Department of Community Medicine and Rehabilitation, Forensic Medicine, Umeå University, P.O. Box 7642, SE-907 12 Umeå and
1 Department of Statistics, SE-901 87 Umeå University, Sweden
Received 10 September 1999; in revised form 30 May 2000; accepted 13 June 2000
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ABSTRACT |
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INTRODUCTION |
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A number of attempts have been made to assess the proportion of deaths caused/prevented by alcohol in other countries. English et al. (1995) performed a meta-analysis of the published scientific literature and found that 5% of all deaths in Australia were attributable to high alcohol intake, relative to low alcohol intake (Holman and English, 1995). Scragg (1995) used data on the proportion of current alcohol drinkers from recent New Zealand surveys, and pooled relative risks derived from a meta-analysis by Holman et al. (1990) to calculate disease-specific population attributable risks for New Zealand. Using a similar approach, Single et al. (1999) in a recent study, estimated the mortality attributable to alcohol use in Canada.
Shultz et al. (1990) estimated alcohol attributable fractions for different diagnoses from a review of clinical research and found that 4.9% of the total number of deaths in the USA were related to alcohol. Other studies from the USA have also used alcohol attributable fractions derived by Shultz et al. (1990), to estimate alcohol-related mortality in different regions (Peterson et al., 1990; Stinson and DeBakey, 1992
; Sutocky et al., 1993
). A Spanish study also used alcohol attributable fractions derived by Shultz et al. (1990) and found that 6.1% of the deaths in Spain were related to alcohol consumption (Yañez et al., 1993
). Similarly, 9% of the overall mortality in France was found to be attributable to alcohol (Pignon and Hill, 1991
). Others have also estimated alcohol attributable fractions for different causes of death from reports in the literature (Parker et al., 1987
; Gorsky et al., 1988
). Harmful/protective effects of alcohol on global mortality have also been estimated by Murray and Lopez (1997).
Despite the fact that alcohol is the most commonly misused substance in Sweden, little is known about its impact on the total mortality in the country. Epidemiologic studies in Sweden have investigated the association between alcohol and mortality and morbidity in selected populations (Petersson et al., 1982; Adami et al., 1992
; Romelsjö et al., 1993
), and also the association between alcohol and specific diagnoses, such as stroke (Harmsen et al., 1990
; Hansagi et al., 1995
), ischaemic heart disease (Messner and Petersson, 1996
), breast cancer (Holmberg et al., 1995
), and gastric cancer (Hansson et al., 1994
). Much has been done on the role of alcohol in specific populations in Sweden in traffic crashes (e.g. Björnstig et al., 1985; Öström et al., 1995; Sjögren et al., 1997) and other unnatural deaths (e.g. Ormstad et al., 1986; Örnehult and Eriksson, 1987; Berglund et al., 1987; Karlsson et al., 1988; Norström, 1988).
The aim of the present study was to estimate the proportion of deaths caused/prevented by alcohol and premature death due to all causes of death in Sweden. Alcohol involvement was assessed for different specific causes of natural and unnatural deaths (cause-specific mortality). As a comparison, alcohol involvement was also assessed for all-cause mortality (all-cause mortality), for ages 2039 years based on risk estimates for a cohort of Swedish conscripts (Andréasson et al., 1991).
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MATERIALS AND METHODS |
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For ischaemic heart disease, pooled relative risks for different alcohol levels of consumption from a recent meta-analysis by Mäkelä et al. (1997) were used to estimate AAFs and alcohol-related mortality. For cerebrovascular disease, we used a stricter selection of studies than that used by English et al. (1995) in their meta-analysis, and estimated pooled relative risks for different levels of alcohol consumption.
The articles were reviewed carefully and those that provided data on a relationship between a disease and alcohol consumption were chosen. Suitable data on relative risk/odds ratio for a particular disease and alcohol consumption were extracted from the articles. The risk ratios adjusted for various confounding variables, such as sex, age or smoking, were preferred.
Pooling multiple study results to estimate the relative risk.
