Alcohol-attributable Mortality Research Articles

Socioeconomic inequities in alcohol-attributable mortality by sex/gender and age in Canada: A 13-year population-representative cohort study.

Individuals with low socioeconomic position (SEP) experience greater rates of alcohol-attributable mortality, contributing to health inequities in mortality and life expectancy. We examined the association between SEP and alcohol-attributable mortality by sex/gender and age in Canada. Census records from the 2006 Canadian Census Health and Environment Cohort (ages 12+; n=5,038,790) were linked to mortality data from 2006-2019. SEP was measured by educational attainment and household income. Poisson and Fine and Gray sub-distribution hazard models estimated rate differences (RD) per 100,000 person-years and hazard ratios (HR). Both educational attainment and household income were inversely associated with alcohol-attributable mortality. Absolute SEP inequities were greater among men than women, with a RD of 30.81 (95% CI: 28.04, 33.57) for men and 9.86 (95% CI: 8.49, 11.22) for women when comparing the lowest to the highest income quintile. Age-stratified analyses showed absolute SEP inequities were most pronounced in middle and older adulthood, above age 30 for women and age 50 for men, with smaller RDs in ages 12-29. Relative SEP inequities were similar in women and men, with greater HRs at younger ages. Public health policies addressing social determinants and population-level alcohol policies should consider patterning of SEP inequities by sex/gender and age group.

Trends of fully alcohol-attributable mortality rates before and during COVID-19 in the Baltic and other European countries.

We tested the polarization hypothesis, which postulates that during times of crises, such as the COVID-19 pandemic, alcohol consumption increases among the heaviest drinkers but decreases among most other drinkers, resulting in an overall decrease in consumption among the population. We posited the increase in heavy drinking would lead to increases in 100% alcohol-attributable (AA) mortality. Furthermore, based on the high level of alcohol consumption in the Baltic countries compared to other European countries, we predicted that the increases in AA mortality would be more pronounced in these countries. Data for 100% AA deaths were obtained from the World Health Organization for the period 2010 to 2022, and standardized to the regional age distribution for 2010. Parametric and non-parametric tests were used to test the study hypotheses. The mean age-standardized 100% AA mortality rate increased during the COVID-19 pandemic in the 19 European countries with data by 3.12 deaths per 100,000 population, constituting an 18% increase (tested against no change: t = 2.52; df = 18; p = 0.021). This increase was higher in the Baltic countries (mean difference = 13.41 deaths per 100,000 population; standard deviation (SD) = 7.44; 46% increase) than for other European countries (mean difference = 1.19; SD = 1.55; 8% increase). The increases in 100% AA mortality were associated with decreases in the level of alcohol consumption in the majority of countries. As predicted, 100% AA mortality increased in 19 European countries during the COVID-19 pandemic, with the Baltic countries seeing a higher increase. Renewed alcohol control policy efforts should be considered.

Trends in alcohol-attributable morbidity and mortality in Germany from 2000 to 2021: A modelling study.

We aimed to assess: (i) trends in alcohol-specific - that is, fully attributable - morbidity and mortality in the German adult population aged 15-69 between 2000 and 2021; and (ii) changes in alcohol-attributable disease burden - that is, fully and partially alcohol-attributable categories - for 2006, 2012, 2018 and 2021. Morbidity data was pulled from hospitalisation and rehabilitation statistics and mortality data was pulled from the causes of death registry. Alcohol use, adjusted for unrecorded consumption, was estimated using the Epidemiological Survey of Substance Abuse and triangulated with per capita consumption from annual sales data. For major disease categories, alcohol-attributable fractions were estimated for males and females by age groups (15-29, 30-49, 50-69 years) using the comparative risk assessment methodology. For males and females, the age-standardised rate of alcohol-specific morbidity peaked in 2012 and decreased thereafter showing a steep decline from 2019 to 2021. The rates of alcohol-specific mortality decreased constantly from 2000 to 2019 but increased from 2019 to 2021. Compared to 2006 the age-standardised alcohol-attributable morbidity and mortality rates in males and females were lower in 2021. For both sexes, the age-standardised alcohol-attributable morbidity and mortality rates and the proportions of morbidity/mortality rates relative to all-cause morbidity/mortality decreased between 2006 and 2021. The declines in alcohol-attributable morbidity and mortality are in line with decreases in consumption and signal that the importance of alcohol in health service utilisation and mortality has weakened. Sex ratios in morbidity and mortality do not indicate a strong converging trend.

