alcohol-related mortality in europe: a tentative analysis from the eu project “alcohol consumption...

Substance Abuse, Vol. 22, No. 1, 2001

Alcohol-Related Mortality in Europe: A TentativeAnalysis from the EU Project ‘‘Alcohol Consumptionand Alcohol Problems among Women in EuropeanCountries’’

Francesco Cipriani, M.D.,1,3,4 Sandro Landucci, B.Sc.,1,4 andKim Bloomfield, Dr.P.H.2,4

Mortality data were collected for eight of the nine study countries in the BIOMED-II concerted action ‘‘Alcohol Consumption and Alcohol Problems among Womenin European Countries’’: Finland, France, Germany, Italy, The Netherlands, theUnited Kingdom (Scotland), Sweden, and Switzerland. An analysis of mortality thatis limited to causes of death that are fully attributable to alcohol (DAA) results in alarge underestimation of alcohol-related mortality (ARM) rates in all study countriesand especially among females. These estimates can be improved by including ananalysis of selected causes of death that are indirectly attributable to alcohol. Thisproduces geographic and time-trend variability of ARM rates that are more congruentwith alcohol drinking levels and trends. From this study, it is evident that whenGerman data are analyzed separately for the former German Democratic Republic(GDR) and the former Federal Republic of Germany (FRG), two distinct ARMpatterns result. The authors underline methodologic limits of this study and recom-mend procedures for a more reliable calculation of European ARM estimates.

KEY WORDS: alcohol; mortality; Europe; gender; attributable risk.

1U.O. Epidemiologia, Azienda Sanitaria di Firenze, Firenze, Italy.2Institute for Medical Informatics, Biostatistics & Epidemiology, Free University of Berlin, Berlin,Germany.

3To whom correspondence and review proofs should be addressd at UO Epidemiologia, Azienda Sanitariadi Firenze, Villa Margherita, Vle Michelangelo 41, 50125 Firenze, Italy. Ph: �� 39 055 6577300; Fax:�� 39 055 6577533; e-mail: [email protected].

4With the collaboration of Salme Ahlstrom, Allaman Allamani, Marie Choquet, Gerhard Gmel, BeatriceJanin Jacquat, Ronald Knibbe, Ludek Kubicka, Therese Lecomte, Patrick Miller, Moira Plant, andFredrik Spak.

55

0889-7077/01/0300-0055$19.50/1 2001 Association for Medical Education and Research in Substance Abuse

56 Cipriani, Landucci, and Bloomfield

INTRODUCTION

It is well known that death certificates tend to underreport alcohol involvementfor many reasons: physicians do not code alcohol etiology to avoid social or economicdamage to the relatives or because they are not experienced in detecting alcohol-related conditions; diagnosis of alcohol etiology may be difficult because biologicmarkers of alcohol exposure often have low specificity and sensitivity; alcohol ismetabolized within a few hours and may be not detectable at the time of death(1–4). Also, the autopsy confirmation of diagnosis may be low in most populationsand, more relevant, autopsy rates may vary across countries (5). For these reasons,for comparing consequences of alcohol consumption across different populations,the World Health Organization (WHO) suggests using liver cirrhosis mortalityrates without any reference to alcohol etiology, as well as psychosis mortality andhospitalization rates. In other cases, alcohol-related motor vehicle crash fatalitieshave been proposed as an indicator for acute alcohol-related consequences. How-ever, the relationship between population per capita alcohol intake and liver cirrho-sis mortality fits well in most but not all countries, and both traffic fatalities anddeaths due to cirrhosis account only for a limited proportion of overall alcohol-related deaths. Therefore, alcohol-related mortality (ARM) has been proposed asa method to evaluate the impact of alcohol consumption on life expectancy (6–8).

The study ‘‘Alcohol Consumption and Alcohol Problems among Women inEuropean Countries,’’ which was carried out to examine the relationship betweendrinking patterns and problems in nine European countries with a particular focuson women, offered the opportunity to collect country-specific mortality datasetsand consequently to produce a preliminary and low-cost evaluation of variabilityof ARM rates in Europe.

