High Alcohol-Related Premature Mortality in France: Concordant Estimates from a Prospective Cohort Study and National Mortality Statistics

This study examines the magnitude of alcohol-related premature death in the French population, which still has the highest average alcohol intake in the world and a relatively low coronary heart disease mortality rate. Two data sources were used: the national mortality data in 1990 and a prospective mortality experience in a cohort of 2,687 middle-aged working men examined in 1980–1985 and followed-up during an average of 9.3 years. In the general population study, alcohol-related premature mortality (35–64 years) was calculated using alcohol-attributable fractions (AAFs) derived from studies of alcohol involvement in deaths from various causes. In the cohort, it was estimated from AAFs and attributable risk using both alcohol exposure prevalence and relative risks of death according to alcohol intake categories. In 1990, estimates of 19.1% and 13.0% of all premature deaths in French men and women were attributed to alcohol. Digestive diseases followed by malignant neoplasms in men and by unintentional injuries in women were major contributors to the total number of alcohol-related premature deaths. In the cohort study, 90 deaths occurred during the follow-up period. The estimation of alcohol-related premature mortality using AAFs was 24.4%. The relative risk of total mortality (adjusted for age, smoking habits, and body mass index) for men who consumed >60 ml/day of alcohol, compared with those who consumed 0–25 ml/day was 1.9 (95% confidence interval: 1.1–3.5). The consumption of 26–60 ml/day was not associated with reduced risk of mortality, and the adjusted relative risk for this group was 1.3 (95% confidence interval: 0.7–2.5). The estimated attributable risk of premature mortality caused by consumption of >25 ml/day of alcohol was 29.9%. This study reports the persisting high alcohol-related premature mortality in the French general population, as well as in middle-aged working men. The results suggest that efforts should be paid to reduce further the consumption of alcohol in France.     

Alcohol-attributable mortality and potential years of life lost in Canada 2001: implications for prevention and policy

BACKGROUND: Alcohol is one of the most important risk factors for burden of disease. OBJECTIVE: To estimate the number of deaths and the years of life lost attributable to alcohol for Canada 2001 using different ways to measure alcohol exposure. METHODS: Distribution of exposure was taken from a major national survey of Canada, the Canadian Addiction Survey, and corrected for per capita consumption from production and sales. For chronic disease, risk relations were taken from the published literature and combined with exposure to calculate age- and sex-specific alcohol-attributable fractions (AAFs). For injury, AAFs were taken directly from available statistics. Information on mortality, with cause of death coded according to the International Classification of Diseases version 10 (ICD-10) was obtained from Statistics Canada. RESULTS: For Canada in 2001, 4,010 of all deaths in the group below 70 years of age were attributable to alcohol, 3,132 in men and 877 in women. This constituted 6.0% of all deaths in Canada in this age group, 7.6% for men, and 3.5% for women. The 4,010 deaths are a net figure, already taking into account the deaths prevented by moderate consumption of alcohol. Main causes of alcohol-attributable death were unintentional injuries, malignant neoplasms and digestive diseases. Ischaemic heart disease (IHD) was the biggest cause of death prevented by alcohol, with 78.7% of all alcohol-attributable prevented deaths in the age groups of 70 years and above. A total of 144,143 years of life were lost prematurely in Canada in that year, 113,079 years in men and 31,063 years in women. DISCUSSION: Regardless of the assumptions made, alcohol is a major contributor to mortality in Canada. The impact of alcohol on social life is not confined to mortality, as other studies indicated that alcohol is linked even more strongly to disability and social harm. Alcohol-attributable harm could be substantially reduced, however, if known effective policies were introduced.     

