Minimum Prices for Alcohol and Educational Disparities in Alcohol-related Mortality:

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.

Association between genetic risk of alcohol consumption and alcohol-related morbidity and mortality under different alcohol policy conditions: Evidence from the Finnish alcohol price reduction of 2004

AIMS

Harmful alcohol consumption is influenced by both genetic susceptibility and the price of alcohol. Many previous studies have observed that genetic susceptibility to consumption of alcohol is more predictive in less restrictive drinking conditions. We assess whether such a pattern applies when the prices of alcoholic beverages are decreased.

DESIGN

Data consist of genetically informed population-representative surveys (FINRISK 1992, 1997, 2002 and Health 2000) linked to administrative registers. We analysed the interaction between a polygenic score (PGS) for alcoholic drinks per week consumed and price reduction in predicting the incidence of alcohol-related hospitalizations and deaths in difference-in-difference and interrupted time-series frameworks.

SETTING

Individuals in Finland were followed quarter-yearly from 1 March 2000 to 31 May 2008.

PARTICIPANTS

A total of 22 152 individuals (607 132-person quarter-years, 1399 outcome events) aged 30-79 years.

INTERVENTION

A natural experiment stemming from the alcohol tax reduction in March 2004 and import deregulation in May 2004.

MEASUREMENTS

Outcome was quarter-yearly-measured alcohol-related death or hospitalization. The independent variables of main interest were PGS and a price reform indicator. We adjusted for gender, age, age squared, season, 10 first principal components of the genome, data collection round and genotyping batch.

FINDINGS

Both alcohol price reduction and one standard deviation change in PGS were associated with alcohol-related health outcomes; odds ratios (ORs) were 1.32, 95% confidence interval (CI) = 1.13, 1.53 and 1.26, 95% CI = 1.12, 1.42 in the 8-year follow-up, respectively. The association between PGS and alcohol-related morbidity was similar before and after the alcohol price reform (PGS × price reform interaction OR = 0.96, 95% CI = 0.81, 1.14). These results were robust across different follow-up periods and measurement and analysis strategies.

CONCLUSIONS

Although the decrease of alcohol price in Finland in 2004 substantially increased overall alcohol-related morbidity and mortality, the genetic susceptibility to alcohol consumption did not become more manifest in predicting them.

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.

Analysis of gaps in alcohol policies in Brazil using the Pan American Health Organization's Alcohol Policy Scoring

BACKGROUND

National alcohol policies need to be systematized and evaluated to identify the gaps that should be filled by future laws. This study aims to search for and classify Brazilian public alcohol policies at the federal and state levels, based on the ten Alcohol Policy Scoring (APS) domains used by the Pan American Health Organization (PAHO), to identify any gaps METHODS: Documental research was carried out in two phases: document identification and content analysis. The search included laws, decrees, and ordinances for alcohol referred to in this text as regulatory documents (RD), enacted until December 31, 2019, in Brazil and its 26 states and the Federal District. The APS was used to classify and score the RD, which consists of ten policy domains (including pricing, availability, marketing, and health services), weighted according to the level of scientific evidence of each strategy RESULTS: We identified and categorized 435 valid RD (21 national laws and 414 state laws). Overall, Brazilian alcohol policies account for 51.6% (255/494) of the APS score. In the pricing policy domain, the second most robust indicator of the APS, the policy gap reached 87% in 25 states, demonstrating a weakness. Only the federal laws against drink-driving include all the recommended dimensions. There are important legislative contradictions in the definition of an alcoholic beverage and in the content of the policies to control marketing CONCLUSION: At the national level, the federal government adopted alcohol policies in several of the PAHO policy domains but enacted RD with little practical effect. At the subnational level, despite the autonomy to complement federal laws, the states have not yet addressed the most important gaps.

Impact of law enforcement and increased traffic fines policy on road traffic fatality, injuries and offenses in Iran: Interrupted time series analysis

BACKGROUND

Road traffic law enforcement was implemented on 1st April 2011 (the first intervention) and traffic ticket fines have been increased on 1st March 2016 (the second intervention) in Iran. The aim of the current study was to evaluate the effects of the law enforcement on reduction in the incidence rate of road traffic fatality (IRRTF), the incidence rate of road traffic injuries (IRRTI) and the incidence rate of rural road traffic offenses (IRRRTO) in Iran.

METHODS

Interrupted time series analysis was conducted to evaluate the impact of law enforcement and increased traffic tickets fines. Monthly data of fatality on urban, rural and local rural roads, injuries with respect to gender and traffic offenses namely speeding, illegal overtaking and tailgating were investigated separately for the period 2009-2016.

