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Norström T, Landberg J. The association between population drinking and ischemic heart disease mortality in educational groups. Alcohol Alcohol 2023:7161016. [PMID: 37208001 DOI: 10.1093/alcalc/agad033] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 04/07/2023] [Accepted: 04/11/2023] [Indexed: 05/21/2023] Open
Abstract
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.
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Affiliation(s)
- Thor Norström
- Swedish Institute for Social Research (SOFI), Stockholm University, Stockholm 109 91, Sweden
| | - Jonas Landberg
- Department of Public Health Sciences, Stockholm University, Stockholm 106 91, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm 171 77, Sweden
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Is there a relationship between adverse childhood experiences and problem drinking behaviors? Findings from a population-based sample. Public Health 2017. [DOI: 10.1016/j.puhe.2017.05.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Dukes JW, Dewland TA, Vittinghoff E, Olgin JE, Pletcher MJ, Hahn JA, Gladstone RA, Marcus GM. Access to alcohol and heart disease among patients in hospital: observational cohort study using differences in alcohol sales laws. BMJ 2016; 353:i2714. [PMID: 27301557 PMCID: PMC4908314 DOI: 10.1136/bmj.i2714] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To investigate the relation between alcohol consumption and heart disease by using differences in county level alcohol sales laws as a natural experiment. DESIGN Observational cohort study using differences in alcohol sales laws. SETTING Hospital based healthcare encounters in Texas, USA. POPULATION 1 106 968 patients aged 21 or older who were residents of "wet" (no alcohol restrictions) and "dry" (complete prohibition of alcohol sales) counties and admitted to hospital between 2005 and 2010, identified using the Texas Inpatient Research Data File. OUTCOME MEASURES Prevalent and incident alcohol misuse and alcoholic liver disease were used for validation analyses. The main cardiovascular outcomes were atrial fibrillation, acute myocardial infarction, and congestive heart failure. RESULTS Residents of wet counties had a greater prevalence and incidence of alcohol misuse and alcoholic liver disease. After multivariable adjustment, wet county residents had a greater prevalence (odds ratio 1.05, 95% confidence interval 1.01 to 1.09; P=0.007) and incidence (hazard ratio 1.07, 1.01 to 1.13; P=0.014) of atrial fibrillation, a lower prevalence (odds ratio 0.83, 0.79 to 0.87; P<0.001) and incidence (hazard ratio 0.91, 0.87 to 0.99; P=0.019) of myocardial infarction, and a lower prevalence (odds ratio 0.87, 0.84 to 0.90; P<0.001) of congestive heart failure. Conversion of counties from dry to wet resulted in statistically significantly higher rates of alcohol misuse, alcoholic liver disease, atrial fibrillation, and congestive heart failure, with no detectable difference in myocardial infarction. CONCLUSIONS Greater access to alcohol was associated with more atrial fibrillation and less myocardial infarction and congestive heart failure, although an increased risk of congestive heart failure was seen shortly after alcohol sales were liberalized.
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Affiliation(s)
- Jonathan W Dukes
- Division of Cardiology, Department of Medicine, University of California, 505 Parnassus Ave, M-1180B, Box 0124, San Francisco, CA 94143-0124, USA
| | - Thomas A Dewland
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Jeffrey E Olgin
- Division of Cardiology, Department of Medicine, University of California, 505 Parnassus Ave, M-1180B, Box 0124, San Francisco, CA 94143-0124, USA
| | - Mark J Pletcher
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA
| | - Judith A Hahn
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Rachel A Gladstone
- Division of Cardiology, Department of Medicine, University of California, 505 Parnassus Ave, M-1180B, Box 0124, San Francisco, CA 94143-0124, USA
| | - Gregory M Marcus
- Division of Cardiology, Department of Medicine, University of California, 505 Parnassus Ave, M-1180B, Box 0124, San Francisco, CA 94143-0124, USA
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Contribution of alcohol to hypertension mortality in Russia. JOURNAL OF ADDICTION 2014; 2014:483910. [PMID: 24829843 PMCID: PMC4007745 DOI: 10.1155/2014/483910] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2013] [Revised: 12/03/2013] [Accepted: 01/13/2014] [Indexed: 11/22/2022]
Abstract