MATERIALS AND METHODS

The procedures to calculate ARM require identification of a set of alcohol-related diseases and the corresponding proportion of cases due to alcohol (alcoholattributable fraction; AAF). In this project, the list of alcohol-related causes ofdeath has been drawn up, including the 12 causes directly related to alcohol useand misuse for which AAF is by definition set to 1.0 (causes of death directlyattributable to alcohol � DAA), and 9 diagnoses for which alcohol is a contributingrisk factor with AAFs less than 1.0 (causes of death indirectly attributable to alcohol� IAA). Among the many IAAs proposed in the literature, only a few havebeen selected here—those focusing only on more frequent causes and with strongevidence of a causal relationship with alcohol consumption (Table I). AAFs arenot country-specific, but were collected mainly from U.S. reports (6). However, forthe diagnoses ‘‘not well defined causes of death’’ (ICD-9: 780-799) and ‘‘deathsdue to injury or poisoning’’ (ICD-9: E800-E999), the more conservative Frenchand Italian values were used (9–11). AAFs are not gender-specific, and for all butone cause (‘‘injuries’’), they have been applied to ages over 35 years. Individualdiagnoses or specific accidents within the injury category have not been considered.

Alcohol-Related Mortality in Europe 57

Table I. Alcohol-Related Causes of Death Classified into Causes Directly Attributable to Alcohol(DAA) or Indirectly Attributable to Alcohol (IAA) and Their Own Alcohol-Attributable Fractions

(AAFs) Expressed as a Percentage of Deaths Due to Alcohol

Cause of death ICD-IX Code Disease AAF

DAA—Directly attributable 291 Alcoholic psychosis 100to alcohol

303 Alcoholic dependence syndrome 100305.0 Nondependent abuse of alcohol 100357.5 Alcoholic polyneuropathy 100425.5 Alcoholic cardiomyopathy 100535.3 Alcoholic gastritis 100571.0 Alcoholic fatty liver 100571.1 Acute alcoholic hepatitis 100571.2 Alcoholic cirrhosis of the liver 100571.3 Alcoholic liver damage, unspecified 100790.3 Excessive blood level of alcohol 100E860.0–E860.1 Accidental poisoning by ethyl alcohol, 100

not elsewhere specifiedIAA—Indirectly attributable 140–149 Malignant neoplasm of the lip, oral 50

to alcohol cavity, and pharynx150 Malignant neoplasm of the esophagus 75155 Malignant neoplasm of the liver and 15

intrahepatic bile ducts161 Malignant neoplasm of the larynx 50401 Essential hypertension 8430–438 Cerebrovascular diseases 7571.4–571.9 Other, not alcoholic cirrhosis 50780–799 Now well-defined causes of death 10E800–E999a Deaths due to injury or poisoning 33

Note: Age group: �35 yr; E800–E999 includes all ages.aExcluding E860.0–E860.1.

With the cooperation of national or local institutes of statistics, each study partneracquired national mortality data by diagnosis, 5-year age groups, and gender.5

Therefore, for each alcohol-related diagnosis, the overall number of deaths bygender, in 5-year age groups, study country, and calendar year, was multiplied by thecorresponding AAF value to calculate alcohol-related mortality (ARM � Deaths �AAF). Using 1983 and 1993 country-, 5-year age group, and sex-specific populationdata, age-specific mortality rates have been calculated. Hence, age-adjusted mortal-

