Joint effects of alcohol use, smoking and body mass index as an explanation for the alcohol harm paradox: causal mediation analysis of eight cohort studies.

BACKGROUND AND AIMS: Lower socio-economic status (SES) is associated with higher alcohol-related harm despite lower levels of alcohol use. Differential vulnerability due to joint effects of behavioural risk factors is one potential explanation for this 'alcohol harm paradox'. We analysed to what extent socio-economic inequalities in alcohol-mortality are mediated by alcohol, smoking and body mass index (BMI), and their joint effects with each other and with SES. DESIGN: Cohort study of eight health examination surveys (1978-2007) linked to mortality data. SETTING: Finland. PARTICIPANTS: A total of 53 632 Finnish residents aged 25+ years. MEASUREMENTS: The primary outcome was alcohol-attributable mortality. We used income as an indicator of SES. We assessed the joint effects between income and mediators (alcohol use, smoking and BMI) and between the mediators, adjusting for socio-demographic indicators. We used causal mediation analysis to calculate the total, direct, indirect and mediated interactive effects using Aalen's additive hazards models. FINDINGS: During 1 085 839 person-years of follow-up, we identified 865 alcohol-attributable deaths. We found joint effects for income and alcohol use and income and smoking, resulting in 46.8 and 11.4 extra deaths due to the interaction per 10 000 person-years. No interactions were observed for income and BMI or between alcohol and other mediators. The lowest compared with the highest income quintile was associated with 5.5 additional alcohol deaths per 10 000 person-years (95% confidence interval = 3.7, 7.3) after adjusting for confounders. The proportion mediated by alcohol use was negative (-69.3%), consistent with the alcohol harm paradox. The proportion mediated by smoking and BMI and their additive interactions with income explained 18.1% of the total effect of income on alcohol-attributable mortality. CONCLUSIONS: People of lower socio-economic status appear to be more vulnerable to the effects of alcohol use and smoking on alcohol-attributable mortality. Behavioural risk factors and their joint effects with income may explain part of the alcohol harm paradox.

Measurement error as an explanation for the alcohol harm paradox: analysis of eight cohort studies.

BACKGROUND: Despite reporting lower levels of alcohol consumption, people with lower socio-economic status (SES) experience greater alcohol-related harm. Whether differential biases in the measurement of alcohol use could explain this apparent paradox is unknown. Using alcohol biomarkers to account for measurement error, we examined whether differential exposure to alcohol could explain the socio-economic differences in alcohol mortality. METHODS: Participants from eight representative health surveys (n = 52 164, mean age 47.7 years) were linked to mortality data and followed up until December 2016. The primary outcome was alcohol-attributable mortality. We used income and education as proxies for SES. Exposures include self-reported alcohol use and four alcohol biomarkers [serum gamma-glutamyl transferase (available in all surveys), carbohydrate-deficient transferrin, alanine aminotransferase and aspartate aminotransferase (available in subsamples)]. We used shared frailty Cox proportional hazards to account for survey heterogeneity. RESULTS: During a mean follow-up of 20.3 years, totalling 1 056 844 person-years, there were 828 alcohol-attributable deaths. Lower SES was associated with higher alcohol mortality despite reporting lower alcohol use. Alcohol biomarkers were associated with alcohol mortality and improved the predictive ability when used in conjunction with self-reported alcohol use. Alcohol biomarkers explained a very small fraction of the socio-economic differences in alcohol mortality, since hazard ratios either slightly attenuated (percent attenuation range 1.0-12.1%) or increased. CONCLUSIONS: Using alcohol biomarkers in addition to self-reported alcohol use did not explain the socio-economic differences in alcohol mortality. Differential bias in the measurement of alcohol use is not a likely explanation for the alcohol-harm paradox.

Alcohol-attributed disease burden in four Nordic countries between 2000 and 2017: Are the gender gaps narrowing? A comparison using the Global Burden of Disease, Injury and Risk Factor 2017 study.

