Wednesday, 10 December 2014

Alcohol use disorders and mortality in Nordic countries

This post was originally written by Andrew Jones for the Mental Elf. You can see the original here.

Alcohol Use Disorder (AUD) is one of the most prevalent mental disorders, affecting an estimated 3.6 % of the world population. AUDs are a major contributor of morbidity and mortality, with excessive alcohol consumption associated with increased burden of disease, accidents and social problems (Samohkvalov et al, 2010).
A recent meta-analysis including studies across many countries demonstrated that men with AUD have three-fold higher mortality, whereas women have four-fold mortality, than the general population (Roerecke et al, 2013). Increased mortality is also seen in younger people and those in TREATMENT FOR addiction. However, little is known about the mortality data of patients with AUD in Nordic countries.
Because of alcohol-related problems, Sweden, Denmark and Finland created alcohol policies to restrict availability and reduce population consumption of alcohol. However in 1995, after joining the European Union, both Sweden and Finland shifted to more liberal polices such as tax reductions and lengthened opening hours.
In a recent population based REGISTER study published in Acta Pyschiatrica Scandinavica, the authors evaluated the mortality and life expectancy rates in people diagnosed with AUD in Denmark, Finland and Sweden over a twenty year period (Westman et al, 2014). Within these countries, Sweden has the most restrictive alcohol policies, whilst Denmark has the least restrictive policies.
The study
The study used National HEALTH Registers to follow the entire adult population of Denmark, Finland and Sweden.


The authors used National HEALTH Registers to follow the entire population of the three countries aged over 15 (approximately 20 million people in total). They identified all people who had been admitted to HOSPITAL through AUD over a twenty-year observation period, between 1987 and 2006. Data about alcohol consumption per capita was collected from an international database. Each person was followed from the date of their hospital administration until death or the end of a 5 year follow up period.
The study population was stratified into 5 age groups (15-29, 30-44, 45-59, 60-74, >75 years) and frequency of mortality was calculated for each group. For analysis of time trends the 20 year observation period was split into four periods (1987-1991, 1992-1996, 1997-2001 and 2002-2006).
The main outcome measures were the standardised mortality rate per 100,000 person-years and life-expectancy.
The authors
The authors were primarily interested in links between alcohol use disorder, mortality and life expectancy.


During the entire study alcohol consumption per capita was lowest in Sweden and highest in Denmark. Small fluctuations in consumption were evident across the time periods. For example, in Finland alcohol consumption peaked during 2002-2006, coinciding with alcohol tax reductions.


Mortality was higher overall in Denmark, than Finland or Sweden. Standardized mortality increased over the twenty years in both men and woman in Denmark. In Finland and Sweden standardized mortality decreased in both men and women over time.
In all three countries, mortality rates in people with AUD were higher in younger age groups. People with AUD had higher mortality from all causes of death, including all diseases, medication conditions and suicide.

Life expectancy

Life expectancy was highest in Sweden and lowest in Denmark. In all three countries, life expectancy was longer in woman than men. Difference in life expectancy was calculated as the life expectancy in the general population minus life expectancy of people with AUD. In Denmark this was approximately 27.6 years; Finland 26.9 years; Sweden 24.9 years.
Over the 20 year period life expectancy differences increased in Men (Denmark, 1.8 years; Finland, 2.6 years; Sweden, 1.0 years). In women, life expectancies differences increased in Denmark (0.3 years), but decreased in Finland (0.8 years) and Sweden (1.8 years).
Denmark had the
Denmark had the highest alcohol consumption and the worst outcomes in terms of mortality and life expectancy.


Across three Nordic countries, individuals who are HOSPITALIZED with AUD have an average life expectancy of 47-53 years if male, and 50-58 years if female. The main finding of the study was the shorter life expectancy (~26.5 years) of individuals with AUD compared with the general population.
A particular strength of this study was the comparison of mortality and life expectancy across the whole population in the three Nordic countries. The authors used nationwide HEALTH registers to provide highly reliable population data.


