Public health successes and missed opportunities: trends in alcohol consumption and attributable mortality in the WHO European Region, 1990–2014

The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Offi ce for Europe is one of six regional offi ces throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan The former Yugoslav Republic of Macedonia Turkey Turkmenistan Ukraine United Kingdom Uzbekistan World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 E-mail: euwhocontact@who.int Website: www.euro.who.int Public health successes and missed opportunities 9 789289 051675 > ISBN 9789289051675 Public health successes and m issed opportunities Trends in alcohol consumption and attributable mortality in the WHO European Region, 1990–2014 Public health successes and missed opportunities Trends in alcohol consumption and attributable mortality in the WHO European Region, 1990–2014 By Kevin D. Shield, Margaret Rylett and Jürgen Rehm Public health successes and missed opportunities Photo: Yuriy Seleznev/Shutterstock.com © World Health Organization 2016 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization. ABSTRACT The level of alcohol consumption is high in the WHO European Region. This results in a substantial burden of alcohol- attributable mortality. The overall standardized rate for alcohol-attributable mortality increased in the WHO European Region over the time period between 1990 and 2014. Data are provided by country and show huge differences between countries. This underlines opportunities for countries to benchmark against others and introduce alcohol policies to reduce the burden of alcohol-attributable mortality. It also underlines the overall need to further reduce alcohol consumption in the WHO European Region. Keywords Alcohol drinking - prevention and control Alcohol drinking - adverse effects Alcohol drinking - mortality Harm reduction Risk factors Europe Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe UN City, Marmorvej 51 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office web site (http://www.euro.who.int/pubrequest). ISBN 978 92 890 5167 5 COnTenTS Acknowledgements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vi Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .viii Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Monitoring alcohol exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Methods for estimating trends in alcohol exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Countries and regions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Trends in total adult per capita alcohol consumption for all countries in the WHO European Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Regional trends in total adult per capita alcohol consumption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Trends in alcohol consumption per drinker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Conclusion: trends in alcohol consumption over the past 25 years in the WHO European Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Comparisons between the WHO European Region and other WHO regions . . . . . . . . . . . . . . . . . . 14 Burden of alcohol-attributable mortality in the WHO European Region, 1990–2014 . . . . . . . . . . . . . . . . 16 On the selection of mortality as the main outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Main categories of alcohol-attributable causes of death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Methodology to estimate the alcohol-attributable burden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Burden of alcohol-attributable mortality in 2014 in the WHO European Region . . . . . . . . . . . . . . . 18 Burden of mortality due to alcohol-attributable liver cirrhosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Burden of mortality due to alcohol-attributable cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Burden of mortality due to alcohol-attributable cardiovascular diseases . . . . . . . . . . . . . . . . . . . . . 32 Burden of mortality due to alcohol-attributable injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Burden of mortality due to alcohol-attributable unintentional injury . . . . . . . . . . . . . . . . . . . . . 41 Burden of mortality due to alcohol-attributable intentional injury . . . . . . . . . . . . . . . . . . . . . . . 46 Regional differences in alcohol-attributable mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Overall trend in alcohol-attributable mortality between 1990 and 2014 by major cause-of-death categories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Sex-specific trends in alcohol-attributable mortality between 1990 and 2014 by major cause-of-death categories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Trends in alcohol-attributable fractions of mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Regional trends in age-standardized rates of major cause-of-death categories, 1990–2014 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Conclusion: the need for an alcohol policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 iv vACKnOWledgemenTS The following are the authors of this report: • Dr Kevin D. Shield, Section of Cancer Surveillance, International Agency for Research on Cancer, Lyon, France; Pan American Health Organization (PAHO)/WHO Collaborating Centre for Mental Health and Addiction, Toronto, Canada; • Ms Margaret Rylett, MA, PAHO/WHO Collaborating Centre for Mental Health and Addiction, Toronto, Canada; Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, Canada; • Professor Jürgen Rehm, PAHO/WHO Collaborating Centre for Mental Health and Addiction, Toronto, Canada; Institute for Mental Health Policy Research and Campbell Family Mental Health Research Institute, CAMH, Toronto, Canada; Institute of Medical Science, Department of Psychiatry and Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; Institute for Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany. The WHO Regional Office for Europe would like to thank members of the expert group that reviewed this publication: • For referencing and producing the initial graphs, Ms Michelle Tortolo, Institute for Mental Health Policy Research, CAMH, Toronto, Canada; and Mr Sameer Imtiaz, Institute of Medical Science, University of Toronto, Toronto, Canada/ Institute for Mental Health Policy Research, CAMH, Toronto, Canada, PAHO/WHO Collaborating Centre for Mental Health and Addiction; • For contributing to the analyses and graphical display, Mr Aaron Merey and Ms Charlotte Probst, Institute for Mental Health Policy Research, CAMH, Toronto, Canada, PAHO/WHO Collaborating Centre for Mental Health and Addiction. For reviewing the text, the WHO Regional Office for Europe would like to thank Ms Charlotte Probst and Dr Norman Giesbrecht, CAMH, Toronto, Canada; Dr Gerhard Gmel, Addiction Switzerland, Lausanne/University Hospital Lausanne, Switzerland; Dr Ludwig Kraus, Institute for Therapy Research, Munich, Germany/Centre for Social Research on Alcohol and Drugs, Stockholm University, Stockholm, Sweden; and Dr Robin Room, Centre for Alcohol Policy Research, La Trobe University, Melbourne, Australia/Centre for Social Research on Alcohol and Drugs, Stockholm University, Sweden. Special thanks to members of the steering committee of the project: Dr Joan Colom and Ms Lidia Segura, Programme on Substance Abuse, Public Health Agency of Catalonia, Barcelona, Spain; Dr Antoni Gual, Hospital Clínic de Barcelona, August Pi i Sunyer Biomedical Research Institute, Barcelona, Spain; Dr Marcin Wojnar, Department of Psychiatry, Medical University of Warsaw, Warsaw, Poland; Dr Lubomir Okruhlica, Centre for Treatment of Drug Dependencies, Bratislava, Slovakia; Dr Konstantin Vyshinskiy, Epidemiology Department, Federal Medical Research Centre for Psychiatry and Narcology, Ministry of Health, Moscow, Russian Federation; Professor Emanuele Scafato, WHO Collaborating Centre for Research and Health Promotion on Alcohol and Alcohol-Related Health Problems, National Observatory on Alcohol – CNESPS, National Health Institute, Rome, Italy; and Dr Silvia Ghirini, National Centre for Epidemiology, Surveillance and Health Promotion, National Health Institute, Rome, Italy. Thanks to Dr Alexandra Fleischmann and the Department of Mental Health and Substance Abuse at WHO headquarters, and Dr Elena Yurasova from the WHO Office for the Russian Federation. Technical editing was done by Dr Lars Møller, Programme Manager; Ms Julie Brummer, Consultant; Ms Lisa Schölin, Consultant; and Dr Gauden Galea, Director, Division of Noncommunicable Diseases and Promoting Health through the Life-course, WHO Regional Office for Europe. This report was produced with the financial assistance of the Ministry of Health of the Russian Federation. ABBReviATiOnS CI confidence interval CVD cardiovascular diseases EU European Union FAS fetal alcohol syndrome GDP gross domestic product GISAH Global Information System on Alcohol and Health ICD International Statistical Classification of Diseases and Related Health Problems NCD noncommunicable disease PAHO Pan American Health Organization STEPS STEPwise approach to surveillance TB tuberculosis vi FOReWORd I am pleased to present this report, which gives an overview of alcohol consumption and alcohol-attributable mortality in the WHO European Region during the period 1990–2014. The European Region was the first to adopt an alcohol action plan in 1992, which was later followed by a number of policy instruments and, most recently, by the global strategy to reduce the harmful use of alcohol from 2010, and the European action plan to reduce the harmful use of alcohol 2012–2020. Thus, this report provides information on the entire period when policy guidance has been available from WHO. There is high variability in alcohol consumption and the harms caused by it between countries of the WHO European Region, as well as within countries over time. Despite divergent trends at the country level, the WHO European Region continues to be the WHO region with the highest adult per capita alcohol consumption. There was a slight decrease in the consumption level between 1990 and 2014, and this was fuelled by decreases in the richest countries in the central- western European Union (EU) and Mediterranean parts of the Region, whereas drinking levels in central-eastern EU remained stable over the past 25 years, and increased in the eastern and the south-eastern parts of the WHO European Region. The high level of alcohol consumption led to a substantial burden of attributable mortality from cardiovascular diseases, cancer, liver cirrhosis, and unintentional and intentional injury. The overall standardized rate of alcohol-attributable mortality increased in the WHO European Region over the time period between 1990 and 2014. There is a need to reduce the overall alcohol consumption and the number of irregular heavy drinking occasions, as alcohol is causally related to considerable mortality. Different policy options have proven effective and cost-effective in reducing the level of alcohol consumption, and heavy drinking in particular. These include, but are not limited to, the so-called “best buys” of increasing price, restricting availability and imposing bans on marketing. They should include a wide range of policies as described in the WHO action plan. We at the WHO Regional Office for Europe hope that Member States can use the information in this publication for further improvement of relevant areas of their alcohol policies in order to reduce alcohol consumption and resulting harm. Zsuzsanna Jakab WHO Regional Director for Europe vii exeCuTive SummARy This report aims to contribute to a monitoring system for harmful alcohol consumption in the WHO European Region by describing the trends in alcohol consumption and attributable mortality for the time period 1990–2014 for all countries of the Region and for the Region as a whole. It is based on data from the Global Information System on Alcohol and Health, and uses standard methodology developed for comparative risk assessments over the past decade. While the main emphasis of the report is on the country level, trends are also reported for selected subregions identified partly on the basis of geography and partly on drinking patterns. There is high variability in alcohol consumption between countries of the WHO European Region, as well as within countries over time. Despite divergent trends at the country level, the WHO European Region continues to be the WHO region with the highest adult per capita alcohol consumption. Slight decreases in the level of alcohol consumption were seen between 1990 and 2014, which, combined with increases in alcohol consumption in Asia and Africa over the same time period, led to some convergence in global drinking levels. The decrease in alcohol consumption levels in the WHO European Region has been fuelled by decreases in the richest countries in the central-western European Union (EU) and Mediterranean parts of the Region (see Fig. A), whereas drinking levels in central-eastern EU remained stable over the past 25 years, and drinking levels in the eastern WHO European Region, and in the south-eastern part of the WHO European Region increased. There are indications that the Russian Federation and surrounding countries with similar drinking patterns (Belarus, the Republic of Moldova and Ukraine) have decreased their consumption levels in recent years (around 2007), contributing to the overall decrease in the Region. Unrecorded consumption in the WHO European Region amounted to 18.5% in the year 2012, and has proportionally been relatively stable over the 25 years analysed (1990: 20.5%). It is higher in the eastern part of the WHO European Region, especially in the Russian Federation and surrounding countries. Fig. A. Trends in adult per capita alcohol consumption in the WHO european Region and selected subregions, 1990–2014a a For definitions of regions, see Box 2, page 5. The high level of alcohol consumption in the WHO European Region led to a substantial burden of attributable mortality from chronic and acute causes of death, as evidenced by the burden of mortality from cardiovascular diseases (CVD), cancer, liver cirrhosis, and unintentional and intentional injury. These causes of death were selected as they comprise 0 2 4 6 8 10 12 14 16 18 2014201220102008200620042002200019981996199419921990 Li tre s of p ur e al co ho l Central-western EU Mediterranean South-eastern WHO European Region Central-eastern EU Eastern WHO European Region WHO European Region viii more than three fourths of all-cause mortality in the WHO European Region (data for 2013), as alcohol has a causal impact, and as almost 90% of the alcohol-attributable mortality burden stems from these causes of death. While attributable deaths in general followed the trends in average level of alcohol consumption, the overall standardized rate for alcohol-attributable mortality increased in the WHO European Region over the time period between 1990 and 2014 (+4%; see Fig. B). Fig. B. Comparisons of age-standardized alcohol-attributable mortality for major causes of death, 1990 vs 2014, in the WHO european Region and selected subregions The increase in the burden of attributable mortality in the WHO European Region was mainly fuelled by the mortality trends in the eastern WHO European Region (+22% in 2014 compared to 1990) and in the south-eastern part (+65%, albeit from a relatively small base). On the other hand, regions within the EU and surrounding countries decreased their burden of alcohol-attributable mortality, more in the Mediterranean (–27%) and the central-western EU regions (–25%) than in the central-eastern EU region (–15%). The increase in the burden of alcohol-attributable mortality in the WHO European Region, despite a small decrease in overall consumption, is due to a number of reasons: • the exponential increase in mortality risk with increasing levels of average consumption, which led to a substantial increase in alcohol-attributable mortality, especially in the regions where already high consumption levels further increased (such as in the eastern WHO European Region); • the effect of episodic and chronic heavy drinking on cardiovascular mortality and injury; and • the overall increased adult mortality rate and low life expectancy in some parts of the WHO European Region, in particular, the eastern WHO European Region. The decrease in alcohol-attributable mortality in the central-eastern EU countries was due to an overall decline in mortality rates in this region. Even with relatively stable alcohol-attributable fractions, such a decline results in lower standardized rates. The following conclusions can be drawn for formulating an alcohol policy: overall consumption in the WHO European Region needs to be reduced, as alcohol consumption is causally related to considerable mortality – up to 25% of all mortality from liver cirrhosis, cancer, CVD and injury in certain parts of the Region. Currently, in this Region, the average level of alcohol consumption per drinker already exceeds the threshold for acceptable risk in modern societies 0 200 400 600 800 1000 1200 1400 1600 intentional injury unintentional injury CVD cancer liver cirrhosis WHO European Region 2014 WHO European Region 1990 Mediterranean 2014 Mediterranean 1990 South-eastern WHO European Region 2014 South-eastern WHO European Region 1990 Central-western EU 2014 Central-western EU 1990 Eastern WHO European Region 2014 Eastern WHO European Region 1990 Central-eastern EU 2014 Central-eastern EU 1990 Rate per million ix xfor voluntary behaviours.1 Second, heavy drinking, including episodic heavy drinking occasions, should be reduced in particular. Episodic heavy drinking is an important determinant of CVD and injuries, over and above the average level of consumption. Different policy options have proven effective and cost-effective in reducing the level of alcohol consumption, and heavy drinking in particular. These include, but are not limited to, the so-called “best buys”2 of increasing price via taxation (unless there is too much unrecorded consumption), restricting availability, and imposing a ban on marketing and advertising. Unfortunately, despite the availability of effective and cost-effective policy options to reduce alcohol- attributable mortality, and despite marked decreases in alcohol consumption in several countries of the WHO European Region, which could serve as benchmarks, the overall trend of alcohol-attributable mortality burden in this Region cannot be seen as a public health success, as the age-standardized alcohol-attributable mortality rate in 2014 was even slightly higher than 25 years earlier. This means that other policies to reduce the alcohol-attributable mortality burden should be considered. The specific causes of alcohol-attributable mortality burden may be focused on, such as traffic injury via implementation and enforcement of per se laws on blood alcohol concentration while operating machinery. Such specialized measures seem to be better supported by the general population and politicians than omnibus measures. Finally, interventions in the health-care system such as screening and brief interventions in primary health care, or treatment of alcohol use disorders have been shown to impact on alcohol-attributable mortality. 1 People have different standards for risks from voluntary behaviours vs involuntary exposures. While they accept only a lifetime risk of one in a million for things the State is responsible for, such as drinking-water, they take much higher risks for behaviours they initiate, such as skiing, drinking, etc. 2 A “best buy” is a more pragmatic concept introduced into the discussion of interventions for noncommunicable disease that extends beyond the economic efficiency and cost–effectiveness of an intervention. It is defined as an intervention for which there is compelling evidence that it is not only highly cost-effective but is also feasible, low-cost and appropriate to implement within the constraints of the local health system. 13 While there have been a few country-level studies (15–17), this is the first time that trends in alcohol exposure or attributable burden have been examined systematically for all countries of the WHO European Region for an extended period of 25 years. inTROduCTiOn Alcohol use is one of the most important risk factors for disease (1) (for comparison with other risk factors, see (2,3)). The WHO European Region has the highest level of alcohol consumption in the world, in part driven by high consumption in the eastern part of the Region (1). Consequently, the disease burden caused by alcohol is also high in this Region, in particular, the eastern part (1,4,5), despite the overall high life expectancy in large parts of this Region (6). The high burden of alcohol-attributable disease has led to a plea for interventions globally (7,8) and for Europe in particular (9,10). These intervention initiatives have also been driven by recent insights that substance use policies may be key for population health, and getting them wrong may even lead to reversals in life expectancy for large groups of people or for nations (11). Public health policy planning needs to be based on empirical evidence (12), and monitoring of and surveillance for alcohol consumption and the burden of alcohol-attributable disease have been key elements both of the Global strategy to reduce the harmful use of alcohol (7) and of the Global action plan for the prevention and control of noncommunicable diseases (13). The global strategy asked for monitoring of the “harmful use of alcohol”, and defined this concept as broadly encompassing all drinking that causes detrimental health and social consequences for the drinker, the people around the drinker (often labelled as harm to others (14)), and society at large. It also asked for monitoring the patterns of drinking associated with an increased risk of adverse health outcomes. More operational definitions with concrete indicators used in this report were given within the monitoring framework for noncommunicable diseases (NCDs) (13). This report aims to contribute to the monitoring and surveillance of alcohol-attributable harm. Specifically, it has the following objectives: • to describe the trends in alcohol consumption and attributable mortality burden for the time period 1990–2014 in the WHO European Region; • to describe country-level trends,3 as health-care planning and policy decision-making are mainly at the country level; • to describe trends in selected regions; • to help establish a monitoring system for the WHO European Region and for countries as an evidence base for an alcohol policy. 2mOniTORing AlCOHOl exPOSuRe The key indicator for monitoring harmful alcohol consumption at the country and international level is adult (defined as age 15 years and over) per capita consumption (18), which is a composite measure comprising mainly recorded and unrecorded consumption. Recorded consumption refers to all alcoholic beverages that are officially registered by the respective country where they are consumed, most commonly based on taxation (18–20). Unrecorded consumption is a summary term for all non-registered products, which include the following main categories (21,22): legal but unrecorded alcohol products (mostly homemade alcohol); alcohol products recorded outside the jurisdiction where they are consumed (cross-border shopping); surrogate alcohol (non-beverage ethanol-based alcohol products not or not officially intended for human consumption); and illegally produced or smuggled alcohol products intended for human consumption (including illegal homemade alcohol). With respect to surrogate alcohol, sometimes products may not officially be intended for human consumption, but in reality they are only declared as such to avoid the higher taxation of officially declared alcoholic beverages. Ethanol-based medicinal tinctures or perfumes with fragrances would be one such example in the Russian Federation (23,24). Globally, unrecorded alcohol has constituted at least 20% of all alcohol consumed in the past decades, but with high variability between countries and regions, and over time (25–27). The proportion of unrecorded to total alcohol consumption is in general associated with economic wealth: the higher the wealth of a country (e.g. as measured by its gross domestic product [GDP]), the lower the proportion of unrecorded alcohol to overall consumption (1,28). In addition to recorded and unrecorded consumption, tourist consumption is subtracted for a small number of countries where tourists consume a sizable share of the overall alcohol consumed (see (29) for definitions). For most countries, it is assumed that tourist consumption is balanced by the consumption of inhabitants while spending time outside of their country. The objective of this chapter is to describe the long-term adult per capita alcohol consumption4 for all countries that are part of the WHO European Region from 1990 onwards. This is the earliest year for which there are systematic estimates of unrecorded consumption. In addition, it has been the goal to provide estimates of recorded versus unrecorded consumption, and estimates of average consumption per drinker. While some regional trends are included, these will be used only to illustrate trends for groups of countries with similar drinking levels or drinking patterns. The main emphasis is on the country level. meTHOdS FOR eSTimATing TRendS in AlCOHOl exPOSuRe dATA The Global Information System on Alcohol and Health (GISAH) (29) has been used for estimates of adult per capita consumption of alcohol, mostly derived from taxation, or production, import and export data (18,19). Estimates of recorded adult per capita alcohol consumption exist as time series of yearly data since 1960 for all WHO Member States; these data are regularly updated according to an algorithm based on the validity and reliability of sources (18). For the year 2014, data on recorded adult per capita consumption for the minority of countries without available data were estimated based on regressions of previous trends for this indicator. For the time after 1990, there are estimates of unrecorded consumption for select years (1990; 2000; 2010–2014), mostly assembled by the WHO Collaborating Centre for Mental Health and Addiction, Toronto within the WHO monitoring system on alcohol (for methodology, see (28,30,31)) (see Box 1). The years in between the estimated years were imputed based on linear interpolation between data points. 4 In the remaining text, adult per capita consumption or alcohol per capita consumption is used as total consumption. Sub-categories will be specified. 