Relation between average alcohol consumption and disease: an overview

OBJECTIVE: To conduct an overview of alcohol-related health consequences and to estimate relative risk for chronic consequences and attributable fractions for acute consequences. METHODS: Identification of alcohol-related consequences was performed by means of reviewing and evaluating large-scale epidemiological studies and reviews on alcohol and health, including epidemiological contributions to major social cost studies. Relative risks and alcohol-attributable fractions were drawn from the international literature and risk estimates were updated, whenever possible, by means of meta-analytical techniques. RESULTS: More than 60 health consequences were identified for which a causal link between alcohol consumption and outcome can be assumed. CONCLUSIONS: Future research on alcohol-related health consequences should focus on standardization of exposure measures and take into consideration both average volume of consumption and patterns of drinking.     

Average volume of alcohol consumption, drinking patterns and related burden of mortality in young people in established market economies of Europe

OBJECTIVE: To determine the burden of mortality in young people (age 15-29) in established market economies in Europe in 1999, which is attributable to alcohol consumption. Two dimensions of alcohol consumption were considered: average volume of consumption, and patterns of drinking. METHODS: Mortality data were obtained from the WHO EIP data bank, average volume data from the WHO global databank on alcohol, pattern of drinking data from a questionnaire sent out to experts, from the published literature and from the WHO global databank. Methods are explained and discussed in detail in two other contributions to this volume. RESULTS: More than 8,000 deaths of people aged 15-29 in Europe in 1999 were attributable to alcohol. Young males show a higher proportion of alcohol-attributable deaths (12.8%) than females (8.3%). Both average volume and patterns of drinking contribute to alcohol-related death. CONCLUSIONS: Alcohol-related deaths constitute a considerable burden in young people in Europe.     

Do the rich really die young? Alcohol-related mortality and social class in Great Britain, 1988-94

Aims. To determine whether social class is a major influence on alcohol-related mortality in the general, economically active population of Great Britain. Design and participants. Poisson regression of rates of mortality known to be directly caused by alcohol consumption by age, sex and social class in England, Wales and Scotland. Measurements. The measure of alcohol-related mortality is total deaths from ICD-9 categories 291; 303; 357.5; 425.5; 535.3; 305; 790.3; and 571.0-571.3 over the 7-year period 1988-94. (It excludes deaths for which alcohol-attributable fractions would need to be calculated.) The measure of social class is the British Registrar General's six-fold occupational classification, used to code census and death certification data. Findings. Alcohol-related mortality rates are higher for men in the manual occupations than in the non-manual occupations, but the relative magnitude depends on age. Men aged 25-39 in the unskilled manual class are 10-20 times more likely to die from alcohol-related causes than those in the professional class, whereas men aged between 55 and 64 in the unskilled manual class are only about 2.5-4 times more likely to die. For women in paid employment there is no consistent class gradient; younger women in the manual classes are more likely to die from alcohol-related causes, but for older women it is those in the professional class who suffer elevated mortality . Conclusions. Social class is a risk factor for alcohol-related mortality in Britain, although it is mediated by age and sex. Alcohol appears to be similar to other psychoactive substances, therefore, in that problem use is linked to social structural factors such as poverty, disadvantage and social class. This suggests that social interventions aimed at reducing poverty and inequality have the potential to reduce current levels of alcohol-related harm among the poorest groups in the community.     

Measuring the health consequences of alcohol consumption: current needs and methodological challenges

BACKGROUND/AIMS: Extensive research has shown that alcohol consumption leads to poor health and premature death through its causal or contributing roles in numerous chronic health conditions and acute health outcomes, including various cancers, liver disease, and injuries. Paradoxically, advances in understanding of the causal associations between alcohol consumption and various conditions have complicated our ability to discern trends in the health consequences of alcohol consumption over time. METHODS: Four distinct needs for information on alcohol's role in causing adverse health outcomes are identified. Estimates of alcohol-attributable mortality from two US studies are compared and differences identified. RESULTS: Differences in the conditions included and alcohol-attributable fractions employed accounted for large differences in the estimated alcohol-attributable mortality for several health outcomes. CONCLUSION: Despite the broad consensus on many health consequences of alcohol consumption, further research is needed to clarify the conditions that are caused by alcohol consumption, magnitudes of causal relationships, and effects of different patterns of consumption and individual characteristics. Comparisons over time are needed to identify areas where improvements in public health may be occurring or are most needed, to support evaluation of specific interventions, and to encourage the public awareness of alcohol problems that is necessary to change attitudes and behaviors involving alcohol consumption.     