Background. Hypertension (HTN) is reported to be the leading contributor to premature death globally. Considerable research evidence suggests that excessive alcohol intake (binge drinking) is an independent risk factor for HTN. It was repeatedly emphasized that binge drinking is a major contributor to a high cardiovascular mortality rate in Russia. Objective. The aim of this study was to examine the aggregate-level relation between alcohol consumption and HTN mortality rates in Russia. Method. Age-standardized sex-specific male and female HTN mortality data for the period 1980–2005 and data on overall alcohol consumption were analyzed by means of ARIMA (autoregressive integrated moving average) time-series analysis. The level of alcohol consumption per capita has been estimated using the indirect method based on alcohol psychoses incidence rate and employing ARIMA time-series analysis. Results. Alcohol consumption was significantly associated with both male and female HTN mortality rates: a 1-liter increase in overall alcohol consumption would result in a 6.3% increase in the male HTN mortality rate and in a 4.9% increase in female HTN mortality rate. The results of the analysis suggest that 57.5% of all male HTN deaths and 48.6% of all female HTN deaths in Russia could be attributed to alcohol. Conclusions. The outcomes of this study provide support for the hypothesis that alcohol is an important contributor to the high HTN mortality rate in the Russian Federation. The findings from the present study have important implications with to regards HTN mortality prevention, indicating that a restrictive alcohol policy can be considered as an effective measure of prevention in countries with a higher rate of alcohol consumption.
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Finegold JA, Asaria P, Francis DP. Mortality from ischaemic heart disease by country, region, and age: statistics from World Health Organisation and United Nations. Int J Cardiol 2013; 168:934-45. [PMID: 23218570 PMCID: PMC3819990 DOI: 10.1016/j.ijcard.2012.10.046] [Citation(s) in RCA: 530] [Impact Index Per Article: 48.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2012] [Revised: 10/24/2012] [Accepted: 10/28/2012] [Indexed: 11/27/2022]
Abstract
BACKGROUND Ischaemic heart disease (IHD) is the leading cause of death worldwide. The World Health Organisation (WHO) collects mortality data coded using the International Statistical Classification of Diseases (ICD) code. METHODS We analysed IHD deaths world-wide between 1995 and 2009 and used the UN population database to calculate age-specific and directly and indirectly age-standardised IHD mortality rates by country and region. RESULTS IHD is the single largest cause of death worldwide, causing 7,249,000 deaths in 2008, 12.7% of total global mortality. There is more than 20-fold variation in IHD mortality rates between countries. Highest IHD mortality rates are in Eastern Europe and Central Asian countries; lowest rates in high income countries. For the working-age population, IHD mortality rates are markedly higher in low-and-middle income countries than in high income countries. Over the last 25 years, age-standardised IHD mortality has fallen by more than half in high income countries, but the trend is flat or increasing in some low-and-middle income countries. Low-and-middle income countries now account for more than 80% of global IHD deaths. CONCLUSIONS The global burden of IHD deaths has shifted to low-and-middle income countries as lifestyles approach those of high income countries. In high income countries, population ageing maintains IHD as the leading cause of death. Nevertheless, the progressive decline in age-standardised IHD mortality in high income countries shows that increasing IHD mortality is not inevitable. The 20-fold mortality difference between countries, and the temporal trends, may hold vital clues for handling IHD epidemic which is migratory, and still burgeoning.
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Affiliation(s)
- Judith A Finegold
- International Centre for Circulatory Health, National Heart and Lung Institute, London, UK.
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Alcohol-attributable fraction of ischemic heart disease mortality in Russia. ISRN CARDIOLOGY 2013; 2013:287869. [PMID: 23956877 PMCID: PMC3728494 DOI: 10.1155/2013/287869] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 06/27/2013] [Indexed: 11/18/2022]
Abstract
Objective. The aim of the present study was to estimate the premature ischemic heart disease (IHD) mortality attributable to alcohol abuse in Russia on the basis of aggregate-level data of mortality and alcohol consumption. Method. Age-standardized sex-specific male and female IHD mortality data for the period 1980-2005 and data on overall alcohol consumption were analyzed by means of autoregressive integrated moving average (ARIMA) time series analysis. Results. The results of the analysis suggest that 41.1% of all male deaths and 30.7% of female deaths from IHD in Russia could be attributed to alcohol. The estimated alcohol-attributable fraction for men ranged from 24.0% (75+ age group) to 62.0% (15-29 age group) and for women from 20.0% (75+ age group) to 64.0% (30-44 age group). Conclusions. The outcomes of this study provide indirect support for the hypothesis that the high rate of IHD mortality in Russia may be related to alcohol, as indicated by a close aggregate-level association between number of deaths from IHD and overall alcohol consumption per capita.
