Alcohol and Alcoholism Advance Access originally published online on February 3, 2007
Alcohol and Alcoholism 2007 42(5):456-464; doi:10.1093/alcalc/agl099
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Differential trends in alcohol-related mortality: a register-based follow-up study in Finland in 1987–2003
1 Population Research Unit, Department of Sociology, University of Helsinki, Finland
2 National Research and Development Centre for Welfare and Health (Stakes), Helsinki, Finland
3 Helsinki Collegium for Advanced Studies, Helsinki, Finland
* Author to whom correspondence should be addressed at: Department of Sociology, University of Helsinki, FIN-00014, Finland. Tel: +358 9 19125401; Fax: +358 9 19123967; E-mail: kimmo.herttua{at}helsinki.fi
Received 26 September 2006; ; accepted 8 October 2006
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ABSTRACT |
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 TOP ABSTRACT IntroductionData and MethodsResultsDiscussionConclusionsReferences |
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Aims: To assess to what extent alcohol-related mortality has changed by age, sex and education in Finland in 1987–2003, a period which saw two periods of economic growth, separated by a severe depression (1991–1995). Methods: A register-based follow-up study of all over 15-year-old Finnish men and women. Age, sex and education of the participants were measured at the time of the 1985, 1990, 1995 and 2000 censuses. Follow-up for mortality was for 1987--2003. The outcome measure was alcohol-related mortality, which was defined using information on the underlying and contributory causes of death. Results: Among men and women aged 45 years and over, the trends in alcohol-related mortality were associated with economic cycles. Among those aged less than 45 years, alcohol-related mortality decreased from the early 1990s, but intoxication-related accidents and violence still contributed largely to premature mortality. The unfavourable trend for older men resulted from an increase in mortality due to directly alcohol-attributable diseases, alcohol-related diseases of the circulatory system and accidents and violence, and for older women from an increase due to intoxication-related accidents and violence, and alcohol-attributable diseases. Alcohol-related mortality was higher in lower educational groups, and among women the educational gap widened towards the end of the study period. Conclusions: This study shows that trends in both economic conditions and per capita consumption of alcohol are not associated with trends in alcohol-related mortality in all population subgroups. In health policy more attention should be paid to divergent trends in gender, age and education specific alcohol-related mortality.
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Introduction |
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TOPABSTRACTIntroductionData and MethodsResultsDiscussionConclusionsReferences |
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Alcohol is a major determinant of premature death and population subgroup differences in mortality. It has been estimated that alcohol contributes 3.2% to global mortality (Rehm et al., 2004
). These types of estimates of alcohol's contribution are most often produced at the national level, and only seldom have differences between other population subgroups than age and sex been shown. The standard procedure for estimating alcohol-related mortality is based on risk ratios and survey data on consumption, and special studies on the contribution of alcohol to injuries and violence (e.g. Mokdad et al., 2004; Murray et al., 2004). This approach may yield a good estimate at the population level, but it is not suitable for studying differences between subgroups of the population. In Finland, the death register provides exceptionally extensive and reliable data on the contribution of alcohol on deaths at the individual level, which enables comparisons between population subgroups.
Previously it has been found, particularly in the Nordic countries, that alcohol-related harms have closely followed changes in per capita alcohol consumption (see Edwards et al., 1994; Norström et al., 2002). On the other hand, it has been reported that in Sweden alcohol-related deaths in 1994–2002 did not increase despite an increase in estimated total alcohol consumption (Holder et al., 2005).
Our observation period, 1987–2003, was characterized by two periods of economic growth (1987–1991 and 1995–2003), separated by a severe depression (1991–1995) that involved large scale unemployment. In the late 1980s, the unemployment rate in Finland was 
5%. However, unemployment in Finland began to increase in late 1990. By the end of 1992, unemployment had climbed to 15%, and by early 1994 a peak figure of about 19% was recorded. Long-term unemployment became more common and redundancy also affected the well-educated labour force and white-collar occupations although to a lesser extent than less educated and blue-collar workers (Martikainen and Valkonen, 1996). The total consumption of alcohol rose in the periods of growth and declined in the course of the depression (Hein and Vuorjoki, 1998; Österberg, 2005). Similarly, deaths from alcohol-related diseases and poisoning increased along with the rapid economic boom of 1987–1991, and decreased during the recession (e.g. Valkonen et al., 2000).