3Box 1. estimating the level of unrecorded alcohol consumption This report is based on the best available data from all sources for different categories of unrecorded consumption (22,28,30): • surveys (such as the STEPwise approach to surveillance (STEPS)) where use of unrecorded alcohol is asked in the expanded alcohol module (32); • expert Delphi rounds; • industry estimates; and • research studies. However, even based on this best available and recently increasing evidence base, the quantification of unrecorded consumption is still fraught with difficulties and contains considerably more bias than recorded consumption. Tourist consumption was estimated with the algorithm developed for the Global status report on alcohol and health (1), based on World Bank data on the annual number of tourists per country. This algorithm specifies that tourist consumption is taken into account only if the number of tourists exceeds the number of inhabitants, with special consideration given to the proportion of Muslims in the country (33). The sum of recorded, unrecorded and tourist consumption (all measured in adults – defined as age 15 years and older – per capita consumption of pure alcohol) yields total alcohol consumption. All trends are presented as moving three- year averages to reduce some of the random yearly variation. For estimates of consumption per drinker, adult per capita alcohol consumption data were divided by the proportion of drinkers, separated by sex. Any information on drinking by sex and age was derived from surveys, collected by the WHO Collaborating Centre (34) and made publicly available via the GISAH (15) (see Web Appendix 60 for an overview of sources for surveys on drinking status). The yearly per country population size by sex and age was taken from the United Nations Population Division (35). COunTRieS And RegiOnS All countries with separate estimates of recorded and unrecorded consumption over time were included: Albania, Armenia, Austria, Azerbaijan, Belarus, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Cyprus, the Czech Republic, Denmark, Estonia, Finland, France, Georgia, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, the former Yugoslav Republic of Macedonia, Malta, the Republic of Moldova, Montenegro, the Netherlands, Norway, Poland, Portugal, Romania, the Russian Federation, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland, Tajikistan, Turkey, Turkmenistan, Ukraine, the United Kingdom of Great Britain and Northern Ireland, and Uzbekistan. Estimates of exposure for Luxembourg are also presented, but these estimates were derived via the consumption in the neighbouring countries, as it is difficult to determine how much alcohol is sold to people living in this country as opposed to people from surrounding countries (i.e. France and Germany), or how often inhabitants of these countries buy their alcoholic beverages in surrounding countries. The countries with consumption trends shown in Fig. 1–9 comprise all countries in the WHO European Region with the exception of the following small countries: Andorra, Monaco and San Marino. During the observation period, there was considerable political change, and some of the countries above achieved political independence after 1990. Usually, data are presented from the year of political independence or, in case estimates existed for years before independence, for these years as well (for instance, for the Czech Republic, data are presented from 1990, even though Czechoslovakia split up into the Czech Republic and Slovakia only in 1993). Any national trends in per capita consumption are based on three-year moving averages. Monitoring alcohol exposure 4Public health successes and missed opportunities In addition to country estimates, adult per capita consumption for the WHO European Region is estimated as a whole and for several clusters of countries within the Region (see below for definition of clusters) based on drinking style and wealth (36). In terms of drinking style, the following traditional drinking styles can be found in the WHO European Region (37): first, a drinking style with wine as the predominant alcoholic beverage and frequent (daily or almost daily) alcohol consumption, mostly as a part of meals. (For a wider discussion on the categorization of drinking patterns, see (38).)5 This so-called Mediterranean drinking style was prevalent in major wine-producing countries in the Mediterranean region (such as France, Greece, Italy, Portugal and Spain) (41). In western and central-western Europe, beer was the predominant alcoholic beverage and, compared to the Mediterranean drinking style, there was less frequent drinking as well as a higher proportion of alcohol consumed outside of meals (1,25,27,37). In the Nordic countries, as well as in many countries in central-eastern and eastern Europe, the traditional drinking style was non-daily drinking, mainly outside of meals, and spirits were the most popular beverage (36,42). Abstinence is low overall in the WHO European Region (1), but substantial in several south-eastern and central Asian countries with higher proportions of Muslim populations. Modern European drinking has been moving into similar drinking levels and patterns in most countries, with almost no more prototypical drinking styles dominating at the population level of any country, with the exception of the countries around the Russian Federation (see below; for more details on current drinking styles, see (1,37,43,44)). Based on the current drinking patterns and economic wealth of countries,6 the following regional clusters were separated.7 Please note that these clusters were selected as illustrations, and were neither intended to cover all countries in at least one cluster, nor to be disjunctive. • european union (eu) countries in central-western europe (including Switzerland) comprise Austria, Belgium, Denmark, Germany, the Netherlands and Switzerland. The countries in the central-western part of the EU were all categorized as high-income by the World Bank (47), and would rank at the higher end within that category within the WHO European Region. All central-western EU countries had been part of this category for the whole observation period (i.e. 1990–2014). The drinking styles in these countries are characterized by a large proportion of beer and wine as the preferred beverages, and by drinking both with and outside of meals in a relatively frequent style (see also footnote 6). • eu countries in central and eastern europe comprise Bulgaria, Croatia, the Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Romania, Slovakia and Slovenia. All of these countries joined the EU since 1990, and although categorized as high income, their per capita gross national income is lower than in the other parts of the EU. The drinking style in most of these countries was traditionally characterized by consumption of a comparably large proportion of spirits, with frequent episodes of heavy drinking in most countries. However, in 2014, only Bulgaria, Estonia, Lithuania and Slovakia had a preference for spirits, and the difference between drinking beer and spirits even in these countries was small and mostly within measurement error of standard surveys. A considerable proportion of drinking occasions occur outside of meals. • mediterranean countries comprise Cyprus, France, Greece, Israel, Italy, Malta, Portugal, Spain and Turkey. All of these are high-income countries. Drinking styles were at one time similar and the Mediterranean drinking style had even become a standard term for describing the predominant consumption of (moderate) amounts of wine with meals on an almost daily basis (49) (but see footnote 8). However, since 2000, there has been a shift to both beer and spirits in Cyprus, Israel and Turkey; and to beer in Spain (1,25,27). 5 In the WHO European Region, alcohol consumption has roots dating back to the Neolithic age (39), and some scholars argue that the roots for some of the traditional drinking patterns date back to antiquity (40). 6 Economic wealth is related to the level of alcohol consumption, but more so in low- and lower–middle-income countries (45,46). Within the group of high-income countries, indicators of economic wealth no longer have predictive value for the overall level of consumption. 7 For some regional comparisons, trends have been used for the EU as a whole (2015) comprising the following countries: Austria, Belgium, Bulgaria, Croatia, Cyprus, the Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg (only for exposure), Malta, the Netherlands, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden and the United Kingdom. The EU is mainly of interest as a political organization of high-income countries, albeit with different drinking styles. Thus, in 2014, all EU countries were categorized as high-income by the World Bank (47), and most EU countries had been part of this category for the whole observation period (i.e. 1990–2014). While drinking levels are similar, drinking styles differ within the EU with regard to the highest percentage of pure alcohol consumed by alcoholic beverage type. Countries where currently (2014) beer is the preferred beverage type are: Austria, Belgium, the Czech Republic, Finland, Germany, Hungary, Ireland, Latvia, the Netherlands, Poland, Romania, Spain and the United Kingdom. Countries with wine as the preferred beverage type are: Croatia, Denmark, France, Greece, Italy, Luxembourg, Malta, Portugal, Slovenia, Sweden and Switzerland. Countries where relatively the most alcohol is consumed from spirits are: Bulgaria, Cyprus, Estonia, Lithuania and Slovakia. Please note that for several countries, the most preferred and the second most preferred beverage types were of almost equal proportions. EU countries also differ with respect to drinking frequency, proportion of heavy drinking occasions and drinking with meals (for more details, see (1,36,37,48)). 8 Turkey and Israel were exceptions with respect to almost daily drinking. 5• eastern european countries with similar drinking habits comprise the Russian Federation, Belarus, the Republic of Moldova and Ukraine. These countries have lower per capita gross national income than countries in the western parts of WHO European Region, and are in the middle-income category. Their drinking style is characterized by episodic heavy drinking, with both longer duration and larger volume of alcohol consumed per occasion than in other parts of the WHO European Region (50,51). • Countries in the south-east of the WHO european Region comprise Armenia, Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, Tajikistan, Turkey, Turkmenistan and Uzbekistan. This part of the WHO European Region is characterized by lower-than-average per capita gross national income, a relatively low level of alcohol consumption (1), in part due to the fact that in many countries, the majority of people are Muslims (52). Spirits are the preferred beverage type, except in Georgia (wine) and Turkey (beer) (1). Box 2 gives an overview of the regions used in this report. Box 2. Regions used in this report and included countries Regions Countries Central-western EU Austria, Belgium, Denmark, France, Germany, Luxembourg, Netherlands and Switzerland EU Austria, Belgium, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden and United Kingdom Central-eastern EU Bulgaria, Croatia, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Romania, Slovakia and Slovenia Mediterranean Cyprus, France, Greece, Israel, Italy, Malta, Portugal, Spain and Turkey Eastern WHO European Region Russian Federation, Belarus, Republic of Moldova and Ukraine South-eastern WHO European Region Armenia, Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, Tajikistan, Turkey, Turkmenistan and Uzbekistan Any regional trends are based on population-weighted three-year moving averages of the respective countries (weighted by the population aged 15 years and older) for the year under consideration (i.e. for the year 2010, the average of 2009– 2011 is presented). Finally, the trend in adult per capita consumption in the WHO European Region is compared with other WHO regions by comparing the net difference in consumption between 1990 and 2014. TRendS in TOTAl AdulT PeR CAPiTA AlCOHOl COnSumPTiOn FOR All COunTRieS in THe WHO euROPeAn RegiOn Trends in total adult per capita alcohol consumption are presented, which includes the sum of recorded, unrecorded and tourist consumption, for all countries in the WHO European Region, with clusters of several neighbouring countries being on the same graph. For comparison purposes, each graph will contain the trend in the WHO European Region as well. Monitoring alcohol exposure 6Public health successes and missed opportunities In 1990, the western European countries of Ireland and the United Kingdom (England, Scotland, Wales and Northern Ireland) had similar consumption as the WHO European Region as a whole (Fig. 19), but lower alcohol consumption than most continental EU countries (Fig. 2). While these continental EU countries and the WHO European Region as a whole decreased alcohol consumption over the time period of 25 years, both Ireland and the United Kingdom experienced increases in consumption before decreases were observed. Currently, adult per capita alcohol consumption in the United Kingdom is still higher than the WHO European Region average. Fig. 1. Trends in adult per capita alcohol consumption for ireland and the united Kingdom, 1990–2014 Central-western European countries around Germany very much reflect the downward trend in consumption in most high- income countries of the WHO European Region, which is slightly more pronounced than the trend in the WHO European Region as a whole. The variation between the countries in this region has been relatively small. Fig. 2. Trends in adult per capita alcohol consumption for Austria, Belgium, denmark, France, germany, luxembourg, the netherlands and Switzerland, 1990–2014 0 2 4 6 8 10 12 14 16 WHO Euro United Kingdom Ireland 2014201220102008200620042002200019981996199419921990 WHO European Region United Kingdom Ireland Li tre s of p ur e al co ho l 0 2 4 6 8 10 12 14 16 18 2014201220102008200620042002200019981996199419921990 Denmark France Luxembourg Germany Netherlands Switzerland WHO European Region Belgium Austria Li tre s of p ur e al co ho l 9 As the main purpose of the figures on trends in adult per capita exposure is the comparison between neighbouring countries, different scales have been used in different figures. For overall comparison within the WHO European Region, the trend line for the Region as a whole is added as well. 7Overall, alcohol consumption in countries in the south of the WHO European Region around the Mediterranean Sea has been decreasing, especially in the largest countries of Spain and Italy (Fig. 3). However, adult per capita alcohol consumption in the south of the WHO European Region is converging, and countries with historically the lowest consumption have shown increasing trends (Israel, Malta), but are still markedly below other Mediterranean countries and the average for the WHO European Region as a whole. Fig. 3. Trends in adult per capita alcohol consumption for Cyprus, greece, israel, italy, malta, Portugal and Spain, 1990–2014 In 2014, all six countries in Fig. 4 consumed alcohol at a level that was higher than the WHO European Region average. Alcohol consumption in this region can also be characterized by the higher variation in consumption levels between countries and across time compared to the central-western EU countries. However, there seems to be convergence over time, with 2014 per capita consumption being similar for all countries. Fig. 4. Trends in adult per capita alcohol consumption for the Czech Republic, Hungary, Poland, Romania, Slovakia and Slovenia, 1990–2014 0 2 4 6 8 10 12 14 16 18 2014201220102008200620042002200019981996199419921990 Israel Italy Malta Portugal Spain WHO European Region Greece Cyprus Li tre s of p ur e al co ho l 0 2 4 6 8 10 12 14 16 18 20 2014201220102008200620042002200019981996199419921990 Poland Romania Slovakia Slovenia WHO European Region Hungary Czech Republic Li tre s of p ur e al co ho l Monitoring alcohol exposure 8Public health successes and missed opportunities The Nordic countries in Fig. 5 were historically at the lower end of the alcohol consumption continuum of Europe. This changed in the 2000s, and in 2014, consumption in Finland was higher than the WHO European Region average; and the other Nordic countries had increased their consumption since 1990 as well. Fig. 5. Trends in adult per capita alcohol consumption for Finland, iceland, norway and Sweden, 1990–2014 The eastern European countries in Fig. 6 had markedly higher consumption levels when compared to the WHO European Region average in 2014; however, this was not always the case. For several of these countries, in the beginning of the 1990s, consumption levels were below or at the WHO European Region average. The trends in these countries showed markedly more variation than trends in other countries of the WHO European Region. Fig. 6. Trends in adult per capita alcohol consumption for Belarus, estonia, latvia, lithuania, the Republic of moldova and ukraine, 1990–2014 0 2 4 6 8 10 12 14 WHO Euro Sweden Norway 2014201220102008200620042002200019981996199419921990 Norway Sweden WHO European Region Iceland Finland Li tre s of p ur e al co ho l 0 5 10 15 20 25 WHO Euro Ukraine Moldova 2014201220102008200620042002200019981996199419921990 Latvia Lithuania Republic of Moldova Ukraine WHO European Region Estonia Belarus Li tre s of p ur e al co ho l 9The Russian Federation is the most populous country in eastern Europe, and has a long history of heavy drinking associated with considerable alcohol-attributable harm, which persists into the present (5,53–55). Fig. 7 shows that in the past two-and-a-half decades, consumption levels have continued to be high (and in 2014, higher than the central-eastern EU countries). There is a good indication, however, that over the past seven years, consumption has decreased in the Russian Federation. This decrease may have been due to recent changes in alcohol policies (56,57). Fig. 7. Trends in adult per capita alcohol consumption for the Russian Federation with several comparator regions, 1990–2014 The trends in alcohol consumption have been contrasted with two more regions (for definitions, see Box 2, page 5) to illustrate how different the trends in the Russian Federation have been. In 1990, shortly after an anti-alcohol campaign was initiated in 1985, the alcohol consumption level in the Russian Federation was relatively low, below the WHO European Region average, slightly below the average of the Mediterranean countries and markedly below the average of the central-eastern EU countries. In the following years, consumption levels increased markedly until 2007, when the Russian Federation population consumed 3 litres more per capita of pure alcohol than central-eastern EU countries, 5 litres more than the average of the WHO European Region, and 8 litres more than the Mediterranean countries. In 2014, the three averages came closer together, with the Russian Federation decreasing consumption levels again, but there are still marked differences, as both the WHO European Region average and the average of the Mediterranean countries decreased as well. There is considerable variation in the alcohol consumption levels among countries in central south-eastern Europe (Fig. 8) over the past decades, both between and within countries, with no clear overall trend and no convergence. Many of these countries were part of the former Yugoslavia, and some of the observed variation may also reflect the establishment of national recording systems. Bulgaria, Croatia and Serbia have had levels above the WHO European Region average for almost a decade, whereas Bosnia and Herzegovina, the former Yugoslav Republic of Macedonia and Albania are clearly below the WHO European Region average levels of alcohol consumption. In the latter countries, there is a marked proportion of people who follow the Muslim faith (52). 0 2 4 6 8 10 12 14 16 18 Mediterranian c. Central Eastern countries in EU WHO Euro 2014201220102008200620042002200019981996199419921990 WHO Euro WHO European Region Russian Federation Mediterranean Central-eastern EU Li tre s of p ur e al co ho l Monitoring alcohol exposure 10 Public health successes and missed opportunities Fig. 8. Trends in adult per capita alcohol consumption for Albania, Bosnia and Herzegovina, Bulgaria, Croatia, montenegro, Serbia and the former yugoslav Republic of macedonia, 1990–2014 Alcohol consumption in countries of the south-eastern part of the WHO European Region, which are primarily geographically situated in Asia, showed marked variation within and between countries, often within a short time span (Fig. 9). The exception is Turkey, where the adult per capita alcohol consumption has been stable at approximately 2 litres per year. The other countries show no clear pattern, except that all of them are considerably below the WHO European Region average. Most countries in this region have a large proportion of Muslims, but operated under alcohol regulations influenced by prior Soviet Union laws in the first years of the observation period. Fig. 9. Trends in adult per capita consumption for Armenia, Azerbaijan, georgia, Kazakhstan, Kyrgyzstan, Tajikistan, Turkey, Turkmenistan and uzbekistan, 1990–2014 0 2 4 6 8 10 12 14 16 18 WHO Euro Macedonia Serbia 2014201220102008200620042002200019981996199419921990 Bulgaria Croatia Montenegro Serbia The former Yugoslav Republic of Macedonia WHO European Region Bosnia and Herzegovina Albania Li tre s of p ur e al co ho l 0 2 4 6 8 10 12 14 WHO Euro Uzbekistan Turkey 2014201220102008200620042002200019981996199419921990 Georgia Kazakhstan Kyrgyzstan Tajikistan Turkmenistan Turkey Uzbekistan WHO European Region Azerbaijan Armenia Li tre s of p ur e al co ho l 11 RegiOnAl TRendS in TOTAl AdulT PeR CAPiTA AlCOHOl COnSumPTiOn Fig. 10 summarizes the trends in different subregions within the WHO European Region and for the Region as a whole between 1990 and 2014.10 There are clear differences in trend: consumption in the WHO European Region in the past 25 years has decreased by about 11%, with almost all of the decrease occurring since 2007. The economic recession may have played a role there, as during recession overall less money is spent on alcoholic beverages, despite a potential increase in the number of unemployed people (58,59). (For the relationship between unemployment and alcohol consumption, see (60).) Such an effect would be most relevant for countries with a lower income, such as those in the eastern part of the WHO European Region. The decrease in alcohol consumption in the WHO European Region has also been fuelled primarily by an almost linear decrease in the countries of the EU over the period (approximately –18% based on the 1990 level). Countries in the central- western EU region around Germany showed a very similar pattern as the EU as a whole (–22%). Within the EU, consumption in the Mediterranean countries decreased the most (–34% for all Mediterranean countries). This decrease in alcohol consumption in Mediterranean countries actually started earlier than 1990, and is primarily the result of a decrease in wine consumption in the traditional wine-drinking countries of France, Greece, Italy, Portugal and Spain (61–63). Fig. 10. Trends in adult per capita alcohol consumption in the WHO european Region and selected subregions, 1990–2014 However, not all regions of the EU showed a decrease in alcohol consumption. The central-eastern part of the EU had almost stable consumption over the observation period. The eastern WHO European Region in 1990 had consumption levels that were below that of the EU and Mediterranean countries, and now their consumption exceeds the consumption in these regions by far: in 2014, the eastern WHO European Region had 3.1 (28%) and 6.6 (85%) litres per capita higher consumption than the average of the EU and Mediterranean countries, respectively. While in most parts of the WHO European Region alcohol consumption is higher than the global average (see below for a quantification), this is not the case for its south-eastern part. Alcohol consumption levels are markedly lower here, in part because a considerable proportion of the population is from the Muslim faith (52). The sharp increase to 1991 in the south-eastern part followed by a decrease in 1992 is partly due to the different composition of the region in these years and the methodology of using three-year averages.11 0 2 4 6 8 10 12 14 16 18 2014201220102008200620042002200019981996199419921990 Li tre s of p ur e al co ho l Central-western EU EU Mediterranean South-eastern WHO European Region Central-eastern EU Eastern WHO European Region WHO European Region 10 While the emphasis of this report is on the country level, and thus the majority of figures concern all countries in comparison with neighbouring countries, the next section gives some regional trends. There is some overlap between regions, as the regions were selected based on geography, economic wealth and drinking tradition (see above for details). 