  • The main limitations of this study include the use of only inpatient data for establishing AUD. This may have led to selection bias towards AUD patients with the most severe HEALTH problems.
  • Secondly, as the study was register-based there was no clinical data about treatment or adherence. In support of these points, it is thought only one in three individuals with dependence will ever seek treatment.
  • Finally, alcohol consumption per capita was determined through aggregate data rather than individual alcohol exposure.
The results of this study have clear clinical implications for policy and treatment. The authors suggest that hazardous alcohol consumers should be a specific TARGET for preventative measures, to ensure they do not develop AUDs. Furthermore, the somatic care of people with AUD should be substantially improved.
To conclude, Alcohol Use Disorder is a significant public HEALTH concern, which severely impacts mortality and life-expectancy.
The authors suggest that
The authors suggest that public HEALTHprevention programmes should focus on hazardous drinkers, to ensure that they do not develop Alcohol Use Disorders.


Key paper
Westman J, Wahlbeck K, Laursen TM, et al (2014). Mortality and life expectancy of people with alcohol use disorder in Denmark, Finland and Sweden. Acta Psychiatrica Scandinavica, doi: 10.1111/acps.12330.
Further reading
Cunningham JA, Breslin FC (2004). Only one in three people with alcohol abuse or dependence ever seek treatment. Addictive Behaviours, 29: 221-3.
Roerecke M, Rehm J (2013). Alcohol use disorders and mortality: a systematic review and meta-analysis. Addiction, 9: 1562-78.
Samohkvalov AV, Popova S, Room R, Ramonas M, Rehm J (2010). Disability associated with alcohol use and dependence. Alcohol: Clinical and Experimental Research, 34: 1871-8.

Friday, 5 December 2014

North West Alcohol Conference 2014

We recently attended the annual North West Alcohol Conference in Liverpool for the second year running. PhD students Inge Kersbergen, Natasha Clarke, Lisa Di Lemma, Jay Duckworth and Pawel Jedras summarise the highlights.
Inge Kersbergen
After a general introduction by Sir Ian Gilmore, John Holmes started the day with a talk about Minimum Unit Pricing, the ineffectiveness of the ban on below cost sales and the complicated politics of alcohol taxation. Pricing influences what and how much alcohol people buy and, consequently, how much they consume. So pricing policies are likely to affect consumption rates and alcohol related harm. The ban on below cost sales stops retailers from selling alcohol below the cost of duty + VAT.  The ban affects the price of less than 1% of alcohol products sold and reduces alcohol consumption by only three units a year (equivalent to a large glass of wine). This makes it a non-policy at best.
MUP creates a minimum price for alcoholic drinks that depends on the strength. With a suggested 45p per unit, that would put the minimum price for a pint of normal strength lager at 90p, which is a lot higher than the cost of duty + VAT. The Sheffield Alcohol Policy Model estimates that MUP exclusively targets heavy drinkers’ consumption and alcohol-related harm, as it only increases the price of cheap alcohol and does not affect drinks that are generally consumed by moderate drinkers, regardless of their income level.
One criticism of MUP is that it would increase revenue for retailers, so the extra income cannot be spent on public health. A possible solution would be to increase taxes so they act like MUP. This requires an overhaul of the tax system, as in the current tax system not all drinks are taxed the same. Some drinks are taxed based on strength, whereas other are taxed on volume. However, that is not the only problem we would face with a tax increase. Retailers are not required to pass tax increases directly on to the customer, so they don’t.  Research showed that retailers raise the prices of cheap alcohol below the level of tax increase (undershifting), whereas the prices of more expensive alcohol are raised above the level of tax increase (overshifting). They artificially keep cheap alcohol cheap. MUP is most likely the easiest strategy to implement and works exactly where we need it most. However, Scotland’s case for the European court shows that there may be some more hoops to jump through before this can be implemented.
Natasha Clarke
Alastair Campbell, Blair’s spin doctor from 1997-2003, has an ongoing interest in the issue of alcohol abuse and its prevalence in the UK. A combination of Alastair’s political background and his experience of tackling his own alcohol abuse gave for a unique and interesting talk. In the 80s Campbell’s drinking spiralled out of control and led to a serious psychotic episode and hospitalisation, a wakeup call leading to 13 years of sobriety. His brutal honesty and admittance that the situation could very nearly have been different led to thought-provoking listening. Campbell also mentioned his novel, “My name is…”, exploring the development of alcoholism in a young woman called Hannah.
One point made by Campbell was the madness of sports sponsorship in the UK. Playing sport emphasises fitness and health, yet drinking is a central aspect of our sports viewing, a rather conflicting and damaging message. For example, research has found that football fans are exposed to roughly two alcoholic brand references per minute when watching a match, in addition to the commercial break advertising. These adverts are seen by millions of children, thus it is an important issue that needs addressing to prevent this level of exposure to our younger generation.  
Campbell (like the majority of the other speakers) also stressed the importance of MUP, and the near miss last year in its introduction after a back track from David Cameron due to heavy pressure from the alcohol industry. He urged those at the conference to continue the ongoing support and campaigning for its introduction. In a culture dominated by alcohol, it’s unlikely that changes will be seen overnight, but it’s vital that those with an interest in tackling harmful drinking continue to spread the message. 
Lisa Di Lemma
Steve Morton, the Health Improvement Manager for Alcohol and Drugs at Public Health England (PHE), gave the last talk in the morning. PHE is the national agency, whose mission is to improve and protect the nation’s wellbeing, and to encourage discussion, advise government and support actions by authorities and local organizations focusing on health issues.
He began by briefly reviewing PHE’s seven priorities for the next 5 years. These priorities represent areas of interest where actions for improvement are most needed and in which PHE will focus its efforts, such as obesity, smoking and alcohol.
Among these areas of interests he identified reducing harmful drinking and alcohol-related hospital admissions as “the” priority, because last year there were approximately 326,000 alcohol-related hospital admissions. North-West was the second region in England with the highest rates, and a total annual cost of £21 billion. Indeed in the past eleven years, since 2001, liver-disease deaths rose 40%.  This data contrasts with other major causes of disease, such as cancer, which has been declining. PHE actions focus on their usual support for Alcohol Concern Dry January campaign and in producing their independent report for the government on the public health impacts of alcohol, and “why it’s such a public priority”. He acknowledged that PHE will keep presenting the evidence (argued previously by John Holmes) for the introduction of MUP and the inclusion of health as a licensing objective. He concluded by emphasizing the importance of strong partnerships between public and private agencies in order to impact government decisions and fight the industry approach to “alcohol normalization”.