We used precision-based weighting to obtain pooled estimates of relative risks as described by English et al. (1995). The pooled estimate of the relative risk from N studies using precision-based weighting is:
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An approximate 95% confidence interval around the pooled estimate is:
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Prevalence of alcohol consumption in Sweden.
The prevalence data of different levels of current alcohol consumption in the Swedish population aged 16 years were estimated from TEMO (test house market opinion) surveys for 1992, 1993, 1994, and 1996. The TEMO national survey was a household survey on a sample of 4434 persons (2224 males, 2210 females). The selected persons were interviewed in their homes by professional interviewers using a structured questionnaire. The sample was randomly drawn from the whole of Sweden taking into consideration age, sex and region to avoid sample bias. It was estimated that there was a 2530% drop-out rate. The crude data from the TEMO surveys were analysed by Håkan Leifman (Department of Sociology, Karolinska Institute, Stockholm, Sweden). The data with alcohol consumption levels used in the present study were provided by Håkan Leifman, and tabulations customized for our purpose were generated.
Derivation of AAFs for different diseases. In the present study, AAF is defined as the fraction of the disease in the population that would not have occurred if the effect associated with alcohol, which is the risk factor, was absent. Since alcohol may cause or prevent deaths, the AAF can be positive or negative. The AAFs were calculated from alcohol exposure prevalence in Sweden and the pooled relative risks for the diseases from the update of meta-analysis, as described by English et al. (1995).
If category 0 is the baseline category, Pi is the prevalence of i-th category, RRi is the relative risk in the corresponding category compared with the reference category, then the attributable fraction due to k categories of exposure is:
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Mortality data.
The age- and sex-specific number of deaths due to each disease included in the present study for Sweden between 1992 through 1996 were obtained from the Swedish Official Register of causes of death (Statistics Sweden, 1992, 1993
; National Board of Health and Welfare, 1994
, 1995
, 1996
).
Unnatural deaths
All unnatural death cases in Sweden (19921996) were included in the study sample (n = 23 132; male n = 14 740, female n = 8389 and three of unknown sex). The sample included medico-legally autopsied (n = 15 630), hospital-autopsied (n = 1144) and non-autopsied (n = 6358) cases.
Information on medico-legally autopsied cases was obtained from the Forensic Medicine Database (FMD) of the National Board of Forensic Medicine. This database includes information on age, sex, the underlying and contributing cause of death (coded according to ICD-9), external cause of death (ICD-9, E-code), circumstances associated with the death, date and place of death, hospitalization, hospital treatment, mode of death (accident, suicide, homicide, undetermined), type of autopsy, and a number of other variables. Unique code numbers of the cases in the FMD made it possible to link the data to the Forensic Toxicology Database of the National Board of Forensic Medicine.
The data for cases which did not undergo a medico-legal autopsy (hospital-autopsied and non-autopsied cases) were obtained from the Cause-of-Death Register (Centre for Epidemiology, National Board of Health and Welfare). The data included information on, e.g. the unique code number, sex, age, underlying and contributing causes of death (N-code), external causes of death (E-code), and type of autopsy where applicable.
The unique code numbers were also used to link our data to the in-patient register of the National Board of Health and Welfare, revealing all episodes of hospitalization, diagnoses for medical conditions treated and for other diagnoses that were of importance for treatment/hospitalization for a period of 3 years prior to death.
Cases with alcohol-related underlying and contributing causes of death (ARCD), and/or with alcohol-related in-patient diagnoses (ARID) were identified. The following diagnoses (ICD-9) were regarded to be related to alcohol: alcoholic psychosis (291A291F, 291W, 291X); chronic alcoholism (303); alcohol abuse (305); alcoholic polyneuropathy (357F); alcoholic cardiomyopathy (425F); oesophageal varices (456A, 456B); alcoholic gastritis (535D); liver cirrhosis (571A571D); pancreatitis (577A577B); and alcohol intoxication (980A 980C, 980W, 980X).