11 The time series for countries like Turkmenistan and Uzbekistan start in 1991, as they became independent in that year. Moreover, for many countries in this region, the data source changed in 1990 (for data sources for each country and year, see (1)), resulting in some changes between 1990 (average 1989–1991, i.e. one year with a different data source) and 1991 (average 1990–1992; all years from the same data source). Monitoring alcohol exposure 12 Public health successes and missed opportunities Most of the changes in alcohol consumption levels were driven by changes in recorded consumption (Fig. 11). The traditionally high-consuming countries in the central-western part of the EU decreased their consumption by 2.7 litres per capita (about 20%), with EU decreasing by 16% and the Mediterranean countries by 33%. In 2014, the central-western part of the EU no longer had the highest level of recorded adult per capita alcohol consumption, as central-eastern EU countries consumed slightly more recorded alcohol per capita. Fig. 11. Trends in recorded adult per capita alcohol consumption in the WHO european Region and selected subregions, 1990–2014 Unrecorded consumption in the WHO European Region and in most of its composite parts, as estimated periodically, was stable or decreased (Fig. 12). The only exception seems to be the south-eastern part of WHO European Region, where some countries increased their unrecorded consumption, albeit at a relatively low level. Central-western EU countries decreased their unrecorded consumption even further. The largest absolute level and relative impact of unrecorded consumption was found in the eastern WHO European Region (22). Fig. 12. Trends in unrecorded adult per capita alcohol consumption in the WHO european Region and selected subregions, 1990–2014 0 2 4 6 8 10 12 14 16 2014201220102008200620042002200019981996199419921990 Li tre s of p ur e al co ho l Central-western EU EU Mediterranean South-eastern WHO European Region Central-eastern EU Eastern WHO European Region WHO European Region 0 1 2 3 4 5 6 2014201220102008200620042002200019981996199419921990 Li tre s of p ur e al co ho l Central-western EU EU Mediterranean South-eastern WHO European Region Central-eastern EU Eastern WHO European Region WHO European Region 13 TRendS in AlCOHOl COnSumPTiOn PeR dRinKeR Fig. 13 and 14 give an overview of the average alcohol consumption per adult drinker by sex. For men, most of the regions cluster around the WHO European Region average (Fig. 13), including even the countries from the south-eastern part of the Region, indicating again that once subpopulations start using alcohol, they often tend to drink at similar levels, almost independent of culture (64,65).12 However, the levels in the eastern WHO European Region are markedly higher in this regard, which helps to explain why this region has experienced a proportionally larger alcohol-attributable burden (1,5,66). The lowest per-drinker consumption was in the central-western part of the EU, where the abstinence rates have traditionally been very low. Fig. 13. Trends in per drinker per capita alcohol consumption for adult men in the WHO european Region and selected subregions, 1990–2014 For women, a largely similar picture as for men has been identified at a lower level, but women from the south-eastern WHO European Region consume markedly less alcohol compared to the other regions and to the WHO European Region as a whole (Fig. 14). COnCluSiOn: TRendS in AlCOHOl COnSumPTiOn OveR THe PAST 25 yeARS in THe WHO euROPeAn RegiOn Adults in the WHO European Region have decreased their alcohol consumption over the past 25 years. This decrease was fuelled by trends in countries with the highest economic wealth in the EU and, in particular, by the wine-drinking countries in the Mediterranean region. However, if countries in the eastern parts of the WHO European Region further increase their consumption, the NCD goals for reduction in the harmful use of alcohol (–10%) could be threatened in the Region (for more general considerations on reaching the NCD goal to reduce the harmful use of alcohol in the Region, see (67)). At this point, it should be mentioned that the NCD goal for alcohol was not too ambitious for the WHO European Region. Despite the overall positive trend in reduction in the level of alcohol consumption in the WHO European Region, the enormous variation between countries, even between neighbouring countries, should be pointed out. The current increase in adult per capita alcohol consumption in several countries is worrisome, especially in the eastern part of the Region. 12 14 16 18 20 22 24 26 28 30 32 34 2014201220102008200620042002200019981996199419921990 Li tre s of p ur e al co ho l Central-western EU EU Mediterranean South-eastern WHO European Region Central-eastern EU Eastern WHO European Region WHO European Region 12 A corollary of this statement is that the drinking level in different countries is markedly determined by the proportion of abstainers in the respective country. For 2010, based on data from the Global status report on alcohol and health (1), the Pearson correlation between the proportion of current abstainers (defined as 12-month abstainers) and adult per capita consumption was –0.82 (n = 190 countries; 95% confidence interval (CI): –0.86, –0.77; t = 19.6; P < 0.001); and for the WHO European Region it was –0.61 (n = 51 countries; 95% CI: –0.76, –0.40; t = 5.4; P < 0.001). Monitoring alcohol exposure 14 Public health successes and missed opportunities Fig. 14. Trends in per drinker per capita alcohol consumption for adult women in the WHO european Region and selected subregions, 1990–2014 More efforts should be undertaken to counter such developments by the respective countries and by the WHO European Region as a whole. Second, despite the overall decrease in alcohol consumption, the Region still has the highest levels of consumption in the world. From a broader public health perspective, the average consumption per adult in the WHO European Region is high, with comparatively more risks associated with drinking as compared with other voluntary activities or other forms of substance use (68–70). This argues for a special effort to reduce alcohol consumption by well beyond 10% in the European Region. More general conclusions will be given after describing the health burden attributable to alcohol consumption. COmPARiSOnS BeTWeen THe WHO euROPeAn RegiOn And OTHeR WHO RegiOnS Fig. 15 and 16 show the main components of per capita consumption in 1990 and the percentage changes in the 25 years by WHO region (for the composition of WHO regions by countries, see Web Appendix 7). The following general statements can be made: • Adult per capita alcohol consumption in WHO regions increased by about 10% over the past 25 years, and the rank order of regions remained stable, with the WHO European Region consuming the most alcohol, followed by the Region of the Americas, Western Pacific Region, African Region, South-East Asia Region and Eastern Mediterranean Region. • Over this time period, the two regions with the highest consumption, the WHO European Region and the Americas, decreased their consumption by 11% and 1%, respectively. • Most of the increase in consumption was in the Asian regions, fuelled by marked increases in consumption in China (Western Pacific Region; see (71)) and India (South-East Asia Region; for more details, see (72)). The African Region also increased its alcohol consumption markedly (for more details on the WHO African Region, see (73)). The overall trends are not only heterogeneous between WHO regions, but also within regions between countries. Fig. 17 gives an overview of this variability. 4 6 8 10 12 14 16 18 20 22 2014201220102008200620042002200019981996199419921990 Li tre s of p ur e al co ho l Central-western EU EU Mediterranean South-eastern WHO European Region Central-eastern EU Eastern WHO European Region WHO European Region 15 Fig. 15. Adult per capita alcohol consumption in WHO regions in 1990 and 2014 Fig. 16. Proportional changes in adult per capita alcohol consumption in WHO regions between 1990 and 2014 Fig. 17. Country-level data on change in adult per capita alcohol consumption between 1990 and 2014 0 2 4 6 8 10 12 14 Recorded Unrecorded Global 2014 Global 1990 Western Pacific Region 2014 Western Pacific Region 1990 South-East Asia Region 2014 South-East Asia Region 1990 European Region 2014 European Region 1990 Eastern Mediterranean Region 2014 Eastern Mediterranean Region 1990 Region of the Americas 2014 Region of the Americas 1990 African Region 2014 African Region 1990 Litres of pure alcohol Monitoring alcohol exposure -20 -10 0 10 20 30 40 50 60 70 Unrecorded Global 1990 Western Pacific Region 1990 South-East Asia Region 1990 European Region 1990 Eastern Mediterranean Region 1990 Region of the Americas 1990 African Region 1990 Percentage (%) Percentage (%) change in adult per capita consumption of alcohol (1990 compared to 2014) O G U T GS +;%'*$)"&)-&#V%&'#"7#&%"7%'-)$%'F0%-'GOOLOOOK !"#$"%&'(%)$*+'" ,$+-"./ !"#$"%&'(%)$*+'" 0."+1'2%3"%4'$+*5+ 6"7"/8*" <;*+" =+:*" >+*?':%@?"?'8 <;*+" =+:*" >+*?':%@?"?'8 <;*+" =+:*">+*?':%@?"?'8 <;*+" =+:*" >+*?':%@?"?'8 <;*+"=+:*" >+*?':%@?"?'8 !"#$"%&'(%)$*+'" ,$+-"./ !"#$"%&'(%)$*+'" !"#$"%&'(%)$*+'" 6"7"/8*" =+:*" >+*?':%@?"?'8 <;*+" =+:*" >+*?':%@?"?'8 <;*+" =+:*" >+*?':%@?"?'8 <;*+" =+:*" >+*?':%@?"?'8 <;*+"=+:*" >+*?':%@?"?'8 -100 0 100 200 Country data Mean United States Russia China India 16 BuRden OF AlCOHOl-ATTRiBuTABle mORTAliTy in THe WHO euROPeAn RegiOn, 1990–2014 On THe SeleCTiOn OF mORTAliTy AS THe mAin OuTCOme Mortality is clearly the most severe health consequence of alcohol consumption. This outcome has other advantages as well; it is more comparable and has less measurement bias than non-fatal health measures (74). However, there are also limitations: progress in medicine and other factors may lead to a prolongation of life (6), and thus, some effects of alcohol on health may be disguised if mortality alone is used as an outcome. Supporting this hypothesis, there is some indication that the trends diverged for alcohol-attributable mortality and morbidity, including but not limited to using hospitalizations as an indicator of the latter (15,75,76). mAin CATegORieS OF AlCOHOl-ATTRiBuTABle CAuSeS OF deATH Alcohol consumption has a causal impact in over 200 three-digit categories of the International Statistical Classification of Diseases and Related Health Problems (ICD)-10 (77–79). However, an overwhelming majority of the burden of alcohol- attributable mortality, especially in Europe (80,81), is in the chronic categories of liver cirrhosis, cancer and cardiovascular deaths, and in the acute categories of unintentional and intentional injury. According to the most recent Global status report on alcohol and health (1), globally 88% of the burden of alcohol-attributable mortality in 2012 was due to these five broad cause-of-death categories reported here (90% in women; 87% in men), with cardiovascular deaths being the largest contributor, followed by unintentional injuries and liver cirrhosis (see Table 7 in (1)). The remaining proportion of alcohol-attributable mortality was due to infectious diseases (tuberculosis [TB], HIV and pneumonia), neuropsychiatric conditions (epilepsy, alcohol use disorders) and neonatal conditions (fetal alcohol syndrome [FAS]). The five categories are not only most relevant for alcohol-attributable deaths, but they also make up 76% of all-cause mortality in the WHO European Region (same proportion in both sexes), most in CVD, followed by cancer, injury and liver cirrhosis (calculations based on the Global Burden of Diseases, 2013 iteration (82)). Details on the cause-of-death categories and their links to alcohol consumption are listed below. • liver cirrhosis, although not identified as part of the NCDs within the WHO Global action plan for the prevention and control of noncommunicable diseases 2013–2020 (13), is one of the more important single causes of death globally and in Europe (83–85). Alcohol consumption has been identified as a causal factor for liver disease in general, and liver cirrhosis in particular, for centuries (86). There is a clear dose–response relationship, which starts slowly and then accelerates (87). Overall, the relative risks of heavy drinking are substantial (87,88) and consequently, mortality due to alcohol-attributable liver cirrhosis constitutes a major part of mortality as a whole (83,89), especially in Europe (90). • Alcohol consumption has been identified as carcinogenic by the International Agency for Research on Cancer (91–93). The following cancers have been identified to be partially attributable to alcohol: cancers of the nasopharynx, oesophagus, larynx, pancreas, liver, colon/rectum and female breast (94). Dose–response relationships are close to linear on the relative risk scale (95,96), with no apparent lower threshold; even light drinking has been shown to increase the risk of cancer (96,97). Thus, alcohol consumption has been consistently shown to be a major risk factor for cancer and, given the high level of consumption in Europe, this is particularly true for the WHO European Region (98,99). • Cvd have a complex relationship with alcohol consumption (100,101) (see Box 3). On the one hand, light-to-moderate regular drinking has been shown to be linked to decreases in morbidity and mortality from ischaemic disorders (102,103). On the other hand, heavy drinking, both episodic and chronic, has detrimental effects (104–106). For most other cardiovascular causes of death, the impact is detrimental with a clear dose–response relationship (hypertension (107), haemorrhagic stroke (103), atrial fibrillation (108)). As a result, the overall impact of alcohol on cardiovascular causes of death has been negative in most countries (1,101), while the net impact on death from ischaemic diseases has been beneficial for many countries, with the exception of countries with pronounced episodic or chronic heavy drinking patterns (109,110). 17 Burden of alcohol-attributable mortality in the WHO European Region, 1990–2014 • Alcohol has a causal impact on almost all categories of injury, both intentional and unintentional (78,118,119). For some kinds of injuries such as traffic injury and violence, there is both the impact on the drinker (120) and the impact on others (14,121). All levels of alcohol consumption have some impact on injury, as alcohol impacts the central nervous system even at low-to-moderate doses (122,123); however, the dose–response relationship increases with higher levels of consumption (124,125). Box 3. limitations of estimating population health effects on cardiovascular causes of death from epidemiological studies As indicated in the Methods section below, the alcohol-attributable fractions that underlie the estimates of the standardized rates presented here for various cause-of-death categories have been derived from meta- analyses of large cohort studies, which is the technical term for studies where people are followed for a while, with exposure such as alcohol consumption usually measured at the beginning of the study and outcomes years later. The association between exposure and different outcomes is estimated after that. However, there are some indications that the beneficial effects of alcohol consumption on ischaemic heart disease and ischaemic stroke as derived from usual epidemiological studies have been overestimated. A number of selection biases were found in the underlying studies (29,111); results from Mendelian randomization studies, another type of study with stricter control, seem to contradict the results (112) (but also see (113)); and finally, aggregate-level studies also found conflicting results (114). While the current evidence suggests that the beneficial effects of alcohol on CVD outcomes may have been overestimated, there are still good biological reasons for the beneficial effect based on experimental evidence from surrogate markers of ischaemic heart disease (115–117). Moreover, it is hard to quantify the overestimation, and the best available estimates have been used from meta-analyses of individual-level studies, even if they overestimate the beneficial effect. The burden for these cause-of-death categories are presented separately for each country from 1990 to 2014; for injuries, also separately by major subcategory, i.e. unintentional and intentional injury. The main calculations will be restricted to drinkers harming themselves, but some indication of harm to others from alcohol consumption will be presented. meTHOdOlOgy TO eSTimATe THe AlCOHOl-ATTRiBuTABle BuRden The same standard methodology that was used for the WHO Global status report on alcohol and health (last iteration 2014 (1)) and the Global Burden of Disease, Injury and Risk Factor studies (last iteration 2013 (2)) was used to estimate the alcohol-attributable burden. While the methodology has been described in detail elsewhere (1,2,126), the main steps are listed below as an overview. • Average level of alcohol exposure was estimated yearly as a continuous variable, separately by sex and age (34), based on a triangulation of adult per capita consumption of alcohol data and survey data (for data sources, see above; for detailed methodology, see (126,127)). Survey data are necessary to distribute information on per capita consumption, mostly derived from taxation, production, export and import figures, into drinking by different groups as defined by sex and age. Heavy drinking occasions, used for the calculation of causes of death from ischaemic heart disease and injury, were taken from surveys (see Appendix 61 for a listing of all sources for heavy drinking occasions). • For all countries except the Russian Federation and surrounding countries with similar patterns of drinking (Belarus, the Republic of Moldova, Ukraine), dose–response relationships were taken from meta-analyses (for liver cirrhosis: (87); for all alcohol-attributable cancer sites: (128); for the various categories of CVD and hypertensive disease: (107); ischaemic heart disease and ischaemic stroke: (101,104); other stroke types: (103); atrial fibrillation: (108); for injury: (128)). For the Russian Federation and surrounding countries with similar patterns of drinking, country-specific estimates were used for dose–response relationships from the Russian Federation from a large prospective study ((54,109); see (66) for further reasoning). 18 Public health successes and missed opportunities • For injury, the relative risks from the meta-analysis of Corrao and colleagues (128) were used, modified to incorporate the effects of binge drinking. While it did not explicitly include risk to others13 in general, some of the effects of alcohol use on traffic injury were included. Thus, the WHO Global status report on road safety 2015 was used (133) as a source for the distribution of the sex of the driver, and the number of passengers per car to add to the alcohol- attributable injury. (For general considerations on harm to others, see (14,121).) • Exposure and dose–response relationships were combined using standard formulas for attributable risk (126) (for foundation, see (134–136)) to derive alcohol-attributable fractions by sex and age (the usual age groups for comparative risk assessments characterizing alcohol exposure (15–34 years; 35–64 years; and 65+ years). • The alcohol-attributable fractions were then applied to the cause-of-death statistics (137) divided by the respective population to derive rates per million population. To achieve comparability, the rates were age-standardized using the standard population of the International Agency for Research on Cancer (138). BuRden OF AlCOHOl-ATTRiBuTABle mORTAliTy in 2014 in THe WHO euROPeAn RegiOn Table 1 gives an overview of standardized mortality rates of major alcohol-attributable disease categories for the year 2014. While the countries with the highest overall rates of alcohol-attributable mortality from the eastern part of the WHO European Region tend to be the highest in many of the six subcategories of causes of death reported here (i.e. liver cirrhosis, cancer, CVD, injury, unintentional injury, intentional injury), the results are differentiated by country and region- specific characteristics. • Like any other type of alcohol-attributable mortality, mortality rates due to alcohol-attributable liver cirrhosis are mainly impacted by two factors: the overall mortality rate from liver cirrhosis in the country/region under consideration and the level of alcohol consumption. For European countries with high rates of alcohol-attributable liver cirrhosis, these two causal factors determine three clusters of countries:14 first, the central Asian countries of Kazakhstan, Kyrgyzstan, Turkmenistan and Uzbekistan have a high overall prevalence of and mortality from liver cirrhosis, in large part driven by hepatitis B and C infections (84). The role of alcohol use may be overestimated by the standard formulas for these countries (see above). On the other hand, alcohol plays a crucial role in liver cirrhosis mortality, independent of the original cause for incidence of this disease category, as even relatively small amounts of alcohol may lead to mortality in people who have the disease, irrespective of its etiological pathway (87). (For the difference in risk curves between morbidity and mortality, see (90,139).15) Second, countries such as Hungary, the Republic of Moldova, Romania and Slovakia have higher liver cirrhosis rates than expected by volume of alcohol consumption alone. There is some speculation that specific kinds of fruit spirits, where pits (stones) were not separated in the production process, may play a role here (141). Finally, countries such as Lithuania or Ukraine would be typical of countries with a high liver cirrhosis rate more or less in line with their high level of overall consumption. It should be noted that overall tissue exposure seems to be the causal determinant (142,143), and that more variable drinking of the same amount of alcohol does not imply additional risks for liver cirrhosis mortality, as abstinence days are favourable for liver regeneration (so-called liver holidays (144,145)). • Of all causes, alcohol-attributable cancer shows by far the least variation between countries and by time. Part of the phenomenon may be due to the long and varying lag-time between exposure and onset of disease (146). Another reason is that alcohol is not causally or is only weakly related to the most numerous cancers. As a result, the level of alcohol consumption is the main determinant of alcohol-attributable cancer mortality, which accounts for less than 10% of all the cancer mortality in any region of the world. However, the variation in Europe – between 1% (Turkey) and 9% (the Republic of Moldova) – in 2014 for alcohol-attributable fractions of cancer mortality in the WHO European Region is still very important,16 given the overall impact of cancer on mortality in the Region. 13 Thus, neither the effects of pregnant women’s drinking on the newborn (such as on FAS or fetal alcohol spectrum disorders, (129,130) or the sequelae of low birth weight (131)) or the effect of alcohol on aggression towards others was included (132). 14 Only countries with the 10 highest age-standardized rates for alcohol-attributable liver cirrhosis and the other disease and injury causes of death are mentioned. 15 It should also be noted that alcohol use is associated with an increased risk of so-called non-alcoholic liver diseases (140). 16 The comparisons of alcohol-attributable fractions were based on the rate itself, as the focus was on the role of alcohol in explaining mortality rather than on the level of standardized rates. 19 Burden of alcohol-attributable mortality in the WHO European Region, 1990–2014 • As described above, mortality from alcohol-attributable CVD is a heterogeneous category based on the different effects (beneficial and detrimental) of different dimensions of alcohol use (average volume of consumption; patterns of drinking) on different causes of cardiovascular death (100). Some countries have slight protective effects on balance, and for many countries, the protective effect of light-to-moderate drinking on deaths due to ischaemic disease, and the detrimental effect of chronic and episodic heavy drinking occasions on all cardiovascular causes of death more or less balance out (Table 1). Several elements are important here: ° the distribution between ischaemic and other causes of death (mainly ischaemic heart disease versus cerebrovascular disease [stroke] (147) and, within stroke, between ischaemic stroke versus haemorrhagic stroke (148)); ° the distribution of drinking levels in the respective populations as well as patterns of drinking (117), in particular, the prevalence of episodic and chronic heavy drinking occasions; ° misclassification of the cause of death (149) (for the specific misclassification of alcohol poisoning as a cardiovascular cause of death, see below); and ° competing causes of mortality. Unfortunately, the exposure data necessary on pattern of drinking are not of the same quality as the adult alcohol per capita data (150), and thus the current estimates include considerable measurement error. Moreover, while current epidemiology has started to use country-specific relative risk estimates (1,151), at present and for this report, only two sets of relative risk estimates are available: the global one (78), and the Russian Federation-specific one (109). The global estimates from meta-analyses are based mainly on cohorts from a limited number of high-income countries with rather favourable and stable drinking patterns, resulting in lower estimates of relative risks compared to Russian estimates. One may speculate that countries like the Baltic countries may have risks that lie in between the global and Russian estimates, given the large amount of episodic heavy drinking (36), which plays such an important role in cardiovascular causes of death (see above and (100)). However, as good epidemiological studies on alcohol and death due to CVD do not exist from most countries, the global estimates were used, which will result in underestimating the real burden for many countries with more detrimental drinking patterns; i.e. patterns that include a large proportion of heavy drinking occasions. • Mortality due to injury is one of the major categories of alcohol-attributable mortality (1), and alcohol is one of the major risk factors for morbidity and mortality due to injury (2). Alcohol has a relatively high impact on the mortality burden from injury; from around 5–8% (Tajikistan, Turkey) to over 60% (Belarus, the Republic of Moldova, the Russian Federation and Ukraine) for intentional injury; and to over 45% for unintentional injury (Belarus, Lithuania, the Russian Federation and Ukraine; see Table 1). Most European countries have alcohol-attributable fractions of around 30–40% for intentional injury, and about 5% lower attributable fractions for unintentional injury. In standardized mortality, the differences between different countries in the WHO European Region are huge, more than 20-fold. Given that all mortality due to alcohol-attributable injury is in principle entirely avoidable from one day to another (152,153), and can be substantially reduced in a short time, these differences between countries in one Region are hard to accept (see also Conclusions below). BuRden OF mORTAliTy due TO AlCOHOl-ATTRiBuTABle liveR CiRRHOSiS Fig. 18 shows that western European countries in 2014, along with most continental EU countries (except for countries in the central-eastern part [see Fig. 21] and the Baltic countries), had a lower liver cirrhosis rate than the WHO European Region. Consistent with the trends in consumption (see Fig. 1), standardized rates of alcohol-attributable liver cirrhosis increased in the first decade of the observation period, and decreased in the later years. The rise in liver cirrhosis mortality in the United Kingdom from historically comparatively low levels to being the third most important cause of death for people under 65 years of age at present has led to discussion and policy action, especially as rates of other chronic diseases have been on the decrease in this country (154).17 17 As will be discussed in more detail, trends in liver cirrhosis mortality rates, especially if they are contrary to other mortality trends, have been identified as important tools for monitoring and surveillance of substance use and as an important indicator for inefficient substance use policies also in other countries of the world, such as the United States (155,156). 