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Vaaramo K., Puljula J., Tetri S. et al.
Neuroepidemiology: 2012, 39, p. 156–162.
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Evidence from Finland that the 2004 decreases in alcohol taxes and increase in availability of cheaper drink from abroad led to an increase in alcohol-related deaths and in deaths overall among harmful drinkers.
Summary The huge annual number of alcohol-related head injuries makes it important to know whether this total is influenced by political decisions. More drinking across a population and particularly more drinking to intoxication will increase alcohol-related harm including head injuries. In turn, consumption may be influenced by the price and availability of alcohol; the cheaper and more available alcohol is, the more is consumed and the more harm results. Alcohol taxation is a key policy lever for reducing harm by reducing consumption.
The sole emergency trauma unit in a Finnish province tracked deaths among head injury (commonly caused by intoxication) patients to assess whether alcohol tax and resultant price decreases in 2004 affected their risk of death.
Over the period 2000 to 2009 increases in the proportion of ‘under the influence’ deaths among the patients paralleled increases in alcohol consumption in the province.
After 2004 death rates markedly increased among patients whose medical records were indicative of harmful drinking, but not among other patients.
The conclusion was that in Finland as elsewhere, alcohol price and availability strongly influence alcohol-related deaths.
In Finland reduced taxes in 2004 on many alcoholic beverages and increased access to much cheaper alcohol from neighbouring Estonia offered a ‘natural experiment’ through which to assess the impact of taxation and price on drinking and resultant harm. The changes were followed by a marked and rapid increase in consumption across Finland and in particular in Oulu province, where the featured study took place and where alcohol sales rose the following year by 9.3%. Across Finland, alcohol-related mortality simultaneously increased.
The featured study assessed the impact of the taxation changes on all 827 patients who in 1999 were recorded as having attended the emergency room of Oulu University Hospital, the only hospital with a trauma team and neurosurgical services in the province. At issue was whether among this cohort, which included many heavy drinkers, death trends between the years 2000 and 2009 changed after alcohol became more affordable and accessible in 2004.
Any such changes might be more apparent among those known to have been drinking in a harmful manner. Totalling 101 out of the 827 patients, they were identified on the basis of hospital records which noted a diagnosis of alcohol-related disease or acute intoxication preceding admittance during the follow-up period 2000 to 2009.
Whether alcohol contributed to any the 160 deaths recorded from 2000 to 2009 was identified from its presence being noted on death certificates, or from hospital records if the deceased had been in hospital immediately before their death. These were presumed to have been deaths which occurred under the influence of alcohol.
During the follow-up period there were clear indications that overall and among harmful drinkers in particular, deaths increased after the 2004 alcohol policy changes. During 2000–2009 the proportion of all deaths which were presumed to have occurred under the influence of alcohol increased significantly, closely paralleling the increase in per capita alcohol consumption in Oulu province. Up until 2004 harmful drinkers died at about the same rate as the other patients, but after then their death rate markedly increased, and their chance of surviving progressively diverged from that of the remaining patients. The result was that after other factors had been taken into account, they were over the whole follow-up period two to three times as likely to have died.
The most striking finding was the significantly increased mortality of harmful drinkers directly after the alcohol price reductions in 2004. Until then harmful drinkers had a similar survival rate to other patients. Moreover, the number of deaths under the influence of alcohol significantly increased after the price reductions.
Such findings have important public health implications. While the example of Finland shows that tax and price decreases increase alcohol-related deaths, the example of the former Soviet Union shows that alcohol control polices which feature price rises can have the opposite effect, dramatically reducing deaths. The lesson from these two ‘natural experiments’ is that political decisions may strongly support or counteract attempts to save lives of hazardous drinkers or those dependent on alcohol.
commentary The featured study adds weight to UK simulation studies which estimate that increasing the price of currently cheaper sources of alcohol would save lives, especially among the heaviest drinkers. These studies are referred to in an Effectiveness Bank hot topic, to which readers are referred for more on price-based strategies as a way to reduce alcohol-related harm.
As the hot topic entry notes, a comprehensive review widely relied on for its assessment of tax and price polices has strongly suggested that tax/price increases and decreases respectively reduce and increase numbers of alcohol-related deaths. However, it found only one study capable of addressing not just deaths due to drink, but net health harm/benefit, because it related tax to overall mortality, whatever the cause. In this study US state alcohol taxes were weakly related to fewer deaths overall, but not with sufficient strength or consistency to eliminate the possibility that the relationship was due to chance rather than to a real link with tax levels.
This too is a gap in the featured study from Finland, which shows that alcohol-implicated deaths (either presumed under the influence or among harmful drinkers) increased after the tax/price reductions in 2004, but did not test whether the overall death rate among the patients also responded in the same way. From the graph showing survival rates, it seems possible that after 2004 the death rate turned down somewhat among the majority of patients not identified as harmful drinkers at the same time as it turned up among the harmful drinkers. The net impact across all patients is unclear.
Other analyses of the impact of the tax changes in 2004 have found that across Finland sudden deaths due to drinking increased steeply in the following months, and that assessed up to the end of 2005, so too did alcohol-related deaths in general, though in the capital Helsinki interpersonal violence did not increase and domestic violence decreased.
Last revised 28 July 2015. First uploaded 25 July 2015
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