According to previous studies (e.g. Mackenbach et al., 1997; Martikainen et al., 2001; Huisman et al., 2005) there are large differences between sexes and socio-economic groups in premature mortality and life expectancy. In many countries a significant part of these differences have been shown due to alcohol (Mäkelä, 1998; Mäkelä et al., 1997; Mackenbach et al., 1999). According to the global burden of disease estimates alcohol-related deaths are 10 times more frequent among men than among women (Rehm et al., 2004). Socio-economic inequalities in mortality due to alcohol-related diseases among manual labourers were 90% higher than among non-manual employees in Sweden (Norström and Romelsjö, 1998), whereas in Finland alcohol-related mortality was about three times higher in lower as compared to higher educational and occupational classes (Mäkelä, 1999).
The two most commonly used indicators of socio-economic status are education and occupation based social class. Education and social class are not simply interchangeable, but emphasize different dimensions of social stratification. For the most part, studies on the socio-economic differences in alcohol-related mortality are based on occupational social class (e.g. Mäkelä et al., 1997; Hemström, 2002; Pensola and Martikainen, 2004; Ljung et al., 2005). One of the purposes of this study is to extend the analyses of differential alcohol-related mortality to the examination of education. As a measure of socio-economic status education reflects the experiences of youth, a time when educational qualifications are usually obtained. From the point of view of this study it is thus particularly relevant and it is also the time of life when the basis for many habits and behaviours are laid.
The aim of this study is to assess how alcohol-related mortality and its population sub-group differences changed in Finland in 1987–2003 when there were substantial changes in economic conditions, unemployment, and alcohol consumption. However, we do not aim to use information on economic cycles explicitly, e.g. in time series analysis, but use information on changes in unemployment rates as a tool for interpretation. First, we will study trends in alcohol-related mortality by cause and also to assess whether alcohol-related mortality changes with alcohol consumption as can be expected on the basis of literature (Edwards et al., 1994). Second, we will study population differences according to sex, age and education, and their changes in alcohol-related mortality. Alcohol-related mortality is defined using information on the underlying and contributory causes of death. The Finnish death certification practices and cause of death validation result in good quality data on alcohol-related underlying as well as contributory causes of death (Lahti and Penttilä, 2001), which makes the data unique from an international point of view.
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Data and Methods |
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TOPABSTRACTIntroductionData and MethodsResultsDiscussionConclusionsReferences |
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Study population
The data in this study were obtained from Statistics Finland (permission CS-53-483-05). The data are registered data from the 1985, 1990, 1995, and 2000 census which were linked individually to records from the death register for the years 1987–90, 1991–95, 1996–2000, and 2001–03, respectively. The analysis comprises all over 15-year-old Finns, altogether 33.7 million person-years among men and 36.4 million person-years among women.
Alcohol-related mortality
The follow-up for mortality was from 1987 to 2003. In 1987, the Finnish Classification of Diseases 1987 (FCD) was introduced and good quality data on alcohol as a contributory cause of death became available. The basis of the FCD is on the 9th Revision of the International Classification of Diseases (ICD), but it is more detailed due to use of five-digit codes, and some categories have codes different to those of the ICD. In 1996–2003, ICD 10 was used. The Finnish classification also includes some specifications to the international classification in this version.
Alcohol-related deaths were defined as those that have a reference to alcohol in the death certificate's underlying or contributory causes of death. Estimating alcohol-related mortality on the basis of the underlying and contributory causes of death yields more versatile and comprehensive data than the standard method based solely on the underlying cause, particularly in Finland where death certificates record alcohol intoxication as a contributory cause of death more frequently and accurately than in most other countries (Mäkelä, 1998, 2000; Lahti and Penttilä, 2001). Frequent use of medicolegal autopsy is one of the major factors that enables a proper use of alcohol intoxication as a contributory cause of death. Medicolegal autopsies were carried out in >97% of all accidental and violent deaths among people aged under 75 years in 1987–1993 (Mäkelä, 1998), where as it was >60% of all deaths among people aged <65 years in 1987–2003.