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Bhattacharya J, Gathmann C, Miller G. The Gorbachev Anti-Alcohol Campaign and Russia's Mortality Crisis. AMERICAN ECONOMIC JOURNAL. APPLIED ECONOMICS 2013; 5:232-260. [PMID: 24224067 PMCID: PMC3818525 DOI: 10.1257/app.5.2.232] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Political and economic transition is often blamed for Russia's 40% surge in deaths between 1990 and 1994. Highlighting that increases in mortality occurred primarily among alcohol-related causes and among working-age men (the heaviest drinkers), this paper investigates an alternative explanation: the demise of the 1985-1988 Gorbachev Anti-Alcohol Campaign. Using archival sources to build a new oblast-year data set spanning 1978-2000, we find a variety of evidence suggesting that the campaign's end explains a large share of the mortality crisis - implying that Russia's transition to capitalism and democracy was not as lethal as commonly suggested.
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Affiliation(s)
- Jay Bhattacharya
- Stanford Medical School and NBER, 117 Encina Commons, Stanford, CA 94305
| | - Christina Gathmann
- University of Heidelberg, CESifo, and IZA, Bergheimerstrasse 20, Heidelberg, Germany, 69115
| | - Grant Miller
- Stanford Medical School and NBER, 117 Encina Commons, Stanford, CA 94305
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Abstract
AIMS This paper presents examples to illustrate the utility and limitations in the use of epidemiology in alcohol research and discusses some promising new directions. METHODS Review of literature, concentrating on epidemiological alcohol research with relevance to public health. FINDINGS AND CONCLUSION Epidemiology offers tools for assessment of causes and effects of alcohol consumption as well as the effects of efforts to prevent alcohol consumption and its consequences. Epidemiological studies have made significant contributions to alcohol research with respect to public health and public policy. Fixed-effects modelling, difference-in-differences estimation and integrated qualitative and epidemiological methods are promising but underused methods in epidemiological studies. Many epidemiological studies have limited transferability of knowledge to other cultures and jurisdictions.
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Affiliation(s)
- Ingeborg Rossow
- Norwegian Institute for Alcohol and Drug Research, Oslo, Norway.
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Abstract
AIMS Alcohol is believed to be an important factor behind the sharp rise in mortality during the period 1990-94 in Russia. However, the rise in the standard alcohol consumption proxy does not seem to be sufficient to explain all the increase in mortality. This study adopts a novel approach to exploring the role of the alcohol factor in the increased mortality by investigating whether the mismatch between trends in mortality and recorded alcohol consumption is due to an underestimation of the consumption increase. DESIGN AND MEASUREMENTS First, the alcohol effect on the male accident rate was estimated using data for the period 1959-89. Next, the estimated alcohol effect and the observed accident mortality rate for the period 1990-98 were used to backcast alcohol consumption during that period. Thirdly, the backcasted alcohol series was used to predict trajectories in alcohol poisoning mortality, the homicide rate and all-cause mortality during the period 1990-98. FINDINGS There was a markedly stronger increase in the backcasted consumption proxy than in the standard alcohol consumption proxy during the period 1990-98. There was a substantial gap between the observed mortality rates and the rates predicted from the standard alcohol consumption proxy, whereas the predictions from the backcasted alcohol proxy were much closer to the target. CONCLUSIONS Much of the rise in Russian mortality in 1990-94 appears to have been due to the increase in population drinking, but this increase is grossly underestimated by the commonly used consumption proxy combining alcohol sales, estimation of illicit alcohol production and proportion of alcohol-positive violent deaths.
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Affiliation(s)
- Thor Norström
- Swedish Institute for Social Research, Stockholm University, Stockholm, Sweden.
