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Alcohol Consumption and Indicators
of Alcohol Related Harm in Slovenia, 1981 - 2002
by Janja Šešok
Misuse of alcohol represents one of the leading causes of
preventable death, illness, and injury throughout the world.
Alcohol consumption is associated with a variety of adverse
health and social consequences. Its use can equally harm drinkers
and nondrinkers (1). A study of the international literature
on disease and death related to alcohol has identified at least
61 different types of injury, illness or death,which are potentially
caused by the consumption of alcohol with some of them 100%
attributed to alcohol. World Health Organization (WHO) estimates
that alcohol accounts for 10-11% of all illness and death each
year in developed countries. Its use is also strongly related
to social consequences, such as drink driving injuries and fatalities,
aggressive behavior, family disruption, and reduced industrial
productivity (2).
Research over the past two decades has found that the level
of alcohol problems is related to the overall amount of drinking
in the country (per capita alcohol consumption) as well as to
the particular patterns of drinking (3).
Consumption trends and drinking habits have changed substantially
over the past 20 years in the European countries as well as
in Slovenia (4,5). In the European countries (the entire WHO
European Region), aggregated recorded alcohol consumption has
decreased by 5.4% from 1987 to 2000. In European Union (EU)
countries (precalculated regional averages for these countries)
during the same period, the consumption decreased by almost
15% (6). The decrease was higher in the high-consumption countries
and lower in the low-consumption countries. One of the most
frequently used labels to denote the trends in alcohol consumption
in the industrialized world is that of homogenization. National
differences in consumption levels are diminishing and the countries’
traditionally dominant type of beverage is loosing ground in
general terms (7). These facts are important, especially from
an alcohol policy point of view.
Slovenia is among the European countries with the higher overall
(registered and unregistered) consumption of alcohol per capita,
and among EU countries with the highest alcohol related disease
ratio, such as liver diseases, traffic accidents due to alcohol,
and alcohol-related deaths (8,9). The harmful consequences of
the use of alcohol affect a significant number of Slovenians
and represent an important public health issue. According to
the Slovenian Public Opinion Survey, conducted in 1999, 173,000
people were addicted to alcohol (10). Every year, more than
500 people die from alcohol-related causes and among them almost
70% die prematurely. In 2002, 9.3% of road traffic accidents
were alcohol-related (11).
This article seeks to document over-time per capita alcohol
consumption as well as the connection between per capita alcohol
consumption and health consequences. Short and long term alcohol-related
harm is presented by the most commonly used indicators, alcohol-related
mortality and alcohol-related road traffic accidents. The summary
of existing control policy, ie, actions undertaken for further
reduction of alcohol consumption and prevention of alcohol-
related harm was analyzed as well.
Methods
A set of indicators was chosen to assess the most important
aspects of the situation in Slovenia as they relate to public
health.
Data sources for the article included registered alcohol consumption
and the data of selected alcohol-attributable causes of death
and alcohol-related road traffic accidents.
The analysis of consumption trends was based on recorded alcohol
consumption. The statistics cover both the total per capita
consumption of alcohol and per capita consumption of beer, spirits,
and wine, expressed in liters of 100% alcohol. Conversion factors
used to estimate the amount of pure alcohol in beer was 5% and
11% in wine.
Until 1994, per capita annual consumption of pure alcohol had
been calculated on the basis of the data obtained from the sale
of alcoholic beverages in stores and restaurants, as well as
home production. Since 1995, consumption of pure alcohol has
been calculated on the basis of the data on production, trade,
and stocks. For the purpose of this analysis all available data
on alcohol production and trade was obtained from the Statistical
Office of the Republic of Slovenia (12).
Annual per capita alcohol consumption was derived as follows:
Total estimated recorded alcohol consumption in a country in
a given year equals total alcohol production plus alcohol imports
minus alcohol export in that year (2,13). Stocks were also taken
into account.
Alcohol-attributable causes of death were taken from death certificates.