5Data were collected according to ICD-8 Code in Switzerland and to ICD-9 codes for all other countries.For time-trend analyses, the 1983 and 1993 official vital statistics have been selected. However, only1983 and 1993 data from Germany, France, Italy, and Finland were collected according an identicalformat. Among the other countries some differences occurred, ranging from small inaccuracies to moreserious problems. In particular, data from the Czech Republic were not coded to the level of the fourthdigit, therefore were completely excluded from the analysis. Data from Sweden were incompletefor 1983, lacking ‘‘alcoholic polyneuropathy,’’ ‘‘alcoholic cardiomyopathy,’’ ‘‘alcoholic gastritis,’’ and‘‘nondependent abuse of alcohol’’ (codes: 357.5, 425.5, 535.3, and 305.0). Therefore, caution should beexercised in interpreting Swedish results when including 1983. In both 1983 and 1993, the Scotland filelacked ‘‘alcoholic polyneuropathy’’ (code: 357.5), whereas the code ‘‘425’’ was not detailed at thefourth digit (‘‘425.5’’: ‘‘alcoholic cardiomyopathy’’), and was therefore estimated from the ‘‘425.5’’ asa proportion for the 1993 year. Swiss information on ‘‘not well defined causes of death’’ (code: 780–799)in 1983 were lacking and calculated according to the proportion of the same code in 1993. Germandata were computed summing both GDR and FRG data (separate statistics have been presented whenappropriate), whereas French data were added in analysis at a subsequent time.


ity rates have been computed with the direct method (standard population: Europe).For the aim of this preliminary analysis, 95% confidence interval of standardizedARM death rates, statistical test of 1983–1993 ARM trend, and alcohol-relatedyears of potential life lost (YPLL) have been assessed.

RESULTS

Table II summarizes the results limited to causes of death directly attributableto alcohol representing the ‘‘official’’ recorded deaths due to alcohol. The absolutenumber of DAAs, the percentage of DAAs to general mortality, the crude andstandardized death rates (� 100,000 population; standard population: Europe) andthe corresponding male/female ratio have been tabulated by study country, calendaryear, and gender. Among males, the percentage of DAAs to general mortality in1993 varies between 0.6% in Italy and 3.3% in Finland, whereas among females therange is narrower, between 0.2% in Italy and Sweden and 0.9% in France, Germany,and Scotland. The variability across countries of standardized DAA rates in 1993is appreciable in males, with Finland scoring at the top (32.6 � 100,000 pop.) andItaly at the bottom (5.9 � 100,000 pop.). However, no particular geographic patternor gradient is evident. In the same year, although at lower levels, among femalesthe country-specific DAA rates rank similarly to those among males, with thehighest value in Germany (9.0 � 100,000 pop.) and the lowest in Italy (1.5 � 100,000pop.). When German data are analyzed separately for the former GDR and theformer FRG, in both sexes and years, the former GDR overtakes all other countries,scoring at the top of the DAA ordering. For both sexes, during the 1983–1993 periodDAA rates tended to increase in Finland, Germany, The Netherlands, Scotland, andItaly, and to decrease in the other countries, with the largest variation (increasingtrend) recorded in the former GDR. In 1993, the male/female DAA rate ratioapproaches 2 in Scotland; 3 in Switzerland; The Netherlands, Germany, and France;4 in Italy; and 5 in Sweden and Finland; without any relevant variation from 1983.

Focusing only on 1993, Table III shows the ARM estimates that have beenproduced if IAAs (i.e., causes with AAFs less than 100%) are added to the analysis.In all study countries the proportion of IAAs to overall ARM (column % ARMin Table III) greatly exceeds 60%, in most cases approaching 80%, with Finlandaccounting for the lowest and Italy for the highest IAA/DAA ratio (2.1 and 12.8,respectively). For both sexes, the highest IAA rates are found in Italy and France(and Scotland, but limited to females). Among males, general ARM rates scorehigh in France (95.6 � 100,000 pop.), Finland (83.8 � 100,000 pop.) and Germany(80.5 � 100,000 pop.), followed by Scotland (64.1 � 100,000 pop.) and Italy (61.3� 100,000 pop.), whereas Switzerland (53.5 � 100,000 pop.), Sweden (46.6 � 100,000pop.), and The Netherlands (40.0 � 100,000 pop.) are at the bottom. Among females,the ARM variability across countries is less evident, ranging from 33.9 in Franceto 20.3 in The Netherlands. When German data are processed considering Germanyas still separated, the former GDR ranks higher for both sexes than the formerFRG. Interestingly, with the inclusion of IAAs in the analysis, in both 1983 (datanot shown) and 1993, the ARM male/female ratio decreases everywhere with

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respect to the DAA male/female ratio because of the much lower gender ratioamong IAAs than among DAAs. In other words, the increase in ARM rates dueto IAA inclusion is proportionally more relevant among females than among males.The largest variations of gender ratio between DAAs and IAAs are recorded inSweden, Finland, and Italy.

