Recent heavy alcohol consumption at death certified as ischaemic heart disease: correcting mortality data from Kaunas (Lithuania)

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.

Alcohol-attributable mortality and alcohol control policy in the Baltic Countries and Poland in 2001-2020: an interrupted time-series analysis

BACKGROUND

The Baltic countries-Lithuania, Latvia and Estonia-are characterized by a high rate of fully alcohol-attributable mortality, compared with Poland. Alcohol control policy measures implemented since 2001 in the Baltic countries included a restriction on availability and an increase in excise taxation, among others. The aim of the current study was to evaluate the relationship between alcohol control policy implementation and alcohol-attributable mortality in the Baltic countries and Poland.

METHODS

Alcohol-attributable mortality data for 2001-2020 was defined by codes 100% alcohol-attributable for persons aged 15 years and older in the Baltic countries and Poland. Alcohol control policies implemented between 2001 and 2020 were identified, and their impact on alcohol-attributable mortality was evaluated using an interrupted time-series methodology by employing a generalized additive model.

RESULTS

Alcohol-attributable mortality was significantly higher in the Baltic countries, compared with Poland, for both males and females. In the final reduced model, alcohol control policy significantly reduced male alcohol-attributable mortality by 7.60% in the 12 months post-policy implementation. For females, the alcohol control policy mean-shift effect was higher, resulting in a significant reduction of alcohol-attributable mortality by 10.77% in the 12 months post-policy implementation. The interaction effects of countries and policy tested in the full model were not statistically significant, which indicated that the impact of alcohol control policy on alcohol-attributable mortality did not differ across countries for both males and females.

CONCLUSIONS

Based on the findings of the current study, alcohol control policy in the form of reduced availability and increased taxation was associated with a reduction in alcohol-attributable mortality among both males and females.

Weekly pattern of alcohol-attributable male mortality before and after imposing limits on hours of alcohol sale in Lithuania in 2018

AIMS

From 1 January 2018, the number of retail hours for the sale of alcohol was reduced from 14 to 5 hours on Sundays and from 14 to 10 hours on the other days of the week in Lithuania. The significant reduction of hours for the sale of alcohol on Sundays may have affected the distribution of alcohol-attributable deaths during the week. This study aimed to examine the change in the weekly pattern of alcohol-attributable male mortality before and after imposing limits on the hours when alcohol can be sold.

METHODS

Age-standardised male death rates by days of the week were calculated for four groups according to cause of death: alcohol poisoning (X45), all external causes of death (V01-Y98), diseases of the circulatory system (I00-I99) and all other causes of death. We compared age-standardised death rates for two periods: before (2015-2017) and after (2018-2019) the intervention. Mortality and population data were obtained from the Lithuanian Institute of Hygiene and Human Mortality Database.

RESULTS

We found that during 2018-2019, earlier observed peak in age-standardised death rates for external causes of death on Sunday diminished, and this day no longer differed from the weekly average. The same tendency was also observed for the Monday excess mortality due to circulatory diseases.

CONCLUSIONS

The reduction of the hours when alcohol can be sold from the beginning of 2018 was associated with a change in a weekly pattern of alcohol-attributable male mortality. However, more studies are needed to examine the causes of the change in mortality pattern.

Changes in Mortality Inequalities in Urban and Rural Populations during 1990-2018: Lithuanian Experience