Causes of death were analyzed and classified by the International
Classification of Diseases (ICD) and related health problems,
ICD-9 and ICD-10 Revisions (14). The following diseases and
injuries were gathered in a group and presented as all alcohol-related
causes of death: Mental and behavioral disorders due to use
of alcohol (F10), Degeneration of nervous system due to alcohol
(G31.2), Alcoholic polyneuropathy (G62.1), Alcoholic myopathy
(G72.1), Alcoholic cardiomyopathy (I42.6), Alcoholic gastritis
(K29.2), Alcoholic liver disease (K70), Alcohol-induced chronic
pancreatitis (K86.0), Maternal care for (suspected) damage to
fetus from alcohol (O35.4), Fetus and newborn affected by maternal
use of alcohol (P04.3), Fetal alcohol syndrome (Q86.0), Finding
of alcohol in blood (R87.0), Accidental poisoning by and exposure
to alcohol (X45), Intentional self poisoning by and exposure
to alcohol (X65), and Poisoning by and exposure to alcohol,
undetermined intent (Y15). Death rates were calculated per 100,000
adult population (14). Age standardized death rates were calculated
by using the Europe Standard Population based on the year 1997,
the year closest to the years for which the data were collected
(15).
Death rates of selected alcohol-related causes from WHO database
were presented separately. This group of causes included: Liver
cirrhosis, Alcoholic psychosis, Alcohol dependency, Alcohol-related
traffic accidents, Pancreatitis, Alcohol-related external injury
and poisoning, and Cancers of upper digestive tract and of the
pancreas (6).
Years of potential life lost (YPLL) before the age of 65 were
calculated for all alcohol-related causes of death. YPLL is
a sophisticated measure of the impact of premature mortality
on a population (17). The advantage of YPLL over the more familiar
mortality measures is that YPLL allows a selective evaluation
of the leading causes of death in younger age groups, because
they are calculated as the sum of the differences between some
predetermined minimum or desired life span and the age of death
of individuals who died earlier than that predetermined age,
usually 65 years of age (17,18).
Data on road traffic accidents were obtained from the Ministry
of Internal Affairs and from WHO’s Health For All database (6,19).
Alcohol-related car accidents were those in which one or more
drivers had been drinking according to the report of the police
officer.
Results
Consumption
Apparent
per capita consumption of ethanol from all beverages combined
decreased from 11.5 L in 1981 to 9.8 L in 2002. The decline
was substantial in the period from 1981 to 1991. From 1991 to
2000 per capita alcohol consumption decreased by 8.5%, and increased
again in 2001 and 2002 (Table 1, Fig. 1).
When volumes of consumed beer, wine, and spiritswere converted
into per capita ethanol volume, apparent per capita ethanol
consumption in 2002 was 9.8 liters, which was 15.1% less than
in 1981 (Table 1). This reduction did not reach the targeted
20% set by the Health For All project (20).
Between 1981 and 1991, the consumption of all alcoholic beverages
decreased, with the biggest decline noted for spirits (20.8%,
Table 1). The trend of the last 20 years is a reduction in per
capita spirits and wine consumption.
The beer proportion of per capita pure alcohol consumption increased
after 1993, peaked at 5 L in 1997, and afterwards declined to
4.1 L in 1998, and remained at about 4.3 L in 2000, 2001, and
2002. The amount of pure alcohol consumed through beer was in
the last years almost the same as the amount consumed through
wine (Fig. 1). The increased proportion of beer in relation
to the total consumption is mainly due to a substantial decrease
in spirits consumption and partly to a reduction in wine consumption
Because of the high level of unrecorded consumption, which was
estimated to be between 7 and 8 liters per capita (21,22), as
well as large fluctuations in alcohol consumption levels from
one year to another, it is difficult to precisely display the
different movements of the trend during the observed period.
Alcohol-related Mortality
A decrease of overall mortality from the selected alcohol-related
diseases and injuries was noted in the observed period of 1986
to 2001 (Fig. 2). There were also yearly oscillations of the
number of deaths per 100,000. Decrease in the number of deaths
was highest in the period from 1993 to 1999. After that, yearly
oscillations continued. The curve of mortality from all alcohol-related
deaths showed a decreasing trend despite substantial yearly
oscillations (Fig. 2). In the observed period the average number
of all alcohol-related deaths in population aged 15 years was
32 per 100,000, with a share of 3% of all deaths in Slovenia.