20 Ta bl e 1. S ta nd ar di ze d m or ta lit y fr om a lc oh ol -a ttr ib ut ab le d is ea se a nd in ju ry c at eg or ie s in 2 01 4 (o ve ra ll ag e- st an da rd iz ed ra te a nd ra te o f a lc oh ol -a ttr ib ut ab le ca us es o f d ea th p er m ill io n) (r an ki ng b y ov er al l A A m or ta lit y ra te ) Co un tr y li ve r li ve r Ca nc er Ca nc er Cv d Cv d A A in ju ry in ju ry u ni nt en t. u ni nt en t. in te nt . in te nt . ci rr ho si s ci rr ho si s A A A A in ju ry in ju ry in ju ry in ju ry A A A A A A Be la ru s 20 7. 8 12 0. 4 13 00 .8 10 8. 5 41 83 .6 12 14 .4 10 60 .1 63 7. 9 64 1. 4 35 3. 7 41 8. 6 28 4. 2 Uk ra in e 25 2. 4 13 0. 7 11 18 .5 85 .3 39 09 .8 92 6. 2 72 2. 6 37 9. 2 43 6. 9 20 3. 2 28 5. 7 17 6. 0 Ru ss ia n Fe de ra tio n 20 3. 7 10 8. 1 11 77 .5 78 .7 35 71 .0 67 4. 9 92 1. 5 47 8. 8 52 3. 9 23 5. 8 39 7. 6 24 2. 9 Re pu bl ic of M ol do va 48 4. 9 27 3. 3 94 6. 4 86 .0 32 99 .3 81 0. 3 52 3. 1 26 5. 8 34 3. 1 15 0. 8 18 0. 1 11 5. 0 Ka za kh st an 34 3. 0 23 2. 9 12 68 .7 92 .3 42 58 .7 20 0. 3 97 1. 8 32 3. 5 52 3. 9 15 9. 7 44 7. 9 16 3. 7 Lit hu an ia 19 7. 1 15 7. 8 11 56 .2 94 .5 24 11 .5 79 .5 72 9. 9 35 1. 7 42 5. 8 20 0. 9 30 4. 0 15 0. 8 Ky rg yz st an 47 5. 4 28 5. 3 82 7. 1 41 .2 39 57 .7 24 1. 9 58 3. 7 11 5. 0 39 7. 1 74 .2 18 6. 7 40 .8 Ro m an ia 25 4. 0 19 0. 6 10 93 .3 86 .5 25 68 .8 97 .9 38 4. 2 15 6. 3 27 3. 2 10 6. 0 11 1. 0 50 .3 Es to ni a 12 6. 1 98 .0 11 68 .6 80 .4 21 15 .1 65 .6 47 7. 4 20 3. 5 29 0. 5 11 9. 4 18 6. 9 84 .1 Hu ng ar y 24 0. 3 18 3. 1 15 78 .8 13 1. 6 21 46 .7 30 .8 40 1. 0 14 7. 8 22 0. 5 76 .1 18 0. 6 71 .8 Tu rk m en is ta n 32 5. 1 17 4. 2 94 6. 6 70 .4 43 73 .3 14 1. 7 56 4. 6 12 1. 7 41 1. 4 81 .7 15 3. 2 39 .9 Ge or gi a 20 3. 9 12 9. 3 94 5. 8 52 .1 36 81 .7 13 7. 8 43 8. 8 14 8. 1 35 0. 4 11 3. 2 88 .4 34 .9 Po la nd 13 8. 4 10 6. 2 13 00 .7 82 .6 18 27 .3 68 .2 43 9. 7 17 7. 5 27 1. 3 10 5. 4 16 8. 4 72 .1 Sl ov ak ia 18 5. 2 14 0. 0 13 08 .4 11 6. 3 23 04 .4 43 .1 35 8. 9 13 9. 2 22 9. 7 85 .6 12 9. 2 53 .7 Uz be ki st an 35 3. 6 19 3. 4 61 7. 0 37 .1 38 81 .8 12 8. 2 53 4. 1 10 2. 8 40 1. 3 71 .2 13 2. 7 31 .6 Bu lg ar ia 13 4. 7 10 2. 4 11 24 .0 77 .7 30 18 .7 16 4. 5 33 5. 0 10 9. 0 22 3. 6 70 .2 11 1. 4 38 .8 La tv ia 11 2. 6 81 .8 11 45 .7 71 .4 26 01 .2 –1 2. 6 56 6. 3 19 9. 7 35 5. 7 12 1. 0 21 0. 7 78 .6 21 Co un tr y li ve r li ve r Ca nc er Ca nc er Cv d Cv d A A in ju ry in ju ry u ni nt en t. u ni nt en t. in te nt . in te nt . ci rr ho si s ci rr ho si s A A A A in ju ry in ju ry in ju ry in ju ry A A A A A A (r an ki ng b y ov er al l A A m or ta lit y ra te ) Sl ov en ia 15 5. 7 11 3. 5 11 65 .6 77 .6 12 00 .1 23 .8 41 0. 7 14 5. 1 24 3. 1 79 .8 16 7. 7 65 .3 Cr oa tia 15 2. 4 11 2. 9 13 31 .1 94 .2 17 95 .7 33 .4 37 7. 3 10 5. 4 24 0. 0 64 .2 13 7. 3 41 .2 M on te ne gr o 42 .8 31 .3 11 21 .1 57 .8 29 17 .5 14 4. 2 39 5. 8 10 0. 6 20 6. 3 49 .4 18 9. 4 51 .1 Ar m en ia 20 5. 9 10 4. 4 12 44 .5 46 .3 25 45 .8 57 .5 38 5. 9 11 2. 0 27 7. 2 76 .3 10 8. 6 35 .7 Fr an ce 91 .5 64 .1 11 77 .6 80 .9 73 9. 0 17 .2 36 6. 8 13 2. 8 22 4. 3 74 .8 14 2. 6 58 .0 Cz ec h Re pu bl ic 12 1. 1 93 .6 12 68 .7 90 .1 17 85 .5 –4 .7 34 3. 1 12 4. 0 22 1. 1 75 .8 12 2. 0 48 .2 Be lg iu m 85 .3 60 .7 11 33 .2 69 .0 95 3. 0 8. 6 37 6. 7 13 7. 7 21 9. 1 74 .9 15 7. 6 62 .8 De nm ar k 11 4. 2 76 .2 10 93 .9 58 .9 10 17 .1 –2 .1 25 7. 4 86 .8 15 0. 9 50 .8 10 5. 7 37 .3 Po rtu ga l 11 7. 1 81 .2 10 78 .7 74 .6 98 8. 3 49 .5 30 1. 4 79 .6 19 2. 2 47 .9 10 9. 2 31 .7 Au st ria 11 9. 3 76 .0 10 75 .8 53 .3 11 39 .2 12 .8 28 4. 8 11 0. 4 16 4. 3 62 .2 12 0. 5 48 .2 Ge rm an y 10 8. 1 73 .6 11 06 .2 67 .0 11 54 .7 13 .6 23 1. 8 10 3. 0 13 4. 6 57 .1 97 .2 45 .9 Fi nl an d 12 1. 4 84 .1 89 7. 8 44 .2 12 00 .4 –5 .8 36 6. 0 11 7. 7 19 6. 2 60 .6 16 9. 8 57 .1 Ire la nd 50 .2 33 .2 10 75 .5 56 .3 11 03 .8 35 .7 23 2. 2 97 .3 13 3. 1 51 .8 99 .1 45 .4 Az er ba ija n 26 0. 0 10 6. 5 76 6. 4 28 .1 31 29 .2 63 .0 31 9. 6 59 .2 24 8. 7 43 .8 70 .9 15 .5 Gr ee ce 46 .1 28 .7 10 68 .4 42 .5 14 83 .4 39 .5 25 0. 6 96 .4 20 9. 8 79 .4 40 .8 17 .0 Sp ai n 85 .5 55 .5 10 16 .5 59 .4 82 5. 9 25 .2 20 4. 9 75 .1 14 3. 3 50 .4 61 .6 24 .7 Se rb ia 59 .3 43 .6 11 41 .5 73 .8 20 81 .4 67 .6 32 2. 2 50 .8 17 9. 3 26 .1 14 2. 9 24 .6 Un ite d Ki ng do m 80 .7 57 .3 11 10 .4 63 .8 97 1. 1 10 .1 17 6. 9 74 .2 11 2. 9 44 .9 63 .9 29 .3 T a jik is ta n 25 1. 8 10 1. 5 67 6. 5 22 .4 35 65 .8 10 5. 3 42 5. 3 24 .2 33 3. 5 17 .8 91 .8 6. 4 Sw ed en 49 .6 31 .3 94 3. 3 40 .9 11 29 .7 14 .8 25 1. 8 89 .8 13 1. 1 44 .2 12 0. 7 45 .6 Bo sn ia a nd He rz eg ov in a 71 .3 43 .3 11 34 .4 44 .8 20 01 .3 59 .8 22 7. 0 52 .4 12 1. 2 25 .1 10 5. 7 27 .2 Ta bl e 1 co nt d 22 AA : a lco ho l-a ttr ib ut ab le ; i nt en t.: in te nt io na l; un in te nt .: un in te nt io na l; gr ee n hi gh lig ht ed co un tri es h av e th e lo w es t a ge -s ta nd ar di ze d al co ho l-a ttr ib ut ab le m or ta lit y r at es (5 lo w es t r at es ); re d hi gh lig ht ed c ou nt rie s ha ve th e hi gh es t s ta nd ar di ze d al co ho l-a ttr ib ut ab le m or ta lit y ra te s fo r t he re sp ec tiv e ca te go rie s (1 0 hi gh es t r at es ). (r an ki ng b y ov er al l A A m or ta lit y ra te ) Co un tr y li ve r li ve r Ca nc er Ca nc er Cv d Cv d A A in ju ry in ju ry u ni nt en t. u ni nt en t. in te nt . in te nt . ci rr ho si s ci rr ho si s A A A A in ju ry in ju ry in ju ry in ju ry A A A A A A N et he rla nd s 47 .8 29 .9 13 01 .3 62 .4 89 4. 5 5. 7 21 7. 8 72 .5 12 7. 6 39 .5 90 .2 33 .0 Ita ly 80 .1 44 .9 10 57 .6 47 .2 88 0. 0 14 .8 21 1. 7 68 .0 15 4. 9 48 .5 56 .8 19 .5 M al ta 41 .9 25 .1 87 6. 6 39 .4 10 37 .9 36 .0 15 6. 6 57 .4 10 7. 4 37 .3 49 .2 20 .0 Al ba ni a 8. 8 4. 5 10 00 .1 32 .1 25 88 .3 44 .1 44 6. 4 66 .3 31 3. 1 45 .2 13 3. 3 21 .1 Sw itz er la nd 50 .5 31 .8 94 9. 0 50 .1 81 6. 6 –1 9. 0 25 6. 3 70 .2 13 5. 3 35 .6 12 1. 0 34 .6 Cy pr us 33 .9 22 .1 66 4. 8 28 .5 94 4. 7 19 .6 18 8. 9 66 .1 15 7. 8 54 .2 31 .1 11 .9 N or w ay 36 .4 20 .3 10 33 .6 34 .7 91 4. 9 –3 2. 8 26 6. 2 73 .5 15 9. 7 42 .4 10 6. 5 31 .2 Th e fo rm er Yu go sl av R ep ub lic of M ac ed on ia 58 .8 25 .0 11 15 .3 32 .7 27 76 .6 21 .8 25 7. 3 39 .1 16 4. 8 24 .1 92 .6 14 .9 Ic el an d 13 .0 6. 6 92 4. 4 24 .3 88 8. 2 –2 2. 6 20 9. 2 74 .6 11 0. 2 37 .3 99 .1 37 .3 Is ra el 48 .6 17 .7 91 2. 9 23 .6 74 7. 1 1. 7 23 8. 8 41 .5 15 5. 0 23 .1 83 .8 18 .4 Tu rk ey 54 .7 14 .7 11 61 .0 15 .0 17 07 .5 36 .0 30 2. 8 21 .8 23 0. 2 16 .2 72 .5 5. 6 Ta bl e 1 co nt d 23 Burden of alcohol-attributable mortality in the WHO European Region, 1990–2014 Fig. 18. Trends in age-standardized adult mortality due to alcohol-attributable liver cirrhosis for ireland and the united Kingdom, 1990–2014 Since early in the twenty-first century, all countries in central-western Europe have lower liver cirrhosis rates than the WHO Region as whole (Fig. 19). Austria, Denmark, France and Germany, all of which had higher rates in the earlier years of the observation period, have all reduced mortality due to alcohol-attributable liver cirrhosis, consistent with their consumption levels (see Fig. 2). Fig. 19. Trends in age-standardized adult mortality due to alcohol-attributable liver cirrhosis for Austria, Belgium, denmark, France, germany, the netherlands and Switzerland, 1990–2014 After 2005, all Mediterranean countries had lower liver cirrhosis mortality rates than the WHO European Region average (Fig. 20). In 1990, Italy, Portugal and Spain had higher rates, but with the continuous decline in adult per capita consumption in these traditionally wine-drinking countries, the liver cirrhosis rates also declined, starting more than a decade before 1990 (157). 0 20 40 60 80 100 120 WHO Euro United KingdomIreland 2014201220102008200620042002200019981996199419921990 WHO European Region United Kingdom Ireland Ra te p er m ill io n 0 20 40 60 80 100 120 2014201220102008200620042002200019981996199419921990 Denmark France Germany Netherlands Switzerland WHO European Region Belgium Austria Ra te p er m ill io n 24 Public health successes and missed opportunities Fig. 20. Trends in age-standardized adult mortality due to alcohol-attributable liver cirrhosis for Cyprus, greece, israel, italy, malta, Portugal and Spain, 1990–2014 All countries from the central-eastern EU region have higher liver cirrhosis mortality rates than the WHO European Region average, albeit to different degrees. The rates are highest in countries where spirits made of fruits with pits have some market share (Hungary, Romania, Slovakia and Slovenia; see earlier the discussion on page 19 on the pit fruit hypothesis (90,141)). However, there is some indication that the highest rates have been decreasing in the past 5 years (see Fig. 21). Fig. 21. Trends in age-standardized adult mortality due to alcohol-attributable liver cirrhosis for the Czech Republic, Hungary, Poland, Romania, Slovakia and Slovenia, 1990–2014 As with level of consumption (see Fig. 5), mortality due to alcohol-attributable liver cirrhosis in Finland is close to the average rate of the WHO European Region. The other Nordic countries are still markedly below this rate, despite slight increases (see Fig. 22). Iceland is among the countries with the lowest liver cirrhosis mortality rates not only in Europe but globally. 0 20 40 60 80 100 120 140 160 2014201220102008200620042002200019981996199419921990 Israel Italy Malta Portugal Spain WHO European Region Greece Cyprus Ra te p er m ill io n 0 50 100 150 200 250 300 350 400 450 500 2014201220102008200620042002200019981996199419921990 Poland Romania Slovakia Slovenia WHO European Region Hungary Czech Republic Ra te p er m ill io n 25 Burden of alcohol-attributable mortality in the WHO European Region, 1990–2014 Fig. 22. Trends in age-standardized adult mortality due to alcohol-attributable liver cirrhosis for Finland, iceland, norway and Sweden, 1990–2014 Although all eastern European countries displayed in Fig. 23 except the Republic of Moldova started with alcohol- attributable liver cirrhosis rates below the average of the WHO European Region, since the turn of the century, their rates are considerably higher. For the past few years, liver cirrhosis rates have been going down in most of these countries, and as a consequence, alcohol-attributable rates have been going down as well. There is no clear reason for this phenomenon in the countries in Fig. 23, but the rates seemed to go down when economic recession started, and the countries in Fig. 23 were hit very hard by recession. Economic recession is linked to consumption in a complex way (58), but overall evidence supports a causal effect that due to tighter budget constraints, less money is spent on alcoholic beverages. Such an effect would be most relevant for countries with lower economic wealth such as those in the eastern part of the EU (at least within Europe). However, although consumption levels in these countries in the central and eastern part of the WHO European Region went up again after the recession was over (Fig. 6), liver cirrhosis rates continued to decline. Fig. 23. Trends in age-standardized adult mortality due to alcohol-attributable liver cirrhosis for Belarus, estonia, latvia, lithuania, the Republic of moldova and ukraine, 1990–2014 0 20 40 60 80 100 120 WHO Euro Sweden Norway 2014201220102008200620042002200019981996199419921990 Norway Sweden WHO European Region Iceland Finland Ra te p er m ill io n 0 50 100 150 200 250 300 350 400 450 WHO Euro Ukraine Moldova Lithuania Latvia Estonia Belarus 2014201220102008200620042002200019981996199419921990 Latvia Lithuania Republic of Moldova Ukraine WHO European Region Estonia Belarus Ra te p er m ill io n 26 Public health successes and missed opportunities The Russian Federation seems to follow the trend of other eastern European countries with increase in liver cirrhosis rates over the past 25 years, surpassing the WHO European Region average around the year 2000, and decreasing again in recent years, albeit not down to the level of the Region (compare Fig. 24 and Fig. 23). Fig. 24. Trends in age-standardized adult mortality due to alcohol-attributable liver cirrhosis the Russian Federation, 1990–2014 As with consumption (see Fig. 8), countries in central south-eastern Europe are both below and above the WHO European Region average for alcohol-attributable liver cirrhosis mortality (Fig. 25). Croatia has the highest rate, and has a relatively high production of spirits from fruits with stones (see page 19). Fig. 25. Trends in age-standardized adult mortality due to alcohol-attributable liver cirrhosis for Albania, Bosnia and Herzegovina, Bulgaria, Croatia, montenegro, Serbia, and the former yugoslav Republic of macedonia, 1990–2014 In 2014, all of the countries in the south-eastern part of the WHO European Region with the exception of Turkey had higher alcohol-attributable liver cirrhosis mortality rates (Fig. 26), even though their consumption was lower than the regional average (Fig. 9). As already mentioned, this phenomenon can be partly explained by liver cirrhosis due to risk 0 20 40 60 80 100 120 140 160 180 WHO Euro Russian Federation 2014201220102008200620042002200019981996199419921990 WHO Euro WHO European Region Russian Federation Ra te p er m ill io n 0 50 100 150 200 250 WHO Euro Macedonia Serbia Montenegro Croatia Bulgaria Bosnia & Herzegovina Albania 2014201220102008200620042002200019981996199419921990 Bulgaria Croatia Montenegro Serbia The former Yugoslav Republic of Macedonia WHO European Region Bosnia and Herzegovina Albania Ra te p er m ill io n 27 Burden of alcohol-attributable mortality in the WHO European Region, 1990–2014 factors along with the use of alcohol, with alcohol also playing a role in the mortality. It should also be noted that the methodology used for comparative risk assessment did not adequately control for other risk factors. Fig. 26. Trends in age-standardized adult mortality due to alcohol-attributable liver cirrhosis Armenia, Azerbaijan, georgia, Kazakhstan, Kyrgyzstan, Tajikistan, Turkey, Turkmenistan and uzbekistan, 1990–2014 BuRden OF mORTAliTy due TO AlCOHOl-ATTRiBuTABle CAnCeR Fig. 27–35 show the age-standardized mortality rates for alcohol-attributable cancer for the various clusters of countries. As indicated above, the overall variability in cancer mortality rates, both within and between countries, is much lower than for other cause-of-death categories; thus, the variation in mortality due to alcohol-attributable cancer is mainly based on differences in the level of overall alcohol exposure (as expressed in adult per capita consumption of alcohol; see above). As a result, despite the overall limited variation, the following regional tendencies can be distinguished: most Mediterranean, Nordic, central-western EU and south-eastern WHO European Region countries were below the WHO European Region average, whereas most of the central-eastern EU and eastern European countries including the Russian Federation were above the EU average. 0 50 100 150 200 250 300 350 WHO Euro Uzbekistan Turkey Turkmenistan Tajikistan Kyrgyzstan Kazakhstan Georgia Azerbaijan Armenia 2014201220102008200620042002200019981996199419921990 Georgia Kazakhstan Kyrgyzstan Tajikistan Turkmenistan Turkey Uzbekistan WHO European Region Azerbaijan Armenia Ra te p er m ill io n 28 Public health successes and missed opportunities Fig. 27. Trends in age-standardized adult mortality due to alcohol-attributable cancer for ireland and the united Kingdom, 1990–2014 Fig. 28. Trends in age-standardized adult mortality due to alcohol-attributable cancer for Austria, Belgium, denmark, France, germany, the netherlands and Switzerland, 1990–2014 0 10 20 30 40 50 60 70 80 WHO Euro United Kingdom Ireland 2014201220102008200620042002200019981996199419921990 WHO European Region United Kingdom Ireland Ra te p er m ill io n 0 20 40 60 80 100 120 2014201220102008200620042002200019981996199419921990 Denmark France Germany Netherlands Switzerland WHO European Region Belgium Austria Ra te p er m ill io n 29 Burden of alcohol-attributable mortality in the WHO European Region, 1990–2014 Fig. 29. Trends in age-standardized adult mortality due to alcohol-attributable cancer for Cyprus, greece, israel, italy, malta, Portugal and Spain, 1990–2014 Fig. 30. Trends in age-standardized adult mortality due to alcohol-attributable cancer for the Czech Republic, Hungary, Poland, Romania, Slovakia and Slovenia, 1990–2014 0 10 20 30 40 50 60 70 80 90 2014201220102008200620042002200019981996199419921990 Israel Italy Malta Portugal Spain WHO European Region Greece Cyprus Ra te p er m ill io n 0 20 40 60 80 100 120 140 160 180 200 2014201220102008200620042002200019981996199419921990 Poland Romania Slovakia Slovenia WHO European Region Hungary Czech Republic Ra te p er m ill io n 30 Public health successes and missed opportunities Fig. 31. Trends in age-standardized adult mortality due to alcohol-attributable cancer for Finland, iceland, norway and Sweden, 1990–2014 Fig. 32. Trends in age-standardized adult mortality due to alcohol-attributable cancer for Belarus, estonia, latvia, lithuania, the Republic of moldova and ukraine, 1990–2014 0 10 20 30 40 50 60 70 80 WHO Euro Sweden Norway 2014201220102008200620042002200019981996199419921990 Norway Sweden WHO European Region Iceland Finland Ra te p er m ill io n 0 20 40 60 80 100 120 WHO Euro Ukraine Moldova 2014201220102008200620042002200019981996199419921990 Latvia Lithuania Republic of Moldova Ukraine WHO European Region Estonia Belarus Ra te p er m ill io n 31 Burden of alcohol-attributable mortality in the WHO European Region, 1990–2014 Fig. 33. Trends in age-standardized adult mortality due to alcohol-attributable cancer for the Russian Federation, 1990–2014 Fig. 34. Trends in age-standardized adult mortality due to alcohol-attributable cancer for Albania, Bosnia and Herzegovina, Bulgaria, Croatia, montenegro, Serbia and the former yugoslav Republic of macedonia, 1990–2014 0 20 40 60 80 100 120 WHO Euro Russian Federation 2014201220102008200620042002200019981996199419921990 WHO Euro WHO European Region Russian Federation Ra te p er m ill io n 0 20 40 60 80 100 120 140 WHO Euro Macedonia Serbia 2014201220102008200620042002200019981996199419921990 Bulgaria Croatia Montenegro Serbia The former Yugoslav Republic of Macedonia WHO European Region Bosnia and Herzegovina Albania Ra te p er m ill io n 32 Public health successes and missed opportunities Fig. 35. Trends in age-standardized adult mortality due to alcohol-attributable cancer for Armenia, Azerbaijan, georgia, Kazakhstan, Kyrgyzstan, Tajikistan, Turkey, Turkmenistan and uzbekistan, 1990–2014 BuRden OF mORTAliTy due TO AlCOHOl-ATTRiBuTABle CARdiOvASCulAR diSeASeS Fig. 36–44 show the burden of mortality due to alcohol-attributable CVD for the different clusters of countries. It shows basically a dichotomous picture: the Russian Federation and some surrounding countries (Belarus, Kazakhstan, Kyrgyzstan, the Republic of Moldova and Ukraine) are considerably above the WHO European Region average, whereas most other countries are markedly below this average. Fig. 36. Trends in age-standardized adult mortality due to alcohol-attributable Cvd for ireland and the united Kingdom, 1990–2014 0 20 40 60 80 100 120 WHO Euro Uzbekistan Turkey 2014201220102008200620042002200019981996199419921990 Georgia Kazakhstan Kyrgyzstan Tajikistan Turkmenistan Turkey Uzbekistan WHO European Region Azerbaijan Armenia Ra te p er m ill io n -50 0 50 100 150 200 250 300 WHO Euro United Kingdom Ireland 2014201220102008200620042002200019981996199419921990 WHO European Region United Kingdom Ireland Ra te p er m ill io n 33 Burden of alcohol-attributable mortality in the WHO European Region, 1990–2014 Fig. 37. Trends in age-standardized adult mortality due to alcohol-attributable Cvd for Austria, Belgium, denmark, France, germany, the netherlands and Switzerland, 1990–2014 Fig. 38. Trends in age-standardized adult mortality due to alcohol-attributable Cvd for Cyprus, greece, israel, italy, malta, Portugal and Spain, 1990–2014 -100 -50 0 50 100 150 200 250 300 2014201220102008200620042002200019981996199419921990 Denmark France Germany Netherlands Switzerland WHO European Region Belgium Austria Ra te p er m ill io n -50 0 50 100 150 200 250 300 2014201220102008200620042002200019981996199419921990 Israel Italy Malta Portugal Spain WHO European Region Greece Cyprus Ra te p er m ill io n 34 Public health successes and missed opportunities Fig. 39. Trends in age-standardized adult mortality due to alcohol-attributable Cvd for the Czech Republic, Hungary, Poland, Romania, Slovakia and Slovenia, 1990–2014 Fig. 40. Trends in age-standardized adult mortality due to alcohol-attributable Cvd for Finland, iceland, norway and Sweden, 1990–2014 -50 0 50 100 150 200 250 300 2014201220102008200620042002200019981996199419921990 Poland Romania Slovakia Slovenia WHO European Region Hungary Czech Republic Ra te p er m ill io n -150 -100 -50 0 50 100 150 200 250 300 WHO Euro Sweden Norway 2014201220102008200620042002200019981996199419921990 Norway Sweden WHO European Region Iceland Finland Ra te p er m ill io n 35 Burden of alcohol-attributable mortality in the WHO European Region, 1990–2014 Fig. 41. Trends in age-standardized adult mortality due to alcohol-attributable Cvd for Belarus, estonia, latvia, lithuania, the Republic of moldova and ukraine, 1990–2014 Fig. 42. Trends in age-standardized adult mortality due to alcohol-attributable Cvd for the Russian Federation, 1990–2014 -200 0 200 400 600 800 1000 1200 1400 WHO Euro Ukraine Moldova 2014201220102008200620042002200019981996199419921990 Latvia Lithuania Republic of Moldova Ukraine WHO European Region Estonia Belarus Ra te p er m ill io n 0 200 400 600 800 1000 1200 WHO Euro Russian Federation 2014201220102008200620042002200019981996199419921990 WHO Euro WHO European Region Russian Federation Ra te p er m ill io n 36 Public health successes and missed opportunities Fig. 43. Trends in age-standardized adult mortality due to alcohol-attributable Cvd for Albania, Bosnia and Herzegovina, Bulgaria, Croatia, montenegro, Serbia and the former yugoslav Republic of macedonia, 1990–2014 Fig. 44. Trends in age-standardized adult mortality due to alcohol-attributable Cvd for Armenia, Azerbaijan, georgia, Kazakhstan, Kyrgyzstan, Tajikistan, Turkey, Turkmenistan and uzbekistan, 1990–2014 BuRden OF mORTAliTy due TO AlCOHOl-ATTRiBuTABle injuRy The burden of mortality due to injury has been decreasing over the past decades, both globally and in Europe (158). As Fig. 45–53 show for all injuries, Fig. 54–62 for intentional injury and Fig. 63–71 for unintentional injury, the same is true for mortality from alcohol-attributable injury,18 albeit to a substantially lesser degree (decrease in age-standardized mortality rate for all injury: –25%, alcohol-attributable: –19%; for intentional injury: –9%, alcohol-attributable: –5%; for unintentional injury: –33%, alcohol-attributable: –27%). 0 50 100 150 200 250 300 WHO Euro Macedonia Serbia 2014201220102008200620042002200019981996199419921990 Bulgaria Croatia Montenegro Serbia The former Yugoslav Republic of Macedonia WHO European Region Bosnia and Herzegovina Albania Ra te p er m ill io n -50 0 50 100 150 200 250 300 350 WHO Euro Uzbekistan Turkey 2014201220102008200620042002200019981996199419921990 Georgia Kazakhstan Kyrgyzstan Tajikistan Turkmenistan Turkey Uzbekistan WHO European Region Azerbaijan Armenia Ra te p er m ill io n 18 The trend was characterized by an increase in age-standardized mortality first, with the decrease happening in the past decade. 