Background and Objectives: Reduction in health inequalities is a highly important task in public health policies worldwide. In Lithuania, inequalities in mortality by place of residence are among the greatest, compared to other European Union (EU) countries. However, studies on inequalities in mortality by place of residence over a long-term period have not been investigated in Lithuania. The aim of this study was to present changes in mortality inequalities in urban and rural populations during 1990-2018. Materials and Methods: Mortality rates from all causes, cardiovascular diseases, cancer, external causes, and gastrointestinal diseases in urban and rural population by sex were calculated per 100,000 populations and were standardized by age. Inequalities in mortality were assessed using rate differences and rate ratio. For the assessment of inequality trends during 1990-2018, the joinpoint regression analysis was applied. Results: Mortality between urban and rural populations varied. In rural areas, mortality lower than that in urban areas was observed only in 1990 among women, in case of mortality from cancer and gastrointestinal diseases (compared with in 2018) (p < 0.05). In 2018, mortality from all causes, cardiovascular diseases, and external causes in urban and rural areas was lower than in 1990 in both sexes. However, mortality from gastrointestinal diseases was higher (p < 0.05). In 2018, mortality from cancer among both sexes was lower only in urban areas (p < 0.05). Mortality inequalities between rural and urban areas decreased statistically significantly only among men from external causes and from all causes (respectively, on average, by 0.52% per year and, on average, by 0.21% per year). Meanwhile, mortality from cardiovascular and gastrointestinal diseases increased in both sexes, and mortality from cancer and all causes of death increased among women. The increase in the inequalities of mortality from gastrointestinal diseases was the most rapid: among men-on average, by 0.69% per year, and among women-on average, by 1.43% per year, p < 0.0001. Conclusions: During 1990-2018, the inequalities in mortality by place of residence in Lithuania statistically significantly decreased only among men, in terms of mortality from external causes and from all causes. Therefore, reduction in inequalities in mortality must be the main the health policy challenge in Lithuania.

Alcohol control policies add to secular trends in all-cause mortality rates in young adults

Alcohol consumption is a major risk factor for premature mortality. Although alcohol control policies are known to impact all-cause mortality rates, the effect that policies have on specific age groups is an important area of research. This study investigates the effect of alcohol control policies implemented in 2009 and 2017 in Lithuania on all-cause mortality rates. All-cause mortality rates (deaths per 100,000 people) were obtained for 2001–2018 by 10-year age groups (20–29, 30–39, 40–49 years, etc.). All-cause mortality rates, independent of macro-level secular trends (e.g., economic trends) were examined. Following a joinpoint analysis to control for secular trends, an interrupted time series analysis showed that alcohol control policies had a significant effect on all-cause mortality rates (p = .018), with the most significant impact occurring among young adults (20–29 and 30–39 years of age). For these age groups, their mortality rate decreased during the 12 months following policy implementation (following the policy in 2009 for those 20–29 years of age, p = .0026, and following the policy in 2017 for those 30–39 years of age, p = .011). The results indicate that alcohol control policy can impact all-cause mortality rates, above and beyond secular trends, and that the impact is significant among young adults.

Spatial patterns of male alcohol-related mortality in Belarus, Lithuania, Poland and Russia

INTRODUCTION AND AIMS

Eastern Europe is known to suffer from a large burden of alcohol-related mortality. However, persisting unfavourable conditions at the national level mask variation at the sub-national level. We aim to explore spatial patterns of cause-specific mortality across four post-communist countries: Belarus, Lithuania, Poland and Russia (European part).

DESIGN AND METHODS

We use official mortality data routinely collected over 1179 districts and cities. The analysis refers to males aged 20-64 years and covers the period 2006-2014. Mortality variation is mainly assessed by means of the standardised mortality ratio. Getis-Ord Gi* statistic is employed to detect hot and cold spots of alcohol-related mortality.

RESULTS

Alcohol-related mortality exhibits a gradient from very high levels in northwestern Russia to low levels in southern Poland. Spatial transitions from higher to lower mortality are not explicitly demarcated by national boundaries. Within these countries, hot spots of alcohol-related mortality dominate the territories of northwestern and western Russia, eastern and northwestern Belarus, southeastern Lithuania, and eastern and central Poland.

DISCUSSION AND CONCLUSIONS

The observed mortality gradient is likely associated with the spread of alcohol epidemics from the European part of Russia to the other countries, which appears to have started more than a century ago. Contemporary socioeconomic and demographic factors should be taken into account when developing anti-alcohol policies. The same is true for the peculiarities of culture, norms, traditions and behavioural patterns observed in specific geographical areas of the four countries. Reducing alcohol-related harm in the areas identified as hot spots should be prioritised.