INTRODUCTION AND AIMS: The gender difference in alcohol use seems to have narrowed in the Nordic countries, but it is not clear to what extent this may have affected differences in levels of harm. We compared gender differences in all-cause and cause-specific alcohol-attributed disease burden, as measured by disability-adjusted life-years (DALY), in four Nordic countries in 2000-2017, to find out if gender gaps in DALYs had narrowed. DESIGN AND METHODS: Alcohol-attributed disease burden by DALYs per 100 000 population with 95% uncertainty intervals were extracted from the Global Burden of Disease database. RESULTS: In 2017, all-cause DALYs in males varied between 2531 in Finland and 976 in Norway, and in females between 620 in Denmark and 270 in Norway. Finland had the largest gender differences and Norway the smallest, closely followed by Sweden. During 2000-2017, absolute gender differences in all-cause DALYs declined by 31% in Denmark, 26% in Finland, 19% in Sweden and 18% in Norway. In Finland, this was driven by a larger relative decline in males than females; in Norway, it was due to increased burden in females. In Denmark, the burden in females declined slightly more than in males, in relative terms, while in Sweden the relative decline was similar in males and females. DISCUSSION AND CONCLUSIONS: The gender gaps in harm narrowed to a different extent in the Nordic countries, with the differences driven by different conditions. Findings are informative about how inequality, policy and sociocultural differences affect levels of harm by gender.

The Road to the Alcohol Act 2018 in Finland: A conflict between public health objectives and neoliberal goals.

Finnish alcohol policy has aimed for decades years to mitigate alcohol-related harm by using high taxation and restrictions on the physical availability of alcohol. The state monopoly on the retail of alcohol has played a central role in reducing the availability of alcohol. In 2011, preparations began for a comprehensive reform of the Alcohol Act 1994. Over time, the issue became highly politicised, lobbied and divisive. It took intense work of two consecutive governments to finalise the reform. The new Alcohol Act came into force in 2018. It expanded the rights of grocery stores to sell alcohol and reduced the administrative burden for on-premise sales. As a result, the state monopoly on the retail of alcohol was weakened, but it still has an important impact on the physical availability of alcohol. The Finnish public health community expected an increase in alcohol sales following the reform because of greater alcohol availability and expected price reductions related to greater competition of sales in grocery stores. However, prices decreased less than expected in 2018, partly due to a simultaneous increase in alcohol taxes. It is difficult to evaluate the impact of the reform at this early stage. However, after the reform, the 10-year (2008-2017) downward trend in the total per capita alcohol consumption was discontinued despite the tax increase. According to preliminary analyses, the change in the law may have slightly increased recorded alcohol sales but the effect was not statistically significant.

The connection between per capita alcohol consumption and alcohol-specific mortality accounting for unrecorded alcohol consumption: The case of Finland 1975-2015.

INTRODUCTION AND AIMS: Unrecorded alcohol consumption has increased strongly in Finland after 1995 when the country joined the European Union. This development may have rendered alcohol sales less trustworthy as a proxy for population drinking, and less powerful as predictor of alcohol-related harm. The study aims to test this contention by analyzing the association between recorded and unrecorded alcohol consumption on the one hand, and alcohol-specific mortality on the other. DESIGN AND METHODS: We analysed age-standardised rates of alcohol-specific deaths for the working-age (15-64 years) population. For alcohol consumption, we used (i) alcohol sales in litres of 100% alcohol per capita, and (ii) estimated unrecorded consumption in litres of 100% alcohol per capita. The data spanned the period 1975-2015. As the data were cointegrated, the relations between mortality and the alcohol indicators were estimated through time-series analysis of the raw data. RESULTS: A one litre increase in alcohol sales was associated with an increase in alcohol-specific deaths of 7.590 deaths per 100 000; the corresponding figure for unrecorded consumption was 9.112 deaths per 100 000. Both estimates were statistically significant (P < 0.001), but the difference between them was not significant (P = 0.293). Although recoded consumption captured the main feature of the trends in alcohol-specific mortality, it accounted for only half of its marked increase in 1975-2007, while unrecorded consumption explained the remaining part. DISCUSSION AND CONCLUSIONS: Our study confirms previous findings that recorded alcohol consumption is an important determinant of alcohol-specific mortality in Finland. A more novel insight is the importance of unrecorded consumption in this context.

Estimating the public health impact of disbanding a government alcohol monopoly: application of new methods to the case of Sweden.