The pool of alcohol-related deaths used here consists of the following two main categories of death: (i) the underlying cause of death is an alcohol-attributable disease (see below) or fatal alcohol poisoning, and (ii) the contributory cause of death is alcohol-attributable disease or alcohol intoxication. The two categories were defined to be mutually exclusive. Below, we use the term `intoxication-related' for deaths where alcohol intoxication is a contributory cause of death. Alcohol-attributable diseases were: alcohol dependence syndrome (ICD10 code F102; FCD9 code 303), other mental and behavioural disorders due to use of alcohol (F101, F103–109; 291), alcoholic cardiomyopathy (I426; 4255A), alcoholic liver disease (K70; 5710–5713), alcoholic diseases of the pancreas (K860, K8600; 5770D–F, 5771C–D), and additionally some rarely occurring categories (K292, G312, G4051, G621, G721; 3575A, 5353A). We used alcoholic liver cirrhosis instead of all liver cirrhosis, because there does not seem to be any strong tendency to underreport the alcoholic cases in Finland: for example, in 2004 among men aged 15–64 years, 97% of deaths due to liver cirrhosis were classified as alcoholic in the death certificate (Statistics Finland, 2005a).
In the figures for the period 1987–95, we combined the deaths from fatal alcohol poisoning and alcohol dependence syndrome, because a part of the cases defined as alcohol poisoning under ICD9 were defined as alcohol dependence under ICD10.
Measurement of explanatory variables
Sociodemographic data came from censuses in 1985, 1990, 1995, and 2000. These variables included sex, 5 year age groups (15–19, ... , 90–94, 95+), and education. For education, the following categories were used: basic (10 years or less), intermediate (11–12 years), and high (13+ years).
Methods
Trends in mortality by cause and age were assessed by calculating crude death rates per 100 000 person-years. Age standardization did not affect the results on cause-specific mortality due to the short observation period. When comparing educational groups, the effect of differences in the age distribution was controlled by calculating age-adjusted mortality rates, using combined population of men and women in 1987–2003 as the standard population. Per capita alcohol consumption was calculated as the sum of recorded consumption and estimated unrecorded consumption—based on survey data on the consumption of privately imported, smuggled or home-made beverages (Österberg, 2000)—per inhabitants aged 15 or more (an unpublished table by STAKES 2005). Unemployment rate was used as an indicator for economic trend (Statistics Finland, 1997a, b, 1999a, b, 2005b, c, d).
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Results |
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TOPABSTRACTIntroductionData and MethodsResultsDiscussionConclusionsReferences |
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When alcohol-related mortality comprises not only underlying but also contributory causes of death, the average annual number of alcohol-related deaths was 3140 (2681 for men and 459 for women) in the period of study 1987–2003 in Finland, with the peak in 2003 (3581 deaths). Alcohol-related deaths encompassed on average 6.5% (11.2% among men, 1.9% among women) of all deaths (Table 1). Of all alcohol-related deaths 85% were among men.
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Trends in alcohol-related mortality by cause and alcohol consumption
Among men, total alcohol-related mortality increased along with the economic boom of the late 1980s, as did alcohol consumption, and hit record level in 1990 (Fig. 1). During the recession, alcohol-related mortality decreased along with consumption, until the lowest level was observed in 1996. In that year, ICD10 was introduced, which resulted in changes in diagnosing causes of death (Lahti and Vuori, 2002
). This may explain the large drop in both total alcohol-related mortality among men and alcohol intoxication as the contributory cause of death in both sexes in 1996. The results for 1996 should thus be interpreted cautiously.
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Among men, alcohol-related mortality had another high point in 1998 and was succeeded by a slight decrease and a slight increase at the end of the study period. Alcohol consumption was stable in the late 1990s, and did not exceed the record of 1990 until 2001. Intoxication-related deaths followed the changes of total mortality quite closely, although declining slightly, representing an average 44% of all alcohol-related deaths, whereas other alcohol-related causes of death increased slightly.