Alcohol as a risk factor for global burden of disease

AIM: To make quantitative estimates of the burden of disease attributable to alcohol in the year 2000 on a global basis. DESIGN: Secondary data analysis. MEASUREMENTS: Two dimensions of alcohol exposure were included: average volume of alcohol consumption and patterns of drinking. There were also two main outcome measures: mortality, i.e. the number of deaths, and disability-adjusted life years (DALYs), i.e. the number of years of life lost to premature mortality or to disability. All estimates were prepared separately by sex, age group and WHO region. FINDINGS: Alcohol causes a considerable disease burden: 3.2% of the global deaths and 4.0% of the global DALYs in the year 2000 could be attributed to this exposure. There were marked differences by sex and region for both outcomes. In addition, there were differences by disease category and type of outcome; in particular, unintentional injuries contributed most to alcohol-attributable mortality burden while neuropsychiatric diseases contributed most to alcohol-attributable disease burden. DISCUSSION/CONCLUSIONS: The underlying assumptions are discussed and reasons are given as to why the estimates should still be considered conservative despite the considerable burden attributable to alcohol globally.     

US emergency department visits for alcohol-related diseases and injuries between 1992 and 2000

BACKGROUND: Alcohol-related diseases and injuries pose a significant burden on hospital emergency departments (EDs). Recognized limitations of self-reported data suggest that previous single-year national studies may have underestimated the magnitude of this burden. METHODS: Data were obtained from the National Hospital Ambulatory Medical Care Survey for 1992 through 2000. Thirty-seven alcohol-related diagnoses and their corresponding alcohol-attributable fractions (AAFs) were used to estimate the number of ED visits attributable to alcohol. Diagnoses with an AAF of 1 were analyzed by age, sex, and race. Disposition to inpatient settings and alcohol screening also were examined. RESULTS: During these 9 years, there were an estimated 68.6 million (95% confidence interval [CI], 65.6 million to 71.7 million) ED visits attributable to alcohol, a rate of 28.7 (95% CI, 27.1-30.3) per 1000 US population. The number of alcohol-related visits increased 18% during this period. Visit rates for diagnoses with AAFs of 1 were highest for those who were aged 30 through 49 years, male, and black. From 1992 to 2000, these disparities remained stable for age group but significantly changed for sex (+22%) and race (-76%). Most patients with diagnoses with AAFs of 1 were not admitted to an inpatient unit, and the percentage of patients who underwent blood alcohol concentration testing was substantially lower than corresponding AAFs. CONCLUSIONS: Alcohol-related ED visits are approximately 3 times higher than previous estimates determined by physician documentation or patient disclosure of alcohol involvement. Rising trends, changing disparities, and suboptimal ED management of such visits are a call to action.     

The Influence of Much Increased Alcohol Consumption on Mortality Rates: The Netherlands Between 1950 and 1975

It has often been suggested that a higher rate of alcohol consumption will eventually lead to a higher rate of death from traumata and diseases typically observed in alcoholics and other excessive drinkers. In the Netherlands alcohol consumption has much increased in recent years. However, an examination of mortality by cause and age over a 25–year period has indicated that it is very difficult indeed to render the presumed effects of much increased alcohol consumption on public health statistically visible. Some of these effects may well have been obscured by more significant developments in mortality such as the higher rates of death from cardiovascular diseases and from neoplasm of the lung. Other effects may not have happened at all. In the case of liver cirrhosis mortality - which doubled while alcohol consumption quadrupled during the period of study - it was noted that the rate of death from all liver diseases (including liver cirrhosis) has been declining. In the case of several other alcohol-related (?) causes of death it was found that mortality rates were not responsive to recent trends in alcohol consumption in the Netherlands.     