Alcohol liver cirrhosis was the most frequent single cause of
all alcohol-related deaths, with a share of 64.2%, followed
by alcohol dependence syndrome (13.1%) and alcoholic cardiomyopathy
(12.4%, Fig. 2). There was an increasing trend of alcohol dependence
syndrome mortality (Fig. 3). The external cause of death for
more than 40% of deaths from mental and behavioral disorders
due to use of alcohol was suicide.
Alcohol-related Premature Mortality
A trend of decrease is visible in years of potential life lost
due to premature deaths from alcohol-related causes in the period
from 1987 to 2002 (Fig. 4). The major contributor of YPLL was
alcoholic liver disease with an average number of 2,999.8 YPLL,
followed by mental and behavioral disorders due to the use of
alcohol with an average number of 1,024.4 YPLL. In the period
from 1987 to 1995, alcohol liver disease was responsible for
more than 70% of all YPLL due to alcohol related premature deaths.
In the same period, the share of mental and behavioral disorders
due to alcohol was 14%. After 1996, the share of YPLL due to
mental and behavioral disorders due to alcohol increased to
32% and has been rising since. In the same period, the share
of YPLL due to alcohol liver disease started to drop and leveled
at about 56% in 1997.
Figure 1. Consumption trends for major groups of alcoholic beverages
in Slovenia for 1981-2002. Diamonds – beer; squares – wine;
triangles – spirits.
Figure 2. Adult per capita consumption of pure alcohol, standardized
death rates for selected indicators of alcohol-related harm
and road traffic accidents involving alcohol in Slovenia for
1985-2001. Open squares – selected alcohol-related causes of
death; closed squares – adult per capita alcohol consumption;
triangles – road traffic accidents involving alcohol; diamonds–
chronic liver disease and cirrhosis.
Road Traffic Accidents Due to
Alcohol
The level of alcohol-related traffic accidents had been
relatively stable from 1986 to 1993. In 1994, a substantial
increase of 87% in the number per 100,000 was registered, ie,
an increase from the average number of 35.5 per 100,000 to 66.5
per 100,000 (Fig. 2). The number has been high ever since, on
average 72.6 per 100,000 road traffic.
Discussion
Based on the recorded level of alcohol consumption for the past
20 years, with an average adult per capita consumption of more
than 10 L of pure alcohol, the consumption of pure alcohol decreased
by 12.2% and 8.2% in the past 20 and 10 years, respectively,
which was less than the targeted 25%. Target 17 of the WHO Health
For All by the Year 2000 program was to reduce alcohol consumption
by 25%, ie, from the 9.2 L per capita in 1991 to the targeted
6.9 L in 2000 (15). Slovenia did not achieve that goal. Furthermore,
if this trend of consumption continues, the targeted consumption
of 6 L per capita by the year 2015, which was set by WHO health
21 target 12, will not be achieved (23). The critical point
of 10 L per adult per capita consumption, which is an indicator
of high health risk, has been surpassed in almost all years.
Figure 3. The link between per capita alcohol consumption and
age-standardized death rates for selected alcohol-related causes
due to long term alcohol abuse in Slovenia for 1986-2001. Open
diamonds – alcohol dependence; open squares – alcoholic psychosis;
triangles – alcoholic liver disease; crosses – all alcohol-caused
deaths; closed diamonds – per capita consumption (L); open circles
– targeted consumption.
Figure 4. Years of potential life lost (YPLL) due to selected
alcohol-related causes in Slovenia for 1987-2002. Triangles
– all alcohol- related causes of death; squares – mental and
behavioral disorders due to use of alcohol; diamonds – alcoholic
liver disease.
Until 1994, Slovenia was a typical wine-drinking country, with
an average share of pure alcohol consumption amounting to more
than 50%. After that, beer became a very popular beverage. Since
then, the share of pure alcohol consumed in the form of beer
has risen substantially, and was almost equal to the share of
pure alcohol consumed in wine, ie, about 5 liters. This shift
away from the dominant type of beverage towards various other
beverages is also seen in other European countries, (which clearly
do not belong to a single group). As in most EU countries, the
proportion of spirits has declined in Slovenia since 1981 (11).