Jay Duckworth
Dr Nick Sheron’s talk was passionate and illuminating. He spoke broadly on the negative consequences of excessive alcohol consumption in the UK, from the cost – which is estimated at around £21bn per year (however, see here) – to the direct consequences to human mortality. He lamented that during his time at the liver unit in Southampton, rates of alcohol-related liver disease have steadily increased – indeed, England and Wales saw a 10-year rise in this issue from 2002-2012. He was also kind enough to present his “most depressing slide” – a graph showing 3 conclusions drawn from his team’s data:
  1. Even though alcohol-related liver disease takes 10 years to develop, ~1/3 of patients die from recent drinking. Thus, an effective intervention could save ~1,500 lives per year (based on 2012 England-Wales data).

  1. The overall mortality rate for liver disease is ~70%. Also, in terms of sheer numbers, it accounts for more years of life lost than lung, breast, cervical, ovarian and prostate cancer combined.

  1. We are no better at saving lives in people who have liver disease today than we were 20 years ago.
 These figures are appalling, and Dr Sheron has called for the government to stop ignoring the issue and take action.

A possible contrast to Dr Sheron’s gloomy talk was witnessing DrinkWise’s TV campaign to convince parents to minimise alcohol’s influence on children (I say “possible” as some may find the advert at least as scary as Dr Sheron’s figures). The advert features “The Party Fox”, who manages to lure children into a world where alcohol is both the solution to all life’s problems and the only way to celebrate a good time, while simultaneously possessing the ability to instil a feeling of creepiness in the audience not achieved since Carrot Top started hitting the gym. A well-made film.
The “Breakout Session” Public Health Master Class consisted of a great panel and lots of great discussion; however, I’m going to focus on the less-than-stellar aspects of it here (because this is the internet and this post hasn’t yet met its quota of negativity). My first contention concerned DrinkWise director Ali Wheeler’s suggestion that what we really need is education. This was said frequently and by numerous members of the panel, with MP Luciana Berger backing Wheeler’s claims and suggesting education as a central focus for Labour:

How can educating people about the dangers of alcohol be a bad thing? Berger even offers the caveat that education isn’t enough. But this is not my contention. Mine concerns the continually-repeated claim that there is strong evidence for education as an intervention, but this is so broad a claim as to be essentially meaningless. What type of education? In what setting should it be administered and for how long? Who should be targeted? All of these factors have been looked at and the evidence is inconsistent at best. This was a view shared by Professor Harry Sumnall:

The same was said of alcohol labelling:

Again, the evidence simply isn’t there. This is not to say these proposals should not be seriously considered, but if we are going to make claims regarding intervention effectiveness, let’s make sure that they’re based in evidence.
A final point of contention concerned Liverpool City Council’s idea to implement breathalyser tests in the city centre in a bid to Say No To Drunks. This topic was ignited by an audience member but seemed to elicit nods of agreement from some panel members as well as others in the audience. But the idea is flawed. The limit is set at 70mcg/100ml of breath – twice the drink-drive limit. That businesses – whose enterprise depends on selling alcohol – would refuse entry to individuals because they had consumed a few drinks is ludicrous. Further, given that premises security are already supposed to refuse access to individuals who look intoxicated, I fail to see what extra power they would gain.
Overall, these were somewhat fleeting topics of discussion entered into after a long day of conferencing; however, I think it’s best to keep our claims about intervention effectiveness on a tight leash, and always constrained by the evidence.
Pawel Jedras
Without a shadow of a doubt, MUP was the hot topic of this year’s conference. As presented by Dr John Holmes from the University of Sheffield the concept of alcohol pricing seems to be an effective way of tackling problems associated with excessive consumption. However, we should not forget about the other means of controlling alcohol-related harm.
Dr Lynn Owens emphasised the significant role of accurate assessment of alcohol-related problems based on three factors: drinking behaviour, level of harm and selection of matching treatment. The ‘every patient is unique’ philosophy may sound like a cliché, but it is very true when it comes to the treatment of alcohol related problems. The general public and practitioners need to understand that people who are at risk, or who experience health problems caused by alcohol use do not represent a homogeneous population. There is a significant difference between excessive alcohol use and alcohol dependence. Understanding this difference is the key to the right selection of care options.
Some health professionals believe that the ‘drink in moderation’ approach is not effective, sends an inappropriate message and is inconsistent with the addiction treatment philosophy. However, the choice of treatment goal should depend on the severity of the problem. While treatment modalities which focus on the achievement of abstinence could be more suitable for people with severe dependence, they may not necessarily be appropriate for people who are not severely dependent. A harm reduction approach which focuses on a decrease or a normalization of alcohol use seems to be a more appropriate goal for people who exceed recommended alcohol limits, but have not been diagnosed with severe dependence.
Research indicates that a primary care based ‘brief alcohol intervention’ aimed at reducing alcohol consumption is an effective method of reducing alcohol use in individuals who are not severely-dependent. This means that reduction of alcohol consumption in harmful and hazardous drinkers does not necessarily require a team of addiction specialists and could be achieved through a brief intervention provided by general practitioners. To conclude, a widely available intervention for people who misuse alcohol is crucial for the reduction of alcohol-related harm.
Introduction of MUP seems to be an effective way of decreasing overall alcohol consumption however; the problem of alcohol misuse will never entirely disappear. Prohibition artificially increased prices of illegal alcohol but it did not prevent some people from binge drinking - some people will keep drinking excessively no matter how expensive alcohol is. We can all agree that fire prevention is an effective way of dealing with fire hazards but it does not mean that we should undermine the importance of fire departments.
Although I found the conference to be very informative, I believe that practitioners would benefit from the better coverage and discussion of treatment related topics. I am quite surprised that the important and interesting topic of treatment covered by Dr Owens received only fifteen minutes presentation time. The improvement of identification and risk-stratification of problem alcohol drinkers which could lead to better treatment should always be one of the key points of conferences related to alcohol misuse.
Overall the conference gave us a lot to think about. The talks were informative, interesting and inspiring and reminded us why our research is so important. We are very much looking forward to next year!