Distilled Spirits Overconsumption as the Most Important Factor of Excessive Adult Male Mortality in Europe

Aims

To explain comprehensively variations in adult male mortality rate in Europe, and in particular, high mortality in some East European countries with particular focus on specific patterns of alcohol consumption.

Short summary

Per capita distilled spirits consumption is found to be the strongest determinant of the adult male mortality rate in Europe as soon as the unrecorded alcohol consumption is taken into account. It turns out to be much stronger than the other tested significant determinants such as per capita health expenditures, smoking prevalence, consumption of hard drugs and per capita consumption of vegetables and fruit.

Methods

Ordinary least squares (OLS) multiple regression with adult male mortality rate as a dependent variable, and various indicators of alcohol and drug consumption as well as logarithm of gross domestic product (GDP) per capita, logarithm of total per capita health expenditures, latitude (climatic factors), per capita fruit and vegetable consumption, smoking prevalence as independent factors.

Results

Per capita distilled spirits consumption turns out to be the strongest determinant of the adult male mortality rate in Europe as soon as the unrecorded alcohol consumption is taken into account. It turns out to be much stronger than the other tested significant determinants of the adult male mortality rate such as per capita health expenditures, smoking prevalence, consumption of hard drugs and per capita consumption of vegetables and fruit. Still, higher per capita wine consumption has turned out to be a marginally significant determinant of the higher adult male mortality rate in some tests. Latitude, beer and soft drug consumption have turned out insignificant in this study.

Conclusions

Spirits consumption is a major risk factor of adult male mortality, with significantly greater impact compared to beer and wine. Therefore, reduction in distilled spirits consumption in hard liquor drinking areas should be a major target in health policy.

Psychological well-being and mortality: longitudinal findings from Lithuanian middle-aged and older adults study

BACKGROUND

The study aimed to examine whether after confounding by possible socio-demographic and other risk factors, psychological well-being is independently associated with reduced all-cause and cardiovascular mortality.

METHODS

Initial data were collected within the framework of the international project HAPIEE in 2006-2008. A random sample of 7115 individuals aged 45-72 years was screened. Deaths were evaluated by death register of Kaunas city (Lithuania) in a follow-up study till 2016. Psychological well-being was evaluated by a CASP-12 questionnaire. Socio-demographic, lifestyle, biologic factors and depressive symptoms were evaluated.

RESULTS

Age-adjusted survival curves revealed that psychological well-being predicts longevity in men and women (p < 0.001). After adjustment for many possible confounders psychological well-being was independently associated with all-cause mortality in men (HR 0.77; 95% CI 0.62-0.94) and women (HR 0.73; 95% CI 0.56-0.96). However, psychological well-being association with cardiovascular mortality attained statistical significance only in the women's group (HR 0.53; 95% CI 0.33-0.87), but not in men (HR 0.98; 95% CI 0.72-1.33).

CONCLUSIONS

Psychological well-being is an important predictor of longevity, controlling well-recognized risk factors such as age, education, cardiovascular diseases, social status, marital status, lifestyle and biological factors and depressive symptoms. Positive psychological well-being should be taken into account when screening older people to prevent negative health outcomes.

Individual- and area-level characteristics associated with alcohol-related mortality among adult Lithuanian males: A multilevel analysis based on census-linked data

Background

Although excessive alcohol-related mortality in the post-Soviet countries remains the major public health threat, determinants of this phenomenon are still poorly understood.

Aims

We assess simultaneously individual- and area-level factors associated with an elevated risk of alcohol-related mortality among Lithuanian males aged 30–64.

Methods

Our analysis is based on a census-linked dataset containing information on individual- and area-level characteristics and death events which occurred between March 1^st, 2011 and December 31^st, 2013. We limit the analysis to a few causes of death which are directly linked to excessive alcohol consumption: accidental poisonings by alcohol (X45) and liver cirrhosis (K70 and K74). Multilevel Poisson regression models with random intercepts are applied to estimate mortality rate ratios (MRR).