BACKGROUND: Government alcohol monopolies were created in North America and Scandinavia to limit health and social problems. The Swedish monopoly, Systembolaget, reports to a health ministry and controls the sale of all alcoholic beverages with > 3.5% alcohol/volume for off-premise consumption, within a public health mandate. Elsewhere, alcohol monopolies are being dismantled with evidence of increased consumption and harms. We describe innovative modelling techniques to estimate health outcomes in scenarios involving Systembolaget being replaced by 1) privately owned liquor stores, or 2) alcohol sales in grocery stores. The methods employed can be applied in other jurisdictions and for other policy changes. METHODS: Impacts of the privatisation scenarios on pricing, outlet density, trading hours, advertising and marketing were estimated based on Swedish expert opinion and published evidence. Systematic reviews were conducted to estimate impacts on alcohol consumption in each scenario. Two methods were applied to estimate harm impacts: (i) alcohol attributable morbidity and mortality were estimated utilising the International Model of Alcohol Harms and Policies (InterMAHP); (ii) ARIMA methods to estimate the relationship between per capita alcohol consumption and specific types of alcohol-related mortality and crime. RESULTS: Replacing government stores with private liquor stores (Scenario 1) led to a 20.0% (95% CI, 15.3-24.7) increase in per capita consumption. Replacement with grocery stores (Scenario 2) led to a 31.2% (25.1-37.3%) increase. With InterMAHP there were 763 or + 47% (35-59%) and 1234 or + 76% (60-92%) more deaths per year, for Scenarios 1 and 2 respectively. With ARIMA, there were 850 (334-1444) more deaths per year in Scenario 1 and 1418 more in Scenario 2 (543-2505). InterMAHP also estimated 10,859 or + 29% (22-34%) and 16,118 or + 42% (35-49%) additional hospital stays per year respectively. CONCLUSIONS: There would be substantial adverse consequences for public health and safety were Systembolaget to be privatised. We demonstrate a new combined approach for estimating the impact of alcohol policies on consumption and, using two alternative methods, alcohol-attributable harm. This approach could be readily adapted to other policies and settings. We note the limitation that some significant sources of uncertainty in the estimates of harm impacts were not modelled.

Purchases of prescription drugs before an alcohol-related death: A ten-year follow-up study using linked routine data.

BACKGROUND: Physician's intention to prescribe drugs could potentially be used to improve targeting of alcohol interventions and enhanced disease management to patients with a high risk of severe alcohol-related harm within outpatient settings. METHODS: Comparison of ten-year incidence trajectories of 13.8 million reimbursed purchases of prescription drugs among 303,057 Finnish men and women of whom 7490 ultimately died due to alcohol-related causes (Alc+), 14,954 died without alcohol involvement (Alc-), and 280,613 survived until the end of 2007. RESULTS: 5-10 years before death, 88% of the persons with an Alc+ death had received prescription medication, and over two-thirds (69%) had at least one reimbursed purchase of drugs for the alimentary tract and metabolism, the cardiovascular system, or the nervous system. Among persons with an Alc+ death, the incidence rate (IR) for purchases of hypnotics, and sedatives was 1.38 times higher (95% confidence interval (CI):1.32,1.44) compared to those with an Alc- death, and 4.07 times higher (95%CI:3.92,4.22) compared to survivors; and the IR for purchases of anxiolytics was 1.40 times higher (95%CI:1.34,1.47) compared to those with an Alc- death, and 3.61 times higher (95%CI:3.48,3.78) compared to survivors. CONCLUSIONS: Using physician's intention to prescribe drugs affecting the alimentary tract and metabolism, cardiovascular system and nervous system could potentially be used to flag patients who might benefit from screening, targeted interventions or enhanced disease management. In particular, patients who are to be prescribed anxiolytics, hypnotics, and sedatives, and antidepressants may benefit from enhanced interventions targeted to problem drinking.

Alcohol Consumption and the Physical Availability of Take-Away Alcohol: Systematic Reviews and Meta-Analyses of the Days and Hours of Sale and Outlet Density.

