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Research

INGEBORG ROSSOW report

Trends in alcohol I. Rossow: Trends in aLcohoL


consumption and alcohol- consumption and alcohoL-reLated
harms in Norway around the turn of the
related harms in Norway miLLennium
.AIMS
around the turn of the This study aims to examine whether

millennium the significant increase in aLcohoL


consumption in Norway since 1993 is
refLected in various aLcohoL-related
harms over the same period .
DATA
The study draws on various register
statistics and popuLation sample
surveys that provide mostLy annuaL time
series data on alcohoL-related mortality.
Introduetion morbidity. crimes and other sociaL
Alcohol-related harms constitute the main harms.
concern and basis for alcohol policy. Alcohol- RESULTS AND DISCUSSION
related harms cover a wide range of harmful When examining a wide range of
consequences both in the health and in the alcohol-related harms some-but not
social domain and are due to both the acute all-harm trends were found to follow
and chronic effects of drinking (Babor et al. the same increasing trend as alcohoL
2003). At the population level we expect that consumption. The resuLts are discussed
the number of heavy-drinking episodes as with respect to data accuracy as well as
well as the number of chronic heavy-drinking more substantive possibie expLanations
individuals are closely associated with the for a mismatch in trends in consumption
amount of alcohol-related harm in that popu- and harms.
lation. Thus, if alcohol consumption in a pop- .KEYWORDS
ulation increases, we assume that the amount ALcohoL. harms. population. trends.
of risky drinking occasions and the number
of high-risk drinkers also increases, and con-
sequently that the amount of alcohol-related
harms also increases. Such associations be-
tween changes in alcohol consumption and
alcohol-related harms have been shown for
some harm indicators (e.g., cirrhosis mortal-
itY (Ramstedt 2001; violent assaults (Skog &
Bjrk 1988, Lenke 1990); and homicides

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(Rossow 2001). It is, however, not clear eral of the data series and survey data re-
whether--or to what extent-a wide range of sults presented in this study have not been
indicators of alcohol-related harms display presented previously.
a consistent picture in mirroring trends in
alcohol consumption. In the present study Trends in alcohol consumption
a significant increase in alcohol consump- In Norway statistics on registered sales of
tion over a 12-year period was the point alcohol have been recorded since 1851,
of departure for examining all obtainable and over this one and a half centuries
indicators of alcohol-related harm over the there have been huge variations in re-
same period so as to assess whether there carded sales (Statistics Norway 2007). We
are consistencies or discrepancies in these will in the following only consider the
trends. Such an exercise has probably not more recent period from the early 1990s
been done previously in Norway, though and onwards. Registered sales of alcohol
Thorkild Thorsen's monograph (1990) on in Norway increased steadily during the
alcohol consumption and alcohol-related period 1993-2005 (see Figure 1). In 1993
harms in Denmark over a 100-year period the total sales were 4.55litres ofpure alco-
provides a comprehensive example. hol per inhabitant (aged over 15), whereas
The present study is based on a collec- in 2004 the sales were 6.22 litres, which
tion of various types of data: registered implies a 37% increase in registered sales
alcohol sales; survey data on unregistered over the 12-year period. The sales statistics
consumption and self-reported consump- further show that the increase in alcohol
tion among young people; death statistics; sales is mainly due to the doubling in sales
somatic hospital statistics; crime statistics; ofwine (from 0.9 to 1.9Iitres) and particu-
child welfare statistics and surveys in the larly so table wines, which constitute the
adult population and among young peo- vast majority of all wine sales in Norway.
pIe covering self-reported alcohol-related It is noteworthy that the increase in wine
harrns. Most ofthese data are annual series sales reflects a significant increase in sales
for the period 1994 to 2004/2005; how- of "bag-in-box" wine, which now consti-
ever, survey data in the adult population tutes half of the wine sales in N orway. The
cover only three data points: 1994, 1999 beer sales have been fairly stable during
and 2004. The data have been collected this period (increasing only from 2.8 to 3.0
from various sources; mortality statistics litres), as have spirits sales (mostly around
from Statistics Norway (2006); morbid- 1.0 litre per year, except for the past couple
ity statistics were ordered for the purpose of years when the sales have increased to
of this study from the Norwegian Patient around 1.2 litres).
Registry (2006); social harm statistics were The unregistered consumption of alco-
collected from Statistics Norway (2006) hol (due to tax free and other travellers'
and the survey data are part of series of imports, smuggled alcohol and home
surveys conducted by the Norwegian In- production of wine and spirits) has been
stitute for Alcohol and Drug Research (SI- estimated on the basis of surveys in na-
RUS) annually (youth surveys) ar every tional samples of the adult population in
five years (adult population). Hence, sev- 1994,1999 and 2004 (Horverak et al. 2001;