Among women, the trend of total alcohol-related mortality was to some extent different from men: total alcohol-related mortality increased more clearly during the economic boom of the late 1980s and even more strongly after 1996 until a slight decrease towards the end of the study period, while it was relatively stable during the recession of the early 1990s. In other words, the increase in total consumption was associated with a larger increase in alcohol-related mortality among women than men, and the increase was due to other alcohol-related causes than intoxication. The proportion of intoxication- related deaths was clearly lower among women than among men, i.e. an average of 34% of all alcohol-related deaths. Women's alcohol-related mortality was 13% of that of men at the beginning of the study period and at the end of the period it was 18%.
Among men the decomposition of total alcohol-related mortality shows that intoxication-related accidental and violent deaths decreased strongly (Fig. 2). The trend for alcoholic liver diseases, as well as for the intoxication-related diseases of the circulatory system roughly followed the development in alcohol consumption. The trends of the other categories did not display strong trends. The relation between two major alcoholic causes of death changed remarkably. At the beginning of the study period there were 3.1 times more deaths from intoxication-related accidents and violence than from alcoholic liver disease, while towards to the end of the study period this ratio had decreased to 1.7.
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Among women, almost all specific alcohol-related causes contributed to the increase in alcohol-related mortality. The only exception was intoxication-related accidental and violent deaths.
Trends in alcohol-related mortality by age
Among men, alcohol-related mortality increased between late 1980s and early 1990s in all age-groups after which the trends began to diverge (Fig. 3). For men under 45 years alcohol-related mortality decreased 30% from the beginning until the end of study period. In older age-groups among whom alcohol-related mortality was at the outset clearly the highest, mortality increased considerably: in the age-group 45–59 years alcohol-related mortality increased by 15% and among those aged 60+ by 31%.
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Alcohol-attributable diseases contributed 39% and intoxication-related diseases of circulatory system and intoxication-related accidents and violence >20% each of the increase among men aged 45 and older in 1997–2003 (the period in which ICD10 was used). Among men <45 years the decrease in alcohol-related mortality was above all due to a significant decrease in intoxication-related accidents and violence but also in alcohol-attributable diseases.
This divergence by age was also prominent for women. Alcohol-related mortality was low and stable throughout the study period among the youngest. In the age-group 30–44 years, alcohol-related mortality increased first but remained stable after 1990–1991. In the age-group 45–59 years, alcohol-related mortality increased by 44% and among the oldest by 94%. A closer examination for the period 1997–2003 revealed that among women aged 45 years and older, intoxication-related accidents and violence and alcohol-attributable diseases were responsible for a good 35% each of the increase. Among women aged <45 years, the decrease in alcohol-related mortality was due to a decrease in intoxication-related accidents and violence.
Trends in alcohol-related mortality by education
Among men, age-adjusted alcohol-related mortality was highest among lowest educated men and lowest among highest educated men (Fig. 3). During the study period, alcohol-related mortality of the highest group was stable, but mortality increased in the intermediate and basic educational groups.
Among women, the difference between basic and intermediate educational classes was, in relative terms, similar to that of men. Also among women absolute mortality differences increased rapidly during the study period. However, relative differences between the basic educated and highly educated women decreased, because of a rapid proportional increase in alcohol-related mortality among the higher educated.
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Discussion |
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TOPABSTRACTIntroductionData and MethodsResultsDiscussionConclusionsReferences |
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The aim of this study was to assess to what extent alcohol-related mortality has changed by age, sex, and education in Finland in 1987–2003, and to assess previous empirical findings about the association between economic cycles and alcohol-related mortality.
When alcohol as a cause of death comprises not only underlying but also contributory causes an average of slightly over 3000 alcohol-related deaths occurred annually in Finland in the period 1987–2003 which is in agreement with the results that were reported in earlier studies for the period 1987–1995 (Mäkelä, 2000). The proportion of men of all alcohol-related deaths was 85%.