The role of alcohol control policies in the reversal of alcohol consumption levels and resulting attributable harms in China

Yearly adult per capita consumption of alcohol in China between 2016 and 2019 decreased by 2.4 L of pure alcohol, or 33%. According to the World Health Organization, this decrease in consumption was accompanied by reductions in alcohol-attributable mortality of 23% between 2015 and 2019. This paper examines the contribution of alcohol control policies in China to these public health gains. A systematic search of the literature was conducted on alcohol control policies and their effectiveness in China as part of a larger search of all countries in WHO Western Pacific Region. In addition to articles on empirical evidence on the impact of such alcohol control policies, we also searched for reviews. The plausibility of changes of traditional alcohol control policies (taxation increases, availability restrictions, restriction on advertisement and marketing, drink-driving laws, screening and brief interventions) in explaining reductions of consumption levels and attributable mortality rates was explored. There was some progress in the successful implementation of strict drink-driving policies, which could explain reductions in traffic injuries, including fatalities. Other traditional alcohol control policies seem to have played a minimal role in reducing alcohol consumption and attributable harms during the time period 2016–2019. However, an anti-corruption campaign was extensive enough to have substantially contributed to these reductions. The campaign prohibited the consumption of alcoholic beverages in everyday life of government officials and thus contributed to a de-normalization of alcohol. While this anti-corruption campaign was the only policy to potentially explain marked decreases in levels of alcohol consumption and attributable mortality, more detailed research is required to determine exactly how the campaign achieved these decreases.

Changes in Six Categories of Alcohol-Attributable Mortality From Before to During the Early Phases of the COVID-19 Pandemic.

The shelter-in-place mandates enacted early in the COVID-19 pandemic resulted in changes in alcohol use and consequent outcomes. We assessed changes in six categories of season-specific alcohol-attributable mortality from before to during the early phases of the COVID-19 pandemic in the United States. We used logistic regression models to assess alcohol-attributable mortality in the United States from 2017 through 2020 (n = 11,632,725 decedents ages 18 and older). Outcomes included chronic fully alcohol-attributable deaths, poisonings, motor vehicle accidents, suicides, homicides, and falls. Exposure variables included year, season, the interaction between the year 2020 and season, rurality, the interaction between the year 2020 and rurality, decedent age, sex, race, ethnicity, marital status, and education. Compared with 2019, season-specific mortality age-adjusted rates of chronic fully alcohol-attributable deaths, homicides, poisonings, and falls increased during the COVID-19 pandemic. Suicide rates decreased in most 2020 seasons relative to the same seasons in 2019. Motor vehicle deaths decreased in spring 2020 versus 2019. Relative to dying by any other cause, the odds of death by chronic fully alcohol-attributable causes and poisonings were higher across seasons in 2020 versus 2019. The odds of death by suicide were higher among residents of rural counties in spring 2020 versus 2019. There were distinct temporal changes in six types of alcohol-attributable deaths during the early phases of the COVID-19 pandemic.

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

BackgroundLithuania, 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.MethodsThe 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.ResultsAge-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.ConclusionsMale 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 use, economic development and health burden: A conceptual framework

Economic development has been identified as an important influencing contributor to life expectancies: wealthier countries have lower mortality rates and different causes of death. Economic development also impacts alcohol consumption, as upper-middle and high-income countries, on average, have higher levels of consumption and less abstention. This often leads to a paradoxical situation whereby for low- and middle income countries increases in alcohol consumption are associated with decreases in alcohol-attributable mortality rates. These increases in consumption may diminish the benefits of economic development. Alcohol control policies can reduce the health and social burdens of increased alcohol use that result from economic development. Two case examples of Thailand and Vietnam which are presented. From 2010 to 2019 Thailand experienced a 3.7% increase in APC, a 9.8% decrease in all-cause mortality per 100,000 people, and a 1.4% decrease in alcohol-attributable mortality per 100,000 people. From 2010 to 2019 Vietnam experienced a 26.8% increase in APC, a 6.7% decrease in all-cause mortality per 100,000 people, and a 3.7% increase in alcohol-attributable mortality per 100,000 people. Due to a failure to implement strong alcohol control policies Vietnam has experienced an increase in alcohol-attributable mortality despite decreases in all-cause mortality. Accordingly, the implementation of alcohol control policies, can diminish the increases in alcohol use for low- and middle-income countries that accompany economic development.