Considering the variation of ARM rates in the 1983–1993 period, data showthat for both sexes and in most countries ARM tends to decline (Fig. 1 and 2).However, among males a somewhat increasing trend in ARM is evident in Finland,Scotland, and marginally in Germany, whereas among females ARM rates havenot increased in any single country. When German data are considered separately,it appears that the former GDR and the former FRG present opposite time trends.The increase of ARM rates in the former GDR for both sexes is remarkable. Withthe exception of Sweden, where a slight increase in alcohol consumption and adecrease in ARM rates is evident, the direction of ARM rate variation in the othercountries over the 1983–1993 period is in agreement with alcohol consumptiontrends (Fig. 3). In particular, both alcohol consumption and ARM rates increaseconsiderably among males and females in the former GDR; slightly in the formerFRG, Finland, and Scotland; and decrease in France, Italy, The Netherlands, andSwitzerland.

DISCUSSION

Although country-specific alcohol-related mortality statistics have been pub-lished recently (10–18), information on the impact of alcohol consumption on public

Fig. 1. Percentage change of alcohol-related mortality rates from 1983 to 1993, males.


Fig. 2. Percentage change of alcohol-related mortality rates from 1983 to 1993, females.

Fig. 3. Percentage change of alcohol-related mortality rates and alcohol intake in the 1983–1993 period,both sexes combined. For the former GDR and former FRG, alcohol consumption data refer to the1983–1990 period, whereas for all of Germany combined data before 1991 are not available.


health in Europe is still lacking. The demand for measures for disease surveillanceand for evaluation of prevention initiatives that allow correlations of lifestyle habitsto adverse consequences for communities is increasing with the ongoing process ofeconomic and cultural integration across Europe. The ideal indicator of the impactof alcohol consumption on public health should be valid, precise, and reproducible.At present, the most popular method of comparing alcohol consequences acrossgeographic areas still relies on liver cirrhosis and psychosis morbidity and mortalitystatistics, as proposed many years ago by WHO, assuming the former as an indicatorof chronic alcohol-related disease and the latter as an indicator of acute conse-quences of alcohol consumption. Utilization of alcohol-related motor vehicle crashfatalities, when available, has also been proposed (19). However, these indicatorsin no way account for all alcohol-related mortality, as required for an analysis ofthe social costs of alcohol consumption (20). In theory, one could approach thetrue value for alcohol-related mortality by counting all deaths whose certificatesmention alcohol etiology explicitly. The International Classification of Diseases–IXrevision (ICD-9) provides 12 codes corresponding to the causes of death in whichalcohol is the sole etiologic factor. However, several studies have shown that formany reasons, alcohol-related deaths are considerably underreported on deathcertificates (1, 3). This is also very evident from our study when focusing only oncauses of death directly attributable to alcohol. In particular, among males in both1983 and 1993, DAAs do not account for more than 3% of general mortality inany study country, and among females the proportion is even lower, close to almostundetectable values (less than 1%). Moreover, the fact that the male/female ratiois always higher for DAA than for IAA in all study countries for both 1983 and1993 suggests several interpretations (e.g., real gender differences in the 12 alcoholicdiseases’ incidence; gender selection bias of autopsy rates, whose variability acrosscountries is a well-known factor affecting mortality statistics). These differencescould also be accounted for under the hypothesis that DAA causes are reportedless often on death certificates for women than for men as a consequence of thegeneral perception of gender roles in most European societies according to whichalcoholism is less tolerable among females than among males. The plausibility ofall these explanations may differ across European countries according to multiplesocial factors. However, the stable values of DAAs (as mortality rates, proportionof general mortality, or as gender ratios) in those countries that experienced thelargest decreases in per capita alcohol consumption over the 1983–1993 period (i.e.,Italy, France, and the Netherlands) (21) confirm that DAAs are not good indicatorsof alcohol consequences among European countries. They may be of some valueonly within selected countries where the death certificate recording proceduresseem more accurate (Finland) (18).