Results

The selected individual-level characteristics are important predictors of alcohol-related mortality, whereas area-level variables show much less pronounced or insignificant effects. Compared to married men, never married (MRR = 1.9, CI:1.6–2.2), divorced (MRR = 2.6, CI:2.3–2.9), and widowed (MRR = 2.4, CI: 1.8–3.1) men are disadvantaged groups. Men who have the lowest level of educational attainment have the highest mortality risk (MRR = 1.7 CI:1.4–2.1). Being unemployed is associated with a five-fold risk of alcohol-related death (MRR = 5.1, CI: 4.4–5.9), even after adjusting for all other individual variables. Lithuanian males have an advantage over Russian (MRR = 1.3, CI:1.1–1.6) and Polish (MRR = 1.8, CI: 1.5–2.2) males. After adjusting for all individual characteristics, only two out of seven area-level variables—i.e., the share of ethnic minorities in the population and the election turnout—have statistically significant direct associations. These variables contribute to a higher risk of alcohol-related mortality at the individual level.

Conclusions

The huge and increasing socio-economic disparities in alcohol-related mortality indicate that recently implemented anti-alcohol measures in Lithuania should be reinforced by specific measures targeting the most disadvantaged population groups and geographical areas.

Trends in major risk factors and mortality from main non-communicable diseases in Lithuania, 1985-2013

Background

This study aimed to assess the trends in the prevalence and levels of risk factors and mortality from main non-communicable diseases in the Lithuanian population aged 45–64 years during 1985 to 2013.

Methods

Data from four general population surveys conducted between 1985 and 2008 were used. All these surveys were carried out in Kaunas city and five randomly selected municipalities of Lithuania. Risk factors measured at each survey included regular smoking, overweight, obesity, arterial hypertension, and high levels of blood lipids. In total, data of 10,719 subjects (4,965 men and 5,754 women) aged 45–64 were analysed. Trends in standardized all-cause mortality and mortality from cardiovascular disease (CVD), coronary heart disease (CHD), and malignant neoplasms were estimated for both sexes by joinpoint regression analysis.

Results

In 1985–2013, some favourable trends were observed in the age-standardized mean levels and prevalence of risk factors and mortality from main non-communicable diseases in the Lithuanian middle-aged population. The mean values of blood lipids (with the exception of triglycerides) and the prevalence of dyslipidemias declined. In women, mean levels of systolic blood pressure and body mass index decreased, while in men, the levels of these factors increased. The prevalence of arterial hypertension and obesity increased in men. The proportion of obese women decreased. Smoking prevalence increased in both men and women. From 2007 to 2008, significant downward trends, which were steeper in women than in men, were observed in all-cause, CVD, and CHD mortality.

Conclusions

Despite the favourable changes in some risk factors and mortality rates, the prevalence of risk factors and mortality from main non-communicable diseases in Lithuania are still high. This indicates the importance of the ongoing primary and secondary prevention and optimal treatment of these diseases.

The Prognostic Value of Family History for the Estimation of Cardiovascular Mortality Risk in Men: Results from a Long-Term Cohort Study in Lithuania

AIM

To evaluate the additional prognostic value of family history for the estimation of cardiovascular (CVD) mortality risk in middle-aged urban Lithuanian men.

METHODS

The association between family history of CVD and the risk of CVD mortality was examined in a population-based cohort of 6,098 men enrolled during 1972-1974 and 1976-1980 in Kaunas, Lithuania. After up to 40 years of follow-up, 2,272 deaths from CVD and 1,482 deaths from coronary heart disease (CHD) were identified. Multivariate Cox proportional hazards models were used to estimate hazard ratios (HR) for CVD and CHD mortality.