Differential Associations of Alcohol Use With Ischemic Heart Disease Mortality by Socioeconomic Status in the US, 1997-2018

People with low socioeconomic status (SES) experience greater burden from alcohol-attributable health conditions and mortality at equal levels of alcohol consumption compared with those with high SES. A U-shaped association has been established between alcohol use and ischemic heart disease (IHD), but no study has explored how such an association differs by SES in the US. To investigate how the association of alcohol use with ischemic heart disease mortality differs by SES in the general US population. This cohort study used record-linked, cross-sectional National Health Interview Survey data for US adults aged 25 years and older, covering 1997 to 2018 with mortality follow-up until 2019. Data analysis was performed from March to June 2023. SES (operationalized using education attainment) and alcohol consumption were obtained from self-reported questionnaires. The outcome was time to IHD mortality or last presumed alive by December 31, 2019. Cox proportional hazard models were applied to evaluate the interaction of SES and alcohol use on IHD mortality, with age as the time scale. Sex-stratified analyses were performed, adjusting for race and ethnicity, marital status, smoking, body mass index, physical activity, and survey year. Fine-Gray subdistribution models were applied to account for competing risks. This cohort study of 524 035 participants (mean [SD] age at baseline, 50.3 [16.2] years; 290 492 women [51.5%]) found a statistically significantly greater protective association of drinking less than 20 g per day (vs lifetime abstinence) with IHD mortality in the high-SES group compared with the low-SES group (interaction term hazard ratio [HR], 1.22 [95% CI, 1.02-1.45] in men; HR, 1.35 [95% CI, 1.09-1.67] in women). In addition, the differential associations of drinking less than 20 g per day with IHD mortality by SES were observed only among people with less than monthly heavy episodic drinking (HED) (interaction term, HR, 1.20 [95% CI, 1.01-1.43] in men; HR, 1.34 [95% CI, 1.08-1.67] in women); no difference was found in people with at least monthly HED. Among women there was a greater protective association of drinking less than 20 g per day with IHD mortality in the high-SES group than the middle-SES group (interaction term, HR, 1.35 [95% CI, 1.06-1.72]). Among men, the harmful association of drinking more than 60 g per day with IHD mortality in the low-SES group was largely explained by other behavioral risk factors (ie, smoking, body mass index, and physical activity). This cohort study found a greater protective association between drinking less than 20 g per day with less than monthly HED and IHD mortality in the high-SES group compared with the low-SES group, in both sexes even after adjusting for key covariables and behavioral risk factors. The findings suggest that public health interventions on alcohol use should account for different socioeconomic backgrounds when assessing the level of risk related to alcohol exposure, bearing in mind that levels of consumption deemed safe regarding a specific outcome such as IHD may indeed be less safe or not safe across all sociodemographic groups.

The economic costs of alcohol-related harms at the local level in New South Wales.

Alcohol is a harmful, toxic and addictive substance that causes many diseases and injuries. Alcohol use also incurs a financial cost to the health care system and wider economy. This project aimed to undertake a cost impact analysis of alcohol-related harms at the local level in New South Wales (NSW). The alcohol-related harms costing model is an interactive tool designed for use by local health districts, stakeholders such as Liquor and Gaming NSW, NSW Independent Liquor and Gaming Authority and community stakeholders. Costs included in the analysis were alcohol-related hospitalisations, deaths, crimes, emergency department attendances, outpatient presentations and their impacts on productivity. Two local government areas (LGA) were used as case studies to demonstrate local impacts. In 2019-2020, the total cost of alcohol-related harms for NSW was estimated at $9 billion, at a rate of $120.3 million per 100,000 population. The total costs were comprised of alcohol-attributable premature mortality ($8.3 billion), non-fatal health care costs ($275 million) and crime costs ($457 million). A comparative analysis of two case study LGAs estimated that alcohol-related harms cost $195 million for the Northern Beaches LGA and $351 million for the Central Coast LGA. This research has developed a 'proof-of-concept' model to estimate the cost of alcohol-related harms at the local level in Australia, empowering health agencies and local community stakeholders to use economic evidence in their submissions in response to new liquor licence applications and other policies that impact their local community. This economic evidence can be used to improve the quality of decisions on alcohol regulation and policies. There are a number of future research opportunities that would enhance the economic evidence available to liquor licensing decision-makers.