RESULTS

Results showed a reduction in the incidence rate of total road traffic fatality (IRTRTF), the incidence rate of rural road traffic fatality (IRRRTF) and the incidence rate of urban road traffic fatality (IRURTF) by -21.44% (-39.3 to -3.59, 95% CI), -21.25% (-31.32 to -11.88, 95% CI) and -26.75% (-37.49 to -16, 95% CI) through the first intervention which resulted in 0.383, 0.255 and 0.222 decline in casualties per 100 000 population, respectively. Conversely, no reduction was found in the incidence rate of local rural road traffic fatality (IRLRRTF) and the IRRTI. Second intervention was found to only affect the IRURTF with -26.75% (-37.49 to -16, 95% CI) which led to 0.222 casualties per 100 000 population. In addition, a reduction effect was observed on the incidence rate of illegal overtaking (IRIO) and the incidence rate of speeding (IRS) with -42.8% (-57.39 to -28.22, 95% CI) and -10.54% (-21.05 to -0.03, 95% CI which implied a decrease of 415.85 and 1003.8 in monthly traffic offenses per 100 000 vehicles), respectively.

CONCLUSION

Time series analysis suggests a decline in IRTRTF, IRRRTF, and IRURTF caused by the first intervention. However, the second intervention found to be only effective in IRURTF, IRIO, and IRS with the implication that future initiatives should be focused on modifying the implementation of the traffic interventions.

Influence of affordability of alcohol on educational disparities in alcohol-related mortality in Finland and Sweden: a time series analysis

BACKGROUND

Prices of alcohol and income tend to influence how much people buy and consume alcohol. Price and income may be combined into one measure, affordability of alcohol. Research on the association between affordability of alcohol and alcohol-related harm is scarce. Furthermore, no research exists on how this association varies across different subpopulations. We estimated the effects of affordability of alcohol on alcohol-related mortality according to gender and education in Finland and Sweden.

METHODS

Vector-autoregressive time series modelling was applied to the quarter-annual aggregations of alcohol-related deaths and affordability of alcohol in Finland in 1988-2007 and in Sweden in 1991-2008. Alcohol-related mortality was defined using information on both underlying and contributory causes of death. We calculated affordability of alcohol index using information on personal taxable income and prices of various types of alcohol.

RESULTS

Among Finnish men with secondary education, an increase of 1% in the affordability of total alcohol was associated with an increase of 0.028% (95% CI 0.004 to 0.053) in alcohol-related mortality. Similar associations were also found for affordability for various types of alcohol and for beer only in the lowest education group. We found few other significant positive associations for other subpopulations in Finland or Sweden. However, reverse associations were found among secondary-educated Swedish women.

CONCLUSIONS

Overall, the associations between affordability of alcohol and alcohol-related mortality were relatively weak. Increased affordability of total alcoholic beverages was associated with higher rates of alcohol-related mortality only among Finnish men with secondary education.

Evidence for the effectiveness of minimum pricing of alcohol: a systematic review and assessment using the Bradford Hill criteria for causality

OBJECTIVES

To assess the evidence for price-based alcohol policy interventions to determine whether minimum unit pricing (MUP) is likely to be effective.

DESIGN

Systematic review and assessment of studies according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, against the Bradford Hill criteria for causality. Three electronic databases were searched from inception to February 2017. Additional articles were found through hand searching and grey literature searches.

CRITERIA FOR SELECTING STUDIES

We included any study design that reported on the effect of price-based interventions on alcohol consumption or alcohol-related morbidity, mortality and wider harms. Studies reporting on the effects of taxation or affordability and studies that only investigated price elasticity of demand were beyond the scope of this review. Studies with any conflict of interest were excluded. All studies were appraised for methodological quality.

RESULTS

Of 517 studies assessed, 33 studies were included: 26 peer-reviewed research studies and seven from the grey literature. All nine of the Bradford Hill criteria were met, although different types of study satisfied different criteria. For example, modelling studies complied with the consistency and specificity criteria, time series analyses demonstrated the temporality and experiment criteria, and the analogy criterion was fulfilled by comparing the findings with the wider literature on taxation and affordability.

CONCLUSIONS

Overall, the Bradford Hill criteria for causality were satisfied. There was very little evidence that minimum alcohol prices are not associated with consumption or subsequent harms. However the overall quality of the evidence was variable, a large proportion of the evidence base has been produced by a small number of research teams, and the quantitative uncertainty in many estimates or forecasts is often poorly communicated outside the academic literature. Nonetheless, price-based alcohol policy interventions such as MUP are likely to reduce alcohol consumption, alcohol-related morbidity and mortality.