RESULTS

After adjustment for traditional CVD risk factors, the HR for CVD mortality was 1.24 (95% CI 1.09-1.42) and for CHD mortality 1.20 (1.02-1.42) in men with first-degree relatives having a history of myocardial infarction (MI), compared to men without positive family history. A significant effect on the risk of CVD and CHD mortality was also observed for the family history of sudden cardiac death and any CVD. Addition of family history of MI, sudden death, and any CVD to traditional CVD risk factors demonstrated modest improvement in the performance of Cox models for CVD and CHD mortality.

CONCLUSIONS

Family history of CVD is associated with a risk of CVD and CHD mortality significantly and independently of other risk factors in a middle-aged male population. Addition of family history to traditional CVD risk factors improves the prediction of CVD mortality and could be used for identification of high-risk individuals.

The Huge Reduction in Adult Male Mortality in Belarus and Russia: Is It Attributable to Anti-Alcohol Measures?

BACKGROUND AND AIM

Harmful alcohol consumption has long been recognized as being the major determinant of male premature mortality in the European countries of the former USSR. Our focus here is on Belarus and Russia, two Slavic countries which continue to suffer enormously from the burden of the harmful consumption of alcohol. However, after a long period of deterioration, mortality trends in these countries have been improving over the past decade. We aim to investigate to what extent the recent declines in adult mortality in Belarus and Russia are attributable to the anti-alcohol measures introduced in these two countries in the 2000s.

DATA AND METHODS

We rely on the detailed cause-specific mortality series for the period 1980-2013. Our analysis focuses on the male population, and considers only a limited number of causes of death which we label as being alcohol-related: accidental poisoning by alcohol, liver cirrhosis, ischemic heart diseases, stroke, transportation accidents, and other external causes. For each of these causes we computed age-standardized death rates. The life table decomposition method was used to determine the age groups and the causes of death responsible for changes in life expectancy over time.

CONCLUSION

Our results do not lead us to conclude that the schedule of anti-alcohol measures corresponds to the schedule of mortality changes. The continuous reduction in adult male mortality seen in Belarus and Russia cannot be fully explained by the anti-alcohol policies implemented in these countries, although these policies likely contributed to the large mortality reductions observed in Belarus and Russia in 2005-2006 and in Belarus in 2012. Thus, the effects of these policies appear to have been modest. We argue that the anti-alcohol measures implemented in Belarus and Russia simply coincided with fluctuations in alcohol-related mortality which originated in the past. If these trends had not been underway already, these huge mortality effects would not have occurred.

Trends in out-of-hospital ischemic heart disease mortality for the 25-64 year old population of Kaunas, Lithuania, based on data from the 1988-2012 Ischemic Heart Disease Registry

AIM

The aim of the study was to evaluate trends in out-of-hospital ischemic heart disease (IHD) mortality in the Kaunas, Lithuania population aged 25-64, from 1988 to 2012.

METHODS

The registry was maintained according to the World Health Organisation (WHO) recommendations for the multinational MONICA (MONItoring of trends and determinants in CArdiovascular disease) project. We analysed out-of-hospital deaths from IHD, by sex and age groups, using the linear logistic regression model for identifying trends.

RESULTS

In 1988-2012, the out-of-hospital IHD deaths in Kaunas accounted for 78.4% and 68.4%, on average, of all IHD deaths in men and women aged 25-64, respectively. During the study period, the out-of-hospital IHD mortality for the Kaunas population aged 25-64 was 134.5 per 100,000 men and 18.2 per 100,000 women. From 1988 to 2012, the out-of-hospital IHD mortality for men and women aged 25-64 tended to decline by, on average, 8.3% per year (p = 0.269) and 16.2% per year (p = 0.101), respectively; whereas the corresponding rates for men aged 25-44 were declining significantly, by 22.5% per year (p = 0.047). The most significant changes in out-of-hospital IHD mortality were among men aged 25-44 with no previous history of acute myocardial infarction (AMI), in whom the out-of-hospital IHD mortality was significantly declining, by 21.3% per year (p = 0.015); whereas the corresponding rates for men aged 45-54 with a previous history of AMI tended to decline by 20.4% per year (p = 0.114).