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Litres 100% alcohol/inhabitant 15+

4
7

5
- ~-- ---
3
.. .. -- --
2

~
-.II.
. ~

..().
o
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

--Total --8- Spirits --.- VVine -ti- Beer -<>- Alcopops

Figure 1. Trends in alcohol sales by beverage type and in total sales. Annual sales
in litres of pure alcohol per inhabitant aged 15 and over.
Note: Data on alcohol sales were not recorded by the Central Bureau of Statistics in 1998.
Source: Statistics Norway, 2006a

Horverak & Bye 2007). The trends in un- and 31 % in the three survey years, respec-
registered consumption appear to differ tively. Self-reported consumption has in-
from that of registered sales. In 1994 the creased in all age groups, and no huge dif-
estimated unregistered consumption was ferences in trends across age groups have
1.8 litres of pure alcohol per adult inhab- been noted. The survey data further indi-
itant, and the corresponding figure was cate that the mean number of times per
1.9 litres for 1999 and 1.3 litres for 2004. ' year of events of subjective intoxication
Thus, when taking into account the un- has been quite stable from 1994 to 2004.
registered consumption the estimated to- Data from annual surveys among 15-20-
tal consumption of alcohol was approxi- year-olds show an even more dramatic
mately 6.4 litres in 1994, whereas in 2004 increase in alcohol consumption among
the estimated total consumption was 7.5 young people than what is seen in the
litres of pure alcohol per adult inhabitant, general population surveys. Figure 2
which implies an increase of 17% in total shows the trends in self-reported annual
consumption over the 12-year period from consumption in litres of pure alcohol per
1993 to 2004. year.
Analyses of the data from national sur- As can be seen from Figure 2 the in-
veys in the adult population in 1994,1999 crease in consumption among young peo-
and 2004 for the purpose of this study in- pIe is not at all due to an increase in wine
dicate that the proportion of alcohol drunk consumption, as is the case with the gen-
by women has been fairly stable over this eral population, but rather among young
period, i.e. the proportion being 28%,29% people it is due to an increase in beer and

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Litres 100% alcohol/person


6

o
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

-Total -s- Spirits -+- Wine -II- Beer --<>- Alcopops

Figure 2. Trends in self-reported alcohol consumption among 15-20-year-


olds by beverage type and in total consumption. Annual consumption in
litres of pure alcohol per person.
Source: Norwegian Institute for Alcohol and Drug Research 2007

spirits eonsumption as well as the intro- that the signifieant reduetion in alcohol
duetion of alcopops on the Norwegian eonsumption (28%) in Russia from 1984 to
market in 1998? 1987 was aeeompanied by a reduetion in
liver cirrhosis mortality rates of the same
Trends in mortality magnitude (30%) (Nemtsov 1998).
Although it typieally takes many years of Norwegian data on eause-specifie mor-
heavy drinking before death from alcohol- tality (based on underlying diagnoses)
ie liver cirrhosis or alcohol dependenee between 1993 and 2003 generally show
is likely to oeeur, the trends in mortality rather stable or slightly deereasing trends
rates due to ehronic heavy drinking do in mortality rates for those eauses of death
often refleet those of alcohol eonsump- that are often or mostly due to alcohol eon-
tion. Most striking are probably historie sumption. We ean see that liver cirrhosis
examples of signifieant ehanges in alcohol mortality rates as well as mortality rates for
eonsumption over relatively short periods alcohol psyehosis and aleohol dependenee
during which there have also been signifi- (eombined) appear to be slightly deereas-
eant ehanges in alcohol-related mortality. ing for men and rather stable for women
For instanee, in Denmark alcohol eon- (see Figures 3 and 4). Thus, in sum we find
sumption deereased by 77% from 1916 that despite a rather signifieant inerease
to 1918, and over the same 2-year period in total alcohol eonsumption in Norway
liver cirrhosis mortality deereased by 50% over the period from 1993 to 2004, similar
(Thorsen 1990). Correspondingly, we see trends were not found for eause-specifie

64 NORDIC STUDIES ON ALCOHOL AND DRUGS VOL. 24.2007 SUPPLEMENT


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Deaths/100 000 inhabitants 15+


9
...............
8
7
6
--- -Ir"'" .............