Estimation of alcohol-related deaths in France in 1985

The number of deaths attributable to alcohol in France during 1985 has been estimated from national death statistics, and from records attributable risks for each disease related to alcohol. The attributable risks for alcohol by sex and by disease were computed from the 1974 survey by the Institut Fran?ais d'Opinion Publique of a national sample of 981 adults on consumption of alcohol, and from the relative risk of death for alcohol drinkers estimated from epidemiological studies. The total number of deaths attributable to alcohol in the population aged 20 or more was 52,000 in 1985 (44,500 men and 7,500 women). Half of these deaths occurred before age 65. Nine percent of the overall mortality was attributable to alcohol (3 percent for women and 16 percent for men). This proportion was 28 percent for men between ages 45 and 64. Among these 52,000 deaths, 14,000 were due to liver cirrhosis or alcoholic psychosis, 16,500 to cancer, mainly from oral cavity, pharynx, larynx, esophagus, or liver, 8,900 to external causes of injury, 9,050 to cardiovascular disease, 550 to pneumonia, and 3,000 to ill-defined diseases.     

Alcohol-attributable injuries in admissions to a swiss emergency room--an analysis of the link between volume of drinking, drinking patterns, and preattendance drinking

BACKGROUND: An association between alcohol consumption and injury is clearly established from volume of drinking, heavy episodic drinking (HED), and consumption before injury. Little is known, however, about how their interaction raises risk of injury and what combination of factors carries the highest risk. This study explores which of 11 specified groups of drinkers (a) are at high risk and (b) contribute most to alcohol-attributable injuries. METHODS: In all, 8,736 patients, of whom 5,077 were injured, admitted to the surgical ward of the emergency department of Lausanne University Hospital between January 1, 2003, and June 30, 2004, were screened for alcohol use. Eleven groups were constructed on the basis of usual patterns of intake and preattendance drinking. Odds ratios (ORs) comparing injured and noninjured were derived, and alcohol-attributable fractions of injuries were calculated from ORs and prevalence of exposure groups. RESULTS: Risk of injury increased with volume of drinking, HED, and preattendance drinking. For both sexes, the highest risk was associated with low intake, HED, and 4 (women), 5 (men), or more drinks before injury. At the same level of preattendance drinking, high-volume drinkers were at lower risk than low-volume drinkers. In women, the group of low-risk non-HED drinkers taking fewer than 4 drinks suffered 47.5% of the alcohol-attributable injuries in contrast to only 20.4% for men. Low-volume male drinkers with HED had more alcohol-attributable injuries than that of low-volume female drinkers with HED (46.9% vs 23.2%). CONCLUSIONS: Although all groups of drinkers are at increased risk of alcohol-related injury, those who usually drink little but on occasion heavily are at particular risk. The lower risk of chronic heavy drinkers may be due to higher tolerance of alcohol. Prevention should thus target heavy-drinking occasions. Low-volume drinking women without HED and with only little preattendance drinking experienced a high proportion of injuries; such women would be well advised to drink very little or to take other special precautions in risky circumstances.     

Oxidative stress in alcohol-related liver disease

Alcohol consumption is one of the leading causes of the global burden of disease and results in high healthcare and economic costs. Heavy alcohol misuse leads to alcohol-related liver disease, which is responsible for a significant proportion of alcohol-attributable deaths globally. Other than reducing alcohol consumption, there are currently no effective treatments for alcohol-related liver disease. Oxidative stress refers to an imbalance in the production and elimination of reactive oxygen species and antioxidants. It plays important roles in several aspects of alcohol-related liver disease pathogenesis. Here, we review how chronic alcohol use results in oxidative stress through increased metabolism via the cytochrome P4502E1 system producing reactive oxygen species, acetaldehyde and protein and DNA adducts. These trigger inflammatory signaling pathways within the liver leading to expression of pro-inflammatory mediators causing hepatocyte apoptosis and necrosis. Reactive oxygen species exposure also results in mitochondrial stress within hepatocytes causing structural and functional dysregulation of mitochondria and upregulating apoptotic signaling. There is also evidence that oxidative stress as well as the direct effect of alcohol influences epigenetic regulation. Increased global histone methylation and acetylation and specific histone acetylation inhibits antioxidant responses and promotes expression of key pro-inflammatory genes. This review highlights aspects of the role of oxidative stress in disease pathogenesis that warrant further study including mitochondrial stress and epigenetic regulation. Improved understanding of these processes may identify novel targets for therapy.     