37 Burden of alcohol-attributable mortality in the WHO European Region, 1990–2014 Moreover, it is striking that the countries with the highest mortality due to alcohol-attributable injury seem to have a lesser reduction in mortality rates (see also for regions below) and, in some cases, the rates have even increased: for the WHO European Region, the standardized mortality rate for all alcohol-attributable injury decreased by 19%, but in the three countries with the highest such mortality, one had a marked increase (Belarus: +41%), one a slight decrease (the Russian Federation: –5%) and one about the average decrease (Ukraine: –17%). For intentional injury, the overall decrease was 5%, but in all the three countries, the age-standardized mortality due to alcohol-attributable intentional injury increased (Belarus: +61%; the Russian Federation: +10%; Ukraine: +1%). Finally, for unintentional injury, the overall decrease was –27%, with a 27% increase in Belarus, and decreases of 17% and 28% in the Russian Federation and Ukraine, respectively. Fig. 45. Trends in age-standardized adult mortality due to alcohol-attributable injury for ireland and the united Kingdom, 1990–2014 Fig. 46. Trends in age-standardized adult mortality due to alcohol-attributable injury for Austria, Belgium, denmark, France, germany, the netherlands and Switzerland, 1990–2014 0 50 100 150 200 250 300 350 WHO Euro United Kingdom Ireland 2014201220102008200620042002200019981996199419921990 WHO European Region United Kingdom Ireland Ra te p er m ill io n 0 50 100 150 200 250 300 350 2014201220102008200620042002200019981996199419921990 Denmark France Germany Netherlands Switzerland WHO European Region Belgium Austria Ra te p er m ill io n 38 Public health successes and missed opportunities Fig. 47. Trends in age-standardized adult mortality due to alcohol-attributable injury for Cyprus, greece, israel, italy, malta, Portugal and Spain, 1990–2014 Fig. 48. Trends in age-standardized adult mortality due to alcohol-attributable injury for the Czech Republic, Hungary, Poland, Romania, Slovakia and Slovenia, 1990–2014 0 50 100 150 200 250 300 350 2014201220102008200620042002200019981996199419921990 Israel Italy Malta Portugal Spain WHO European Region Greece Cyprus Ra te p er m ill io n 0 50 100 150 200 250 300 350 2014201220102008200620042002200019981996199419921990 Poland Romania Slovakia Slovenia WHO European Region Hungary Czech Republic Ra te p er m ill io n 39 Burden of alcohol-attributable mortality in the WHO European Region, 1990–2014 Fig. 49. Trends in age-standardized adult mortality due to alcohol-attributable injury for Finland, iceland, norway and Sweden, 1990–2014 Fig. 50. Trends in age-standardized adult mortality due to alcohol-attributable injury for Belarus, estonia, latvia, lithuania, the Republic of moldova and ukraine, 1990–2014 0 50 100 150 200 250 300 350 WHO Euro Sweden Norway 2014201220102008200620042002200019981996199419921990 Norway Sweden WHO European Region Iceland Finland Ra te p er m ill io n 0 100 200 300 400 500 600 700 800 WHO Euro Ukraine Moldova 2014201220102008200620042002200019981996199419921990 Latvia Lithuania Republic of Moldova Ukraine WHO European Region Estonia Belarus Ra te p er m ill io n 40 Public health successes and missed opportunities Fig. 51. Trends in age-standardized adult mortality due to alcohol-attributable injury for the Russian Federation, 1990–2014 Fig. 52. Trends in age-standardized adult mortality due to alcohol-attributable injury for Albania, Bosnia and Herzegovina, Bulgaria, Croatia, montenegro, Serbia and the former yugoslav Republic of macedonia, 1990–2014 0 200 400 600 800 1000 1200 WHO Euro Russian Federation 2014201220102008200620042002200019981996199419921990 WHO Euro WHO European Region Russian Federation Ra te p er m ill io n 0 50 100 150 200 250 300 350 WHO Euro Macedonia Serbia 2014201220102008200620042002200019981996199419921990 Bulgaria Croatia Montenegro Serbia The former Yugoslav Republic of Macedonia WHO European Region Bosnia and Herzegovina Albania Ra te p er m ill io n 41 Burden of alcohol-attributable mortality in the WHO European Region, 1990–2014 Fig. 53. Trends in age-standardized adult mortality due to alcohol-attributable injury for Armenia, Azerbaijan, georgia, Kazakhstan, Kyrgyzstan, Tajikistan, Turkey, Turkmenistan and uzbekistan, 1990–2014 BuRden OF mORTAliTy due TO AlCOHOl-ATTRiBuTABle uninTenTiOnAl injuRy Fig. 54. Trends in age-standardized adult mortality due to alcohol-attributable unintentional injury for ireland and the united Kingdom, 1990–2014 0 50 100 150 200 250 300 350 400 450 WHO Euro Uzbekistan Turkey 2014201220102008200620042002200019981996199419921990 Georgia Kazakhstan Kyrgyzstan Tajikistan Turkmenistan Turkey Uzbekistan WHO European Region Azerbaijan Armenia Ra te p er m ill io n 0 20 40 60 80 100 120 140 160 180 200 WHO Euro United Kingdom Ireland 2014201220102008200620042002200019981996199419921990 WHO European Region United Kingdom Ireland Ra te p er m ill io n 42 Public health successes and missed opportunities Fig. 55. Trends in age-standardized adult mortality due to alcohol-attributable unintentional injury for Austria, Belgium, denmark, France, germany, the netherlands and Switzerland, 1990–2014 Fig. 56. Trends in age-standardized adult mortality due to alcohol-attributable unintentional injury for Cyprus, greece, israel, italy, malta, Portugal and Spain, 1990–2014 0 20 40 60 80 100 120 140 160 180 200 2014201220102008200620042002200019981996199419921990 Denmark France Germany Netherlands Switzerland WHO European Region Belgium Austria Ra te p er m ill io n 0 20 40 60 80 100 120 140 160 180 200 2014201220102008200620042002200019981996199419921990 Israel Italy Malta Portugal Spain WHO European Region Greece Cyprus Ra te p er m ill io n 43 Burden of alcohol-attributable mortality in the WHO European Region, 1990–2014 Fig. 57. Trends in age-standardized adult mortality due to alcohol-attributable unintentional injury for the Czech Republic, Hungary, Poland, Romania, Slovakia and Slovenia, 1990–2014 Fig. 58. Trends in age-standardized adult mortality due to alcohol-attributable unintentional injury for Finland, iceland, norway and Sweden, 1990–2014 0 50 100 150 200 250 2014201220102008200620042002200019981996199419921990 Poland Romania Slovakia Slovenia WHO European Region Hungary Czech Republic Ra te p er m ill io n 0 20 40 60 80 100 120 140 160 180 200 WHO Euro Sweden Norway 2014201220102008200620042002200019981996199419921990 Norway Sweden WHO European Region Iceland Finland Ra te p er m ill io n 44 Public health successes and missed opportunities Fig. 59. Trends in age-standardized adult mortality due to alcohol-attributable unintentional injury for Belarus, estonia, latvia, lithuania, the Republic of moldova and ukraine, 1990–2014 Fig. 60. Trends in age-standardized adult mortality due to alcohol-attributable unintentional injury for the Russian Federation, 1990–2014 0 50 100 150 200 250 300 350 400 450 500 WHO Euro Ukraine Moldova 2014201220102008200620042002200019981996199419921990 Latvia Lithuania Republic of Moldova Ukraine WHO European Region Estonia Belarus Ra te p er m ill io n 0 100 200 300 400 500 600 WHO Euro Russian Federation 2014201220102008200620042002200019981996199419921990 WHO Euro WHO European Region Russian Federation Ra te p er m ill io n 45 Burden of alcohol-attributable mortality in the WHO European Region, 1990–2014 Fig. 61. Trends in age-standardized adult mortality due to alcohol-attributable unintentional injury for Albania, Bosnia and Herzegovina, Bulgaria, Croatia, montenegro, Serbia and the former yugoslav Republic of macedonia, 1990–2014 Fig. 62. Trends in age-standardized adult mortality due to alcohol-attributable unintentional injury forArmenia, Azerbaijan, georgia, Kazakhstan, Kyrgyzstan, Tajikistan, Turkey, Turkmenistan and uzbekistan, 1990–2014 0 20 40 60 80 100 120 140 160 180 200 WHO Euro Macedonia Serbia 2014201220102008200620042002200019981996199419921990 Bulgaria Croatia Montenegro Serbia The former Yugoslav Republic of Macedonia WHO European Region Bosnia and Herzegovina Albania Ra te p er m ill io n 0 50 100 150 200 250 WHO Euro Uzbekistan Turkey 2014201220102008200620042002200019981996199419921990 Georgia Kazakhstan Kyrgyzstan Tajikistan Turkmenistan Turkey Uzbekistan WHO European Region Azerbaijan Armenia Ra te p er m ill io n 46 Public health successes and missed opportunities BuRden OF mORTAliTy due TO AlCOHOl-ATTRiBuTABle inTenTiOnAl injuRy Fig. 63. Trends in age-standardized adult mortality due to alcohol-attributable intentional injury for ireland and the united Kingdom, 1990–2014 Fig. 64. Trends in age-standardized adult mortality due to alcohol-attributable intentional injury for Austria, Belgium, denmark, France, germany, the netherlands and Switzerland, 1990–2014 0 20 40 60 80 100 120 140 160 WHO Euro United Kingdom Ireland 2014201220102008200620042002200019981996199419921990 WHO European Region United Kingdom Ireland Ra te p er m ill io n 0 20 40 60 80 100 120 140 160 2014201220102008200620042002200019981996199419921990 Denmark France Germany Netherlands Switzerland WHO European Region Belgium Austria Ra te p er m ill io n 47 Burden of alcohol-attributable mortality in the WHO European Region, 1990–2014 Fig. 65. Trends in age-standardized adult mortality due to alcohol-attributable intentional injury for Cyprus, greece, israel, italy, malta, Portugal and Spain, 1990–2014 Fig. 66. Trends in age-standardized adult mortality due to alcohol-attributable intentional injury for the Czech Republic, Hungary, Poland, Romania, Slovakia and Slovenia, 1990–2014 0 20 40 60 80 100 120 140 160 2014201220102008200620042002200019981996199419921990 Israel Italy Malta Portugal Spain WHO European Region Greece Cyprus Ra te p er m ill io n 0 20 40 60 80 100 120 140 160 2014201220102008200620042002200019981996199419921990 Poland Romania Slovakia Slovenia WHO European Region Hungary Czech Republic Ra te p er m ill io n 48 Public health successes and missed opportunities Fig. 67. Trends in age-standardized adult mortality due to alcohol-attributable intentional injury for Finland, iceland, norway and Sweden, 1990–2014 Fig. 68. Trends in age-standardized adult mortality due to alcohol-attributable intentional injury for Belarus, estonia, latvia, lithuania, the Republic of moldova and ukraine, 1990–2014 0 20 40 60 80 100 120 140 160 WHO Euro Sweden Norway 2014201220102008200620042002200019981996199419921990 Norway Sweden WHO European Region Iceland Finland Ra te p er m ill io n 0 50 100 150 200 250 300 350 WHO Euro Ukraine Moldova 2014201220102008200620042002200019981996199419921990 Latvia Lithuania Republic of Moldova Ukraine WHO European Region Estonia Belarus Ra te p er m ill io n 49 Burden of alcohol-attributable mortality in the WHO European Region, 1990–2014 Fig. 69. Trends in age-standardized adult mortality due to alcohol-attributable intentional injury for the Russian Federation, 1990–2014 Fig. 70. Trends in age-standardized adult mortality due to alcohol-attributable intentional injury for Albania, Bosnia and Herzegovina, Bulgaria, Croatia, montenegro, Serbia and the former yugoslav Republic of macedonia, 1990–2014 0 100 200 300 400 500 600 WHO Euro Russian Federation 2014201220102008200620042002200019981996199419921990 WHO Euro WHO European Region Russian Federation Ra te p er m ill io n 0 20 40 60 80 100 120 140 160 WHO Euro Macedonia Serbia 2014201220102008200620042002200019981996199419921990 Bulgaria Croatia Montenegro Serbia The former Yugoslav Republic of Macedonia WHO European Region Bosnia and Herzegovina Albania Ra te p er m ill io n 50 Public health successes and missed opportunities Fig. 71. Trends in age-standardized adult mortality due to alcohol-attributable intentional injury for Armenia, Azerbaijan, georgia, Kazakhstan, Kyrgyzstan, Tajikistan, Turkey, Turkmenistan and uzbekistan, 1990–2014 RegiOnAl diFFeRenCeS in AlCOHOl-ATTRiBuTABle mORTAliTy OveRAll TRend in AlCOHOl-ATTRiBuTABle mORTAliTy BeTWeen 1990 And 2014 By mAjOR CAuSe-OF-deATH CATegORieS Fig. 72 gives an overview of the age-standardized alcohol-attributable mortality rates per million by major categories of cause of death at the beginning and the end of the observation period, i.e. 1990 and 2014. For the WHO European Region as a whole, there was higher alcohol-attributable mortality in 2014 than in 1990 (+4%), even though the overall consumption decreased slightly over this time period (see Fig. 10). The increase in attributable mortality burden was mainly driven by the mortality trends in the eastern WHO European Region (+22%) and in the south-eastern part of the WHO European Region (+65%, albeit from a relatively low level in 1990). On the other hand, alcohol consumption decreased in more affluent countries such as most parts of the EU, more in the Mediterranean (–27%) and the central- western (–25%) than in the central-eastern regions (–15%). The increase in the burden of alcohol-attributable mortality in the WHO European Region, despite a small decrease in overall per capita consumption, is due to a number of reasons: first and foremost, the exponential increase in mortality risk for many cause-of-death categories with increasing levels of average consumption (159–161), which led to a substantial increase in alcohol-attributable mortality, especially in regions where already high consumption levels per drinker further increased (see the eastern WHO European Region in Fig. 13 and 14). Second and related to this, heavy drinking occasions have a specific detrimental effect on cardiovascular and injury mortality, over and above the level of drinking (see also next paragraph). Finally, the Russian Federation and surrounding countries can be characterized by an overall raised adult mortality rate and low life expectancy (141,162), which had even led to a separate mortality stratum in the WHO classification (163,164). The decrease in alcohol-attributable mortality in the central-eastern EU countries was due to an overall decline in mortality rates in this region (141,162). Even with stable alcohol-attributable fractions or slightly increasing alcohol-attributable fractions, such a decline results in lower standardized rates. 0 50 100 150 200 WHO Euro Uzbekistan Turkey 2014201220102008200620042002200019981996199419921990 Georgia Kazakhstan Kyrgyzstan Tajikistan Turkmenistan Turkey Uzbekistan WHO European Region Azerbaijan Armenia Ra te p er m ill io n 51 Burden of alcohol-attributable mortality in the WHO European Region, 1990–2014 Fig. 72. Comparisons of age-standardized alcohol-attributable mortality for major causes of death, 1990 vs 2014, in the WHO european Region and selected subregions In terms of composition of causes of alcohol-attributable death (see Fig. 72), as indicated before, mortality rates due to cancer seem to be relatively stable. This is not surprising, given the considerable and varying lag time of two decades, especially of cancer sites where acetaldehyde plays a key role (165–168). While alcohol consumption plays an important part in cancer mortality, any change in alcohol consumption and thus also the potential effects of alcohol policy measures, will be evident in the long term, as could be seen from the major short-term policy changes such as the Gorbachev-era anti-alcohol campaign, which had no effect on cancer rates (169,170). Mortality due to liver cirrhosis moves predictably and almost instantly with changes in consumption (90), and is a good indicator of harmful drinking in a society (171,172) and thus is relevant for policy (156). However, if liver cirrhosis is to be used for monitoring harm or alcohol use, the impact of hepatitis B and C infections have to be taken into account as well (173), and the indicator should reflect the net impact of alcohol. The main drivers of marked changes in the burden of alcohol-attributable mortality in the WHO European Region are CVD and injuries. As for cardiovascular mortality, alcohol consumption has no marked impact as long as drinking is maintained at moderate levels. The beneficial effects on ischaemic diseases (104,174), described earlier, are almost negated by the detrimental effects on all other CVD (96). As a result, in 2014, the proportion of alcohol-attributable cardiovascular mortality was less than 5% of all alcohol-attributable mortality for the central-western part of the EU, about 12% for the Mediterranean countries, and 14% for the central-eastern part of the EU (for the EU as a whole, it was 10%). This cause-of-death category comprised 54% of all alcohol-attributable mortality in the eastern WHO European Region, and 36% in the WHO European Region as a whole. Cultures with both episodic and chronic heavy drinking will experience mainly detrimental effects, which are obviously most pronounced when very heavy binges are the dominant pattern of drinking for a large part of the population such as in the eastern WHO European Region during the observation period. (For individual large-scale studies, see (5,54,175,176); for discussion, see (110,177); for supporting aggregate-level studies, see (178–181).) Morbidity and mortality rates due to injury have been decreasing globally, including in the European Region (158). The speed of this decline may be halted and even reversed by alcohol consumption (see Fig. 72 and below; for a historical comparison of alcohol poisoning deaths in the Russian Federation, see (182)). It needs to be mentioned that mortality due to alcohol-attributable unintentional injury (i.e. alcohol poisoning) may be underestimated in countries with a high prevalence of heavy binge drinking (e.g. the Russian Federation (183–185); Estonia (186,187)). (For a discussion, see (188,189).) 0 200 400 600 800 1000 1200 1400 1600 intentional injury unintentional injury CVD cancer liver cirrhosis WHO European Region 2014 WHO European Region 1990 Mediterranean 2014 Mediterranean 1990 South-eastern WHO European Region 2014 South-eastern WHO European Region 1990 Central-western EU 2014 Central-western EU 1990 Eastern WHO European Region 2014 Eastern WHO European Region 1990 Central-eastern EU 2014 Central-eastern EU 1990 Rate per million 52 Public health successes and missed opportunities Sex-SPeCiFiC TRendS in AlCOHOl-ATTRiBuTABle mORTAliTy BeTWeen 1990 And 2014 By mAjOR CAuSe-OF-deATH CATegORieS Fig. 73 shows the alcohol-attributable cause-of-death rates separately by sex. In all countries, more alcohol is consumed by men compared to women, as men abstain less (see Fig. 13 and 14 for European Region and subregions). As a consequence, alcohol-attributable mortality is higher in men than in women. Overall, the ratio of male-to-female age- standardized rates of alcohol-attributable mortality for the WHO European Region is about 2:1 and has not changed much over the past 25 years (1990: 2.1:1; 2014: 2.0:1). The ratio varies for different causes of death (see Fig. 74–78 below), and by region, however. Whereas in most regions the ratio is around 2:1, countries in the south-eastern part of the European Region and Mediterranean countries have higher ratios. This reflects, in part, the correlation between gender inequality and proportion of alcohol consumed by women, which was –0.65 in 2010 for the WHO European Region (based on 44 countries with available data; 95% CI: –0.79 to 0.44; t = 5.4; P < 0.001); the higher the gender inequality, the lower the proportion of alcohol consumed by women).19 Fig. 73. Comparisons of age-standardized alcohol-attributable mortality for major causes of death, 1990 vs 2014, by sex in the WHO european Region and selected subregions WHO European Region Mediterranean South-eastern WHO European Region Central-western EU Eastern WHO European Region Central-eastern EU Rate per million 0-100 250 500 750 1000 1250 1500 1750 2000 1990 2014 1990 2014 1990 2014 1990 2014 1990 2014 1990 2014 1990 2014 1990 2014 1990 2014 1990 2014 1990 2014 1990 2014 Men Women Men Women Men Women Men Women Men Women Men Women intentional injury unintentional injury CVD cancer liver cirrhosis 19 Own calculations based on data for the WHO Global status report on alcohol and health (1) and the UN Gender Inequality Index (190). 53 Burden of alcohol-attributable mortality in the WHO European Region, 1990–2014 The proportional differences for men and women for 1990 versus 2014 are similar, albeit at a lower level for women. The same can be said for most of the full trend lines for sex-specific mortality rates, covering all years for the WHO European Region (see Fig. 74–78). Fig. 74 shows that standardized mortality rates due to liver cirrhosis fluctuate over time in concert, with rates among men about twofold higher than among women, and a slight tendency for this ratio to decrease over time (from 2.1 in 1990 to 1.8 in 2014). This standardized rate ratio may seem low, given the much higher average lifetime exposure to alcohol in men compared to women, and the exponential dose–response relationship (see (142) for lifetime exposure; and (87) for dose–response relationships between average drinking and liver cirrhosis mortality). However, there are also clear sex differences in acceleration of the risks for liver cirrhosis: women have a much higher risk of mortality due to liver cirrhosis for the same amount of drinking (87). Overall, mortality due to liver cirrhosis increased till about 2007 for both sexes, and decreased thereafter, as did per capita consumption (see Fig. 10), but while the WHO European Region trends converge, the trends in different countries do not show a close association between consumption and liver cirrhosis rates (see for instance the discussion before Fig. 23 for eastern European countries). Fig. 74. Trends in age-standardized rates of adult mortality due to alcohol-attributable liver cirrhosis in the WHO european Region, comparing men and women, 1990–2014 For cancer (Fig. 75) the ratio is almost the same (2:1), but it slightly increased over the time period (from 1.9 in 1990 to 2.2 in 2014). For CVD mortality, a completely different picture emerges, with the standardized mortality trend lines much closer together (ratios varied between 0.9 and 1.3 with no consistent trend), and for some time in the beginning of the study period, women had a higher rate of cardiovascular mortality compared to men (Fig. 76). As discussed earlier, the different levels and patterns of drinking have different impacts on cardiovascular mortality, and these impacts also differ by sex. Most importantly, for the curvilinear dose–response relationships between average volume of drinking and ischaemic heart disease outcomes, the relative minimum (i.e. the largest beneficial effect) is at lower alcohol exposure levels for women than for men (101,103). 0 20 40 60 80 100 120 140 WHO Euro Female WHO Euro Male 2014201220102008200620042002200019981996199419921990 WHO European Region Women WHO European Region Men Ra te p er m ill io n 54 Public health successes and missed opportunities Fig. 75. Trends in age-standardized rates of adult mortality due to alcohol-attributable cancer in the WHO european Region, comparing men and women, 1990–2014 Fig. 76. Trends in age-standardized rates of adult mortality due to alcohol-attributable Cvd in the WHO european Region, comparing men and women, 1990–2014 Fig. 77 and 78 compare standardized mortality ratios of unintentional (Fig. 77) and intentional injury (Fig. 78) by sex. First, the ratios are much higher (unintentional between 4.1 and 4.7; intentional between 3.6 and 4.4) compared to other causes of death, reflecting the overall higher injury risk for men compared to women, which was consistent for some time in all countries and regions globally (158,191). 0 20 40 60 80 100 120 WHO Euro Female WHO Euro Male 2014201220102008200620042002200019981996199419921990 WHO European Region Women WHO European Region Men Ra te p er m ill io n 0 50 100 150 200 250 300 WHO Euro Female WHO Euro Male 2014201220102008200620042002200019981996199419921990 WHO European Region Women WHO European Region Men Ra te p er m ill io n 55 Burden of alcohol-attributable mortality in the WHO European Region, 1990–2014 Fig. 77. Trends in age-standardized rates of mortality due to alcohol-attributable unintentional injury in the WHO european Region, comparing men and women, 1990–2014 Fig. 78. Trends in age-standardized rates of mortality due to alcohol-attributable intentional injury in the WHO european Region, comparing men and women, 1990–2014 TRendS in AlCOHOl-ATTRiBuTABle FRACTiOnS OF mORTAliTy Fig. 79 gives an overview of the temporal trends of overall alcohol-attributable fractions of mortality summed up over the different cause-of-death categories. Please note that these fractions are not fractions for all mortality; the denominator comprises only the deaths in the categories analysed. 0 50 100 150 200 250 300 350 WHO Euro Female WHO Euro Male 2014201220102008200620042002200019981996199419921990 WHO European Region Women WHO European Region Men Ra te p er m ill io n 0 50 100 150 200 250 WHO Euro Female WHO Euro Male 2014201220102008200620042002200019981996199419921990 WHO European Region Women WHO European Region Men Ra te p er m ill io n 56 Public health successes and missed opportunities Fig. 79. Trends in alcohol-attributable fractions of mortality in the WHO european Region and selected subregions, 1990–2014 As expected by the formula on attributable risk, the values closely follow the adult per capita alcohol consumption trends (see Fig. 10), albeit with a slightly higher variation between regions. Given this pattern, it is all the more surprising that in 2014, the Mediterranean countries, after a decade-long decline in consumption (8.0%), had an almost similar proportion of alcohol-attributable mortality compared to the south-eastern part of the WHO European Region with a high prevalence of people with Muslim faith (6.8%; see Fig. 79). RegiOnAl TRendS in Age-STAndARdiZed RATeS OF mAjOR CAuSe-OF-deATH CATegORieS, 1990–2014 Standardized liver cirrhosis rates have been and are the highest in central-eastern EU (see Fig. 80), a region with high overall consumption. However, consumption alone would not be enough to explain the rates. As indicated earlier, this is also the region where spirits based on fruits with pits are traditionally consumed (Hungary, Romania, Slovakia and Slovenia (90,141)). Alternatively, short-chain aliphatic alcohols contained in unrecorded products have been hypothesized as a possible explanation (192); but see (193,194). The increase in mortality due to alcohol-attributable liver cirrhosis in the south-eastern part of the WHO European Region is of concern. While some of this mortality may be overestimated based on global risk functions derived from meta- analyses, which may not apply to these countries with high rates of mortality due to hepatitis-attributable liver cirrhosis, it should also be taken into consideration that liver cirrhosis mortality may be impacted by alcohol, irrespective of the causal factors leading to the liver cirrhosis in the first place (89). Relatively small amounts of alcohol may thus lead to a high risk of mortality in already damaged livers (87). Otherwise, the reduction in standardized liver cirrhosis mortality rates in the past few years, even in countries where consumption has not been going down, should be researched further. 