~--
5

-./" ~ ---- ~ -
",,/
4
3 --'
~~
~

2 ~

o
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

--liI,er cirrhosis rates, all --IiIr cirrhosis rates, men __ IiIr cirrhosis rates, women

Figure 3. Number of deaths from liver cirrhosis per 100 000 inhabitants aged 15
and over, overall and by gender, per year.
Source: Statistics Norway 2006b

Deaths/100 000 inhabitants 15+


14
12
10 / ------- -- -....... ...
8
6
4
--- - -- ~ ......

--
2
O
- -
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

- - alcohol psychosis + dependence, all --aleohol psychosis + dependence, men


__ alcohol psychosis + dependence, women
Figure 4. Number of deaths from alcohol psychosis and alcohol dependence per
100 000 inhabitants aged 15 and over, overall and by gender, per year.
Source: Statistics Norway 2006b

mortality rates, where an association with cirrhosis and alcohol intoxication (lCD-9
alcohol consumption might be expected. 291, 303, 571, E860; lCD-lO Fl0, K70-73,
X45, X65). These data were combined, as
Trends in morbidity it was assumed that the shift from lCD-9
Data on in-patient hospital admissions to lCD-lO in 1999 could have some impact
in somatic hospitals for the period 1993 on the comparability over time. A some-
to 2004 were based on the folIowing al- what similar approach was taken by Hjem
cohol-related underlying diagnoses: alco- & Allebeck (2004) when assessing alcohol-
hol psychosis, alcohol dependence, liver related disorders based on both lCD-9 and

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Admissions/1 00 000 inhabitants 15+


140
-II
120
~
~

100 ~

I
I
80

60 ----- I
40
~ - I
20
..... ----- i

o I
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

- - flJl ---- Men --.- Women


Figure 5. Trends in somatic hospital admissions with underlying alcohol-
related diagnoses (alcohol psychosis, alcohol dependence, liver cirrhosis
and alcohol intoxication). Number of admissions per 100 000 for men,
women and total population aged 15 and over.
Source: Norwegian Patient Registry 2006

Admissions/1 00 000 inhabitants 15+


70
60 ....-- -II

50 ~
40
.- .... !
,I
30
20
i
I
10
O
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Figure 6. Trends in somatic hospital admissions with underlying diagnosis
alcohol intoxication. Number of admissions per 100 000 inhabitants aged 15 and
over.
Source: Norwegian Patient Registry 2006

lCD-lO diagnoses. The Norwegian morbid- tion as underlying diagnosis inereased by


ity data show an inerease in the number of 52% over this 12-year period.
somatie hospital admissions per 100 000 in A more detail ed deseription of the
the population over the seeond half of the trends in alcohol-related morbidity (both
period for both men and women (Figure 5). from somatic and psyehiatrie hospitals)
Whereas Figure 5 shows that the rates of for the period 1999-2003 ean be found in
somatic hospital admissions with a broad Pedersen (2004). Over this five-year pe-
range of underlying alcohol-related diag- riod the number of somatic hospital ad-
noses inereased by 29% from 1993 to 2004, missions with underlying alcohol-related
Figure 6 shows that the rates of somatie diagnoses inereased by 17% (from 4 001
hospital admissions with alcohol intoxiea- to 4 699), whereas the number of somatie

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Cases/1 00 000 inhabitants 15+


450
400
.... I
--- i
350
300
250
--- ../
I
J
II
200
I
150 ......
100
I
50 ---------- I
I

I
O
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

-+- public drunkenness rate - - lolent assault rate


Figure 7. Number af arrests for public drunkenness and number of violent assaults
reported to the police per 100 000 inhabitants aged 15 and over. per year.
Source: Statistics Norway 2006c

Drink-driving incidents/100 000 inhabitants 15+


350
300
.... ....
250
200
150
--------
100
50 I
I
I
O
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Figure 8. Drink-driving incidents reported by the police per 100 000 inhabitants
aged 15 and over, per year.
Source: Statistics Norway 2006d

hospital admissions with both underlying where alcohol is known to be an important


and contributing alcohol-related diagnoses factor, such as violent assaults, vagrancy
increased by 41 % (from 8 015 to 11 307). and child abuse. The latter two indicators
are particularly sensitive to resources, ac-
Trends in social harms tivities and priorities in the police and the
In the following description of trends in child welfare system and therefore not pre-
social harms a number of indicators have sented here.
been chosen. These indicators are in part Figures 7 and 8 show increasing trends
directly alcohol-related, such as public in the number of public drunkenness of-
drunkenness offences and drink driving, fences and the number of violent assaults,
whereas other indicators are social harms whereas the trend in drink driving appears

