IJE Advance Access originally published online on April 12, 2007
International Journal of Epidemiology 2007 36(2):468-469; doi:10.1093/ije/dym057
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Commentary: The role of alcohol in mortality differences between European countries
Centre for Health Equity Studies, CHESS, Stockholm University/Karolinska Institute.
E-mail: denny.vagero{at}chess.su.se
Accepted 6 March 2007
Mortality trends in European countries have diverged since the late 1960s mainly because of the long period (1968–84) of health stagnation in the countries that once made up communist Europe coupled with steady health improvements in the West. Perestroika and the anti-alcohol policies of Gorbachev in the mid-1980s led to an abrupt break in this pattern in the East which was almost immediately followed by the collapse of the communist system in 1989–91. This in turn led to an immediate widening of health differences between East and West. Today differences are still large—life expectancy for men differs by almost two decades between the European Union (EU) (15 old members) and Russia. However, the 12 new members of the EU now show signs of beginning to catch up with the old.
In this issue of IJE, Jürgen Rehm and collaborators1 present new evidence about mortality differences between European countries, based on their study of eight countries, representing old and new members of the EU. For comparison, they added Russia (a very relevant addition in this context). For each of the eight countries, the authors estimate firstly the general level of alcohol consumption and secondly, its pattern of drinking. Both are found to contribute importantly to mortality variation between countries, in particular to differences between new and old members of the EU and to the exceedingly high levels of mortality in Russia.
Male/female differences in drinking are, in general, larger in Eastern than Western Europe. Reflecting this, East–West differences in drinking habits are smaller for women than men. Among women in the UK, in fact, heavy drinking is slightly more common and abstention less common than among women in both the Czech Republic and Russia, a finding reported in one previous study.2 Despite this, Rehm et al. suggest that alcohol accounts for about 5% of the female mortality difference between the old and new EU Member States. For male mortality, this East–West gap within the EU is considerably larger, with a much larger proportion of the male gap (around one-fifth) attributed to alcohol. Even larger differences are seen in comparisons with Russia. While the all-cause mortality rate ratio comparing Russia with Sweden (men aged 20–64) is around five, the equivalent alcohol-related mortality rate ratio is around 10.
The above estimates are derived in a fairly complicated series of steps, each of which involves assumptions, for instance about the size of risk from a particular level and style of drinking in relation to a specific cause-of-death in a specific age group. It thus goes without saying that there is a large uncertainty around the final estimates that the authors arrive at. However, in spite of this uncertainty, Rehm et al. make a convincing case for alcohol being a very important factor underlying health differences inside the EU. In addition, one must conclude, alcohol contributes to the large (and increasing) life expectancy gap between Russia and the countries of the EU.
Rehm et al. found the alcohol-attributable fraction of mortality in Russia to be 18% at ages 20–64; an estimate they suggest may be biased downwards. A previous study by Rehm et al.3 covering European Russia and age groups 15–59, estimated this fraction to be 27%. Leon et al.4 in their study of mortality in Izhevsk, Russia, focused on the contribution of surrogate alcohol, estimated to be drunk by around 8% of men in this region. Surrogate drinking, or other types of extreme drinking, were estimated to account for much more than a third of mortality among men in this region aged 20–54. If we consider the role of surrogates, the underestimation of the mortality toll attributable to alcohol to which Rehm and colleagues allude may only be part of the problem. Western epidemiology has largely missed out on the fact that large quantities of alcohol in Russia are drunk as surrogate liquids of very high alcohol content, which allows fast and potentially lethal intoxication.
Nevertheless, the recent studies by Rehm et al.1 and Leon et al.4 suggest that a very considerable fraction of male working age mortality in Russia is attributable to alcohol, and further that mortality variation across Europe in no small part is shaped by European alcohol consumption patterns.
Is there cause for concern in the European region? Yes, indeed there is. Europe is that region of the world where alcohol drinking is highest and probably also where it takes the largest toll of death. Problems inside old and new member states of the EU, as well as the problems in Russia and Ukraine are connected in a myriad of direct and indirect ways. In fact, they constitute one common problem.
It is obvious that countries change their alcohol taxes and policies in response to what neighbouring countries do, and in particular, to the legal, semi-legal and illegal trade in alcohol for human or industrial purposes across the continent. We have seen several countries being forced into a negative spiral of mutual lowering of taxes and relaxing of alcohol control measures. The EU's common agricultural policy has helped to provide cheap raw materials for spirits in the eastern part of the continent. The net result of such regional dynamics in Europe has been increasing levels of alcohol consumption and a growing concern about alcohol-related harm across the European region at large.
WHO–Euro and in particular the EU, should now take a much more proactive role in this. This is an issue where action at the EU level is indispensable. There are four steps that could be taken without delay:
- EU health ministers should make explicit their common view that alcohol is not just another commodity to be traded in the single market, but a potential public health hazard throughout Europe.
- The EU should encourage Member States who want to pursue a policy which limits alcohol consumption and alcohol-related harm at home and abroad.
- EU governments should work towards appropriate restrictive measures across the whole continent, rather than encouraging the expansion of alcohol trade in each other's backyards.
- EU and Russia should start a dialogue within the ‘EU–Russia framework agreement’ and EU and Ukraine should do the same within ‘the EU–Ukraine new enhanced agreement’ about ways of reducing alcohol-related harm across the continent, in particular, in countries which suffer the most harmful consequences of alcohol. This dialogue could be facilitated by WHO–Europe.
 |
References |
|---|
 Top References |
|---|
1 Rehm J, Sulkowska U, Manczuk M, et al. Alcohol accounts for a high proportion of premature mortality in central and eastern Europe. Int J Epidem (2007) 36:458–467.
2 Adam E, Golding J. Chapter 9: Maternal smoking and drinking during pregnancy. In: Pregnancy in the Nineties: The First Report from the European Longitudinal Study of Pregnancy and Childhood (ELSPAC).—Dragonas T, Golding J, Ignatyeva R, Prokhorskas R, eds. (1996) Bristol: Redcliffe Press. 55–59.
3 Rehm J, Taylor B, Patra J. Volume of alcohol consumption, pattern of drinking and burden of disease in the European Region 2002. Addiction (2006) 101:1086–95.[CrossRef][ISI][Medline]
4 Leon D, Saburova L, Tomkins S, et al. Hazardous alcohol drinking and premature mortality in Russia: The Izhevsk family case-control study of men aged 25-54 years, 2003-2005. In: Lancet. forthcoming.
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  D. A. Khaltourina and A. V. Korotayev Potential for Alcohol Policy to Decrease the Mortality Crisis in Russia Eval Health Prof, September 1, 2008; 31(3): 272 - 281. [Abstract] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||