Alcohol was regarded to be associated with the death: if there was any indication in the information from the FMD that the deceased was a known alcoholic or ever had any health or other problem associated with drinking; if they had ARCD; if they had ARID during a period of 3 years prior to death; if the case tested positive for blood alcohol (Sjögren et al., 2000a,b
).
Potential years of life lost/gained
Potential years of life lost/gained up to the age of 69 years were estimated according to the method described by Hakulinen and Teppo (1976) which was also used by English et al. (1995).
All-cause mortality analysis
The role of alcohol for all-cause mortality between the ages of 2039 years was worked out by using current alcohol consumption in Sweden together with relative risk of death for different levels of alcohol consumption estimated by Andréasson et al. (1991) in their nationwide study of a 20-year follow-up of 50 465 Swedish conscripts up to 1988. Current alcohol consumption in Sweden was estimated from recent Swedish surveys (see above). The methodology used for assessing AAFs by using the relative risk estimates (from the report by Andréasson et al., 1991) and the current Swedish alcohol consumption was as described above for natural deaths.
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RESULTS |
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Unnatural deaths
These are shown in Table 2. Just over 28% of the unnatural deaths were associated with alcohol; more than twice as common in deaths of males (35%) than of females (16%). When only autopsied cases or only blood-tested cases were taken as the denominators, 38% and 44% of the deaths were associated with alcohol, respectively. Alcohol involvement was also twice as common in intentional deaths (36%) than in unintentional deaths (18%). The intoxication group (78%) had the highest fraction of deaths that could be associated with alcohol, followed by the undetermined group (62%), homicide (49%), fire (41%), suicide (35%), asphyxia (29%), traffic (18%), and fall (9%) groups.
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DISCUSSION |
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Cause-specific alcohol-related mortality
The present study is unique, because it is the first to attempt to quantify alcohol-related mortality in Sweden. Quantification of alcohol-related mortality is difficult, especially the role of alcohol in diseases which are associated with long-term use/misuse of alcohol.
In general, comparison of our results with those from other studies is difficult due to differences in the categorization of deaths, in criteria used to define alcohol involvement, in survey periods, in selection of study populations, in the extent of blood-alcohol testing, in geographical differences in alcohol consumption, in drinking patterns in the population, and also in restrictions in availability of alcohol in the population.
The present study showed that 3.5% of deaths in all ages and one-tenth of deaths in those aged 69 years were caused by alcohol in Sweden. This is in line with recent studies showing that alcohol contributed to 3.4% of deaths in Canada (Single et al., 1999
) and 3.3% of deaths in Italy (Cipriani et al., 1998
). The study by Scragg (1995), which based its quantification of alcohol-related mortality on the meta-analysis by Holman et al. (1990), showed that 5.3% of all deaths in New Zealand were caused by alcohol. Others have shown alcohol involvement in 3.3% of deaths in Minnesota, USA (Parker et al., 1987
), 4% of deaths in New Hampshire, USA (Gorsky et al., 1988
), 4.95% of deaths in the USA (Shultz et al., 1990
, Stinson and DeBakey, 1992
), 6.2% of deaths in California, USA (Sutocky et al., 1993
), 4.5% of deaths in Wisconsin, USA (Peterson et al., 1990
), 6.1% of deaths in Spain (Yañez et al., 1993
), 9% of deaths in France (Pignon and Hill, 1991
), and 6% of premature deaths in Canada (Ouellet et al., 1979
). A more recent study, using the Finnish official death register, found that 6% of all deaths in Finland were related to alcohol (Mäkelä, 1998
).
We found that 5.2% of the deaths in Sweden were prevented by alcohol. This is slightly lower (6.9%) than that found by Scragg (1995) in the study from New Zealand, but higher than a recent study from Canada (Single et al., 1999) showing that 3.8% of deaths were prevented. In line with the study by Scragg (1995), we found that, in those aged
69 years, alcohol drinking was estimated to have a net harmful effect, but in all ages, a net protective effect was found. The present findings are in line with estimates of alcohol-related global mortality, where it was found that, in established market economies, the protective effects of alcohol probably avert as many deaths as its harmful effects cause, and that a net harmful effect is apparent in those below 69 years of age (Murray and Lopez, 1997
). Further support for the present finding of a net protective effect of alcohol on mortality is provided by a recent study by Single et al. (1999) showing that 0.4% of deaths in Canada are in net averted by low-level alcohol use.