The practical way to approach the best estimates of overall ARM is to includein the analysis additional causes of death indirectly attributable to alcohol. Thevalidity of ARM relies on the inclusion criteria of alcohol-related diseases and onthe method used for computing the corresponding alcohol-attributable fractions.Both are based on several assumptions, and limitations of this type of calculationhave been addressed (6). In brief, the selection of diseases to be considered alcohol-related is generally based on reviewing the medical literature according to the


standard procedures of scientific consensus assessments. However, in many in-stances, general agreement has not been reached. For instance, the role of alcoholin the etiology of colon cancer has often been suggested, but not well confirmed(22), so that the choice of including or excluding such relevant causes of deathgreatly affects final ARM estimates. In other cases, the role of alcohol consumptionon the risk of disease may be complex. An example is the recently suggested J-shaped function risk of cardiovascular diseases (23), which raises the questionof whether both attributable and preventive fractions should be considered (24),probably specific for wine and other alcoholic beverages (25–28). For each alcohol-related disease, AAFs are calculated as attributable risks when at least two parame-ters are known: relative risk (RR) and the proportion of subjects exposed to alcoholin the study population. RR is (or should be) independent of the study populationand hence may also be derived from studies carried out in other countries. However,the proportion of alcohol drinkers is a time- and space-specific parameter thatmust be estimated from local or national surveys. Relevant variation of alcoholconsumption in a short period may affect the natural history of alcohol-relateddiseases and modify the proportion of deaths attributable to alcohol, as may havebeen the case for France and Italy during the 1960s and 1970s. Furthermore, AAFsestimated from studies based on incident cases might not be completely appropriatefor mortality data, as may be the case with some low-grade malignant neoplasmsthat rarely cause death. Finally, although it rarely happens, AAFs should be adjustedat least for smoking habits, a relevant confounding or interactive factor for manyalcohol-related diseases. Other problems concern AAFs of deaths from injuriesand adverse effects that are calculated directly from clinical studies, according tothe prevalence of positives to alcoholimetric tests. In this case, the reliability of theAAF depends on the analytic method, the choice of the cutoff point, the availabilityof a control group, and the level of information on use of other drugs.

The primary aim of this study was to compare ARM rates across study countriesaccording to the 12 causes of death with explicit mention of alcohol etiology, andto obtain some kind of indication of the extent to which ARM underestimationwould be produced using these ‘‘official’’ recorded deaths. For this reason, weselected an additional brief list of alcohol-related causes of death and the corre-sponding AAFs (6) among those proposed by the Centers for Disease Control(CDC) in the United States. The appropriate method, which would have been toestimate country-specific AAFs from an international review of RRs and fromnational alcohol intake surveys, was beyond the scope of this study. This choicemay have greatly under- or overestimated ARM results. In fact, we used the sameAAFs for both sexes and for all study countries as if their populations were partof the same ‘‘nation’’; hence assuming absence of geographic variability of alcoholdrinking patterns, which in reality is clearly not the case. In other words, if similarAAFs are used independently of country-specific alcohol drinking patterns, thevariability of ARM rates across countries simply reflects the variability of theindividual causes of death considered in ARM analysis. In this sense, ARM estimatesare equivalent to a sort of new large cause of death, including individual causes ofdeath that have been reduced by a constant rate, namely the AAFs. Furthermore,for some countries the original data used in this study are not completely homoge-


neous with the others. In particular, some inaccuracies may have affected the resultsfor Sweden in 1983, whereas those occurring for Switzerland and Scotland are notrelevant for final ARM estimates. In any case, we decided to carry out this typeof analysis in the belief that, within the study resources, it allows an elucidation ofsome aspects of harmful consequences of alcohol consumption better than consider-ing only cirrhosis mortality. We are aware that our ARM estimates are crude andprobably in some ways inaccurate, but they may be of some value in exploring theeffects of alcohol drinking in different cultures. For these reasons, the study resultsare more meaningful if evaluated in relative rather than absolute terms. Withinthese limitations, some general conclusions may be drawn.