Trends in alcohol-related mortality
Although early studies (e.g. Brenner, 1979) have been criticized on methodological grounds later studies have mainly validated the counter-cyclical association with mortality (see Ruhm, 2003; Tapia Granados, 2005, and comments in the same issue). The association between economic cycles and alcohol-related mortality may partly be mediated by concurrent changes in alcohol consumption. It has been shown that alcohol consumption increases during economic expansion while the probability of being drinker remains unchanged (Johansson et al., 2006). In numerous studies, it has been reported that alcohol-related harm follows the changes of alcohol consumption at the population level (see e.g. Edwards et al., 1994; Norström et al., 2002).
Among Finnish men, the trend in alcohol-related mortality was associated with economic booms and recessions until mid 1990s, but after that the clear association ended. The economic boom began in 1995, involving decreasing unemployment from 18% in 1994 to <10% in 1999, and continued until the end of the study period, but total alcohol-related mortality mainly decreased after 1998. The trend for different causes of alcohol-related deaths was different. Intoxication-related accidental and violent deaths decreased strongly whereas alcoholic liver diseases and diseases of the circulatory system that had alcohol-related contributory causes increased.
The difference in cause-specific trends is accounted for by diverging trends for those aged 45 years and over and under 45 years. Among men aged 45 years and over, the trend in alcohol-related mortality was mainly increasing even after the mid 1990s. Among them even intoxication-related accidental and violent deaths increased. Together with directly alcohol-attributable diseases and alcohol-related diseases of the circulatory system these causes were responsible for almost 90% of the increase in alcohol-related mortality among men aged 45 years and over. Among young men, the development was favourable due to a decrease in intoxication-related accidents and violence, and alcohol-attributable diseases. Intoxication-related accidents and violence still contributed largely to premature mortality. Unemployment level was highest among those aged <30 years, and it remained relatively high (15%) even in early 2000s. Additionally, the jobs of young people were more often precarious due to their more frequent fixed-term nature (Sutela et al., 2001). Hence, even though national economy improved in the late 1990s, due to continued labour market and economic disadvantage among the young, alcohol-related mortality did not increase.
Due to lack of accurate consumption data by population subgroups it is somewhat difficult to evaluate to what extent the association between economic cycles and alcohol-related mortality is mediated by alcohol consumption. The distribution of alcohol consumption by sex and age can, however, be assessed through estimations derived from surveys. According to Helakorpi et al. (2005), alcohol consumption after the mid 1990s increased among men aged 45 years and over, whereas it was stable or decreased among the younger. Consequently, the association between economic cycles, alcohol consumption, and alcohol-related mortality were consistent among men aged 45 years and older, whereas among younger there was consistency only in the association between alcohol consumption and alcohol-related mortality. In summary, among the older, alcohol consumption increased during an upturn in economy (when unemployment level decreased and earnings increased) and alcohol-related mortality increased, whereas among the young, alcohol consumption decreased or remained stable (when high unemployment level and precarious jobs restrained expenditure) and alcohol-related mortality decreased.
Among women, alcohol-related mortality during the study period was mainly slowly increasing. Almost all of the specific alcohol-related causes were responsible for the increase. As among men, alcohol-related mortality increased only in the two oldest age-groups. Among them, intoxication-related accidents and violence and alcohol-attributable diseases covered three-quarters of the increase. Like among men, the economic depression affected those aged <30 years the most, and the association between alcohol-related mortality and economic cycles was weaker than among them. Also among women the mediating role of alcohol is supported by a survey. Metso et al. (2002) report a slight increase in women's consumption in Finland from the early 1990s to 2000. According to an unpublished table from the Health behaviour and health among the Finnish adult population—surveys in 1982–2005 of the National Public Health Institute by Helakorpi, consumption increased among women aged 45 years and over just as among men, while it decreased or was stable among the younger. Thus like among men, the economic cycles resulted in increased consumption and increased alcohol-related mortality merely among women aged 45 years and older.