0 5 10 15 20 25 30 2014201220102008200620042002200019981996199419921990 % o f a ll ca us es o f d ea th fo r w hi ch th er e is a c au sa l i m pa ct o f a lc oh ol Central-western EU EU Mediterranean South-eastern WHO European Region Central-eastern EU Eastern WHO European Region WHO European Region 57 Burden of alcohol-attributable mortality in the WHO European Region, 1990–2014 Fig. 80. Trends in age-standardized rates of adult mortality due to alcohol-attributable liver cirrhosis in the WHO european Region and selected subregions, 1990–2014 Alcohol-attributable cancer mortality rates have shown relatively small variations over the observation period within regions, and predictably, the rates between regions reflect the consumption level, with the south-eastern WHO European Region having markedly lower consumption and lower alcohol-attributable cancer mortality (Fig. 81). Fig. 81. Trends in age-standardized rates of adult mortality due to alcohol-attributable cancer in the WHO european Region and selected subregions, 1990–2014 Alcohol-attributable cardiovascular mortality varies widely between and within regions over time (Fig. 82). Cardiovascular causes of death, especially ischaemic categories, are impacted by fluctuations in heavy drinking occasions, and thus even relatively small changes in the level of consumption, which increase irregular or chronic heavy drinking, will have a considerable impact also on cardiovascular mortality. During the already-mentioned Gorbachev-era anti-alcohol campaign, alcohol consumption in the Soviet Union went down, even after correcting for increases in unrecorded alcohol (170) and, in association, deaths due to “circulatory disease” decreased, which was the code used for cardiovascular causes of death in the Soviet Union in 1987 (–9% in men from 1984, –6% in middle-aged women) (169). Cardiovascular 0 20 40 60 80 100 120 140 160 180 2014201220102008200620042002200019981996199419921990 Ra te p er m ill io n Central-western EU EU Mediterranean South-eastern WHO European Region Central-eastern EU Eastern WHO European Region WHO European Region 0 20 40 60 80 100 120 2014201220102008200620042002200019981996199419921990 Ra te p er m ill io n Central-western EU EU Mediterranean South-eastern WHO European Region Central-eastern EU Eastern WHO European Region WHO European Region 58 Public health successes and missed opportunities mortality changes were reversed when alcohol consumption increased again (169,170) (for discussions of causality and implications, see (156,177,195,196)). Fig. 82. Trends in age-standardized rates of adult mortality due to alcohol-attributable Cvd in the WHO european Region and selected subregions, 1990–2014 Mortality rates due to alcohol-attributable injury can be characterized by a dichotomy between a few countries (Belarus, Estonia, Kazakhstan, Latvia, Lithuania, the Republic of Moldova, the Russian Federation and Ukraine; see Fig. 50, 51 and 53) concentrated in a particular region (the eastern WHO European Region, see Fig. 83) with similar drinking levels and patterns, and the rest of the WHO European Region. Thus, all of the countries with higher-than-average rates are situated in the eastern part of the Region, from the Baltic countries in the north-east of the EU, over the Russian Federation to Kazakhstan in the south-eastern part of the WHO European Region. Fig. 83. Trends in age-standardized rates of mortality due to alcohol-attributable injury in the WHO european Region and selected subregions, 1990–2014 -200 0 200 400 600 800 1000 1200 2014201220102008200620042002200019981996199419921990 Ra te p er m ill io n Central-western EU EU Mediterranean South-eastern WHO European Region Central-eastern EU Eastern WHO European Region WHO European Region 0 100 200 300 400 500 600 700 800 900 1000 2014201220102008200620042002200019981996199419921990 Ra te p er m ill io n Central-western EU EU Mediterranean South-eastern WHO European Region Central-eastern EU Eastern WHO European Region WHO European Region 59 Burden of alcohol-attributable mortality in the WHO European Region, 1990–2014 Overall, the same patterns prevail for unintentional and intentional injury mortality (see Fig. 84 and 85), with the difference that the central-eastern part of the EU is much closer to the WHO European Region average for unintentional injury than for intentional injury. For all injury mortality in EU countries, most countries seem to converge with the exception of the central-eastern part and, in particular, the Baltic countries. However, part of this appearance of convergence is due to the comparison level with the Russian Federation and the surrounding countries with similar drinking levels and patterns. As has been shown in Fig. 45–53, there are still marked between-country differences even within the EU, and to reduce mortality due to injury, other EU countries could benchmark with countries like Italy or Cyprus (see Table 1). Fig. 84. Trends in age-standardized rates of mortality due to alcohol-attributable unintentional injury in the WHO european Region and selected subregions, 1990–2014 Fig. 85. Trends in age-standardized rates of mortality due to alcohol-attributable intentional injury in the WHO european Region and selected subregions, 1990–2014 0 50 100 150 200 250 300 350 400 450 500 2014201220102008200620042002200019981996199419921990 Ra te p er m ill io n Central-western EU EU Mediterranean South-eastern WHO European Region Central-eastern EU Eastern WHO European Region WHO European Region 0 50 100 150 200 250 300 350 400 450 500 2014201220102008200620042002200019981996199419921990 Ra te p er m ill io n Central-western EU EU Mediterranean South-eastern WHO European Region Central-eastern EU Eastern WHO European Region WHO European Region 60 COnCluSiOn: THe need FOR An AlCOHOl POliCy Even though alcohol consumption in Europe dates back a long time, the past decades have shown that, despite historical traditions, modern drinking patterns can change quickly and sustainably. The decrease in alcohol consumption in the traditional wine-producing and wine-drinking countries of the Mediterranean region over the past 40 years or so may serve as an illustration of this point (1,61–63,197). It has been shown that this decrease in consumption in the Mediterranean countries resulted in a large reduction in alcohol-attributable mortality, which had marked effects on life expectancy (141). A second example of changing drinking patterns and resulting mortality are the Russian experiences following the Gorbachev-era reform, as well as more recent examples (53,57,169,170). Some of the changes in drinking patterns and subsequent harm reflect fundamental changes in the nature of society. For example, with shifts away from agriculture in most European economies, the widespread tradition of drinking at lunchtime is inconsistent with the demands of the twenty-first century modern economy (for some empirical evidence, see (198)). Other changes were caused or enforced by alcohol policies. Certainly, effective (10,199,200) and cost-effective policies (201–203) are available to further minimize the burden of alcohol consumption in European societies. However, even though such policies have been proposed for many years (204,205) as well as various European action plans (see (9) for the last iteration), relatively little has changed in the Region, and the age-standardized alcohol-attributable mortality rate for major chronic and acute causes of death for the WHO European Region in 2014 was even higher than 25 years ago. There have been public health successes in countries, as shown above, and these countries could be used as benchmarks, but there have also been drastic public health failures, and the overall picture certainly cannot be called a public health success. Moreover, as recent examples have shown, getting alcohol policies wrong may also impact dramatically on the disease burden (156). In order to initiate policies, up-to-date epidemiological data are needed, integrated into a monitoring and surveillance system (171,172). Time is of the essence here, and if relevant data are available to decision-makers within a short period of one or maximum two years, they will serve the purpose much better (206). This report hopes to stimulate the establishment of monitoring and surveillance systems at the national level, which routinely yield relevant data on the harmful use of alcohol and attributable harm in a relevant way for decision-makers (and this can be done with the NCD monitoring framework (13,207)), but should additionally include liver cirrhosis and injury burden. So what would be the policy conclusions from this report, and epidemiological findings on alcohol for Europe in general? First and foremost, it must be stated that overall alcohol consumption is clearly too high in Europe, resulting in considerable harm. Ideally, assuming that alcohol consumption will persist in Europe, those who choose to drink should limit their consumption to under 20 g/day (68,208), corresponding to a yearly consumption of 11.6 litres of pure alcohol. However, this upper threshold for drinking is lower than the current mean drinking level among drinkers in Europe both for men (19.4 litres pure alcohol) and for women (12.9 litres pure alcohol). The question is how to shift the current drinking level to one that would incur the least harm. Drinking guidelines have become popular in recent years (see recent efforts in Australia, Canada, the United Kingdom and the EU (209–212)) as they conform to the modern ideal of a consumer society, with well-informed consumers putatively adjusting their behaviour based on advice from governmental, research and professional sources (213). However, their effectiveness in changing actual drinking habits is questionable (214,215). Nevertheless, the development of guidelines reflecting best evidence provides an important reference point for engaging with policy-makers in developing more directly effective approaches to reducing consumption. On the other hand, the known cost-effective policy options as outlined by the “best buys” in the WHO NCD framework ((13,216), see also footnote 2), i.e. reduction in availability, increase in taxation, and ban on marketing and advertising, have not been overly popular with governments, and there are no signs that this trend will stop.20 How could epidemiology 20 There is surprisingly little research on how the “best buys” of availability and taxation need to be shaped in light of different environments, as characterized by the level and availability of unrecorded alcohol in different countries (see (217) for a discussion about African countries; and (218) for an example of a failed taxation increase because unrecorded consumption was too important), but such research would be especially necessary for countries in the WHO European Region, where unrecorded consumption is very common and there are huge price differentials. 61 help in improving the situation? There is still a knowledge gap among the general population about alcohol’s impact on mortality, especially for cancer (219). This knowledge gap should be closed, but knowledge may not necessarily change behaviour, especially if knowledge concerns rather broad areas without more general implications such as the reduction of consumption. A more promising approach seems to be to look into the concrete mortality risks, and work on these. There is a need to go beyond passive approaches such as drinking guidelines, so that ministries of health and other public health agencies consider where and how in a particular society there are concerns about alcohol-related problems, and how those concerns might be energized to bring tools in the policy impact literature into play, or create new tools. The model from successful public health action on drink–driving and on cigarette smoking has been to focus attention on the problems (with epidemiology playing a major part), and to push for preventive policies and actions in the context of that focus. One of these foci could be mortality due to alcohol-attributable injury, as this indicator has been decreasing more slowly than injury mortality in general. This opens specific prevention opportunities, such as programmes on impaired driving, lowering the legal limit for blood alcohol level via per se laws for traffic participation and operating machinery, and enforcing such laws via random breath testing or sobriety checks, depending on the legal situation (199,220,221). Drink– driving measures have been standard in many countries (1), but can be further improved to be more effective, and 0.02 g pure alcohol per decilitre should be the goal (9). Another possibility for more specific interventions would be the recent Dutch law for determining a threshold for a causal effect of substance use in general and alcohol consumption in particular on aggression and violence (for the law published on 19 January 2016, see (222); for a first report on the scientific evidence, see (223)). Addressing both unintentional and intentional injury seemed to work in an initiative in South Dakota, encouraging 24/7 sobriety. A group of people who had been arrested for or convicted of alcohol-involved offenses, were monitored continuously for abstinence with sanctions. Results showed that at the county level, following adoption of the programme, there was a 12% reduction in arrests for repeat driving under the influence of alcohol and a 9% reduction in arrests for domestic violence (224). Equally important would be to develop programmes for prevention of other injury types. The current efforts of the Dutch government to develop per se laws with respect to intentional injury should be carefully evaluated and, if successful, replicated in other countries. With respect to reduction in alcohol-attributable mortality in the WHO European Region, the most urgent policy needs relate to those countries that have by far the largest burden, characterized by relatively frequent very heavy binge drinking episodes, such as the eastern WHO European Region. While there are indications that some of the recent policy changes in the Russian Federation have had success (57,225) (but see (56)), more is needed. One of the most promising measures against binge drinking is minimum pricing schemes (226,227), but most of the arguments for this measure are based on modelling studies with limited empirical evidence from Canadian provinces (228,229). The chances of successfully transferring such policies to all of the eastern European countries with a large proportion of unrecorded consumption, which is especially important for binge drinking in the most vulnerable populations (22,230–232), is questionable. Another study from Russia (233) is not a counter-example, as it only deals with home-produced alcohol and not with surrogate alcohol such as medicinal alcohol or industrial alcohol. Obviously, once recorded consumption is reduced by as much as was done in the Soviet Union in the 1980s (170), increases in unrecorded consumption do not matter that much, but for slight reductions in recorded consumption, potential compensations by increase in unrecorded consumption do matter, given the fact that unrecorded alcohol, especially surrogate alcohol, tends to be considerably cheaper (22,24,234). Thus, it would be important to find local solutions to reduce heavy drinking occasions in countries with a large proportion of unrecorded consumption. It is interesting that in the 24/7 sobriety programme, effects on mortality were found, which were most pronounced for cardiovascular mortality (235). Such a programme could be adopted in the eastern WHO European Region. Reduction of average alcoholic strength in beverages may also be considered (11), and the Russian government is trying this strategy by favouring beverages with a lower ethanol content via taxation (e.g. beer versus vodka; see also (57,233)). Taxation is one important tool of an alcohol policy, and different taxation schemes can be used for different purposes, such as switching beverage preferences (236–238), reducing alcoholic content in certain beverages (11,239,240), increasing the age of onset of drinking or keeping abstention rates high (241,242). For a more general overview of the effects of alcohol taxation, see (243). Conclusion: the need for an alcohol policy 62 Public health successes and missed opportunities The main conclusion of the current study for alcohol policy is clear: if governments do not initiate policies to reduce alcohol consumption in societies with a large number of heavy drinking occasions, a disproportionate burden of alcohol- attributable morbidity and mortality will result. Reduction in alcohol consumption among heavy drinkers plays a key role. If proven effective policies such as reduction in availability, increase in price via taxation, and ban on marketing and advertisements do not work out to be feasible, reducing the consumption of the heaviest drinkers via brief interventions or treatment could have a population health impact (202,244) (see also (159,245)).21 In most of the other countries of the WHO European Region, governments should be aware of the fact that the current level of alcohol consumption is in no way acceptable from a public health perspective and associated with considerable harm, and thus they should continue or initiate successful measures to reduce alcohol consumption. Moreover, governments should be aware of the fact that wrong policies could lead to substantial harm in a relatively short time (10,156). No matter what policies the respective governments choose, reducing the alcohol-attributable burden of mortality in Europe is an urgent matter. It is needed to reduce not only individual suffering and harm to others around the drinker, but also the economic burden attributable to alcohol (77,247,248). To summarize, although alcohol consumption has been decreasing in the WHO European Region as a whole over the past 25 years, it continues to be a major risk factor for mortality, and the overall alcohol-attributable mortality burden increased slightly over this time period. The major contribution to the increased mortality burden came from eastern European countries, in which the alcohol-attributable mortality rates increased substantially. Alcohol policy measures to reduce the mortality burden are urgently needed, and while they are the most urgent in the eastern part of the Region, most other countries could rapidly be faced with a larger alcohol-attributable mortality burden if they do not continue to decrease their overall level of alcohol consumption and occasions of episodic heavy drinking. (As an illustration, see how the alcohol-attributable mortality rates increased in the United Kingdom when this nation increased consumption in the 1990s.) Given the overall failure in reducing the alcohol-attributable mortality burden in the WHO European Region in the past 25 years, despite the existence and promotion of traditional evidence-based and cost-effective interventions, some rethinking seems necessary on introducing additional alcohol policies. 21 There are other evidence-based ways to impact on heavy drinkers specifically, such as rationing schemes (246) or the above-cited sobriety enforcement (224,235), but realistically, brief interventions and treatment will be the most discussed policy options in the current environment of the WHO European Region (9). 63 ReFeRenCeS 1. Global status report on alcohol and health. Geneva: World Health Organization; 2014 (http://apps.who.int/iris/ bitstream/10665/112736/1/9789240692763_eng.pdf, accessed 6 July 2016). 2. Forouzanfar MH, Alexander L, Anderson HR, Bachman VF, Biryukov S, Brauer M et al. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;386:2287–323 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4685753/, accessed 6 July 2016). 3. Shield KD, Rehm J. The effects of addictive substances and addictive behaviours on physical and mental health. In: Anderson P, Rehm J, Room R, editors. The impact of addictive substances and behaviours on individual and societal well-being. Oxford: Oxford University Press; 2015:77–118. 4. Rehm J, Anderson P, Barry J, Dimitrov P, Elekes Z, Feijão F et al. Prevalence of and potential influencing factors for alcohol dependence in Europe. Eur Addict Res. 2015;21:6–18 (http://www.karger.com/Article/Abstract/365284, accessed 6 July 2016). 5. Zaridze D, Lewington S, Boroda A, Scélo G, Karpov R, Lazarev A et al. Alcohol and mortality in Russia: prospective observational study of 151 000 adults. Lancet. 2014;383(9927):1465–73 (http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4007591/, accessed 6 July 2016). 6. Deaton A. The great escape: health, wealth and the origins of inequality. Princeton: Princeton University Press; 2013. 7. Global strategy to reduce the harmful use of alcohol. Geneva: World Health Organization; 2010 (http://www.who. int/substance_abuse/msbalcstragegy.pdf, accessed 6 July 2016). 8. Prevention and control of NCDs: priorities for investment. Discussion paper for the First Global Ministerial Conference on Healthy Lifestyles and Noncommunicable Disease Control, Moscow, 28–29 April 2011. Geneva: World Health Organization; 2011 (http://www.who.int/nmh/publications/who_bestbuys_to_prevent_ncds.pdf, accessed 10 July 2016). 9. European action plan to reduce the harmful use of alcohol 2012–2020. Copenhagen: WHO Regional Office for Europe; 2012 (http://www.euro.who.int/en/health-topics/disease-prevention/alcohol-use/publications/2012/european- action-plan-to-reduce-the-harmful-use-of-alcohol-20122021, accessed 27 May 2016). 10. Anderson P, Braddick F, Conrod P, Gual A, Hellman M, Matrai S et al. The new governance of addictive substances and behaviours. Oxford: Oxford University Press; 2016. 11. Rehm J, Lachenmeier DW, Jané Llopis E, Imtiaz S, Anderson P. Evidence of reducing ethanol content in beverages to reduce harmful use of alcohol. Lancet Gastroenterol Hepatol. 2016:1(9):78–83. 12. Teutsch SM, Churchill RE. Principles and practice of public health surveillance. 2nd ed. New York: Oxford University Press; 2000. 13. Global action plan for the prevention and control of noncommunicable diseases 2013–2020. Geneva: World Health Organization; 2013 (http://apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.pdf, accessed 6 July 2016). 14. Gell L, Ally A, Buykx P, Hope A, Meier P. Alcohol’s harm to others: an Institute of Alcohol Studies report. London: Institute of Alcohol Studies; 2015 (http://www.ias.org.uk/uploads/pdf/IAS%20reports/rp18072015.pdf, accessed 6 July 2016). 15. Kraus L, Pabst A, Piontek D, Gmel G, Shield KD, Frick H et al. Temporal changes in alcohol-related morbidity and mortality in Germany. Eur Addict Res. 2015;21:262–72 (http://www.karger.com/Article/Abstract/381672, accessed 6 July 2016). 16. Marmet S, Gmel G, Gmel GJ, Frick H, Rehm J. Alcohol-attributable mortality in Switzerland between 1997 and 2011. Lausanne: Addiction Suisse; 2013. (http://www.addictionsuisse.ch/fileadmin/user_upload/Endbericht_2013_-_ Mortalit%C3%A4t.pdf accessed 20 June 2016). 17. Marmet S, Rehm J, Gmel G. The importance of age groups in estimates of alcohol-attributable mortality: impact on trends in Switzerland between 1997 and 2011. Addiction. 2016;111:255–62 (http://onlinelibrary.wiley.com/ doi/10.1111/add.13164/abstract, accessed 6 July 2016). 18. Poznyak V, Fleischmann A, Rekve D, Rylett M, Rehm J, Gmel G. The World Health Organization’s Global Monitoring System on Alcohol and Health. Alcohol Res. 2013;35:244–9 (http://pubs.niaaa.nih.gov/publications/arcr352/244- 249.htm, accessed 6 July 2016). 64 Public health successes and missed opportunities 19. Rehm J, Klotsche J, Patra J. Comparative quantification of alcohol exposure as risk factor for global burden of disease. Int J Methods Psychiatr Res. 2007;16:66–76 (http://onlinelibrary.wiley.com/doi/10.1002/mpr.204/abstract, accessed 6 July 2016). 20. OECD health statistics 2015: definitions, sources and methods. Paris: Organisation for Economic Co-operation and Development; 2016 (http://www.oecd.org/els/health-systems/Table-of-Content-Metadata-OECD-Health- Statistics-2015.pdf, accessed 11 July 2016). 21. Lachenmeier DW, Gmel G, Rehm J. Unrecorded alcohol consumption. In: Boyle P, Boffetta P, Lowenfels AB, Burns H, Brawley O, Zatonski W et al., editors. Alcohol: science, policy, and public health. Oxford: Oxford University Press; 2013:132–42. 22. Rehm J, Kailasapillai S, Larsen E, Rehm MX, Samokhvalov AV, Shield KD et al. A systematic review of the epidemiology of unrecorded alcohol consumption and the chemical composition of unrecorded alcohol. Addiction. 2014;109:880–93 (http://onlinelibrary.wiley.com/doi/10.1111/add.12498/abstract, accessed 6 July 2016). 23. Gigienicheskie sredstva. Zakaz produkcii [Health-and-beauty aids. Product order] [website]. Saint Petersburg: RosProdTorg; 2016 (http://spirt-packet.ru, accessed 26 May 2016). 24. Gil A, Polikina O, Koroleva N, McKee M, Tomkins S, Leon DA. Availability and characteristics of nonbeverage alcohols sold in 17 Russian cities in 2007. Alcohol Clin Exp Res. 2009;33:79–85 (http://onlinelibrary.wiley.com/ doi/10.1111/j.1530-0277.2008.00813.x/abstract, accessed 9 July 2016). 25. Global status report on alcohol. Geneva: World Health Organization; 2004 (http://www.who.int/substance_abuse/ publications/global_status_report_2004_overview.pdf, accessed 6 July 2016. 26. Global status report on alcohol. Geneva: World Health Organization; 1999 (http://www.who.int/substance_abuse/ publications/en/GlobalAlcohol_overview.pdf, accessed 6 July 2016). 27. Global status report on alcohol and health. Geneva: World Health Organization; 2011 (http://www.who.int/ substance_abuse/publications/global_alcohol_report/msbgsruprofiles.pdf, accessed 6 July 2016). 28. Rehm J, Larsen E, Lewis-Laietmark C, Gheorghe P, Poznyak V, Rekve D et al. Estimation of unrecorded alcohol consumption in low-, middle-, and high-income economies for 2010. Alcohol Clin Exp Res. 2016;40:1283–9 (http:// onlinelibrary.wiley.com/doi/10.1111/acer.13067/abstract, accessed 6 July 2016). 29. Global Information System on Alcohol and Health [online database]. Geneva: World Health Organization; 2016 (http://apps.who.int/gho/data/node.main.A1022?lang=en&showonly=GISAH, accessed 22 May 2016). 30. Rehm J, Poznyak V. On monitoring unrecorded alcohol consumption. Alkoholizm i Narkomania [Alcoholism and Drug Addiction]. 2015;28:79–89 (http://www.sciencedirect.com/science/article/pii/S0867436115000280, accessed 6 July 2016). 31. Rehm J, Room R, Monteiro M, Gmel G, Graham K, Rehn N et al. Alcohol use. In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, editors. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. Geneva: World Health Organization; 2004:959–1109 (http://www.who.int/publications/ cra/chapters/volume1/0000i-xxiv.pdf, accessed 6 July 2016). 32. The STEPS instrument and support materials. Geneva: World Health Organization; 2013 (http://www.who.int/chp/ steps/instrument/en/, accessed 8 July 2016). 33. International tourism, number of arrivals [website]. Washington, DC: The World Bank; 2016 (http://data.worldbank. org/indicator/ST.INT.ARVL, accessed 25 May 2016). 34. Shield K, Rylett M, Gmel G, Gmel G, Kehoe-Chan T, Rehm J. Global alcohol exposure estimates by country, territory and region for 2005 – a contribution to the Comparative Risk Assessment for the 2010 Global Burden of Disease Study. Addiction. 2013;108:912–22 (http://onlinelibrary.wiley.com/doi/10.1111/add.12112/abstract, accessed 6 July 2016). 35. World Population Prospects: the 2012 revision. New York: United Nations; 2013 (http://esa.un.org/wpp/, accessed 6 July 2016). 36. Popova S, Rehm J, Patra J, Zatonski W. Comparing alcohol consumption in central and eastern Europe to other European countries. Alcohol Alcohol. 2007;42:465–73 (http://alcalc.oxfordjournals.org/content/42/5/465.long, accessed 6 July 2016). 37. Rehm J, Shield KD, Rehm MX, Gmel G, Frick U. Alcohol consumption, alcohol dependence, and attributable burden of disease in Europe: potential gains from effective interventions for alcohol dependence. Toronto: Centre for Addiction and Mental Health; 2012. 38. Room R. Sociocultural aspects of alcohol consumption. In: Boyle P, Boffetta P, Lowenfels AB, Burns H, Brawley O, Zatonski W et al., editors. Alcohol: science, policy, and public health. Oxford: Oxford University Press; 2013:38–45. 39. McGovern PE. Ancient wine: the search for the origins of viniculture. Princeton: Princeton University Press; 2003. 65 References 40. Engs RC. Do traditional western European drinking practices have origins in antiquity? Addict Res. 1995;2:227–39 (http://www.indiana.edu/~engs/articles/ar1096.htm, accessed 6 July 2016). 41. Charters S. Wine and society: the social and cultural context of a drink. Oxford: Elsevier Butterworth-Heinemann; 2006. 42. Iontchev A. Central and eastern Europe. In: Grant M, editor. Alcohol and emerging markets: patterns, problems, and responses. Washington, DC: International Center for Alcohol Policies; 1998:177–201. 