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Guillot M, Gavrilova N, Pudrovska T. Understanding the "Russian mortality paradox" in Central Asia: evidence from Kyrgyzstan. Demography 2011; 48:1081-104. [PMID: 21618068 PMCID: PMC3315848 DOI: 10.1007/s13524-011-0036-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
In the former Soviet republics of central Asia, ethnic Russians have exhibited higher adult mortality than native ethnic groups (e.g., Kazakh, Kyrgyz, Uzbek) in spite of the higher socioeconomic status of ethnic Russians. The mortality disadvantage of ethnic Russians at adult ages appears to have even increased since the breakup of the Soviet Union. The most common explanation for this "Russian mortality paradox," is that deaths are better reported among ethnic Russians. In this study, we use detailed mortality data from Kyrgyzstan between 1959 and 1999 to evaluate various explanations for the Russian mortality paradox: data artifacts, migration effects, and cultural effects. We find that the most plausible explanation is the cultural hypothesis because the personal behaviors that appear to generate a large part of the observed mortality differences (alcohol consumption, in particular) seem to be closely tied to cultural practices. We examine the implications of this finding for understanding the health crisis in post-Soviet states.
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Affiliation(s)
- Michel Guillot
- Population Studies Center, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Kerr WC, Karriker-Jaffe K, Subbaraman M, Ye Y. Per capita alcohol consumption and ischemic heart disease mortality in a panel of US states from 1950 to 2002. Addiction 2011; 106:313-22. [PMID: 21059185 PMCID: PMC3058887 DOI: 10.1111/j.1360-0443.2010.03195.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS To estimate the overall impact of alcohol on ischemic heart disease (IHD) mortality in the United States using aggregate-level models and to consider beverage-specific effects that may represent more effectively the changes in drinking patterns over time that are related to both harmful and protective impacts of alcohol consumption on IHD. DESIGN Several model specifications are estimated, including state-specific autoregressive integrated moving average (ARIMA) models and generalized least squares (GLS) panel models on first-differenced data. SETTING US states from 1950 to 2002. PARTICIPANTS US general population. MEASUREMENTS Per capita alcohol sales and cigarette sales, age-standardized IHD and cirrhosis mortality rates. FINDINGS Apparent consumption of total alcohol was associated with a significant overall increase of IHD of about 1% mortality per litre of ethanol. Beverage-specific models found that spirits consumption was significantly positively related to IHD mortality overall, for both genders and in three regions defined by drinking culture (or 'wetness'), while beer was found to have a significant protective relationship overall and in the wet region. The results for wine also suggest a protective relationship, but only marginally significant effects were found. Cirrhosis mortality rates were consistently positively related to IHD mortality. Combined results from state-specific ARIMA models including both cigarette sales and cirrhosis rates were generally consistent with the GLS results. CONCLUSIONS Population-level models confirm individual-level findings of both harmful and protective relationships between alcohol use patterns and ischemic heart disease mortality. However, an overall harmful impact of per capita alcohol consumption on IHD mortality was found.
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Beverage-specific alcohol sale and cardiovascular mortality in Russia. JOURNAL OF ENVIRONMENTAL AND PUBLIC HEALTH 2011; 2010:253853. [PMID: 21318145 PMCID: PMC3034963 DOI: 10.1155/2010/253853] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Accepted: 12/29/2010] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Recent research evidence suggests that the consumption of different types of alcoholic beverage may have a differential effect on cardiovascular diseases (CVD) mortality rates. The aim of this study was to examine the relation between the consumption of different beverage types and CVD mortality rates in Russia across the later-Soviet and post-Soviet periods. METHOD Age-standardized male and female CVD mortality data for the period 1970-2005 and data on beverage-specific alcohol sales were obtained Russian State Statistical Committee (Rosstat). Time-series analytical modeling techniques (ARIMA) were used to examine the relation between the sales of different alcoholic beverages and CVD mortality rates. RESULTS Vodka consumption as measured by sales was significantly associated with both male and female CVD mortality rates: a 1 liter increase in vodka sales would result in a 5.3% increase in the male CVD mortality rate and a 3.7% increase in the female rate. The consumption of beer and wine were not associated with CVD mortality rates. CONCLUSIONS The findings from this study suggest that public health efforts should focus on both reducing overall consumption and changing beverage preference away from distilled spirits in order to reduce cardiovascular mortality rates in Russia.