Socio-economic differences
The studies on socio-economic differences in alcohol-related mortality are most commonly based on occupational social class. Education lays stress on a different dimension of social stratification than occupation. Education reflects the experiences of early life, a time when educational qualifications are usually obtained and it is also the time when the basis for many attitudes and behaviours are established—as, for example, the relationship to alcohol—that may last till later life. The specific nature of education is knowledge and other non-material resources that are likely to promote healthy lifestyles. Occupational social class, on the other hand, mirrors experiences and exposures in adult life, and its positions indicate status and power, and reflect material conditions related to paid work (e.g. Lahelma et al., 2004). Education is one of the criteria that define social class (e.g. Dahl, 1994) by providing formal qualifications that contribute to the socio-economic status of destination through occupation and income (Lahelma et al., 2004).
This study showed that among both men and women, mortality differences were substantial between educational groups. Alcohol-related mortality was clearly higher in lower educational groups, and among both men and women the absolute gap widened in the study period but the changes in time were somewhat different for men and women. Among men, large differences between educational groups remained during the whole study period, but among women the absolute gap in mortality increased rapidly towards the end of the study period.
The trend in mortality in the lowest educational group followed economic cycles more closely than trends in other educational groups. The unemployment level was clearly highest in the lowest educational group during the whole study period. Those who belong to this group earn less, and during recession they earn even less because of their larger unemployment rate, and economic availability is entangled with drinking habits. The adverse development among the lowest educated can be mediated by alcohol consumption which increased more rapidly in the lower educational groups at the beginning of the 21st century (Helakorpi et al., 2005). In summary, it thus appears that in the past 20 years economic fluctuations were not associated with alcohol-related mortality among better educated men and women. In the lowest educational group, alcohol consumption and alcohol-related mortality seemed to follow economic cycles: during upturn (when unemployment decreased and earnings increased) consumption and mortality increased, during depression (when unemployment level increased and earnings decreased) consumption and mortality, on the contrary, decreased.
There are certain similarities and differences in alcohol-related mortality when these results are set to comparison with previous findings where the indicator for socio-economic status was occupational social class (see Mäkelä, 2000). The order of the hierarchical educational and occupational categories in alcohol-related mortality is similar. However, alcohol-related mortality among unspecialized blue-collar men is one-third larger than men in the lowest educational group. The very high alcohol-related mortality in the unspecialized blue-collar class could be accounted for by differences in total consumption or in drinking habits. There is no, however, accurate data available on trends in consumption or drinking habits by occupational social class. Furthermore, it is likely that the relative position on the social hierarchy of unspecialized blue-collar workers is lower than that for those with basic education. Unspecialized blue-collar workers constituted about 8% of men aged 50–54 years in the mid 1990s, while the corresponding proportion for the basic educated was 49%. In any case these differences show that education and occupational social class are not interchangeable, and thus support the use of different dimensions of socio-economic status in analyses of differential alcohol-related mortality. The trends are approximately similar in both categorizations until the end of 1995, after which no data exist for occupational social class.
Alcohol-related burden of disease
In the global context, alcohol-related burden of disease is substantial. It is found that 3.2% of global mortality is estimated to be accounted for by alcohol. According to Rehm et al. (2004) one-third of the global burden of alcohol-related mortality is due to unintentional injuries, one-fifth to malignant neoplasm, and 13–15% to cardiovascular diseases (percentage includes both beneficial and detrimental effects), intentional injuries and other noncommunicable diseases (i.e. type 2 diabetes and liver cirrhosis) each. According to our study 6.5% of total mortality was related to alcohol in Finland. One-third of the national burden of alcohol-related mortality was due to accidental and violent deaths (i.e. unintentional and intentional injuries), one-fifth to directly alcohol-attributable diseases (including liver cirrhosis), and 11% diseases of the circulatory system (including cardiovascular diseases).