OBJECTIVE: Systematic reviews and meta-analyses were completed studying the effect of changes in the physical availability of take-away alcohol on per capita alcohol consumption. Previous reviews examining this topic have not focused on off-premise outlets where take-away alcohol is sold and have not completed meta-analyses. METHOD: Systematic reviews were conducted separately for policies affecting the temporal availability (days and hours of sale) and spatial availability (outlet density) of take-away alcohol. Studies were included up to December 2015. Quality criteria were used to select articles that studied the effect of changes in these policies on alcohol consumption with a focus on natural experiments. Random-effects meta-analyses were applied to produce the estimated effect of an additional day of sale on total and beverage-specific consumption. RESULTS: Separate systematic reviews identified seven studies regarding days and hours of sale and four studies regarding density. The majority of articles included in these systematic reviews, for days/hours of sale (7/7) and outlet density (3/4), concluded that restricting the physical availability of take-away alcohol reduces per capita alcohol consumption. Meta-analyses studying the effect of adding one additional day of sale found that this was associated with per capita consumption increases of 3.4% (95% CI [2.7, 4.1]) for total alcohol, 5.3% (95% CI [3.2, 7.4]) for beer, 2.6% (95% CI [1.8, 3.5]) for wine, and 2.6% (95% CI [2.1, 3.2]) for spirits. The small number of included studies regarding hours of sale and density precluded meta-analysis. CONCLUSIONS: The results of this study suggest that decreasing the physical availability of take-away alcohol will decrease per capita consumption. As decreasing per capita consumption has been shown to reduce alcohol-related harm, restricting the physical availability of take-away alcohol would be expected to result in improvements to public health.

The contribution of alcohol use and other behavioural, material and social factors to socio-economic differences in alcohol-related disorders in a Swedish cohort.

AIMS: We estimated the degree to which the relationship between socio-economic position (SEP) and alcohol-related disorders is attenuated after adjustment for levels and patterns of drinking, behavioural, material and social factors. DESIGN: A longitudinal cohort study with baseline in 2002, with linkage to register data on patient care and deaths in 2002-11 to yield the outcome measures. SETTING: Stockholm County, Sweden. PARTICIPANTS: Respondents to baseline survey aged 25-64 (n = 17 440) with information on all studied covariates. MEASUREMENTS: Occupational class was the studied SEP indicator and a combined measure of volume of weekly alcohol consumption and frequency of heavy episodic drinking, smoking, employment status, income, social support, marital status and education, all at baseline, were the studied covariates. Alcohol-related disorders (n = 388) were indicated by first register entries on alcohol-related medical care or death during the follow-up. FINDINGS: Unskilled workers had an approximately four times greater risk of alcohol-related disorders than higher non-manual employees, hazard ratio (HR) = 4.08 (2.78, 5.98). After adjustment for alcohol use, the SEP difference in risk for alcohol-related harm fell by a fourth for the same group, HR = 2.91 (1.96, 4.33). The difference was reduced further when behavioural factors and material factors were taken into account, HR = 2.09 (1.34, 3.26), whereas adjusting for social factors and attained education resulted in smaller reductions. CONCLUSIONS: Socio-economic differences in alcohol use explain one fourth of the socio-economic position differences in alcohol-related disorders in Stockholm, Sweden. Hazardous alcohol use and other behavioural, material and social factors together explain nearly 60% of the socio-economic position differences in alcohol-related disorders.

Socioeconomic inequalities in alcohol consumption in Chile and Finland.

BACKGROUND: Reasons for socioeconomic inequalities in alcohol harm are not sufficiently understood. One explanation relates to differential exposure to alcohol by socioeconomic status (SES). The present study investigated socioeconomic inequalities in alcohol use in two countries with high alcohol consumption and alcohol harm. METHODS: Data from nationally representative surveys in 2009-2010 in Chile and in 2008-2011 in Finland were used. Surveys comprised 3477 participants in Chile and 9994 in Finland aged 30-64 years. Outcome measures included abstinence, weekly consumption of pure alcohol, heavy volume drinking and heavy episodic drinking (HED). We employed a novel method in alcohol research, the concentration index, to measure socioeconomic inequalities. RESULTS: Alcohol abstinence showed a strong association with lower SES in Chile and Finland. These were largely driven by inequalities among women in Chile and older subgroups in Finland. In both countries, women aged 45-64 of higher SES showed higher weekly consumption of pure alcohol and heavy volume drinking. Heavy volume drinking among Chilean women aged 45-64 showed the highest inequality, favouring higher SES. HED was equally distributed among SES groups in Chile; in Finland HED disproportionally affected lower SES groups. CONCLUSIONS: Lower SES was associated with higher abstinence rates in both countries and heavy episodic drinking in Finland. Heavy volume drinking was more prevalent in middle-aged women of high SES. The results identified groups for targeted interventions, including middle-aged higher SES women, who traditionally have not been specifically targeted. The concentration index could be a useful measure of inequalities in alcohol use.