Reliability of data
The reliability of the findings of alcohol involvement was greater for unnatural, than for natural, deaths. The assessment of the role of alcohol in unnatural deaths was based on a well-defined sample of all unnatural deaths from the whole of Sweden, of which 73% of the cases were autopsied and 57% were both autopsied and tested for blood alcohol. Furthermore, other well-defined criteria were used to identify unnatural deaths associated with alcohol (Sjögren et al., 2000b).
Limitations in the assessment of alcohol involvement in natural deaths. There are a number of limitations in the methodology used to estimate involvement of alcohol in natural deaths and these need to be borne in mind when evaluating the present results. Furthermore, it should be kept in mind that the relation between alcohol consumption and coronary heart disease and stroke is still controversial. The reliability of the results on natural deaths is dependent on three main factors: (1) the reliability of the data presented in the studies included in the meta-analysis that were used to estimate the pooled relative risks; (2) the reliability of the alcohol consumption data for Sweden that were used for calculation of the AAFs; (3) the reliability of the Cause of Death Register for Sweden used to assess alcohol-related mortality.
Reliability of data from studies included in the meta-analysis.
A number of studies have shown a reduction in coronary heart disease mortality with moderate alcohol consumption (e.g. Doll et al., 1994; Goldberg et al., 1994; Rimm et al., 1996; Rehm et al., 1997; Thun et al., 1997). However, a recent study that adjusted for socioeconomic factors found that there was no clear relation between alcohol consumption and coronary heart disease mortality (Hart et al., 1999). As for stroke, the risk for haemorrhagic stroke is thought to increase with alcohol consumption (Stampfer et al., 1988
; Iso et al., 1995
), whereas the risk for ischaemic stroke has been shown to be reduced (Palomäki and Kaste, 1993
), increased (Iso et al., 1995
), or unaffected (Stampfer et al., 1988
) for moderate drinkers. The risk of mortality from all types of stroke has shown variable associations with alcohol consumption: increased risk with amount of alcohol consumed (Doll et al., 1994
; Iso et al., 1995
; Hart et al., 1999
), and a J-shaped relation (Gill et al., 1991
; Iso et al., 1995
). In view of these contradictory results for coronary heart disease and stroke, the present results on the preventive effects of alcohol are controversial.
A number of assumptions were made in the attributable risk methods used in the meta-analysis: findings from non-Swedish populations can be extrapolated to the Swedish population; relative risks did not vary with age; relative risks did not differ between males and females; relative risks for morbidity would also apply to mortality. The assumption that findings from non-Swedish populations can be extrapolated to the Swedish encompasses a large variety of factors such as patterns of alcohol consumption. However, it needs to be kept in mind that AAF for unnatural deaths were based on medico-legal autopsy cases from Sweden, and that 80% of the deaths caused by alcohol were due to unnatural causes and conditions that are related to alcohol by definition such as alcohol dependence syndrome, suggesting that the reliability of the present results on harmful effects of alcohol is not as questionable as it may seem.
Reliability of alcohol consumption in Sweden.
The other important factor is the reliability of the alcohol consumption data for Sweden used in the present study to calculate the AAFs. The present data were obtained from household surveys when randomly selected subjects from the whole of Sweden were visited at home by professional interviewers who used a structured questionnaire. The drop-out rate was estimated to be 2530%. It is possible that the high alcohol consumers were underestimated in our data, as very high consumers may be unwilling to take part in the survey. There is also some evidence that heavy drinkers underestimate their alcohol intake more than light drinkers (Poikolainen, 1985). Thus if there is an underestimation of heavy drinkers, causes of mortality (for example, the neoplasms) that have an increasing risk with increasing alcohol consumption, are also underestimated in our results.