First, the results of this ARM-rates analysis limited to causes of death fullyattributable to alcohol confirm that the rates do not permit a fair assessment alcoholconsequences among countries. In particular, looking at the percentage of DAAto general mortality, it is evident that a large underestimation has occurred in allcountries, and, as indicated by the high male/female ratio, mostly among females.The variability of DAA rates might be affected by the quality of certificationprocedures across study countries more than by drinking patterns. For example,the low DAA rates among females could be explained by death certification bias,according to which physicians are induced by social considerations to avoid usingcodes that explicitly mention alcohol etiology and do so more often for femalepatients than for male patients. Also, the time-trend analysis over the 1983–1993period supports the hypothesis that methodologic issues affect DAA estimates morethan one imagines all ‘‘facts’’ are real.

Thus, the inclusion of IAAs in the analysis seems to improve the estimates.The geographic and time-trend variability of ARM rates becomes more congruentwith alcohol drinking levels and trends in both males and females. The decreasingtrend in general ARM rates agrees with the decreasing pattern of alcohol intakethat occurred in most European countries in recent years. This study also confirmsthat liver cirrhosis is a reliable indicator of diachronic variation in consequencesof alcohol consumption, although it obviously underestimates the absolute dimen-sion of alcohol-related social harm.

In this study, caution should be exercised in interpreting gender ratios ofARM rates because we have not applied gender-specific AAFs as methodologicallyrequired in any attributable fraction estimate. However, our ARM rates reflectgender mortality patterns of those causes of death selected for ARM analysis, andat first view, the variability of ARM gender ratios, in both 1983 and 1993, seemsto be more reliable than DAA gender ratios. If the outcome concerning smallergender differences using ARM rates would be confirmed using more adequatemethods and data, that would mean that differences between men and women inalcohol-related deaths are smaller than the most often used figures (based onDAA) indicate.

Finally, it is clearly evident that when German data are separately analyzedas the former GDR and the former FRG (independent of reunification year), twodistinct ARM patterns result, suggesting that at least presently, Germany shouldbe treated as two different countries. Because of its larger population, the formerFRG data are similar to that of the unified Germany, and, for the same reason,


the information on the former GDR is masked because it is diluted into that ofthe whole Germany. This is particularly true looking at the stable ARM rates forall of Germany recorded for both sexes during the period 1983–1993, which hidesthe opposite ARM trends of the former GDR (large increase) and of the formerFRG (slight decrease). The variation in ARM rates between 1983 and 1993 in theformer GDR is, among males, much larger than in other countries, and it is theonly positive trend among females. Considering this and observing the variation ofalcohol intake in the same period, we may suspect that some change in deathcertification procedures may have occurred in the former GDR in recent years, asopposed to considering a real change in alcohol consumption.

In conclusion, our estimates are far from being entirely trustworthy, but theyhave supported the need for a more detailed and methodologically appropriateprocedure to calculate an epidemiologic parameter, namely ARM, to monitor harm-ful consequences of alcohol consumption and alcohol policies among Europeancountries.

ACKNOWLEDGMENTS

This research was conducted within the framework of a Concerted Action(BMH4-CT96-0179 and IC20-CT96-0051) funded under the BIOMED II researchprogram of the European Commission, and was also supported in part by theGerman Federal Ministry of Health, the Swiss Federal Office of Public Health, theSwiss Federal Statistical Office, and the Swiss Federal Office of Education andScience. In the Finnish data collection, the expertise of Dr. Kari Pikolainen wasused, as well as the assistance of Ms. Ritva Hein. We are in debt to Dr. Feola andDr. Giovannetti for national and local mortality data collection in Italy. Thanksalso to the German Federal Statistics Office for supplying the German mortalitydata for this analysis.

An earlier version of this paper appeared as a chapter in the final projectreport of the Concerted Action ‘‘Alcohol Consumption and Alcohol Problemsamong Women in European Countries’’ submitted to the European Commission,June 1999.

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