Alcohol-attributed disease burden in four Nordic countries: a comparison using the Global Burden of Disease, Injuries and Risk Factors 2013 study.

AIMS: (1) To compare alcohol-attributed disease burden in four Nordic countries 1990-2013, by overall disability-adjusted life years (DALYs) and separated by premature mortality [years of life lost (YLL)] and health loss to non-fatal conditions [years lived with disability (YLD)]; (2) to examine whether changes in alcohol consumption informs alcohol-attributed disease burden; and (3) to compare the distribution of disease burden separated by causes. DESIGN: A comparative risk assessment approach. SETTING: Sweden, Norway, Denmark and Finland. PARTICIPANTS: Male and female populations of each country. MEASUREMENTS: Age-standardized DALYs, YLLs and YLDs per 100 000 with 95% uncertainty intervals (UIs). FINDINGS: In Finland, with the highest burden over the study period, overall alcohol-attributed DALYs were 1616 per 100 000 in 2013, while in Norway, with the lowest burden, corresponding estimates were 634. DALYs in Denmark were 1246 and in Sweden 788. In Denmark and Finland, changes in consumption generally corresponded to changes in disease burden, but not to the same extent in Sweden and Norway. All countries had a similar disease pattern and the majority of DALYs were due to YLLs (62-76%), mainly from alcohol use disorder, cirrhosis, transport injuries, self-harm and violence. YLDs from alcohol use disorder accounted for 41% and 49% of DALYs in Denmark and Finland compared to 63 and 64% in Norway and Sweden 2013, respectively. CONCLUSIONS: Finland and Denmark has a higher alcohol-attributed disease burden than Sweden and Norway in the period 1990-2013. Changes in consumption levels in general corresponded to changes in harm in Finland and Denmark, but not in Sweden and Norway for some years. All countries followed a similar pattern. The majority of disability-adjusted life years were due to premature mortality. Alcohol use disorder by non-fatal conditions accounted for a higher proportion of disability-adjusted life years in Norway and Sweden, compared with Finland and Denmark.

Inequalities in Alcohol-Related Mortality in 17 European Countries: A Retrospective Analysis of Mortality Registers.

BACKGROUND: Socioeconomic inequalities in alcohol-related mortality have been documented in several European countries, but it is unknown whether the magnitude of these inequalities differs between countries and whether these inequalities increase or decrease over time. METHODS AND FINDINGS: We collected and harmonized data on mortality from four alcohol-related causes (alcoholic psychosis, dependence, and abuse; alcoholic cardiomyopathy; alcoholic liver cirrhosis; and accidental poisoning by alcohol) by age, sex, education level, and occupational class in 20 European populations from 17 different countries, both for a recent period and for previous points in time, using data from mortality registers. Mortality was age-standardized using the European Standard Population, and measures for both relative and absolute inequality between low and high socioeconomic groups (as measured by educational level and occupational class) were calculated. Rates of alcohol-related mortality are higher in lower educational and occupational groups in all countries. Both relative and absolute inequalities are largest in Eastern Europe, and Finland and Denmark also have very large absolute inequalities in alcohol-related mortality. For example, for educational inequality among Finnish men, the relative index of inequality is 3.6 (95% CI 3.3-4.0) and the slope index of inequality is 112.5 (95% CI 106.2-118.8) deaths per 100,000 person-years. Over time, the relative inequality in alcohol-related mortality has increased in many countries, but the main change is a strong rise of absolute inequality in several countries in Eastern Europe (Hungary, Lithuania, Estonia) and Northern Europe (Finland, Denmark) because of a rapid rise in alcohol-related mortality in lower socioeconomic groups. In some of these countries, alcohol-related causes now account for 10% or more of the socioeconomic inequality in total mortality. Because our study relies on routinely collected underlying causes of death, it is likely that our results underestimate the true extent of the problem. CONCLUSIONS: Alcohol-related conditions play an important role in generating inequalities in total mortality in many European countries. Countering increases in alcohol-related mortality in lower socioeconomic groups is essential for reducing inequalities in mortality. Studies of why such increases have not occurred in countries like France, Switzerland, Spain, and Italy can help in developing evidence-based policies in other European countries.

The Socioeconomic Differences in Alcohol-Related Harm and the Effects of Alcohol Prices on Them: A Summary of Evidence from Finland.