Reliability of the official Swedish mortality data.
The official Swedish mortality statistics are based on the underlying cause of death indicated on death certificates issued for each deceased person. Ågren and Jakobsson (1987) studied the mortality and the cause of death in a cohort of male alcoholics in Stockholm and found that the underlying cause of death was incorrect in 21.8% of the cases. They found that, in the alcohol-related conditions, cardiomyopathy was underestimated as an underlying cause of death; in the official statistics 0.5% of the deaths were due to cardiomyopathy and after validation the proportion rose to 6%. Assuming that the underestimation of alcohol cardiomyopathy deaths in official Swedish mortality statistics also applies for the present period studied (19921996), the cardiomyopathy deaths due to alcohol would increase from 157 to 1884, which indicates that the deaths due to conditions directly caused by alcohol as a group should be 57% higher (i.e. 4770 deaths; see Table 1) in the present study. Others in Sweden have also found that deaths due to conditions directly caused by alcohol are underestimated (Petersson et al., 1982
; Romelsjö et al., 1993
).
Person years of life lost/gained
Person years of life lost is useful in that it gives higher weight to deaths at younger ages and thereby is an indicator of premature death. There are, however, statistical limitations when person years of life are estimated and this estimation must be taken to be just an approximation. More person years of life (below 70 years) were net lost than were saved by alcohol, suggesting that alcohol has a negative effect on premature mortality. Alcohol accounted for just over 10% of person years of life lost. This is somewhat higher than that found by Single et al. (1999) for Canada (6.1%).
All-cause mortality analysis
There are many reasons to be cautious about generalizing results from one country to another, particularly when analysing all-cause mortality. The death rate for a specific cause reflects the distribution of all risk factors in the population, not just alcohol, including e.g. specific genetic factors, diet, ethnicity, and smoking, which may themselves be related to alcohol consumption in different populations. In view of this, the present assessment of all-cause alcohol-related mortality for Sweden was based on a Swedish study on a nationwide cohort of conscripts. Since the conscripts were followed up between the ages 18 and 39 years, the all-cause alcohol-related mortality was estimated only for the age interval 2039 years. It was found that 16% of the deaths were associated with alcohol.
There are both strengths and weaknesses in the two different approaches (cause-specific and all-cause) of estimating alcohol-related mortality. The strength in assessment of alcohol association in all-cause mortality is that the risk ratios were based on a nationwide cohort from Sweden. The weaknesses with this all-cause mortality approach are: (1) the cohort was followed up to the age of 39 years which limits the assessment to the age interval 1839 years and the risks cannot be applied to older groups; (2) the cohort was followed between 1969 and 1988 and the spectrum of different causes of deaths and also the alcohol consumption patterns probably differed from that in the period investigated (19921996); (3) the risks were based on males only. The strength in cause-specific alcohol-related mortality was that reliable data for unnatural deaths for all of Sweden between 1992 and 1996 could be obtained. The weaknesses with the cause-specific approach for natural deaths are discussed above (reliability of data).
We found that the cause-specific mortality analysis showed a higher alcohol-related mortality than the all-cause mortality analysis. The difficulties and weaknesses in the two approaches probably explain this difference. However, keeping in mind the weaknesses in the two approaches, it is reasonable to assume that about 20% (range 16%25%) of deaths between the ages of 20 and 39 years in Sweden today are associated with alcohol.
In conclusion, as far as premature mortality (69 years) is concerned, we found that deaths caused by alcohol more than balance the deaths that may be expected to be prevented by alcohol, and more person years of life are lost than averted due to alcohol, indicating that a public health recommendation that emphasizes the positive effects of alcohol and thereby promoting increase in per capita alcohol consumption, would do more harm than good in Sweden. This is in line with the general opinion of other scientists in this field (e.g. Marmot and Brunner, 1991; Addiction Research Foundation, 1993; World Health Organization, 1994; Anderson, 1995).
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FOOTNOTES |
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