43. Mäkelä P, Gmel G, Grittner U, Kuendig H, Kuntsche S, Bloomfield K et al. Drinking patterns and their gender differences in Europe. Alcohol Alcohol Suppl. 2006;41:8–18 (http://www.ncbi.nlm.nih.gov/pubmed/17030504, accessed 6 July 2016). 44. Kuntsche E, Kuntsche S, Knibbe R, Simons-Morton B, Farhat T, Hublet A et al. Cultural and gender convergence in adolescent drunkenness: evidence from 23 European and North American countries. Arch Pediatr Adolesc Med. 2011;165:152–8 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4133118/, accessed 6 July 2016). 45. Shield K, Rehm M, Patra J, Sornpaisarn B, Rehm J. Global and country specific adult per capita consumption of alcohol, 2008. Sucht. 2011;57:99–117 (https://www.researchgate.net/publication/225040876_Global_and_ Country_Specific_Adult_per_capita_Consumption_of_Alcohol_2008, accessed 6 July 2016). 46. Schmidt LA, Mäkelä P, Rehm J, Room R. Alcohol: equity and social determinants. In: Blas E, Kurup AS, editors. Equity, social determinants and public health programmes. Geneva: World Health Organization; 2010:11–29. 47. New country classifications. Washington, DC: The World Bank; 2015. (http://data.worldbank.org/news/new- country-classifications-2015, accessed 13 June 2016). 48. Rehm J, Rehn N, Room R, Monteiro M, Gmel G, Jernigan D et al. The global distribution of average volume of alcohol consumption and patterns of drinking. Eur Addict Res. 2003;9:147–56 (http://isites.harvard.edu/fs/docs/icb. topic108992.files/Rehm_2003_Alcohol.pdf, accessed 6 July 2016). 49. Willett WC. The Mediterranean diet: science and practice. Public Health Nutr. 2006;9:105–10 (http://journals. cambridge.org/action/displayAbstract?fromPage=online&aid=585588&fileId=S1368980006000243, accessed 6 July 2016. 50. Gmel G, Rehm J, Kuntsche E. Binge drinking in Europe: definitions, epidemiology, and consequences. Sucht. 2003;49:105–16 (https://www.researchgate.net/publication/232564065_Binge_drinking_in_Europe_Definitions_ epidemiology_and_consequences, accessed 6 July 2016). 51. Cook S, DeStavola BL, Saburova L, Leon DA. Acute alcohol-related dysfunction as a predictor of employment status in a longitudinal study of working-age men in Izhevsk, Russia. Addiction. 2014;109:44–54 (http://www.ncbi.nlm.nih. gov/pmc/articles/PMC3992905/, accessed 6 July 2016). 52. Table: Muslim population by country [website]. Washington, DC: Pew Research Center; 2011 (http://www.pewforum. org/2011/01/27/table-muslim-population-by-country/, accessed 27 May 2016). 53. Nemtsov AV. A contemporary history of alcohol in Russia. Stockholm: Södertörns högskola; 2011 (http://www.diva- portal.org/smash/get/diva2:425342/FULLTEXT01.pdf, accessed 6 July 2016). 54. Zaridze D, Brennan P, Boreham J, Boroda A, Karpov R, Lazarev A et al. Alcohol and cause-specific mortality in Russia: a retrospective case-control study of 48,557 adult deaths. Lancet. 2009;373:2201–14 (http://www.thelancet.com/ journals/lancet/article/PIIS0140-6736(09)61034-5/fulltext, accessed 6 July 2016). 55. Leon DA, Shkolnikov VM, McKee M. Alcohol and Russian mortality: a continuing crisis. Addiction. 2009;104:1630–6 (http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2009.02655.x/abstract, accessed 11 July 2016). 56. Grigoriev P, Andreev EM. The huge reduction in adult male mortality in Belarus and Russia: is it attributable to anti-alcohol measures? PLoS One. 2015;10:e138021 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4574310/, accessed 6 July 2016). 57. Neufeld M, Rehm J. Alcohol consumption and mortality in Russia since 2000: are there any changes following the alcohol policy changes starting in 2006? Alcohol Alcohol. 2013;48:222–30 (http://alcalc.oxfordjournals.org/ content/48/2/222.long, accessed 6 July 2016). 58. de Goeij MC, Suhrcke M, Toffolutti V, van de Mheen D, Schoenmakers TM, Kunst AE. How economic crises affect alcohol consumption and alcohol-related health problems: a realist systematic review. Soc Sci Med. 2015;131:131– 46 (http://www.sciencedirect.com/science/article/pii/S0277953615001082, accessed 6 July 2016). 59. Dubanowicz A, Lemmens P. Impact of the economic recession on addiction-prone behaviours. In: Anderson P, Rehm J, Room R, editors. The impact of addictive substances and behaviours on individual and societal well-being. Oxford: Oxford University Press; 2015:161–80. 60. Popovici I, French MT. Does unemployment lead to greater alcohol consumption? Ind Relat. 2013;52:444–66 (http:// www.ncbi.nlm.nih.gov/pmc/articles/PMC3609661/, accessed 6 July 2016). 66 Public health successes and missed opportunities 61. Gual A, Colom J. Why has alcohol consumption declined in countries of southern Europe? Addiction. 1997;92:S21– S31 (http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.1997.tb03392.x/abstract, accessed 6 July 2016). 62. Pyörälä E. Trends in alcohol consumption in Spain, Portugal, France and Italy from the 1950s until the 1980s. Br J Addict. 1990; 85:469–77. 63. Sulkunen P. Drinking in France 1965–1979. An analysis of household consumption data. Br J Addict. 1989;84:61–72 (http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.1989.tb00552.x/abstract, accessed 6 July 2016). 64. Room R, Jernigan D, Carlini BH, Gmel G, Gureje O, Mäkelä K et al. El alcohol y los países en desarrollo. Una perspectiva de salud pública. Mexico: Organización Panamericana de la Salud & Fondo de Cultura Económica; 2013. 65. Room R, Babor T, Rehm J. Alcohol and public health. Lancet. 2005;365:519–30 (http://www.thelancet.com/journals/ lancet/article/PIIS0140-6736(05)17870-2/abstract, accessed 6 July 2016). 66. Rehm J. What can we learn from Russia about alcohol epidemiology and alcohol policy? Lancet. 2014;383:1440–2. 67. Kontis V, Mathers CD, Bonita R, Stevens GA, Rehm J, Shield KD et al. Regional contributions of six preventable risk factors to achieving the 25×25 non-communicable disease mortality reduction target: a modelling study. Lancet Glob Health. 2015;3:e746–e57 (http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(15)00179-5/ fulltext, accessed 6 July 2016). 68. Rehm J, Lachenmeier DW, Room R. Why does society accept a higher risk for alcohol than for other voluntary or involuntary risks? BMC Med. 2014;12:189 (http://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-014- 0189-z, accessed 8 July 2016). 69. Lachenmeier DW, Rehm J. Comparative risk assessment of alcohol, tobacco, cannabis and other illicit drugs using the margin of exposure approach. Sci Rep. 2015;5:8126 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4311234/, accessed 11 July 2016). 70. van Amsterdam J, Nutt D, Phillips L, van den Brink W. European rating of drug harms. J Psychopharmacol. 2015;29:655–60 (http://www.ncbi.nlm.nih.gov/pubmed/25922421, accessed 11 July 2016). 71. Tang YL, Xiang XJ, Wang XY, Cubells JF, Babor TF, Hao W. Alcohol and alcohol-related harm in China: policy changes needed. Bull World Health Organ. 2013;91:270–6 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3629448/, accessed 6 July 2016). 72. Devaux M, Sassi F. Trends in alcohol consumption in OECD countries. In: Sassi F, editor. Tackling harmful alcohol use: economics and public health policy. Paris: OECD Publishing; 2015:39–60. 73. Ferreira-Borges C, Rehm J, Dias S, Babor T, Parry CD. The impact of alcohol consumption on African people in 2012: an analysis of burden of disease. Trop Med Int Health. 2016;21:52–60 (http://onlinelibrary.wiley.com/doi/10.1111/ tmi.12618/abstract, accessed 6 July 2016). 74. Murray CJL, Salomon J, Mathers C, Lopez A. Summary measures of population health: concepts, ethics, measurement and applications. Geneva: World Health Organization; 2002 (http://apps.who.int/iris/ bitstream/10665/42439/1/9241545518.pdf, accessed 6 July 2016). 75. Ogeil RP, Gao CX, Rehm J, Gmel G, Lloyd B. Temporal changes in alcohol-related mortality and morbidity in Australia. Addiction. 2016;111:626–34 (http://onlinelibrary.wiley.com/doi/10.1111/add.13213/abstract, accessed 6 July 2016). 76. Livingston M, Matthews S, Barratt M, Lloyd B, Room R. Diverging trends in alcohol consumption and alcohol-related harm in Victoria. Aust N Z J Public Health. 2010;34:368–73 (http://www.academia.edu/378680/Diverging_Trends_ In_Alcohol_Consumption_and_Alcohol_related_Harm_In_Victoria, accessed 6 July 2016). 77. Rehm J, Mathers C, Popova S, Thavorncharoensap M, Teerawattananon Y, Patra J. Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. Lancet. 2009;373:2223–33 (http:// www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60746-7/abstract, accessed 6 July 2016). 78. Rehm J, Baliunas D, Borges GL, Graham K, Irving H, Kehoe T et al. The relation between different dimensions of alcohol consumption and burden of disease: an overview. Addiction. 2010;105:817–43 (http://www.ncbi.nlm.nih. gov/pmc/articles/PMC3306013/, accessed 6 July 2016). 79. Shield KD, Rehm J. Alcohol, impact on health. Reference Module in Biomedical Sciences. Amsterdam: Elsevier; 2014. 80. Shield KD, Kehoe T, Gmel G, Rehm MX, Rehm J. Societal burden of alcohol. In: Anderson P, Møller L, Galea G, editors. Alcohol in the European Union: consumption, harm and policy approaches. Copenhagen: WHO Regional Office for Europe; 2012:10–28 (http://www.euro.who.int/__data/assets/pdf_file/0003/160680/e96457.pdf, accessed 6 July 2016). 81. Shield KD, Rylett MJ, Gmel G, Rehm J. Trends in alcohol consumption and alcohol-attributable mortality in the EU in 2010. In: Status report on alcohol and health in 35 European countries. Copenhagen: WHO Regional Office for Europe; 2013 (http://www.euro.who.int/__data/assets/pdf_file/0017/190430/Status-Report-on-Alcohol-and- Health-in-35-European-Countries.pdf, accessed 6 July 2016). 67 References 82. Global Burden of Disease (GBD). Seattle: Institute for Health Metrics and Evaluation; 2013 (http://www.healthdata. org/gbd, accessed 4 July 2016). 83. Lopez AD, Williams TN, Levin A, Tonelli M, Singh JA, Burney PJG et al. Remembering the forgotten non-communicable diseases. BMC Med. 2014;12:200 (http://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-014-0200-8, accessed 6 July 2016). 84. Mokdad AA, Lopez AD, Shahraz S, Lozano R, Mokdad AH, Stanaway J et al. Liver cirrhosis mortality in 187 countries between 1980 and 2010: a systematic analysis. BMC Med. 2014;12:145 (http://bmcmedicine.biomedcentral.com/ articles/10.1186/s12916-014-0145-y, accessed 6 July 2016). 85. Blachier M, Leleu H, Peck-Radosavljevic M, Valla DC, Roudot-Thoraval F. The burden of liver disease in Europe: a review of available epidemiological data. Geneva: European Association for the Study of the Liver; 2013 (http:// www.easl.eu/medias/EASLimg/Discover/EU/54ae845caec619f_file.pdf, accessed 6 July 2016). 86. Rush B. An inquiry into the effects of ardent spirits upon the human body and mind: with an account of the means of preventing, and of the remedies for curing them. 8th edition. Reprint. Exeter: Richardson; 1785. 87. Rehm J, Taylor B, Mohapatra S, Irving H, Baliunas D, Patra J et al. Alcohol as a risk factor for liver cirrhosis: a systematic review and meta-analysis. Drug Alcohol Rev. 2010;29:437–45. 88. Lachenmeier DW, Kanteres F, Rehm J. Epidemiology-based risk assessment using the benchmark dose/margin of exposure approach: the example of ethanol and liver cirrhosis. Int J Epidemiol. 2011;40:210–8 (http://ije. oxfordjournals.org/content/40/1/210.long, accessed 6 July 2016). 89. Rehm J, Samokhvalov AV, Shield KD. Global burden of alcoholic liver diseases. J Hepatol. 2013;59:160–8 (http:// www.journal-of-hepatology.eu/article/S0168-8278(13)00184-0/abstract, accessed 6 July 2016). 90. Zatonski W, Sulkowska U, Manczuk M, Rehm J, Lowenfels AB, La Vecchia C. Liver cirrhosis mortality in Europe, with special attention to central and eastern Europe. Eur Addict Res. 2010;16:193–201 (http://www.karger.com/Article/ Abstract/317248, accessed 6 July 2016). 91. IARC monographs on the evaluation of carcinogenic risks to humans. Volume 44. Alcohol drinking. Lyon: International Agency for Research on Cancer; 1988 (http://monographs.iarc.fr/ENG/Monographs/vol44/mono44.pdf, accessed 6 July 2016). 92. IARC monographs on the evaluation of carcinogenic risks to humans. Volume 96. Alcohol consumption and ethyl carbamate. Lyon: International Agency for Research on Cancer; 2010 (http://monographs.iarc.fr/ENG/Monographs/ vol96/mono96.pdf, accessed 6 July 2016) 93. IARC monographs on the evaluation of carcinogenic risks to humans. Volume 100E. Personal habits and indoor combustions. A review of human carcinogens. Lyon: International Agency for Research on Cancer; 2012 (http:// monographs.iarc.fr/ENG/Monographs/vol100E/mono100E.pdf, accessed 6 July 2016). 94. Rehm J, Shield K. Alcohol consumption. In: Steward BW, Wild CP, editors. World cancer report. Lyon: International Agency for Research on Cancer; 2014:97–107. 95. Bagnardi V, Rota M, Botteri E, Tramacere I, Islami F, Fedirko V et al. Alcohol consumption and site-specific cancer risk: a comprehensive dose-response meta-analysis. Br J Cancer. 2015;112:580–93 (http://www.nature.com/bjc/ journal/v112/n3/full/bjc2014579a.html, accessed 6 July 2016). 96. Shield KD, Parry C, Rehm J. Chronic diseases and conditions related to alcohol use. Alcohol Res. 2013;35:155–71 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3908707/, accessed 6 July 2016). 97. Shield KD, Soerjomataram I, Rehm J. Alcohol use and breast cancer: a critical review. Alcohol Clin Exp Res. 2016;40:1166–81 (http://onlinelibrary.wiley.com/doi/10.1111/acer.13071/abstract, accessed 6 July 2016). 98. Praud D, Rota M, Rehm J, Shield K, Zaton´ski W, Hashibe M et al. Cancer incidence and mortality attributable to alcohol consumption. Int J Cancer. 2016;138:1380–7 (http://onlinelibrary.wiley.com/doi/10.1002/ijc.29890/ abstract, accessed 6 July 2016). 99. Schütze M, Boeing H, Pischon T, Rehm J, Kehoe T, Gmel G et al. Alcohol attributable burden of incidence of cancer in eight European countries based on results from prospective cohort study. BMJ. 2011;342:d1584 (http://www.bmj. com/content/342/bmj.d1584.long, accessed 6 July 2016). 100. Roerecke M, Rehm J. Alcohol intake revisited: risks and benefits. Curr Atheroscler Rep. 2012;14:556–62 (http://link. springer.com/article/10.1007%2Fs11883-012-0277-5, accessed 6 July 2016). 101. Rehm J, Shield KD, Roerecke M, Gmel G. Modelling the impact of alcohol consumption on cardiovascular disease mortality for comparative risk assessments: an overview. BMC Public Health. 2016;16:363 (https://bmcpublichealth. biomedcentral.com/articles/10.1186/s12889-016-3026-9, accessed 6 July 2016). 102. Roerecke M, Rehm J. The cardioprotective association of average alcohol consumption and ischaemic heart disease: a systematic review and meta-analysis. Addiction. 2012;107:1246–60 (http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3348338/, accessed 7 July 2016). 68 Public health successes and missed opportunities 103. Patra J, Taylor B, Irving H, Roerecke M, Baliunas D, Mohapatra S et al. Alcohol consumption and the risk of morbidity and mortality from different stroke types – a systematic review and meta-analysis. BMC Public Health. 2010;10:258 (http://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-10-258, accessed 7 July 2016). 104. Roerecke M, Rehm J. Alcohol consumption, drinking patterns, and ischemic heart disease: a narrative review of meta-analyses and a systematic review and meta-analysis of the impact of heavy drinking occasions on risk for moderate drinkers. BMC Med. 2014;12:182 (http://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-014- 0182-6, accessed 7 July 2016). 105. Roerecke M, Rehm J. Chronic heavy drinking and ischaemic heart disease: a systematic review and meta-analysis. Open Heart. 2014;1:e000135 (http://openheart.bmj.com/content/1/1/e000135.full, accessed 7 Juy 2016). 106. Roerecke M, Rehm J. Irregular heavy drinking occasions and risk of ischemic heart disease: a systematic review and meta-analysis. Am J Epidemiol. 2010;171:633–44 (http://aje.oxfordjournals.org/content/171/6/633.long, accessed 7 July 2016). 107. Taylor B, Irving HM, Baliunas D, Roerecke M, Patra J, Mohapatra S et al. Alcohol and hypertension: gender differences in dose-response relationships determined through systematic review and meta-analysis. Addiction. 2009;104:1981– 90 (http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2009.02694.x/abstract, accessed 7 July 2016). 108. Samokhvalov AV, Irving HM, Rehm J. Alcohol as a risk factor for atrial fibrillation: a systematic review and meta- analysis. Eur J Cardiovasc Prev Rehabil. 2010;17:706–12 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3065072/, accessed 7 July 2016). 109. Shield K, Rehm J. Russia-specific relative risks and their effects on the estimated alcohol-attributable burden of disease. BMC Public Health. 2015;15:482 (http://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889- 015-1818-y, accessed 7 July 2016). 110. Ezzati M, Obermeyer Z, Tzoulaki I, Mayosi BM, Elliott P, Leon DA. Contributions of risk factors and medical care to cardiovascular mortality trends. Nat Rev Cardiol. 2015;12:508–30 (http://www.nature.com/nrcardio/journal/v12/ n9/full/nrcardio.2015.82.html, accessed 7 July 2016). 111. Naimi TS, Stockwell T, Zhao J, Xuan Z, Dangardt F, Saitz R et al. Selection biases in observational studies affect associations between ‘moderate’ alcohol consumption and mortality. Addiction. 2016; epub ahead of print (http:// onlinelibrary.wiley.com/doi/10.1111/add.13451/abstract, accessed 7 July 2016). 112. Holmes MV, Dale CE, Zuccolo L, Silverwood RJ, Guo Y, Ye Z et al. Association between alcohol and cardiovascular disease: Mendelian randomisation analysis based on individual participant data. BMJ. 2014;349:g4164 (http:// www.bmj.com/content/349/bmj.g4164.long, accessed 7 July 2016). 113. Roerecke M, Rehm J. Alcohol and ischaemic heart disease risk–finally moving beyond interpretation of observational epidemiology. Addiction. 2015;110:723–5 (http://onlinelibrary.wiley.com/doi/10.1111/add.12787/full, accessed 7 July 2016). 114. Hemström Ö. Per capita alcohol consumption and ischaemic heart disease mortality. Addiction. 2001;96:S93–112 (http://onlinelibrary.wiley.com/doi/10.1046/j.1360-0443.96.1s1.8.x/abstract, accessed 7 July 2016). 115. Brien SE, Ronksley PE, Turner BJ, Mukamal KJ, Ghali WA. Effect of alcohol consumption on biological markers associated with risk of coronary heart disease: systematic review and meta-analysis of interventional studies. BMJ. 2011;342:d636 (http://www.bmj.com/content/342/bmj.d636, accessed 7 July 2016). 116. Puddey IB, Rakic V, Dimmitt SB, Beilin LJ. Influence of pattern of drinking on cardiovascular disease and cardiovascular risk factors – a review. Addiction. 1999;94:649–63 (http://onlinelibrary.wiley.com/doi/10.1046/ j.1360-0443.1999.9456493.x/abstract, accessed 7 July 2016). 117. Rehm J, Sempos C, Trevisan M. Average volume of alcohol consumption, patterns of drinking and risk of coronary heart disease – a review. J Cardiovasc Risk. 2003;10:15–20 (http://cpr.sagepub.com/content/10/1/15.abstract, accessed 7 July 2016). 118. Cherpitel CJ. Focus on: the burden of alcohol use – trauma and emergency outcomes. Alcohol Res. 2013;35:150–4 (http://pubs.niaaa.nih.gov/publications/arcr352/150-154.htm, accessed 7 July 2016). 119. Rehm J. The risks associated with alcohol use and alcoholism. Alcohol Res Health. 2011;34:135–43 (http://pubs. niaaa.nih.gov/publications/arh342/135-143.htm, accessed 7 July 2016). 120. Shield KD, Gmel G, Patra J, Rehm J. Global burden of injuries attributable to alcohol consumption in 2004: a novel way of calculating the burden of injuries attributable to alcohol consumption. Popul Health Metr. 2012;10:9 (https:// pophealthmetrics.biomedcentral.com/articles/10.1186/1478-7954-10-9, accessed 7 July 2016). 121. Navarro HJ, Doran CM, Shakeshaft AP. Measuring costs of alcohol harm to others: a review of the literature. Drug Alcohol Depend. 2011;114:87–99 (http://www.drugandalcoholdependence.com/article/S0376-8716(10)00405-9/ abstract, accessed 7 July 2016). 69 References 122. Eckardt M, File S, Gessa G, Grant KA, Guerri C, Hoffman PL et al. Effects of moderate alcohol consumption on the central nervous system. Alcohol Clin Exp Res. 1998;22:998–1040 (http://onlinelibrary.wiley.com/ doi/10.1111/j.1530-0277.1998.tb03695.x/abstract, accessed 7 July 2016). 123. Clausen T, Martinez P, Towers A, Greenfield T, Kowal P. Alcohol consumption at any level increases risk of injury caused by others: data from the Study on Global AGEing and Adult Health. Subst Abuse. 2016;9:125–32 (http:// www.ncbi.nlm.nih.gov/pmc/articles/PMC4878716/, accessed 7 July 2016). 124. Cherpitel C, Ye Y, Bond J, Borges G, Monteiro M, Chou P et al. Alcohol attributable fraction for injury morbidity from the dose-response relationship of acute alcohol consumption: emergency department data from 18 countries. Addiction. 2015;110:1724–32 (http://onlinelibrary.wiley.com/doi/10.1111/add.13031/abstract, accessed 7 July 2016). 125. Taylor B, Irving HM, Kanteres F, Room R, Borges G, Cherpitel C et al. The more you drink, the harder you fall: a systematic review and meta-analysis of how acute alcohol consumption and injury or collision risk increase together. Drug Alcohol Depend. 2010;110:108–16 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2887748/, accessed 7 July 2016). 126. Rehm J, Kehoe T, Gmel G, Stinson F, Grant B, Gmel G. Statistical modeling of volume of alcohol exposure for epidemiological studies of population health: the US example. Popul Health Metr. 2010;8: 3 (http://pophealthmetrics. biomedcentral.com/articles/10.1186/1478-7954-8-3, accessed 7 July 2016). 127. Kehoe T, Gmel G, Shield KD, Gmel G, Rehm J. Determining the best population-level alcohol consumption model and its impact on estimates of alcohol-attributable harms. Popul Health Metr. 2012;10:6 (http://pophealthmetrics. biomedcentral.com/articles/10.1186/1478-7954-10-6, accessed 7 July 2016). 128. Corrao G, Bagnardi V, Zambon A, La Vecchia C. A meta-analysis of alcohol consumption and the risk of 15 diseases. Prev Med. 2004;38:613–9 (http://www.sciencedirect.com/science/article/pii/S0091743503003384, accessed 7 July 2016). 129. Riley EP, Infante MA, Warren KR. Fetal alcohol spectrum disorders: an overview. Neuropsychol Rev. 2011;21:73–80 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3779274/, accessed 7 July 2016). 130. Popova S, Lange S, Shield KD, Mihic A, Chudley AE, Mukherjee RA et al. Comorbidity of fetal alcohol spectrum disorder: a systematic literature review and metaanalysis. Lancet. 2016;387:978–87 (http://www.thelancet.com/ journals/lancet/article/PIIS0140-6736(15)01345-8/abstract, accessed 7 July 2016). 131. Patra J, Bakker R, Irving H, Jaddoe VWV, Malini S, Rehm J. Dose-response relationship between alcohol consumption before and during pregnancy and the risks of low birthweight, preterm birth and small for gestational age (SGA)––a systematic review and meta-analyses. BJOG. 2011;118:1411–21 (http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3394156/, accessed 7 July 2016). 132. Bushman B, Cooper H. Effects of alcohol on human aggression: an integrative research review. Psychol Bull. 1990;107:341–54 (http://psycnet.apa.org/journals/bul/107/3/341/, accessed 7 July 2016). 133. Global status report on road safety 2015. Geneva: World Health Organization; 2015 (http://www.who.int/violence_ injury_prevention/road_safety_status/2015/en/, accessed 7 July 2016). 134. Walter SD. The estimation and interpretation of attributable risk in health research. Biometrics. 1976;32:829–49 (https://www.jstor.org/stable/2529268?seq=1#page_scan_tab_contents, accessed 7 July 2016). 135. Walter SD. Prevention of multifactorial disease. Am J Epidemiol. 1980;112:409–16 (http://www.ncbi.nlm.nih.gov/ pubmed/7424889, accessed 7 July 2016). 136. Ezzati M, Hoorn SV, Lopez AD, Danaei G, Rodgers A, Mathers CD et al. Comparative quantification of mortality and burden of disease attributable to selected risk factors. In: Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL, editors. Global burden of disease and risk factors. Washington, DC: The World Bank; 2006:241–68 (http://www. ncbi.nlm.nih.gov/books/NBK11813/, accessed 7 July 2016). 137. GBD Compare. Seattle: Institute of Health Metrics and Evaluation; 2016. (http://www.webcitation.org/6iKjXLK2n, accessed 1 April 2016). 138. Doll R, Payne P, Waterhouse J. Cancer incidence in five continents: a technical report. Berlin: Springer-Verlag; 1966. 139. European Association for the Study of the Liver. EASL clinical practical guidelines: management of alcoholic liver disease. J Hepatol. 2012;57:399–420 (http://www.journal-of-hepatology.eu/article/S0168-8278(12)00288-7/ fulltext, accessed 7 July 2016). 140. Roerecke M, Nanau R, Rehm J, Neuman M. Ethnicity matters: a systematic review and meta-analysis of the non- linear relationship between alcohol consumption and prevalence and incidence of hepatic steatosis. EBioMedicine. 2016;8:317–30 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4919723/, accessed 7 July 2016). 70 Public health successes and missed opportunities 141. Zatonski W, Manczuk M, Sulkowska U, HEM project team. Closing the health gap in European Union. Warsaw: Cancer Epidemiology and Prevention Division, the Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology; 2008 (http://www.hem.waw.pl/index.Php?idm=87,139&cmd=1, accessed 7 July 2016). 142. Lelbach WK. Cirrhosis in the alcoholic and its relation to the volume of alcohol abuse. Ann NY Acad Sci. 1975;252:85– 105 (http://onlinelibrary.wiley.com/doi/10.1111/j.1749-6632.1975.tb19146.x/abstract, accessed 7 July 2016). 143. Hall P. Alcoholic liver disease: pathobiology, epidemiology and clinical aspects. New York: John Wiley & Sons; 1985. 144. Marugame T, Yamamoto S, Yoshimi I, Sobue T, Inoue M, Tsugane S. Patterns of alcohol drinking and all-cause mortality: results from a large-scale population-based cohort study in Japan. Am J Epidemiol. 2007;165:1039–46 (http://aje.oxfordjournals.org/content/165/9/1039.long, accessed 7 July 2016). 145. Rehm J, Roerecke M. Patterns of drinking and liver cirrhosis – what do we know and where do we go? J Hepatol. 2015;62:1000–1 (http://www.journal-of-hepatology.eu/article/S0168-8278(15)00058-6/fulltext, accessed 7 July 2016). 146. Holmes J, Meier PS, Booth A, Guo Y, Brennan A. The temporal relationship between per capita alcohol consumption and harm: a systematic review of time lag specifications in aggregate time series analyses. Drug Alcohol Depend. 2012;123:7–14 (http://www.drugandalcoholdependence.com/article/S0376-8716(11)00527-8/abstract, accessed 7 July 2016). 147. Kim AS, Johnston SC. Global variation in the relative burden of stroke and ischemic heart disease. Circulation. 2011;124:314–23 (http://circ.ahajournals.org/content/124/3/314.long, accessed 7 July 2016). 