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to display a slight increasing trend when been kept awake because of other people's
disregarding the final year in the series. drinking) appear to be more frequently
reported over the period, whereas other
Trends in self-reported harms self-reported harms (for instance regretting
The Norwegian Institute for Alcohol and something you said at or did while intoxi-
Drug Research (SIRUS) has provided sur- cated and having been scolded at or insult-
vey data from national population samples ed by an intoxicated person) displayed a
for the years 1994, 1999 and 2004 that may decreasing trend over the period, yet most
provide some further evidence for trends of these harms displayed no unidirectional
in certain (mostly minor) alcohol-related trend. It should be note d that the response
harms. These comprise harms due to in- rates in these surveys are around 50%
toxicated behaviour, hangover symptoms (they have not been accurately assessed),
and harms due to other people's drinking. which implies that heavy drinkers most
Table 1 presents the figures on these types probably are severely underrepresented in
of harm from these three surveys. As ean the surveys, and furthermore that the lev-
be seen, there are no significant or unidi- els of harms may well be underestimates.
rectional trends in these data. A few types There is, however, no reason to as sum e
of harm (having been in a scuffle or fight that the response rates may have affected
while intoxicated, having been away from the trends in self-reported harms to any
work the day after drinking and having significant extent.

Table 1. Proportion ofrespondents reporting various alcohol-related harms (whether due to


own drinking or someane else's drinking). %
1994 1999 2004
INTOXICATED BEHAVIOUR
Regretted smth you said ar did 22.4 21.1 20.8
Quarrelled with someane 9.7 8.1 9.4
Been in scuffle ar fight 2.5 3.0 3.3
HANGOVER SYMPTOMS
Nervous or tense 13.4 12.9 22.3
Headache, nausea, etc. 36.3 39.1 35.7
Not been able to get up at usual time 22.6 19.3 19.5
Been away from work the day after drinking n.a. 1.8 2.3
HARMS DUE TO OTHER PEOPLE'S DRINKING
Been bothered by intoxicated persons in public places 13.9 15.2 12.7
Been bothered by intoxicated persons in private parties etc. 5.5 7.5 5.5
Been physically hurt by an intoxicated person 2.4 3.1 2.6
Had clothes/other belongings destroyed by an intoxicated person 4.2 4.8 4.6
Been scolded at ar insulted by an intoxicated person 15.9 14.3 13.5
Been afraid of intoxicated persons on the street 14.4 12.2 10.2
Been kept awake at night due to noise from intoxicated persons 18.8 21.3 22.6

Source: Norwegian Institute for Alcohol and Drug Research 2006b

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Data from SIRUS' annual youth surveys in wine and liquor monopoly outlets; an
among 15-20-year-olds show a tendency increase in on-premise licences and use of
of increasing trends in the proportion of 'bag-in-box' wine), yet it is also likely that
adolescents reporting having experienced the increase in sales reflects an increase in
alcohol-related fights and having experi- purchase power in the Norwegian popula-
enced alcohol-related injuries during the tion during this period.
previous 6 months in the latter part of the As it is generally shown that an increase
12-year period from 1993 to 2004 (Figure 9). in total consumption ten ds to be followed
by an increase in alcohol-related mortal-
Summary and discussion ity and morbidity, it might be somewhat
There has been a significant increase in surprising that liver cirrhosis mortality
alcohol sales in Norway over the past 12 as well as total alcohol-specific mortality
years. This has implied a significant in- appear to be slightly decreasing during a
crease also in estimated total consumption decade when total consumption was in-
of alcohol, although the relative increase creasing. However, similar observations
in total consumption has been less than were made in Sweden for the same period
that of alcohol sales, as unregistered con- by Holder et al. (2005), and they suggested
sumption seems to have decreased in the that improvernents in treatment of alco-
latter part of the period. It is possibIe that hol dependence, liver cirrhosis and other
the increase in alcohol sales to some ex- alcohol-related diseases could have com-
tent may reflect an increase in the avail- pensated for or countered the impact of
ability of alcohol (in terms of an increase increased consumption on mortality risk