Estimating the impact of availability restrictions and taxation increases on alcohol consumption, 100% alcohol-attributable and all-cause mortality in the Baltic countries and Poland 2001-2020

Estimating the impact of availability restrictions and taxation increases on alcohol consumption, 100% alcohol-attributable and all-cause mortality in the Baltic countries and Poland 2001-2020

Here to stay? Policy changes in alcohol home delivery and "to-go" sales during and after COVID-19 in the United States.

During the early phase of the COVID-19 pandemic, legislative changes that expanded alcohol home delivery and options for "to-go" alcohol sales were introduced across the United States to provide economic relief to establishments and retailers. Using data from the Alcohol Policy Information System, we examined whether these changes have persisted beyond the peak phase of the COVID-19 emergency and explored the implications for public health. Illustration of state-level policy data reveals that the liberalisation of alcohol delivery and "to-go" alcohol sales has continued throughout a 2-year period (2020 and 2021), with indications that many of these changes have or will become permanent after the pandemic. This raises concerns about inadequate regulation, particularly in preventing underage access to alcohol, and ensuing changes in drinking practices. In this commentary, we highlight the need for rigorous empirical evaluation of the public health impact of this changing policy landscape and underscore the potential risks associated with increased alcohol availability, including a corresponding increase in alcohol-attributable mortality and other alcohol-related harm, such as domestic violence. Policy makers should carefully consider public health consequences, whose costs may surpass short-term economic interests in the long term.

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

BackgroundThe 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.MethodsAlcohol-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.ResultsAlcohol-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.ConclusionsBased 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.

Unrecorded alcohol consumption in Lithuania: a modelling study for 2000-2021.

The aim of the study was to estimate unrecorded alcohol consumption in Lithuania for the period 2000-2021 using an indirect method for modelling consumption based on official consumption data and indicators of alcohol-related harm. Methodology employed for estimating the unrecorded alcohol consumption was proposed by Norström and was based on the country's 2019 European Health Interview Survey and indicators of fully alcohol-attributable mortality. The proportion of unrecorded alcohol consumption was estimated as 8.30% (95% CI 7.7-8.9%) for 2019 in Lithuania. The estimated total (recorded and unrecorded) alcohol per capita consumption among individuals 15years of age and older in 2019 was 12.2 L of pure alcohol, 1.01 (95% CI 0.94-1.09%) L of which is likely unrecorded. The lowest unrecorded alcohol level was estimated for 2009 and 2014, while 2018 had the highest level (i.e. 9.33% of total alcohol per capita consumption). Unrecorded alcohol consumption in Lithuania is likely to be modest when compared to recorded alcohol consumption, the latter of which still remains a major challenge to public health.

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

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. 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. 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. 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.

Who benefits from alcohol screening and brief intervention? A mini-review on socioeconomic inequalities with a focus on evidence from the United States

Alcohol-attributable mortality contributes to growing health inequalities. Addressing hazardous alcohol use and alcohol use disorders through alcohol screening and brief intervention is therefore a promising public health strategy to improve health equity. In this narrative mini-review, we discuss the extent to which socioeconomic differences exist in the alcohol screening and brief intervention cascade, highlighting the example of the United States. We have searched PubMed to identify and summarize relevant literature addressing socioeconomic inequalities in (a) accessing and affording healthcare, (b) receiving alcohol screenings, and/or (c) receiving brief interventions, focusing predominantly on literature from the Unites States. We found evidence for income-related inequalities in access to healthcare in the United States, partly due to inadequate health insurance coverage for individuals with low socioeconomic status. Alcohol screening coverage appears to be generally very low, as is the probability of receiving a brief intervention when indicated. However, research suggests that the latter is more likely to be provided to individuals with low socioeconomic status than those with high socioeconomic status. Individuals with low socioeconomic status also tend to benefit more from brief interventions, showing greater reductions in their alcohol use. Once access to and affordability of healthcare is ensured and high coverage of alcohol screening is achieved for all, alcohol screening and brief interventions have the potential to enhance health equity by reducing alcohol consumption and alcohol-related health harms.