148. Truelsen T, Begg S, Mathers C. The global burden of cerebrovascular disease. Geneva: World Health Organization; 2000 (http://www.who.int/healthinfo/statistics/bod_cerebrovasculardiseasestroke.pdf, accessed 7 July 2016). 149. Pagidipati NJ, Gaziano TA. Estimating deaths from cardiovascular disease: a review of global methodologies of mortality measurement. Circulation. 2013;127:749–56 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3712514/, accessed 11 July 2016). 150. Gmel G, Rehm J. Measuring alcohol consumption. Contemp Drug Probl. 2004;31:467–540. 151. Roerecke M, Shield KD, Higuchi S, Yoshimura A, Larsen E, Rehm MX et al. Estimates of alcohol-related oesophageal cancer burden in Japan: systematic review and meta-analyses. Bull World Health Organ. 2015;93:329-38c (http:// www.who.int/bulletin/volumes/93/5/14-142141.pdf?ua=1, accessed 7 July 2016). 152. Collins D, Lapsley H, Brochu S, Easton B, Pérez-Gómez, A, Rehm J et al. International guidelines for the estimation of the avoidable costs of substance abuse. Ottawa: Health Canada; 2006 (http://alcsmart.ipin.edu.pl/files/cb04a_ international_guidelines.pdf, accessed 7 July 2016). 153. Rehm J, Taylor B, Patra J, Gmel G. Avoidable burden of disease: conceptual and methodological issues in substance abuse epidemiology. Int J Methods Psychiatr Res. 2006;15:181–91 (http://www.ncbi.nlm.nih.gov/ pubmed/17266014, accessed 7 July 2016). 154. Tackling liver disease in the UK: a Lancet Commission. Lancet. 2014;384:1902 (http://thelancet.com/journals/ lancet/article/PIIS0140-6736(14)62263-7/fulltext, accessed 7 July 2016). 155. Case A, Deaton A. Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. Proc Natl Acad Sci USA. 2015;112:15078–83 (http://www.pnas.org/content/112/49/15078.long, accessed 7 July 2016). 156. Rehm J, Anderson P, Fischer B, Gual A, Room R. Policy implications of marked reversals of population life expectancy caused by substance use. BMC Med. 2016;14:42 (http://bmcmedicine.biomedcentral.com/articles/10.1186/s12916- 016-0590-x, accessed 7 July 2016). 157. Ramstedt M. Liver cirrhosis mortality in 15 European countries: differences and trends during the post-war period. Nordisk Alkohol Nark. 1999;16:55–73 (http://www.nordicwelfare.org/PageFiles/29657/Liver%20cirrhosis%20 mortality%20in%2015%20European%20countries.pdf, accessed 7 July 2016). 158. Haagsma JA, Graetz N, Bolliger I, Naghavi M, Higashi H, Mullany EC et al. The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013. Inj Prev. 2016;22:3–18 (http://injuryprevention.bmj.com/content/early/2015/10/20/injuryprev-2015-041616.full, accessed 7 July 2016). 159. Rehm J, Roerecke M. Reduction of drinking in problem drinkers and all-cause mortality. Alcohol Alcohol. 2013;48:509–13 (http://alcalc.oxfordjournals.org/content/48/4/509.long, accessed 7 July 2017. 160. Nutt DJ, Rehm J. Doing it by numbers: a simple approach to reducing the harms of alcohol. J Psychopharmacol. 2014;28:3–7 (http://www.ncbi.nlm.nih.gov/pubmed/24399337, accessed 7 July 2016). 161. Rehm J, Zatonski W, Taylor B, Anderson P. Epidemiology and alcohol policy in Europe. Addiction. 2011;106:11–9 (http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2010.03326.x/abstract, accessed 8 July 2016). 71 References 162. Leon DA. Trends in European life expectancy: a salutary view. Int J Epidemiol. 2011;40:271–7 (http://ije. oxfordjournals.org/content/40/2/271.long, accessed 7 July 2016). 163. List of Member States by WHO region and mortality stratum. In: Cost effectiveness and strategic planning (WHO- CHOICE) [website]. Geneva: World Health Organization; 2016 (http://www.who.int/choice/demography/mortality_ strata/en/ accessed 11 July 2016). 164. European Region. In: Cost effectiveness and strategic planning (WHO-CHOICE) [website]. Geneva: World Health Organization; 2016 (http://www.who.int/entity/choice/demography/euro_region/en/index.html, accessed 11 July 2016). 165. Rehm J, Patra J, Popova L. Alcohol drinking cessation and its effect on oesophageal and head and neck cancers: a pooled analysis. Int J Cancer. 2007;121:1132–7 (http://onlinelibrary.wiley.com/doi/10.1002/ijc.22798/abstract, accessed 7 July 2016). 166. Heckley GA, Jarl J, Asamoah BO, G-Gerdtham U. How the risk of liver cancer changes after alcohol cessation: a review and meta-analysis of the current literature. BMC Cancer. 2011;11:446 (http://www.ncbi.nlm.nih.gov/pmc/ articles/PMC3229519/, accessed 7 July 2016). 167. Jarl J, Gerdtham UG. Time pattern of reduction in risk of oesophageal cancer following alcohol cessation––a meta- analysis. Addiction. 2012;107:1234–43 (http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2011.03772.x/ abstract, accessed 7 July 2016). 168. Ahmad-Kiadaliri A, Jarl J, Gavriilidis G, Gerdtham UG. Alcohol drinking cessation and the risk of laryngeal and pharyngeal cancers: a systematic reviewand meta-analysis. PLoS One. 2013;8:e58158 (http://journals.plos.org/ plosone/article?id=10.1371/journal.pone.0058158, accessed 7 July 2016). 169. Leon DA, Chenet L, Shkolnikov V, Zakharov S, Shapiro J, Rakhmanova G et al. Huge variation in Russian mortality rates 1984–94: artefact, alcohol, or what? Lancet. 1997;350:383–8 (http://www.thelancet.com/journals/lancet/ article/PIIS0140-6736(97)03360-6/abstract, accessed 7 July 2016). 170. Shkolnikov VM, Meslé F, Vallin J. Recent trends in life expectancy and causes of death in Russia, 1970–1993. In: Bobadilla JL, Costello CA, Mitchell F, editors. Premature death in the New Independent States. Washington, DC: The National Academy Press; 1997:34–65 (http://www.ncbi.nlm.nih.gov/books/NBK233397/, accessed 7 July 2016). 171. Rehm J, Scafato E. Indicators of alcohol consumption and attributable harm for monitoring and surveillance in European Union countries. Addiction. 2011;106:4–10 (http://onlinelibrary.wiley.com/doi/10.1111/j.1360- 0443.2010.03323.x/abstract, accessed 7 July 2016). 172. Rehm J, Room R. Monitoring of alcohol use and attributable harm from an international perspective. Contemp Drug Probl. 2009;36:575–88. 173. Tsochatzis EA, Bosch J, Burroughs AK. Liver cirrhosis. Lancet. 2014;383:1749–61 (http://www.thelancet.com/ journals/lancet/article/PIIS0140-6736(14)60121-5/abstract, accessed 7 July 2016). 174. Zhang C, Qin YY, Chen Q, Jiang H, Chen XZ, Xu CL et al. Alcohol intake and risk of stroke: a dose-response meta- analysis of prospective studies. Int J Cardiol. 2014;174:669–77 (http://www.internationaljournalofcardiology.com/ article/S0167-5273(14)00907-3/abstract, accessed 7 July 2016). 175. Leon DA, Saburova L, Tomkins S, Andreev E, Kiryanov N, McKee M et al. Hazardous alcohol drinking and premature mortality in Russia: a population based case-control study. Lancet. 2007;369:2001–9 (http://www.thelancet.com/ journals/lancet/article/PIIS0140-6736(07)60941-6/abstract, accessed 7 July 2016). 176. Sidorenkov O, Nilssen O, Nieboer E, Kleshchinov N, Grijibovski AM. Premature cardiovascular mortality and alcohol consumption before death in Arkhangelsk, Russia: an analysis of a consecutive series of forensic autopsies. Int J Epidemiol. 2011;40:1519–29 (http://ije.oxfordjournals.org/content/40/6/1519.long, accessed 7 July 2016). 177. Leon DA, Ezzati M. High cardiovascular mortality in Russia: role of alcohol versus smoking, blood pressure, and treatment. Nat Rev Cardiol. 2015;12:740 (http://www.nature.com/nrcardio/journal/v12/n12/full/nrcardio.2015.167. html, accessed 7 July 2016). 178. Razvodovsky YE. Alcohol-attributable fraction of ischemic heart disease mortality in Russia. Int Sch Res Notices: Cardiology. 2013;15:287869 (http://www.hindawi.com/journals/isrn/2013/287869/, accessed 7 July 2016). 179. Razvodovsky YE. Fraction of stroke mortality attributable to alcohol consumption in Russia [Article in English, Spanish]. Adicciones. 2014;26:126–33 (http://www.adicciones.es/index.php/adicciones/article/view/14, accessed 7 July 2016). 180. Razvodovsky YE. Contribution of alcohol to hypertension mortality in Russia. J Addict. 2014;483910 (http://www. hindawi.com/journals/jad/2014/483910/, accessed 7 July 2016). 181. Razvodovsky YE. Aggregate level beverage specific effect of alcohol sale on myocardial infarction mortality rate [Article in English, Spanish]. Adicciones. 2009;21:229–37 (http://www.adicciones.es/index.php/adicciones/article/ view/233, accessed 7 July 2016). 72 Public health successes and missed opportunities 182. Andreev E, Bogoyavlensky D, Stickley A. Comparing alcohol mortality in Tsarist and contemporary Russia: is the current situation historically unique? Alcohol Alcohol. 2013;48:215–21 (http://alcalc.oxfordjournals.org/ content/48/2/215.long, accessed 7 July 2016). 183. Zaridze D, Maximovitch D, Lazarev A, Igitov V, Boroda A, Boreham J et al. Alcohol poisoning is a main determinant of recent mortality trends in Russia: evidence from a detailed analysis of mortality statistics and autopsies. Int J Epidemiol. 2009;38:143–53 (http://ije.oxfordjournals.org/content/38/1/143.long, accessed 7 July 2016). 184. Tishuk EA. Mediko-statisticheskie aspekty dejstvija alkogolja kak prichiny smertnosti naselenija [Medical-statistical aspects of alcohol on population-based death causes]. Zdravoohranenie Rossijskoj Federacii. 1997;2:34–6. 185. Boeva AV, Zimina LA, Semyonov AV. Harakteristika smertnosti naselenija g. Irkutska ot vneshnih prichin i nekotoryh zabolevanij na fone prijoma jetilovogo alkogolja [The characteristics of mortality of the population of Irkutsk region from external causes and some alcohol-related diseases]. Bjulleten’ VSNC SO RAMN. 2013;3:141–3. 186. Tuusov J, Tõnisson VK, Riikoja A, Denissov G, Väli M. Fatal poisoning in Estonia 2000–2009. Trends in illegal drug- related deaths. J Forensic Leg Med. 2013;20:51–6 (http://www.jflmjournal.org/article/S1752-928X(12)00096-0/ abstract, accessed 7 July 2016). 187. Ringmets I, Tuusov J, Lang K, Väli M, Pärna K, Tõnisson M et al. Alcohol and premature death in Estonian men: a study of forensic autopsies using novel biomarkers and proxy informants. BMC Public Health. 2012;12:146 (http:// bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-12-146, accessed 7 July 2016). 188. Rehm J. Commentary: alcohol poisoning in Russia: implications for monitoring and comparative risk factor assessment. Int J Epidemiol. 2009;38:154–5 (http://ije.oxfordjournals.org/content/38/1/154.full, accessed 7 July 2016). 189. Nemtsov AV. Alkogol’ny uron regionov Rossii [Alcohol-induced deaths in the Regions of Russia]. Moskva: NALEX (In Russian); 2003. 190. Gender Inequality Index (GII). New York: United Nations Development Programme; 2015 (http://hdr.undp.org/en/ content/gender-inequality-index-gii, accessed 11 July 2016). 191. Sorenson SB. Gender disparities in injury mortality: consistent, persistent, and larger than you’d think. Am J Public Health. 2011;101:S353–8 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3222499/, accessed 11 July 2016). 192. Szücs S, Sárváry A, McKee M, Adány R. Could the high level of cirrhosis in central and eastern Europe be due partly to the quality of alcohol consumed? An exploratory investigation. Addiction. 2005;100:536–42 (http://onlinelibrary. wiley.com/doi/10.1111/j.1360-0443.2005.01009.x/abstract, accessed 7 July 2016). 193. Lachenmeier DW, Rehm J. What is the main source of human exposure to higher alcohols and is there a link to immunotoxicity? Immunopharmacol Immunotoxicol. 2013;35:451–3 (http://www.tandfonline.com/doi/full/10.3109 /08923973.2013.794147, accessed 7 July 2016). 194. Lachenmeier D, Haupt S, Schulz K. Defining maximum levels of higher alcohols in alcoholic beverages and surrogate alcohol products. Regul Toxicol Pharmacol. 2008;50:313–21 (http://www.sciencedirect.com/science/article/pii/ S0273230008000032, accessed 7 July 2016). 195. Bhattacharya J, Gathmann C, Miller G. The Gorbachev anti-alcohol campaign and Russia’s mortality crisis. Am Econ J Appl Econ. 2013;5:232–60 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3818525/, accessed 7 July 2016). 196. Room R. Commentary: pattern of drinking and the Russian heart. Int J Epidemiol. 2005;34:788–90 (http://ije. oxfordjournals.org/content/34/4/788.long, accessed 8 July 2016). 197. Allamani A, Prina F. Why the decrease in consumption of alcoholic beverages in Italy between the 1970s and 2000s? Shedding light on an Italian mystery. Contemp Drug Probl. 2007;34:187–98 (http://cdx.sagepub.com/ content/34/2/187.abstract, accessed 8 July 2016). 198. Allamani A, Voller F, Pepe P, Baccini M, Massini G, Maurelli G et al. Balance of power in alcohol policy. Balance across different groups and as a whole between societal changes and alcohol policy. In: Anderson A, Braddick F, Reynolds J, Gual A, editors. Alcohol policy in Europe: evidence from AMPHORA. 2nd ed. The AMPHORA project; 2013:34–48 (http://amphoraproject.net/w2box/data/e-book/AM_E-BOOK_2nd%20edition%20-%20final%20Sept% 202013_c.pdf, accessed 8 July 2016). 199. Babor TF, Caetano R, Casswell S, Edwards G, Giesbrecht N, Graham K. Alcohol: no ordinary commodity. Research and public policy. 2nd ed. Oxford: Oxford University Press; 2010. 200. Anderson P, Chisholm D, Fuhr D. Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol. Lancet. 2009;373:2234–46 (http://www.thelancet.com/journals/lancet/article/PIIS0140- 6736(09)60744-3/abstract, accessed 8 July 2016). 201. Chisholm D, Rehm J, van Ommeren M, Monteiro M. Reducing the global burden of hazardous alcohol use: a comparative cost-effectiveness analysis. J Stud Alcohol. 2004;65:782–93 (http://www.jsad.com/doi/10.15288/ jsa.2004.65.782, accessed 8 July 2016). 73 References 202. Sassi F, editor. Tackling harmful alcohol use: economics and public health policy. Paris: Organisation for Economic Co-operation and Development; 2015 (http://www.oecd.org/health/tackling-harmful-alcohol-use-9789264181069- en.htm, accessed 8 July 2016). 203. Chisholm D, Doran C, Shibuya K, Rehm J. Comparative cost-effectiveness of policy instruments for reducing the global burden of alcohol, tobacco and illicit drug use. Drug Alcohol Rev. 2006;25:553–65 (http://onlinelibrary.wiley. com/doi/10.1080/09595230600944487/abstract, accessed 8 July 2016). 204. Bruun K, Edwards G, Lumio M, Mäkelä K, Pan L, Popham RE et al. Alcohol control policies in public health perspective, volume 25. Helsinki: Finnish Foundation for Alcohol Studies; 1975. 205. Edwards G, Anderson P, Babor TF, Casswell S, Ferrence R, Geisbrecht N et al. Alcohol policy and the public good. New York: Oxford University Press; 1994. 206. Rehm J, Gmel G, Rehm MX, Scafato E, Shield KD. What can alcohol do to European societies? In: Anderson P, Braddick F, Reynolds J, Gual A, editors. Alcohol policy in Europe: evidence from AMPHORA. 2nd ed. The AMPHORA project; 2013:4–16 (http://amphoraproject.net/w2box/data/e-book/AM_E-BOOK_2nd%20edition%20-%20final% 20Sept%202013_c.pdf, accessed 8 July 2016). 207. Noncommunicable Diseases Progress Monitor 2015. Geneva: World Health Organization; 2015 (http://apps.who. int/iris/bitstream/10665/184688/1/9789241509459_eng.pdf?ua=1, accessed 8 July 2016). 208. Rehm J, Gmel G, Probst C, Shield KD. Lifetime-risk of alcohol-attributable mortality based on different levels of alcohol consumption in seven European countries. Implications for low-risk drinking guidelines. Toronto: Centre for Addiction and Mental Health; 2015 (https://www.camh.ca/en/research/news_and_publications/reports_and_ books/Documents/Lifetime%20Risk%20of%20Alcohol-Attributable%20Mortality.pdf, accessed 9 July 2016). 209. National Health and Medical Research Council. Australian guidelines to reduce health risks from drinking alcohol. Canberra, Australia: Commonwealth of Australia; 2009 (https://www.nhmrc.gov.au/guidelines-publications/ds10, accessed 9 July 2016). 210. Stockwell T, Butt P, Beirness D, Gliksman L, Paradis C. The basis for Canada’s new low-risk drinking guidelines: a relative risk approach to estimating hazardous levels and patterns of alcohol use. Drug Alcohol Rev. 2012;31:126– 34 (http://onlinelibrary.wiley.com/doi/10.1111/j.1465-3362.2011.00342.x/abstract, accessed 9 July 2016). 211. Department of Health. Alcohol guidelines review – report from the guidelines development group to the UK Chief Medical Officers. United Kingdom: Williams Lea for the Department of Health; 2015 (https://www.gov.uk/government/ uploads/system/uploads/attachment_data/file/489797/CMO_Alcohol_Report.pdf, accessed 9 July 2016). 212. Joint action on reducing alcohol related harm, RARHA. Brussels: European Commission; 2013. 213. Room R, Rehm J. Clear criteria based on absolute risk: reforming the basis of guidelines on low-risk drinking. Drug Alcohol Rev. 2012;31:135–40 (http://onlinelibrary.wiley.com/doi/10.1111/j.1465-3362.2011.00398.x/abstract, accessed 9 July 2016). 214. Rehm J, Single E. Reasons for and effects of low risk drinking guidelines. In: Buhringer G, editor. Strategien und Projekte zur Reduktion alkoholbedingter Störungen. Lengerich: Pabst; 2002:78–90. 215. Stockwell T, Room R. Constructing and responding to low-risk drinking guidelines: conceptualisation, evidence and reception. Drug Alcohol Rev. 2012;31:121–5 (http://onlinelibrary.wiley.com/doi/10.1111/j.1465-3362.2011.00416.x/ abstract, accessed 9 July 2016). 216. From burden to “best buys”: reducing the economic impact of non-communicable diseases in low- and middle- income countries. Cologny/Geneva: World Economic Forum; 2011 (http://www.who.int/nmh/publications/best_ buys_summary.pdf, accessed 9 July 2016). 217. Bird RM, Wallace S. Taxing alcohol in Africa: reflections and updates. Atlanta: Georgia State University; 2010 (http://icepp.gsu.edu/files/2015/03/ispwp1031.pdf, accessed 11 July 2016). 218. Jernigan DH. Country profile on alcohol in Zimbabwe. In: Riley L, Marshall M, editors. Alcohol and public health in eight developing countries. Geneva: World Health Organization; 1999:157–75 (http://apps.who.int/iris/ handle/10665/66009, accessed 11 July 2016). 219. European Commission. EU citizens’ attitudes towards alcohol. Special Eurobarometer 331. Brussels: TNS Opinion & Social; 2010 (http://ec.europa.eu/health/alcohol/docs/ebs_331_en.pdf, accessed 9 July 2016). 220. Zwerling C, Jones MP. Evaluation of the effectiveness of low blood alcohol concentration laws for younger drivers. Am J Prev Med. 1999;16:76–80 (http://www.ncbi.nlm.nih.gov/pubmed/9921389, accessed 9 July 2016). 221. Fell JC, Voas RB. The effectiveness of a 0.05 blood alcohol concentration (BAC) limit for driving in the United States. Addiction. 2014;109:867–74 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4448946/, accessed 9 July 2016). 74 Public health successes and missed opportunities 222. Kamerstuk – Eerste Kamer der Staten-General. 33 799 Wijziging van het Wetboek van Strafvordering in verband met de introductie van de bevoegdheid tot het bevelen van een middelenonderzoek bij geweldplegers en enige daarmee samenhangende wijzigingen van de Wegenverkeerswet 1994 [33 799 Amendment of the Code of Criminal Procedure in connection with the introduction of the power to recommend an agent study of violent offenders and any related amendments to the Road Traffic Act 1994]. Netherlands: Verheid; 2016 (https://zoek.officielebekendmakingen.nl/ dossier/33799/kst-33799-A?resultIndex=11&sorttype=1&sortorder=4, accessed 9 July 2016). 223. Ramaekers JG, Verkes RJ, van Amersterdam JGC et al. Middelengebruik en geweld. Een literatuurstudie naar de relatie tussen alcohol, drugs en geweld. Den Haag: Wetenschappelijk Onderzoek - en Documentatiecentrum; 2016. 224. Kilmer B, Nicosia N, Heaton P, Midgette G. Efficacy of frequent monitoring with swift, certain, and modest sanctions for violations: insights from South Dakota’s 24/7 Sobriety Project. Am J Public Health. 2013;103:e37–43 (http:// www.ncbi.nlm.nih.gov/pmc/articles/PMC3518350/, accessed 9 July 2016). 225. Khaltourina D, Korotayev A. Effects of specific alcohol control policy measures on alcohol-related mortality in Russia from 1998 to 2013. Alcohol Alcohol. 2015;50:588–601 (http://alcalc.oxfordjournals.org/content/50/5/588. long, accessed 9 July 2016). 226. Holmes J, Meng Y, Meier PS, Brennan A, Angus C, Campbell-Burton A et al. Effects of minimum unit pricing for alcohol on different income and socioeconomic groups: a modelling study. Lancet. 2014;383:1655–64 (http://www. thelancet.com/journals/lancet/article/PIIS0140-6736(13)62417-4/abstract, accessed 9 July 2016). 227. Purshouse CR, Meier PS, Brennan A, Taylor KB, Rafia R. Estimated effect of alcohol pricing policies on health and health economic outcomes in England: an epidemiological model. Lancet. 2010; 375:1355–64 (http://www. thelancet.com/journals/lancet/article/PIIS0140-6736(10)60058-X/abstract, accessed 9 July 2016). 228. Stockwell T, Auld MC, Zhao J, Martin G. Does minimum pricing reduce alcohol consumption? The experience of a Canadian province. Addiction. 2012;107:912–20 (http://onlinelibrary.wiley.com/doi/10.1111/j.1360- 0443.2011.03763.x/abstract, accessed 9 July 2016). 229. Stockwell T, Zhao J, Giesbrecht N, Macdonald S, Thomas G, Wettlaufer A. The raising of minimum alcohol prices in Saskatchewan, Canada: impacts on consumption and implications for public health. Am J Public Health. 2012;102:e103–10 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3519328/, accessed 9 July 2016). 230. Razvodovsky YE. Consumption of noncommercial alcohol among alcohol-dependent patients. Psychiatry Journal. 2013; Article ID 691050:1–5 (http://www.hindawi.com/journals/psychiatry/2013/691050/, accessed 9 July 2016). 231. Roshhina JM. Dinamika i struktura potreblenija alkogolja v sovremennoj Rossii [Dynamics and structure of alcohol consumption in today’s Russia]. Vestnik Rossijskogo monitoringa jekonomicheskogo polozhenija i zdorov’ja naselenija. 2012;2:238–58. 232. Nemtsov AV. Alkogol’naja situatsija v Rossii [Alcohol situation in Russia]. Sobriologija. 2014;2:13–19. 233. Radaev V. Impact of a new alcohol policy on homemade alcohol consumption and sales in Russia. Alcohol Alcohol. 2015;50:365–72 (http://alcalc.oxfordjournals.org/content/50/3/365.long, accessed 9 July 2016). 234. Bobrova N, West R, Malutina D, Koshkina E, Terkulov R, Bobak M. Drinking alcohol surrogates among clients of an alcohol-misuser treatment clinic in Novosibirsk, Russia. Subst Use Misuse. 2009;44:1821–32 (http://www.ncbi. nlm.nih.gov/pmc/articles/PMC3941122/, accessed 9 July 2016). 235. Nicosia N, Kilmer B, Heaton P. Can a criminal justice alcohol abstention programme with swift, certain, and modest sanctions (24/7 Sobriety) reduce population mortality? A retrospective observational study. Lancet Psychiatry. 2016;3:226–32 (http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(15)00416-2/abstract, accessed 9 July 2016). 236. Österberg E. The effects of favouring lower alcohol content beverages: four examples from Finland. Nordisk Alkohol Nark. 2012;29:41–56 (http://www.degruyter.com/view/j/nsad.2012.29.issue-1/v10199-012-0004-0/v10199-012- 0004-0.xml, accessed 9 July 2016). 237. Mäkelä P, Mustonen H, Österberg E. Does beverage type matter? Nordic Studies on Alcohol and Drugs. 2007;24:617– 31 (http://www.nordicwelfare.org/PageFiles/4523/M%C3%A4kel%C3%A4%20Mustonen%20%C3%96sterberg. pdf, accessed 9 July 2016). 238. Mäkelä P, Hellman M, Kerr WC, Room R. A bottle of beer, a glass of wine, or a shot of whiskey? Can the rate of alcohol-induced harm be affected by altering the population’s beverage choices? Contemp Drug Probl. 2011;38:599– 619 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3888958/, accessed 9 July 2016). 239. Segal DS, Stockwell T. Low alcohol alternatives: a promising strategy for reducing alcohol related harm. Int J Drug Policy. 2009;20:183–7 (http://www.ijdp.org/article/S0955-3959(08)00135-7/abstract, accessed 9 July 2016). 75 References 240. Chikritzhs T, Stockwell T, Pascal R. The impact of the Northern Territory’s Living With Alcohol program, 1992– 2002: revisiting the evaluation. Addiction. 2005;100:1625–36 (http://onlinelibrary.wiley.com/doi/10.1111/j.1360- 0443.2005.01234.x/abstract, accessed 10 July 2016). 241. Sornpaisarn B, Shield KD, Cohen JE, Schwartz R, Rehm J. Can pricing deter adolescents and young adults from starting to drink: an analysis of the effect of alcohol taxation on drinking initiation among Thai adolescents and young adults. J Epidemiol Glob Health. 2015;5:S45–57 (http://www.sciencedirect.com/science/article/pii/ S2210600615000611, accessed 10 July 2016). 242. Sornpaisarn B, Shield K, Rehm J. Two-Chosen-One taxation: examining its potential effectiveness to reduce drinking initiation and heavy alcohol consumption in low- to middle-income countries. Addiction. 2012;107:1389–90 (http:// onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2012.03961.x/abstract, accessed 10 July 2016). 243. Sornpaisarn B, Kaewmungkun C, Rehm J. Assessing patterns of alcohol taxes produced by various types of excise tax methods – a simulation study. Alcohol Alcohol. 2015;50:639–46 (http://alcalc.oxfordjournals.org/content/ early/2015/06/20/alcalc.agv065, accessed 10 July 2016). 244. Rehm J, Shield KD, Gmel G, Rehm MX, Frick U. Modelling the impact of alcohol dependence on mortality burden and the effect of available treatment interventions in the European Union. Eur Neuropsychopharmacol. 2013;23:89–97 (http://www.europeanneuropsychopharmacology.com/article/S0924-977X(12)00219-2/abstract, accessed 10 July 2016). 245. Roerecke M, Gual A, Rehm J. Reduction of alcohol consumption and subsequent mortality in alcohol use disorders: systematic review and meta-analysis. J Clin Psychiatry. 2013;74:e1181–9 (http://www.psychiatrist.com/JCP/ article/Pages/2013/v74n12/v74n1207.aspx). 246. Norström T. The abolition of the Swedish alcohol rationing system: effects on consumption distribution and cirrhosis mortality. Br J Addict. 1987;82:633–41 (http://www.ncbi.nlm.nih.gov/pubmed/3496914, accessed 10 July 2016). 247. Anderson P, Baumberg B. Alcohol in Europe: a public health perspective. A report for the European Commission. London: Institute of Alcohol Studies; 2006 (http://ec.europa.eu/health/archive/ph_determinants/life_style/alcohol/ documents/alcohol_europe_en.pdf, accessed 11 July 2016). 248. Shield KD, Rehm MX, Rehm J. Social costs of addiction in Europe. In: Anderson P, Rehm J, Room R, editors. The impact of addictive substances and behaviours on individual and societal well-being. Oxford: Oxford University Press; 2015:181–8.

The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Offi ce for Europe is one of six regional offi ces throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan The former Yugoslav Republic of Macedonia Turkey Turkmenistan Ukraine United Kingdom Uzbekistan World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 E-mail: euwhocontact@who.int Website: www.euro.who.int Public health successes and missed opportunities 9 789289 051675 > ISBN 9789289051675 Public health successes and m issed opportunities Trends in alcohol consumption and attributable mortality in the WHO European Region, 1990–2014