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Leon DA, Shkolnikov VM, McKee M, Kiryanov N, Andreev E. Alcohol increases circulatory disease mortality in Russia: acute and chronic effects or misattribution of cause? Int J Epidemiol 2010; 39:1279-90. [PMID: 20591986 PMCID: PMC2972439 DOI: 10.1093/ije/dyq102] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND There is a consensus that the large fluctuations in mortality seen in Russia in the past two decades can be attributed to trends in alcohol consumption. However, the precise mechanisms linking alcohol to mortality from circulatory disease remain unclear. It has recently been argued that a substantial number of such deaths currently ascribed to cardiovascular disorders are misclassified cases of acute alcohol poisoning. METHODS Analysis of routine mortality data and of a case-control study of mortality among working-age (25-54 years) men occurring in the Russian city of Izhevsk, west of the Ural mountains, 2003-05. Interviews were carried out with proxy informants for both the dead cases (N = 1750) and the controls (N = 1750) selected at random from a population register. Mortality was analysed according to indicators of alcohol problems. RESULTS Hazardous drinking was associated with an increased risk of death from circulatory diseases as a whole [odds ratio (OR) = 4.14, 95% confidence interval (CI) 3.23, 5.31] adjusted for age, smoking and education. The association with alcoholic cardiomyopathy was particularly strong (OR = 15.7, 95% CI 9.5, 25.9). Although there was no association with deaths from myocardial infarction (MI; OR = 1.17, 95% CI 0.59, 2.32), there was a strong association with the aggregate of all other ischaemic heart disease (IHD; OR = 4.04, 95% CI 2.79, 5.84). Stronger associations for each of these causes (other than MI) were seen with whether or not the man had drunk very heavily in the previous week. However, associations also remained when analyses were restricted to subjects with no evidence of recent heavy drinking, suggesting that misclassification of acute alcohol poisonings is unlikely to explain these overall associations. CONCLUSION Taken as a whole, the available evidence suggests that the positive association of alcohol with increased cardiovascular disease mortality may be best explained as being the result of a combination of chronic and acute alcohol consumption resulting in alcohol-related cardiac disorders, especially cardiomyopathy, rather than being due to misclassification of acute alcohol poisoning. Further work is required to understand the mechanisms underlying the link between heavy alcohol consumption and deaths classified as being due to IHD (other than MI).
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Affiliation(s)
- David A Leon
- London School of Hygiene and Tropical Medicine, London, UK.
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Rey G, Boniol M, Jougla E. Estimating the number of alcohol-attributable deaths: methodological issues and illustration with French data for 2006. Addiction 2010; 105:1018-29. [PMID: 20331552 DOI: 10.1111/j.1360-0443.2010.02910.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
AIMS Computing the number of alcohol-attributable deaths requires a series of hypotheses. Using French data for 2006, the potential biases are reviewed and the sensitivity of estimates to various hypotheses evaluated. METHODS Self-reported alcohol consumption data were derived from large population-based surveys. The risks of occurrence of diseases associated with alcohol consumption and relative risks for all-cause mortality were obtained through literature searches. All-cause and cause-specific population alcohol-attributable fractions (PAAFs) were calculated. In order to account for potential under-reporting, the impact of adjustment on sales data was tested. The 2006 mortality data were restricted to people aged between 15 and 75 years. RESULTS When alcohol consumption distribution was adjusted for sales data, the estimated number of alcohol-attributable deaths, the sum of the cause-specific estimates, was 20 255. Without adjustment, the estimate fell to 7158. Using an all-cause mortality approach, the adjusted number of alcohol-attributable deaths was 15 950, while the non-adjusted estimate was a negative number. Other methodological issues, such as computation based on risk estimates for all causes for 'all countries' or only 'European countries', also influenced the results, but to a lesser extent. DISCUSSION The estimates of the number of alcohol-attributable deaths varied greatly, depending upon the hypothesis used. The most realistic and evidence-based estimate seems to be obtained by adjusting the consumption data for national alcohol sales, and by summing the cause-specific estimates. However, interpretation of the estimates must be cautious in view of their potentially large imprecision.
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Affiliation(s)
- Grégoire Rey
- INSERM, CépiDc, Université Paris Sud 11, IFR69 Le Vésinet, France.
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