 %); and advertising and marketing restrictions. We postulated that the former two would have immediate effects, while the latter would have mid- to long-term effects.

METHODS

Linear regression analysis.

RESULTS

Taxation increases and availability reductions in all countries were associated with an average reduction in APC of 0.83 litres (ℓ) of pure alcohol per year (95 % confidence interval: -1.21 ℓ, -0.41 ℓ) in the same year, with no significant differences between countries. Restrictions on advertising and/or marketing had no significant immediate associations with APC (average effect 0.04 ℓ per year; 95 % confidence interval: -0.65 ℓ, 0.73 ℓ). Several sensitivity analyses corroborated these main results.

CONCLUSIONS

The WHO "best buy" alcohol control policies of taxation increases and availability restrictions worked as postulated in these four northeastern European Union countries.

The temporal trend of cause-specific mortality: comparing Estonia and Lithuania, 2001 - 2019

BACKGROUND

Despite being two Baltic countries with similar histories, Estonia and Lithuania have diverged in life expectancy trends in recent years. We investigated this divergence by comparing cause-specific mortality trends.

METHODS

We obtained yearly mortality data for individuals 20 + years of age from 2001-2019 (19 years worth of data) through Statistics Lithuania, the Lithuanian Institute for Hygiene, and the National Institute for Health Development (Estonia). Using ICD-10 codes, we analyzed all-cause mortality rates and created eight major disease categories: ischemic heart disease, cerebrovascular disease, all other cardiovascular disease, cancers (neoplasms), digestive diseases, self-harm and interpersonal violence, unintentional injuries and related conditions, and other mortality (deaths per 100,000 population). We used joinpoint regression analysis, and analyzed the proportional contribution of each category to all-cause mortality.

RESULTS

There was a steeper decline in all-cause mortality in Estonia (average annual percent change, AAPC = -2.55%, 95% CI: [-2.91%, -2.20%], P < .001) as compared to Lithuania (AAPC = -1.26%, 95% CI: [-2.18%, -0.57%], P = .001). For ischemic heart disease mortality Estonia exhibited a relatively larger decline over the 19-year period (AAPC = -6.61%, 95% CI: [-7.02%, -6.21%], P < .001) as compared to Lithuania (AAPC = -2.23%, 95% CI: [-3.40%, -1.04%], P < .001).

CONCLUSION

Estonia and Lithuania showed distinct mortality trends and distributions of major disease categories. Our findings highlight the role of ischemic heart disease mortality. Differences in public health care, management and prevention of ischemic heart disease, alcohol control policies may explain these differences.