Estimating the number of alcohol‐attributable deaths: methodological issues and illustration with French data for 2006

Aims Computing the number of alcohol‐attributable deaths requires a series of hypotheses. Using French data for 2006, the potential biases are reviewed and the sensitivity of estimates to various hypotheses evaluated. Methods Self‐reported alcohol consumption data were derived from large population‐based surveys. The risks of occurrence of diseases associated with alcohol consumption and relative risks for all‐cause mortality were obtained through literature searches. All‐cause and cause‐specific population alcohol‐attributable fractions (PAAFs) were calculated. In order to account for potential under‐reporting, the impact of adjustment on sales data was tested. The 2006 mortality data were restricted to people aged between 15 and 75 years. Results When alcohol consumption distribution was adjusted for sales data, the estimated number of alcohol‐attributable deaths, the sum of the cause‐specific estimates, was 20 255. Without adjustment, the estimate fell to 7158. Using an all‐cause mortality approach, the adjusted number of alcohol‐attributable deaths was 15 950, while the non‐adjusted estimate was a negative number. Other methodological issues, such as computation based on risk estimates for all causes for ‘all countries’ or only ‘European countries’, also influenced the results, but to a lesser extent. Discussion The estimates of the number of alcohol‐attributable deaths varied greatly, depending upon the hypothesis used. The most realistic and evidence‐based estimate seems to be obtained by adjusting the consumption data for national alcohol sales, and by summing the cause‐specific estimates. However, interpretation of the estimates must be cautious in view of their potentially large imprecision.     

Volume of alcohol consumption, patterns of drinking and burden of disease in the European region 2002

AIMS: To describe the volume of alcohol consumption and patterns of drinking in the World Health Organization (WHO) European regions in 2002 and to estimate quantitatively the burden of disease attributable to alcohol in that year. METHODS: Secondary data analysis. Exposure data were taken from the WHO Comparative Risk Assessment, outcome data from the WHO Measurement and Health Information department, and used to derive three outcome measures: deaths, years of life lost (YLL) and disability adjusted life years (DALY) for 2002. All calculations were conducted according to age, sex and region. RESULTS: Alcohol consumption in the WHO regions for Europe was high, with 12.1 litres pure alcohol per capita, on average more than 100% above the global consumption. Alcohol consumption caused a considerable disease burden: 6.1% of all the deaths, 12.3% of all YLL and 10.7% of all DALY in all European regions in 2002 could be attributed to this exposure. Intentional and unintentional injuries accounted for almost 50% of all alcohol-attributable deaths and almost 44% of alcohol-attributable disease burden. Young people and men were affected the most. Geographically, the most eastern region around Russia had the highest alcohol-attributable disease burden. CONCLUSIONS: Interventions should be implemented to reduce the high burden of alcohol-attributable disease in the European regions. Given the epidemiological structure of the burden, injury prevention, including but not restricted to the prevention of traffic injuries, and specific prevention for young people should play the most important role in a comprehensive plan to reduce alcohol-attributable burden.     