The contribution of education, social class and economic activity to the income-mortality association in alcohol-related and other mortality in Finland in 1988-2012

AIMS

First, to quantify trends in the contribution of alcohol-related mortality to mortality disparity in Finland by income quintiles. Secondly, to estimate the degree to which education, social class and economic activity explain the income-mortality association in alcohol-related and other mortality in four periods within 1988-2012.

DESIGN

Register-based longitudinal study using an 11% random sample of Finnish residents linked to socio-economic and mortality data in 1988-2012 augmented with an 80% sample of all deaths during 1988-2007. Mortality rates and discrete time survival regression models were used to assess the income-mortality association following adjustment for covariates in 6-year periods after baseline years of 1988, 1994, 2001, and 2007.

SETTING

Finland.

PARTICIPANTS

Individuals aged 35-64 years at baselines. For the four study periods for men/women, the final data set comprised, respectively, 26,360/12,825, 22,561/11,423, 20,342/11,319 and 2651/1514 deaths attributable to other causes and 7517/1217, 8199/1450, 9807/2116, 1431/318 deaths attributable to alcohol-related causes.

MEASUREMENTS

Alcohol-related deaths were analysed with household income, education, social class and economic activity as covariates.

FINDINGS

The income disparity in mortality originated increasingly from alcohol-related causes of death, in the lowest quintile the contribution increasing from 28 to 49% among men and from 11 to 28% among women between periods 1988-93 and 2007-12. Among men, socio-economic characteristics attenuated the excess mortality during each study period in the lowest income quintile by 51-62% in alcohol-related and other causes. Among women, in the lowest quintile the attenuation was 47-76% in other causes, but there was a decreasing tendency in the proportion explained by the covariates in alcohol-related mortality.

CONCLUSIONS

The income disparity in mortality among working-age Finns originates increasingly from alcohol-related causes of death. Roughly half the excess mortality in the lowest income quintile during 2007-12 is explained by the covariates of household income, education, social class and economic activity.

Alcohol-related emergency department admissions among adolescents in the Ghent and Sint-Niklaas areas

Alcohol abuse is a major health concern. The aim of this retrospective study was to analyse the alcohol-related emergency department (ED) admissions among adolescents in all hospitals of distinct areas during a 1-year period. In each hospital, all ED patients with a blood alcohol concentration (BAC) of at least 0.5 g/l were surveyed in a standardised way. Of the 3918 included patients, only 146 (3.7%) were < 18  years. The male-to-female ratio was 1.5:1. There was a strong preponderance of weekend and night time admissions. Most of the patients were transported by ambulance (77% of 138 patients with information on this item). The main reason for ED admittance was depressed level of consciousness (64%), trauma (12%), vomiting and/or abdominal pain (12%), agitation or aggression (4%), syncope (4%) and psychological problems (4%). The context of the alcohol intoxication was related to some kind of festivity in 85%, mental problems in 14% and chronic abuse in 1%. Median BAC values (and range) were 2.08 g/l (0.73-3.70 g/l) for boys and 1.51 g/l (0.73-2.90 g/l) for girls. Most patients (87%) could be discharged home within 24  hours. Our study confirms that problematic alcohol use leading to ED admissions starts in adolescence. Although the numbers of cases below 18 years are low when compared to adults, the phenomenon is alarming as it is associated with substantial health problems. Therefore, Belgium urgently needs a global national alcohol plan, with youngsters being one of the target groups.

The Socioeconomic Differences in Alcohol-Related Harm and the Effects of Alcohol Prices on Them: A Summary of Evidence from Finland

AIMS

We make a case study of Finland to study the connections between socioeconomic status, alcohol use, related harm and possibilities for intervention by means of alcohol pricing.

METHODS

A review of Finnish studies on the topic.

RESULTS

The socioeconomic differences in severe alcohol-related harm were great, and in the past two decades, these differences have widened. Alcohol-related mortality has also strongly contributed to both the level and widening of socioeconomic differences in life expectancy. Both in 2004, when alcohol prices were abruptly cut, and in the longer term with more gradual changes in lowest prices of alcohol, the lowest socioeconomic groups were most affected in absolute-but not so clearly in relative-terms, particularly among men. However, these effects are sometimes weak, not fully consistent by gender and across different measures of harm.

CONCLUSIONS

The large and increasing socioeconomic differences in alcohol-related harm in Finland underline the importance of reducing these differences. The finding that particularly among men the impact of reduced alcohol prices on health has often in absolute terms been the greatest in the lower socioeconomic groups suggests that policies aimed at keeping the price of alcoholic beverages high may help to both minimize the overall level of alcohol-related health problems and to reduce absolute inequalities.