In the estimates by Rehm et al. (2004) several diseases related to alcohol could not be accounted for because of lack of population level data on risk ratios and consumption. In this study we could avoid these restrictions by relying on data on underlying as well as contributory causes of death at the individual level. Additionally, Rehm et al.'s study included an estimate of the protective effects of consumption, which was not done in this study. By design then our approach is likely to yield a higher estimate. Therefore, despite the fact that alcohol-related mortality rate in Finland according to this study is two times higher than global rate derived from Rehm et al. (2004) it is not possible to make a firm conclusion that alcohol-related mortality is actually higher in Finland than elsewhere. A fuller understanding of the issue would require a more careful comparison that is beyond the scope of this study, but our results do highlight the possibility that the estimates of the contribution of alcohol that are based on more traditional data may be underestimates.
Considerations on data
The data we used is unique in many ways; it is based on both underlying and contributory causes of death, and the death certification has good coverage and reliability (see Lahti and Penttilä, 2001), it covers the total population of Finland and it does not suffer from self-report biases and non-response. However, when interpreting the results of this study the following considerations should be made. The assessment of the causal contribution of alcohol at the individual level remains problematic. Consequently, this may lead in some parts to overestimations of alcohol as a cause of death. In some of the cause of death categories, the role of alcohol is clear and simple, and in the other death categories it is more complex and ambiguous. As an example of the latter outcome measures is suicide. The association between alcohol and suicide is complex. Many studies (see Wilcox et al., 2004) have yielded evidence for an association of suicide with alcohol use disorders. Those with alcohol dependence have a lifetime risk of suicide that is estimated to be 7% (Inskip et al., 1998). According to Norström et al. (2002) two main ways in which alcohol might imply an elevated suicide risk have been suggested. One concerns the destructive social consequences of chronic abuse, and the other that intoxication may trigger suicidal impulses. The role of alcohol remains unclear in many cases. The fact that those committing suicide were intoxicated at the moment of suicide does not prove that alcohol causally contributed to the death. When writing alcohol-related contributory causes (e.g. intoxication or alcohol dependence) to the death certificate, the certifying doctor should believe that these causes actually contributed to the death and did not merely co-exist, but it is not possible to assess the true causality in individual cases. Similarly, the fact that someone had a high blood alcohol concentration at the moment of a traffic accident does not prove that the accident would not have happened if the driver had been sober. It is thus possible that our levels of alcohol-related mortality for accident and violent causes are overestimates.
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Conclusions |
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TOPABSTRACTIntroductionData and MethodsResultsDiscussionConclusionsReferences |
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These results confirm and quantify the important contribution of alcohol use to premature mortality and educational and gender differences in mortality. Among men aged <45 years, the development in alcohol mortality has been very favourable mainly due to a decrease in intoxication-related accidents and violence. However, it should be remembered that alcohol-related deaths, and particularly intoxication-related accidents and violence, still have a large impact on premature mortality in these age groups. Among older men, the contribution of alcohol on burden of disease has increased. Among women, alcohol-related mortality has remained at a much lower level compared to men, but the rising trend in alcohol-related mortality in older age groups gives reason to be aware of increasing risks.
The association between economic cycles and alcohol-related mortality, possibly mediated by alcohol consumption, still seems to exist, but only in certain population subgroups and due to certain alcohol-related causes of death, namely among those aged 45 years and over and in lower educational groups, and for alcohol-attributable diseases, intoxication-related accidents and violence, and additionally among men due to alcohol-related diseases of the circulatory system. In summary, national economic fluctuations seem to have different effects on different subgroups, partly because economic conditions in all subgroups do not follow to the same extent developments in national economy. Thus harm in alcohol-related mortality in all subgroups does not necessarily follow the trends in per capita consumption.
The results of our study have relevance for attempts at achieving the Finnish health policy goals of reducing alcohol-related harm, and reducing socio-economic and gender differences in mortality (MSAH, 2001). Many of the trends documented in this study are contrary to the set targets. Our results are also an important reference for further follow-up that extends beyond 2004, the year of substantial changes in pricing and availability of alcohol in Finland brought about by EU jurisprudence.
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ACKNOWLEDGEMENTS |
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This study was supported by the Academy of Finland (grant 200852) and the Finnish Foundation for Alcohol Studies. We are also indebted to Statistics Finland for granting access to the data set (permission CS-53-483-05).
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References |
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