AIMS: We make a case study of Finland to study the connections between socioeconomic status, alcohol use, related harm and possibilities for intervention by means of alcohol pricing. METHODS: A review of Finnish studies on the topic. RESULTS: The socioeconomic differences in severe alcohol-related harm were great, and in the past two decades, these differences have widened. Alcohol-related mortality has also strongly contributed to both the level and widening of socioeconomic differences in life expectancy. Both in 2004, when alcohol prices were abruptly cut, and in the longer term with more gradual changes in lowest prices of alcohol, the lowest socioeconomic groups were most affected in absolute-but not so clearly in relative-terms, particularly among men. However, these effects are sometimes weak, not fully consistent by gender and across different measures of harm. CONCLUSIONS: The large and increasing socioeconomic differences in alcohol-related harm in Finland underline the importance of reducing these differences. The finding that particularly among men the impact of reduced alcohol prices on health has often in absolute terms been the greatest in the lower socioeconomic groups suggests that policies aimed at keeping the price of alcoholic beverages high may help to both minimize the overall level of alcohol-related health problems and to reduce absolute inequalities.

Educational inequalities in hospitalization attributable to alcohol: a population-based longitudinal study of changes during the period 2000-07.

AIMS: To estimate the relative risk of hospitalization from alcohol-related causes among men and women in Finland across different educational categories, and to determine whether these differentials changed following a large reduction in alcohol prices in 2004. DESIGN AND MEASUREMENTS: A register-based longitudinal study of hospitalizations. We used repeated-measures analysis to estimate alcohol-attributable hospitalization rates and assessed effects of the reduction in alcohol prices by comparing two 4-year periods (2000-03 and 2004-07). SETTING: Finland. PARTICIPANTS: A representative sample of the residents of Finland aged 30-79 years in the period 2000-07 (n = 470,627). FINDINGS: There was a clear gradient across educational levels in alcohol-attributable hospitalizations: the incidence rate ratios among men and women with basic education were 1.70 [95% confidence interval (CI) = 1.32, 2.20] and 1.96 (95% CI = 1.36, 2.84), respectively, compared with those with upper-tertiary education. After allowing for the long-term trend, there were no significant changes between the two follow-up periods either among men with an upper tertiary education or among women in any educational level, whereas the rate increased by 21% (95% CI = 5, 41), 16% (95% CI = 6, 27) and 10% (95% CI = 2, 18), respectively, among men with a lower tertiary, secondary and basic education. However, these differences in changes were not statistically significant. CONCLUSIONS: Lower-level education is associated with a substantially increased risk of alcohol-related hospitalization among men and women in Finland, even when adjusted for age, economic activity and income. The results do not provide strong evidence that the 2004 price reduction had differential effects by education.

Minimum prices for alcohol and educational disparities in alcohol-related mortality.

BACKGROUND: Minimum price of alcohol is one of the proposed set of alcohol policies in many high-income countries. However, the extent to which alcohol-related harm is associated with minimum prices across socioeconomic groups is not known. METHODS: Using Finnish national registers in 1988-2007, we investigated, by means of time-series analysis, the association between minimum prices for alcohol overall, as well as for various types of alcoholic beverages, and alcohol-related mortality, among men and women ages 30-79 years across three educational groups. We defined quarterly aggregations of alcohol-related deaths, based on a sample including 80% of all deaths, in accordance with information on both underlying and contributory causes of death. RESULTS: About 62,500 persons died from alcohol-related causes during the 20-year follow-up. The alcohol-related mortality rate was more than threefold higher among those with a basic education than among those with a tertiary education. Among men with a basic education, an increase of 1% in the minimum price of alcohol was associated with a decrease of 0.03% (95% confidence interval = 0.01, 0.04%) in deaths per 100,000 person-years. Changes in the minimum prices of distilled spirits, intermediate products, and strong beer were also associated with changes in the opposite direction among men with a basic education and among women with a secondary education, whereas among the most highly educated there were no associations between the minimum prices of any beverages and mortality. Moreover, we found no evidence of an association between lower minimum prices for wine and higher rates of alcohol-related mortality in any of the population sub-groups. CONCLUSIONS: The results reveal associations between higher minimum prices and lower alcohol-related mortality among men with a basic education and women with a secondary education for all beverage types except wine.