%
8

o
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

--+- Fights - Injuries

Figure 9. Trends in self-reported harms among 15-20-year-olds. Proportion of respondents


who reported to have been in a fight due to own alcohol consumption during the past 6
months and proportion of respondents who reported to have been injured due to own alcohol
consumption in the past 6 months.
Source: Norwegian Institute for Alcohol and Drug Research 2006a

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among the heavy drinkers. It is not known decreasing trends, depending on the type
whether the shift from ICD-9 to lCD-lO in of harm. It may, however, be argued that
1999 as well as a decreasing trend in the these kinds of indicators of alcohol-related
use of autopsy may have any impact on the harms may be problematic when attempt-
trends in alcohol-related mortality data. ing to assess trends in alcohol-related
The observed increase in alcohol-related damages. It is possible-or even likely-
morbidity (in terms of number of somatic that when a society becomes wetter, the
hospital admissions) fits more neatly with meaning of various alcohol-related conse-
an increase in total consumption. The quences is somewhat altered, for instance
shift from ICD-9 to lCD-lO in 1999 could that regretting something or quarrelling
be a possibIe explanation for the higher with someone while drinking is viewed
number of days in hospital in the latter differently in wetter times than in dryer
part of the period; however, the increase in times, and furthermore that social accept-
hospitalisation days with alcohol-related ance of other people's behaviour while in-
causes was most prominent from 2002 and toxicated increases when these behaviours
onwards. It may, however, also be noted are observed more frequently.
that during this period the total number Finally, it is also possibIe that the ob-
of somatic hospital admissions in Norway served recent increase in total consump-
increased by 26%, whereas the average tion to alesser extent than previously has
duration of days in hospital per stay de- been accompanied by an increase in vari-
creased by 25%. ous alcohol-related harms. The increase
Moreover, the trends in social harms that in total alcohol consumption in Norway
are often alcohol-related-such as arrests over the past 12 years is mainly due to an
for public drunkenness and violent as- increase in wine consumption. If this has
saults-also displayed increasing trends, implied that the increase in consumption
as would be expected in line with the in- is distributed over larger consumer groups
crease in total consumption. Nevertheless, and to a larger extent among people with-
these trends should be interpreted with out drinking problems, and/or that the in-
some caution; arrests for public drunken- crease in consumption is mainly related to
ness als o depend on police activity and drinking with meals and in social contexts
priorities, and trends in recorded violent where the risk of social harms is low, it is
assaults may be affected by various factors probable that the increase in consump-
that are not alcohol-related, and hence the tion is being accompanied to alesser ex-
observed increase in these types of social tent by health and social harms than has
harms is not necessarily entirely attribut- previously been found in the Norwegian
able to the increase in alcohol consump- population.
tion.
Data on self-reported social harms-
whether due to one's own or someone
else's drinking-displayed a rather mixed
picture in terms of both increasing and
I Ingeborg Rossow, PhD.
Norwegian Institute for Alcohol and Drug Re-
search (SI RUS)
POB 565 Sentrum, N-0105 Oslo
E-mail: ir@sirus.no

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I NOTES fore, during and after a major anti-alcohol


campaign. Addiction 93: 1501-1510
1) The drop in unregistered consumption Norwegian Institute for Alcohol and Drug
in recent years is mostly due to a fall in Research (2007). [Online: http://statistikk.
consumption of smuggled spirits after a sirus.no/sirus/]
number of fatal poisonings attributed to Pedersen, A. (2004): Omfang av alkoholre-
methanol in smuggled spirits. laterte diagnoser i pasientdata fra Norsk
2) Until January 1st 2003 alcopops were only Pasientregister-og kostnader relatert til
sold in wine monopoly outlets. After this disse (Amount of alcohol-related diagnoses
date alcopops were also sold in grocery in patient data from the Norwegian Patient
shop s and thus became as available as beer. Registry-and costs related to these).
Trondheim: SINTEF-Helse
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I UNPUBLlSHED SOURCES
Norwegian Institute for Alcohol and Drug Norwegian Patient Registry (2006): Unpublis-
Research (2006a): Unpublished data hed data. Data delivered upon request from
Norwegian Institute for Alcohol and Drug Re- Norwegian Institute for Alcohol and Drug
search (2006b): Partly unpublished data Research.

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