Data on alcohol consumption presented in this article are based
on the recorded consumption. Due to the fact that retail sales
data were not available in Slovenia, per capita estimates of
alcohol consumption were calculated, primarily on the basis
of data on production and trade of alcohol beverages. These
estimates did not account for unrecorded consumption, which
has been estimated at about 7 to 8 L of pure alcohol per capita
(or approximately 8.7 to 10 L per adult) (11,21,22). According
to this information, overall per capita consumption would be
about 19 L. Even if the unregistered consumption had been half
of the assessed volume, the total consumption would have been
more than 14 L of pure alcohol per adult, which puts Slovenia
among other countries with the highest alcohol consumption.
The ups and downs of the consumption curve imply that the data
reported on the production and trade had not been as accurate
as they should be.
With an average death rate of more than 20 deaths per 100,000
population for liver disease and cirrhosis, Slovenia ranks among
the countries with an intermediate death rate (between 10 and
25 deaths per 100,000). An upward trend, particularly from 1996,
can be seen for alcohol liver disease mortality, which has been
the most important cause of death in the observed period. This
could also be the result of more accurate coding of causes of
death. It has to be stressed however, that there is underreporting
of alcohol- related underlying causes of death on death certificates.
Premature mortality of all alcohol-related causes has been decreasing
(Fig. 4), but there has been an increasing trend in premature
mortality from mental and behavioral disorders due to alcohol
since 1996. Alcohol dependence and alcoholic cirrhosis, the
two most reported cases of alcohol-related mortality, account
for a substantial number of years of potential life lost due
to alcohol use. However, when average YPLL per death was examined,
it was apparent that deaths resulting from the acute effects
of alcohol accounted for relatively more mortality in younger
persons, e.g., an average of 30 years of life lost for each
death associated with excessive blood alcohol levels, in contrast
with 12 years lost for each death from alcoholic cirrhosis.
In 2002, premature deaths from liver disease and cirrhosis accounted
for 4,635 YPLL (6.7% of all YPLL) and ranked fourth among all
single causes of death (24).
Despite the fact that in Slovenia every death is medically certified
and that we use the common tool, ICD-10 instructions for coding
the underlying cause of death, there are always deviations in
the interpretation of coding rules among nine physicians who
are in charge of coding in the regional institutes of public
health, differences in medical training of medical practitioners
who fill in the death certificates and in diagnostic possibilities
in different levels of health institutions in the country. There
is also probably a certain degree of underreporting of causes
of death that can be 100% attributed to alcohol.
With an average number of 72.6 road traffic accidents per 100,000
inhabitants in the period from 1994 to 2001, Slovenia was among
the countries with the highest rates (6). According to the data
from the Health For All Database, in 2000, Slovenia ranked second
(77.4 traffic accidents per 100,000), followed by Croatia (75.7).
Greece ranked first with a total of 216.1 traffic accidents
per 100,000.
There was a substantial increase in the number of alcohol-related
traffic accidents in 1994, which was partly due to the changes
in methodology of defining causes of accidents. Until 1993,
alcohol was treated as the primary cause of accident. In 1994,
new methodology was introduced which classified alcohol as a
secondary cause of accidents, together with overtaking or changing
lines, and speeding as the primary cause of accidents. The most
frequent primary cause of accidents thus became speeding, and
the most frequent secondary cause alcohol.
The number of alcohol-related non-fatal road traffic accidents
depends on whether the individuals had their blood tested for
alcohol or not. There is a general under-reporting of car accidents,
especially the less severe ones (24). Reliable blood alcohol
concentration testing of drivers in fatal crashes is available
in Slovenia, but in non-fatal crashes blood alcohol concentration
testing is more selective. Yearly oscillations probably depended
on the extent of testing drivers for blood alcohol concentration.
The experience of many EU countries shows that reduction of
harm can be achieved through various restrictions defined by
legislation, health promotion, and education (school based education
– training in social skills, self-control, information programs,
mass media campaigns) as well as coordinated approaches for
the improvement of resource utilization and specific training
in primary health care (early detection, brief intervention),
ensuring easy access to cost-effective health care programs.