Minimum legal drinking age and alcohol-attributable morbidity and mortality by age 63 years: a register-based cohort study based on alcohol reform

Minimum legal drinking age (MLDA) is an effective policy tool in preventing youth drinking and short-term alcohol-attributable harm, but studies concerning long-term associations are scarce. In this register-based, national cohort study, we assessed alcohol-attributable morbidity and mortality of cohorts born in 1944-54 in Finland. Data were from the 1970 census, the Care Register for Healthcare (maintained by the Finnish Institute of Health and Welfare), and the Cause-of-Death Register (maintained by Statistics Finland). As MLDA was lowered from 21 years to 18 years in 1969, these cohorts were effectively allowed to buy alcohol from different ages (18-21 years). We used survival analysis to compare their alcohol-attributable mortality and hospitalisations with a 36-year follow-up. Compared with the first cohort (1951) allowed to buy alcohol from age 18, the hazard ratios (HRs) for alcohol-attributable morbidity and mortality were lower in cohorts who could not buy alcohol until age 20 or 21 years. For alcohol-attributable morbidity in those aged 21 years when the reform took place, HR was 0·89 (95% CI 0·86-0·93) for men and 0·87 (0·81-0·94) for women versus those aged 17 years. For alcohol-attributable mortality, HR was 0·86 (0·79-0·93) for men and 0·78 (0·66-0·92) for women aged 21 years when the reform took place. The outcomes of the later-born 1952-54 cohorts did not differ from the 1951 cohort. Earlier cohorts had consistently lower alcohol-attributable mortality and morbidity; however, other simultaneous increases in alcohol availability probably contributed to increased alcohol-related harm among the younger cohorts. Overall, differences between cohorts born only a few years apart highlight late adolescence as a crucial period for the establishment of lifelong patterns of alcohol use and suggest that higher MLDA could be protective for health beyond young adulthood. Yrjö Jahnsson Foundation, Foundation for Economic Education, Emil Aaltonen Foundation, Academy of Finland, European Research Council, and NordForsk.

Which interventions for alcohol use should be included in a universal healthcare benefit package? An umbrella review of targeted interventions to address harmful drinking and dependence

BackgroundThis study aimed to identify targeted interventions for the prevention and treatment of harmful alcohol use. Umbrella review methodology was used to summarise the effectiveness across a broad range of interventions, in order to identify which interventions should be considered for inclusion within universal health coverage schemes in low- and middle-income countries.Methods and findingsWe included systematic reviews with meta-analysis of randomised controlled trials (RCTs) on targeted interventions addressing alcohol use in harmful drinkers or individuals with alcohol use disorder. We only included outcomes related to alcohol consumption, heavy drinking, binge drinking, abstinence, or alcohol-attributable accident, injury, morbidity or mortality. PubMed, Embase, PsycINFO, Cochrane Database of Systematic Reviews, and the International HTA Database were searched from inception to 3 September 2021. Risk of bias of reviews was assessed using the AMSTAR2 tool. After reviewing the abstracts of 9,167 articles, results were summarised narratively and certainty in the body of evidence for each intervention was assessed using GRADE. In total, 86 studies met the inclusion criteria, of which the majority reported outcomes for brief intervention (30 studies) or pharmacological interventions (29 studies). Overall, methodological quality of included studies was low.ConclusionsFor harmful drinking, brief interventions, cognitive behavioural therapy, and motivational interviewing showed a small effect, whereas mentoring in adolescents and children may have a significant long-term effect. For alcohol use disorder, social network approaches and acamprosate showed evidence of a significant and durable effect. More evidence is required on the effectiveness of gamma-hydroxybutyric acid (GHB), nalmefene, and quetiapine, as well as optimal combinations of pharmacological and psychosocial interventions. As an umbrella review, we were unable to identify the extent to which variation between studies stemmed from differences in intervention delivery or variation between country contexts. Further research is required on applicability of findings across settings and best practice for implementation.Funded by the Thai Health Promotion Foundation, grant number 61–00-1812.