CONCLUSIONS

In 1988-2012, the out-of-hospital IHD deaths of younger men and middle-aged women accounted for the highest percentage of all IHD deaths; and a higher proportion of both men and women with no previous history of AMI, as compared to the proportion of those with a previous history of AMI.

Physical, behavioural and genetic predictors of adult hypertension: the findings of the Kaunas Cardiovascular Risk Cohort study

Background

The roots of adult hypertension go back to childhood. This study aimed to examine the independent effects of physical, behavioural and genetic factors identified in childhood and mid-adulthood for prediction of adult hypertension.

Methods

The study subjects were participants of the Kaunas Cardiovascular Risk Cohort study started in 1977 (n = 1082, age 12–13 years). In 2012, a total of 507 individuals (63.9% of eligible sample) participated in the 35-year follow-up survey. Health examination involved measurements of blood pressure (BP), anthropometric parameters, and interview about health behaviours. Subjects were genotyped for AGT (M235T), ACE (I/D, rs4340), ADM (rs7129220), and CACNB2 (rs12258967) genes polymorphisms. A genetic risk score was calculated as the sum of the number of risk alleles at each of four single nucleotide polymorphisms.

Results

AGT TT genotype male carriers had the highest mean values of systolic BP in childhood. In females, ADM genotype AA was associated with the highest values of systolic and diastolic BP, while CACNB2 genotype CC carriers had the highest values of diastolic BP in childhood. Systolic and diastolic BP in childhood, gain in BMI from childhood to adulthood, and risky alcohol consumption predicted hypertension in middle-aged men. In women, genetic risk score together with diastolic BP in childhood and gain in BMI were significant predictors of adult hypertension. The comparison of four nested logistic regression models showed that the prediction of hypertension improved significantly after the addition of BMI gain. Genetic risk score had a relatively weak effect on the improvement of the model performance in women.

Conclusions

BP in childhood and the gain in BMI from childhood to adulthood were significant predictors of adult hypertension in both genders. Genetic risk score in women and risky alcohol consumption in men were independently related with the risk of adult hypertension.

The contribution of educational class in improving accuracy of cardiovascular risk prediction across European regions: The MORGAM Project Cohort Component

OBJECTIVE

To assess whether educational class, an index of socioeconomic position, improves the accuracy of the SCORE cardiovascular disease (CVD) risk prediction equation.

METHODS

In a pooled analysis of 68 455 40-64-year-old men and women, free from coronary heart disease at baseline, from 47 prospective population-based cohorts from Nordic countries (Finland, Denmark, Sweden), the UK (Northern Ireland, Scotland), Central Europe (France, Germany, Italy) and Eastern Europe (Lithuania, Poland) and Russia, we assessed improvements in discrimination and in risk classification (net reclassification improvement (NRI)) when education was added to models including the SCORE risk equation.

RESULTS

The lowest educational class was associated with higher CVD mortality in men (pooled age-adjusted HR=1.64, 95% CI 1.42 to 1.90) and women (HR=1.31, 1.02 to 1.68). In men, the HRs ranged from 1.3 (Central Europe) to 2.1 (Eastern Europe and Russia). After adjustment for the SCORE risk, the association remained statistically significant overall, in the UK and Eastern Europe and Russia. Education significantly improved discrimination in all European regions and classification in Nordic countries (clinical NRI=5.3%) and in Eastern Europe and Russia (NRI=24.7%). In women, after SCORE risk adjustment, the association was not statistically significant, but the reduced number of deaths plays a major role, and the addition of education led to improvements in discrimination and classification in the Nordic countries only.

CONCLUSIONS

We recommend the inclusion of education in SCORE CVD risk equation in men, particularly in Nordic and East European countries, to improve social equity in primary prevention. Weaker evidence for women warrants the need for further investigations.