Type of alcohol consumed and mortality from all causes, coronary heart disease, and cancer

BACKGROUND: Although the J-shaped relation between alcohol intake and mortality has been reproduced in many large cohort studies, the question of whether the effects of beer, wine, and spirits differ remains controversial. OBJECTIVE: To examine the relation between intake of different types of alcohol and death from all causes, coronary heart disease, and cancer. DESIGN: Pooled cohort studies in which intake of beer, wine, and spirits; smoking status; educational level; physical activity; and body mass index were assessed at baseline. SETTING: Copenhagen, Denmark. PARTICIPANTS: 13 064 men and 11 459 women 20 to 98 years of age. MEASUREMENTS: Number of deaths and time to death from all causes, coronary heart disease, and cancer during follow-up. RESULTS: During 257 859 person-years of follow-up, 4833 participants died. J-shaped relations were found between total alcohol intake and mortality at various levels of wine intake. Compared with nondrinkers, light drinkers who avoided wine had a relative risk for death from all causes of 0.90 (95% CI, 0.82 to 0.99) and those who drank wine had a relative risk of 0.66 (CI, 0. 55 to 0.77). Heavy drinkers who avoided wine were at higher risk for death from all causes than were heavy drinkers who included wine in their alcohol intake. Wine drinkers had significantly lower mortality from both coronary heart disease and cancer than did non-wine drinkers (P = 0.007 and P = 0.004, respectively). CONCLUSION: Wine intake may have a beneficial effect on all-cause mortality that is additive to that of alcohol. This effect may be attributable to a reduction in death from both coronary heart disease and cancer.     

Mortality in England and Wales attributable to any drinking, drinking above sensible limits and drinking above lowest-risk level

AIMS: To quantify mortality attributable to any alcohol consumption, and mortality attributable to consumption above different levels. DESIGN: We related all-cause mortality to alcohol consumption using cause-specific mortality models from a systematic review and using the distribution of alcohol consumption and causes of death by age and sex in England and Wales in 1997. We estimated the deaths and person-years of life lost to age 65 that were attributable: to any drinking; to drinking above the nadir (the level of alcohol consumption carrying the lowest risk); and to drinking more than the British Royal Colleges' recommended limits of 21 units/week in men and 14 units/week in women. FINDINGS: Ischaemic heart disease deaths prevented by alcohol consumption (11 276 in men, 4050 in women) roughly balanced other deaths attributable to alcohol consumption (9246 in men, 4216 in women). Overall, 0.8% of all deaths in men were prevented by alcohol consumption (95% confidence interval, 0.2% to 1.3%), while 0.1% of all deaths in women were attributable to alcohol consumption (95% confidence interval, - 0.3% to 0.4%); 2.1% (1.9-2.3%) of all deaths in men and 0.8% (0.6-1.0%) of all deaths in women were attributable to drinking more than the recommended limits, while 2.8% and 1.2% of deaths, respectively, were attributable to drinking above the nadir. Of all person-years of life lost to age 65, 10.3% in men and 5.6% in women were attributable to any drinking; 8.5% and 4.0% were attributable to drinking above the recommended limits; and 12.6% and 6.0% were attributable to drinking above the nadir. CONCLUSIONS: Although overall mortality risks and benefits of alcohol consumption appear roughly equal, drinking above recommended limits remains responsible for many deaths and a large loss of person-years of life.     

Alcohol use disorder and the gut

Acute and chronic gastrointestinal problems are common in the setting of excessive alcohol use, and excessive alcohol use is associated with injury to all parts of the gastrointestinal tract. There is mounting evidence of gastrointestinal injury and increased cancer risk even from moderate alcohol consumption. The major causes of alcohol-related morbidity and mortality within the gastrointestinal system are liver disease, pancreatitis and gastrointestinal cancer. Other alcohol-related intestinal dysfunction is common but not life-threatening, leading to diarrhoea, malabsorption and nutritional deficiencies. This review describes non-neoplastic and neoplastic alcohol-related disorders of the gastrointestinal tract, omitting the liver, which has been reviewed elsewhere.     