One of the steps Slovenia has taken in reducing alcohol consumption,
which particularly targeted youngsters, was the law on alcohol
adopted by the Slovenian Parliament in 2003 (25). The law restricted
access to alcohol and provided an official background for a
national alcohol policy. It also reduced the availability of
alcoholic beverages. There is a minimum legal age limit of 18
years for drinking alcoholic beverages and for buying alcohol
in shops, grocery stores, or gasoline stations. There is a prohibition
of sale of distilled spirits before 10 a.m. (25).
The advertising of alcoholic beverages in schools, sport centers,
and health care institutions is also prohibited. Advertising
alcoholic beverages on television and radio is permitted only
after 10 p.m. (26). The aim of these measures has been to reduce
the prevalence of male and female drinkers consuming more than
40 g and 20 g of alcohol daily, respectively, to postpone one’s
first drink as much as possible, and to reduce binge drinking
among youngsters. Results from the European School Survey Project
on Alcohol and Drugs (ESPAD) conveyed on 15 to 16 year-olds
in 1995 showed that 73% of the respondents had drunk alcoholic
beverages in the last 12 month, and 43% of them had drunk till
the state of intoxication (27). Lifetime prevalence of alcohol
use was 87% (88% for boys and 86% for girls). The ESPAD survey
conducted in 1999 showed that 30% of boys and 25% of girls consumed
their first glass of beer at the age of 11; 91% of pupils aged
15 had already experienced alcohol; more than two-thirds of
them have experienced drunkenness; for almost 25% of them binge
drinking was an everyday activity (27). Most of them experienced
alcohol for the first time at home (27).
In 1998, some changes relating to alcohol and driving were adopted
in the existing legislation. The blood alcohol concentration
limit was set at 0.05 g% for the general public, 0.0 g% for
professional drivers and young drivers (during the first 2 yeas
after receiving a driving license, ref. 28). Driving license
is taken away from all drivers having a blood alcohol concentration
more than 0.15 g%, and from all drivers causing an accident,
while having a blood alcohol concentration more than 0.11 g%.
In the year following the adopted changes, the number of alcohol-related
road traffic accidents decreased by 37%. Also, the number of
consequences decreased substantially, ie, by 39%, but with an
18% decrease in the number of deaths. The source of worry was
the fact that blood alcohol concentration of drivers who caused
accidents was 13% on average higher than in the year prior to
the adoption of more restrictive measures. This led to the conclusion
that more severe restrictions have had little effect on heavy
drinkers (29).
Experience of many other countries show that restrictions, when
adopted by law, have to be controlled and violations strictly
punished. There is an ongoing public debate on lowering blood
alcohol concentration to 0.02 g%. So far, public opinion is
against this proposal.
These measures will not be efficient until people’s attitude
towards drinking changes. In a household survey from 2001, 91%
of people supported the law on alcohol which would have restricted
availability of alcoholic beverages (29). The percentage of
the interviewers who were opposed to it was the highest in age
groups aged from 18 to 24 years and from 25 to 34 years (30).
This population group should be one of the target groups for
preventive activities and measures.
Despite the high level of unrecorded consumption, there is no
doubt that overall consumption of alcohol is decreasing in Slovenia.
The registered consumption of pure alcohol decreased by 12.2%
in the past 20 years.On average 32 people per 100,000 aged 15
years died annually from alcohol-related causes in the observed
period, mostly of liver disease and cirrhosis, with alcohol
liver disease being the most important cause of death as well
as premature death. In the period from 1994 to 2001, the average
number of road traffic accidents due to alcohol per 100,000
inhabitants was 72.6 which put Slovenia among the countries
with the highest rates. The existing legislation is a good ground
for the reduction of short and long-term alcohol-related harm.
There is a need for improvement of the reporting system for
alcohol consumption as well as for alcohol-related short and
long-term harmful consequences.
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Correspondence to:
Janja Šešok
Institute of Public Health of the Republic of Slovenia
Trubarjeva cesta 2
1000 Ljubljana, Slovenia
Janja.Sesok@ivz-rs.si
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