The extent and distribution of gambling harm in Finland as assessed by the Problem Gambling Severity Index.

BACKGROUND: Preventing gambling harm has become a policy priority in many European countries. Adverse consequences related to problem gambling are well known, but few studies have analyzed gambling-related harm in detail in general population samples. We determined the extent and distribution of gambling harm in Finland, as assessed by the Problem Gambling Severity Index (PGSI), and analyzed gambling involvement, demographics and their association with various types of harm. METHODS: A nationwide telephone survey was conducted among 4484 Finns aged 15-74 years in 2011-12. Gambling-related harms were based on the nine-item PGSI. Gambling involvement was measured by gambling frequency and weekly average gambling expenditure. Associations among harms, demographics and gambling involvement were examined in logistic regression. RESULTS: During the previous year, 13% of respondents experienced at least one gambling-related harm (males 18.1%, females 7.2%). The four commonest harms were 'chasing losses' (8.6%), 'escalating gambling to maintain excitement' (3.1%), 'betting more than could afford to lose' (2.8%), and 'feeling guilty' (2.6%). The harm profile in descending order was the same for both genders but differed in prevalence. Young age (<25 years) was associated with increased likelihood of reporting harms. Both monthly and weekly gambling and spending over €21 per week on gambling were related to the harms. CONCLUSIONS: Our results provide support for the public health approach to gambling: harms were reported even at low gambling frequency-expenditure levels. In addition to the high-risk approach, adopting a population-level approach to preventing gambling harm could shift the population distribution of harm in a lower direction.

Income differences in life expectancy: the changing contribution of harmful consumption of alcohol and smoking.

BACKGROUND: Social differences in mortality have increased in high-income countries, but the causes of these changes remain unclear. We quantify the contribution of alcohol and smoking to trends in income differences in life expectancy from 1988 through 2007 in Finland. METHODS: An 11% sample from the population registration data of Finns 25 years and older was linked with an 80% oversample of death records. Alcohol-attributable mortality was based on underlying and contributory causes of death on individual death certificates and smoking-attributable mortality on an indirect method that used lung cancer mortality as an indicator for the impact of smoking on mortality. RESULTS: Alcohol- and smoking-attributable deaths reduced life expectancy by about 4.5 years among men. Alcohol-attributable mortality increased and smoking-attributable mortality decreased over the period 1988-2007, leaving the joint contribution stable. Among women, the contribution of these risk factors to life expectancy over the same period increased from 0.7 to 1.2 years. In 2003-2007, life expectancy differentials between the lowest and highest income quintile were 11.4 years (men) and 6.3 years (women). In the absence of alcohol and smoking, these differences would have been 60% less for men and 36% less for women. Life expectancy differentials increased rapidly over the study period; without alcohol and smoking, the increase would have been 69% less among men and 85% less among women. CONCLUSIONS: Alcohol and smoking have a major influence on income differences in mortality and, with the exception of smoking among men, their contribution is increasing. Without alcohol and smoking, there would have been little change in life expectancy differentials.

Socio-economic determinants of drugged driving--a register-based study.

AIMS: To examine the associations between socio-economic characteristics and driving under the influence of drugs (DUID), and to elaborate determinants of drugged driving. DESIGN: A register-based case-control study. SETTING: Finland. PARTICIPANTS: Cases (n = 5859) apprehended by the police and suspected of DUID during 1993-2006 and controls (n = 74 809) drawn from the general Finnish population. MEASUREMENTS: The effects of parents' and own education, urbanization of municipality, socio-economic position (SEP), main activity, income, marital status and living arrangements on DUID were estimated using logistic regression analysis. The analyses were conducted separately for men and women, age groups of under 45 years and aged 45 or over, and for substance groups of benzodiazepines only, benzodiazepines with alcohol, amphetamines and cannabinoids. FINDINGS: Low education, unemployment, disability pension, being divorced and living alone were the strongest individual predictors of DUID in all substance groups. Illicit drug users were more disadvantaged compared to those in the benzodiazepines groups. Contrary to other substance and age groups, higher educational level and higher SEP were associated with DUID among benzodiazepine users aged 45 or over. CONCLUSIONS: A disadvantaged social background is a significant predictor of driving while under the influence of drugs for all substance use groups in Finland. The gradient is greater for amphetamines and cannabinoids than benzodiazepines.