Using Direct and Indirect Estimates for Alcohol-Attributable Mortality: A Modelling Study Using the Example of Lithuania

Introduction: Comparative risk assessments (CRAs) for alcohol use are based on indirect estimates of attributable harm, and usually combine country-specific exposure estimates and global risk relations derived from meta-analyses. CRAs for Eastern European countries, such as Lithuania, base their risk relations not on global risk relations, but on a large Russian cohort study. The availability of a direct estimate of alcohol-attributable mortality following the 2017 implementation of a large increase in alcohol excise taxes in Lithuania has allowed a comparison of these indirect estimates with a country-specific gold standard. Methods: A statistical modelling study compared direct (predictions based on a time-series methodology) and indirect (predictions based on an attributable-fraction methodology) estimates of alcohol-attributable mortality before and after a large increase in alcohol excise taxes in Lithuania. Specifically, Russia-specific versus global relative risks were compared against the gold standard of time-series based predictions. Results: Compared to direct estimates, indirect estimates markedly underestimated the reduction of alcohol-attributable mortality 12 months post intervention by at least 63%. While both of the indirect estimates differed markedly from the direct estimates, the Russia-specific estimates were closer to the direct estimates, primarily due to higher estimates for alcohol-attributable cardiovascular mortality. Discussion: As all indirect estimates were markedly lower than direct estimates, current overall relative risks and price elasticities should be re-evaluated. In particular, global estimates should be replaced by new regional estimates based on cohort studies.

Effectiveness of subnational implementation of minimum unit price for alcohol: policy appraisal modelling for local authorities in England.

Evidence exists on the potential impact of national level minimum unit price (MUP) policies for alcohol. This study investigated the potential effectiveness of implementing MUP at regional and local levels compared with national implementation. Evidence synthesis and computer modelling using the Sheffield Alcohol Policy Model (Local Authority version 4.0; SAPMLA). Results are produced for 23 Upper Tier Local Authorities (UTLAs) in North West England, 12 UTLAs in North East England, 15 UTLAs in Yorkshire and Humber, the nine English Government Office regions and England as a whole. Health Survey for England (HSE) data 2011-13 (n = 24 685). Alcohol consumption, consumer spending, retailers' revenues, hospitalizations, National Health Service costs, crimes and alcohol-attributable deaths and health inequalities. Implementing a local £0.50 MUP for alcohol in northern English regions is estimated to result in larger percentage reductions in harms than the national average. The reductions for England, North West, North East and Yorkshire and Humber regions, respectively, in annual alcohol-attributable deaths are 1024 (-10.4%), 205 (-11.4%), 121 (-17.4%) and 159 (-16.9%); for hospitalizations are 29 943 (-4.6%), 5956 (-5.5%), 3255 (-7.9%) and 4610 (-6.9%); and for crimes are 54 229 (-2.4%), 8528 (-2.5%), 4380 (-3.5%) and 8220 (-3.2%). Results vary among local authorities; for example, annual alcohol-attributable deaths estimated to change by between -8.0 and -24.8% throughout the 50 UTLAs examined. A minimum unit price local policy for alcohol is likely to be more effective in those regions, such as the three northern regions of England, which have higher levels of alcohol consumption and higher rates of alcohol harm than for the national average. In such regions, the minimum unit price policy would achieve larger reductions in alcohol consumption, alcohol-attributable mortality, hospitalization rates, NHS costs, crime rates and health inequalities.

Harmful volatile substances in recorded and unrecorded fruit spirits

The alcohol-attributable mortality is an important issue in South-Eastern Europe, whereby consumption of homemade spirits is stated to be one of the leading causes. Presence of harmful volatiles in spirits in Serbia was investigated in 26 recorded and 127 unrecorded fruit spirits, collected in 2020 and analysed using GC-FID methods. Statistical analysis confirmed higher content of ethanol, ethyl acetate, n-propanol and iso-butanol in unrecorded spirits. Regarding concentration limits proposed by the Alcohol Measures for Public Health Research Alliance, the one for methanol was exceeded in 4% of recorded and 17% of unrecorded spirits, for acetaldehyde in 4% of unrecorded and for higher alcohols only in one recorded spirit. Risk assessment, conducted using a margin of exposure approach, showed that spirit consumption, even at average level, posed a risk due to their high ethanol content. Regarding acetaldehyde, for males the risk was indicated starting from the regular drinkers only scenario (mean MOE 9937 for recorded and 9123 for unrecorded spirits) and for females who were chronic heavy drinkers of recorded (2324) or unrecorded spirits (1644). Chronic heavy drinkers of both sexes were in the risk of methanol and higher alcohols in case of exclusive consumption of unrecorded spirits.