Gender-specific mortality associated with alcohol consumption in Poland in transition

AIMS: To show the impact of rapid political and economic transitions on alcohol consumption and associated mortality in different socio-demographic segments of the Polish society, with particular focus on gender differences. Two causes of death associated with drinking (liver diseases and alcohol poisoning) are investigated. DESIGN: Mortality time series 1986-2002 are analysed against consumption estimates and population drinking survey data. SETTING: Poland 1986-2002. PARTICIPANTS: General adult population. MEASUREMENT: Age-standardized annual and 3-year death rates were calculated for age, gender and place of residence subgroups. For education, age-standardized relative frequency of deaths or proportional mortality in four basic educational levels was calculated. FINDINGS: Alcohol-related mortality shows great variability in response to substantial changes in alcohol consumption. Patterns of mortality and their magnitude of change correspond with average alcohol consumption and are therefore different for men and women, for different age and educational groups and in urban and rural areas. Level of education, however, may affect alcohol-related mortality more strongly than overall alcohol intake, particularly with regard to acute consequences of drinking. CONCLUSION: The Polish experience illustrates that the impact of rapid political and economic transitions on alcohol consumption and associated mortality is highly differentiated and specific to gender and social class.     

The impact of the Northern Territory's Living With Alcohol program, 1992-2002: revisiting the evaluation

AIMS: To evaluate the effects of the Living With Alcohol (LWA) program and the LWA Alcoholic Beverage Levy on alcohol-attributable deaths in the Northern Territory (NT) controlling for simultaneous trends in death rates from a control region and non-alcohol related death trends in the NT, between 1985 and 2002. DESIGN: The LWA program was introduced in 1992 with funding from a special NT tax (Levy) on beverages with greater than 3% alcohol content by volume. The Levy was removed in 1997 but the LWA program continued to be funded by the federal government until 2002. Trends in age standardised rates of acute and chronic alcohol-attributable deaths in the NT were examined before, during and after the combined implementation of the LWA program and Levy and before and during the full length of the LWA program. Auto-regressive integrated moving average (ARIMA) time series analyses included internal and external control series and adjustments for possible confounders. Separate estimates were made for Indigenous and non-Indigenous NT residents. FINDINGS: When combined, the Levy and the LWA program were associated with significant declines in acute alcohol-attributable deaths in the NT as well as Indigenous deaths between 1992 and 1997. A significant but delayed decline in chronic deaths was evident towards the end of the study period between 1998 and 2002. CONCLUSIONS: The combined impact of the LWA program Levy and the programs and services funded by the Levy reduced the burden of alcohol-attributable injury to the NT in the short term and may have contributed to a reduction in chronic illness in the longer term. The results of this study present a strong argument for the effectiveness of combining alcohol taxes with comprehensive programs and services designed to reduce the harm from alcohol, and underline the need to distinguish between the acute and chronic effects of alcohol in population level studies.     

Outcome in Subjects with Alcohol-Provoked Seizures

The outcome in 165 subjects with either an unknown (n = 93) or an alcohol-related (n = 72) seizure etiology, admitted to the emergency room of a general hospital in 1977-1978, was assessed after 10 years on the basis of subsequent hospital records and death-certificate-based mortality data. Alcohol and/or drug poisoning was the most frequent cause of death in the group with alcohol-related seizures. Sixty-four percent of the deaths in this group were directly related to alcohol abuse. The crude mortality was 45.8 (expected 8.6)/100 persons/10 years in the group with alcohol-related seizures and 15.1 (expected 6.0)/100 persons/10 years in the other group, the odds ratio between the groups being 4.8. Twenty percent of those with an unknown seizure etiology were found to show alcohol-related seizures, while the seizure etiology remained unknown in 59%, and a specific etiology other than alcohol abuse was revealed in 21% during the follow-up period. We conclude that alcohol abuse is an important, though often undetected, seizure etiology carrying a poor prognosis. The difference in mortality between the groups was due more to alcoholism than to seizures. There was no difference in mortality between those with a first alcohol-related seizure and those with previous alcohol-related seizures.