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Journal of Forensic and Legal Medicine 52 (2017) 40e45

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Journal of Forensic and Legal Medicine

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / j fl m

Ethanol levels in legally autopsied subjects: Analytical approach and

epidemiological relevance in a prospective study in the touristic
region of the Canary Islands (Spain)
Maira Almeida-Gonza ndez a, b, *, 1, Octavio P. Luzardo a, b,
lez a, b, 1, Luis A. Henríquez-Herna
Manuel Zumbado a, b a
, Enrique Zaragoza , María J. Meila n a, María Camacho b,
a, b
Luis D. Boada
Laboratory of Toxicology, Institute of Legal Medicine, Government of the Canary Islands, Spain
Toxicology Unit, Research Institute of Biomedical and Health Sciences (IUIBS), Universidad de Las Palmas de Gran Canaria, Paseo Blas Cabrera Felipe s/n,
35016 Las Palmas de Gran Canaria, Spain

a r t i c l e i n f o a b s t r a c t

Article history: The aim of this study was to analyze the presence of alcohol in individuals (137) that were subjected to a
Received 13 January 2017 mandatory medico-legal autopsy in the Institute of Legal Medicine of Las Palmas (Canary Islands, Spain)
Received in revised form during 2015. Blood and vitreous humor samples (232) were analyzed by gas chromatography. 46.0% of
17 April 2017
the individuals were positive for alcohol, being half of them tourists. Blood alcohol concentrations (BAC)
Accepted 23 August 2017
Available online 24 August 2017
was higher in men over 60 years (p ¼ 0.041). 10.2% of the series died in a traffic accident, and victims had
the highest proportion of positives to alcohol (64.3%) and the highest BAC (2.56 g/L, p ¼ 0.048). The
BAC:VHAC (alcohol in vitreous humor) ratio was higher among victims of traffic crashes (p ¼ 0.036),
Forensic sciences
suggesting a short elapsed interval between the alcohol intake and the fatal accident. The results of this
Blood alcohol concentration study indicate that ethanol is still heavily involved in non-natural deaths.
Vitreous humor alcohol concentration © 2017 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
Traffic accidents
Tourist region
Canary islands

1. Introduction a very important risk factor for traffic accidents and for other causes
of accidents, and is frequently involved in deaths classified as vio-
Ethanol is a psychoactive substance with addictive properties. lent by its accidental, suicidal, or homicidal origin.3 For all this
The World Health Organization (WHO) has estimated that there reasons, alcohol usually tops the list of psychoactive substances
were 2100 million regular consumers of alcohol in the world, which found in postmortem toxicological analysis.4
would mean that about 43% of the world's adult population con- The percentage of alcohol consumers varies widely by region,
sumes alcohol.1 Furthermore, it was estimated that there were 3.3 from as low as 9.8% in Asian countries,1 to close to 90% of the adult
million deaths directly attributable to alcohol, representing 5.9% of population in European countries.5 Within Europe, it has been
all deaths that year worldwide.2 Alcohol consumption is considered estimated that alcohol consumption ranges from 66% in the coun-
tries of Eastern Europe to 88.2% in the countries of Western
Europe.1 In the case of Spain, the data for the period 1997e2007
indicated that about 60% of the population over 15 years consumed
* Corresponding author. Laboratory of Toxicology, Institute of Legal Medicine -
Government of the Canary Islands; Paseo Blas Cabrera Felipe s/n, CP 35016, Las alcohol regularly.6 The statistics indicate that in subsequent years
Palmas de Gran Canaria, Spain. this figure increased to almost 65% of the population between 15
E-mail addresses: (M. Almeida-Gonza lez), luis. and 64 years old.7 It is interesting to note the change in trend from (L.A. Henríquez-Herna ndez), (O. P.
the year 2007, which is the year of the beginning of the economic
Luzardo), (M. Zumbado),
(E. Zaragoza), (M.J. Meil an), maria.camacho@
crisis that still affects this country. In that sense, the economic crisis (M. Camacho), (L. D. Boada). is one of the reasons proposed to explain the increase in alcohol
First and second authors have contributed equally to this work and therefore consumption in the last years. It is well known that psychological
they must be considered indistinctly as first authors.
1752-928X/© 2017 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
lez et al. / Journal of Forensic and Legal Medicine 52 (2017) 40e45
M. Almeida-Gonza 41

distress caused by unemployment and reduced income may in- data collected included age, gender, geographical origin (resident
crease drinking problem.8 Other proposed cause have to do with vs. non-resident), type of sample, cause of death, date of autopsy
the apparent increase in alcohol consumption in adolescence, and concentration of alcohol. The cases represent all the medico-
associated with the widespread fashion in Spain during the last legal autopsies in the province of Las Palmas in 2015.
decade of consuming large amounts of alcohol on the public road. Samples were analyzed in a Trace-Focus GC headspace gas
In fact, it has been recently reported that 41.6% of boys aged be- chromatography (GC-HS) equipped with a flame ionization detec-
tween 14 and 18 y.o. consume alcohol in the street on weekends.9 tor (FID) (Thermo Fisher Inc., Waltham, MA, USA). This method is of
Finally, the increase in alcohol consumption in Spain could be choice in forensic sciences for determination of ethanol and other
influenced by the fact that the tourism sector has grown steadily, volatiles in body fluids.19e21 Samples were diluted 1:50 in a solu-
reaching the highest position in this sector worldwide according to tion of NaCl 8% to a final volume of 5 mL. Tert-Butanol was used as
the World Economic Forum World.10 This is relevant because in internal standard.22 The mixture was kept airtight in 10 mL glass
periods of leisure (holidays), alcohol consumption increases,11 and vials with crimped-on rubber septum (Thermo Fisher Inc.). The
it is also remarkable that workers employed in the tourist sector vials were heated to 85  C for 10 min, and a total of 1 mL of vapor
also show a higher prevalence of alcohol consumption.12 In Spain, was automatically injected with a TriPlus automated sampler
tourism employs more than half million people. (Thermo Fisher Inc.) equipped with a 2.5 mL gas-tight syringe
The Spanish archipelago of the Canary Islands meets several of (Hamilton, Reno, NE, USA) in split mode with a split ratio of 5.
the above cited features. On one side, it is one of the Spanish re- Gas chromatography separation was performed on a J&W HP-
gions hardest hit by the crisis, with a per capita income well below Blood Alcohol column of 7.5 m length, 20 mm film thickness, and
the national average,13 an unemployment rate higher than the 0.32 mm ID (Agilent Technologies, Santa Clara, CA, USA). Helium
national average (23.70 vs. 31.08%, in mainland Spain and in the (99.999% pure) was used as carrier gas. The separation run was
Canary archipelago, respectively), and a youth unemployment rate completed in 6.80 min in a gradient temperature program as fol-
above 50%.14 On the other hand, the Canary Islands is a very lows: 120  C x 1 min, a ramping of 25 C/min till 165  C and a final
important touristic region in the European Union (EU), receiving step of 165  C x 4 min.
around 12 million tourists per year,15 and this activity generated in The peak areas were quantified with the Chrom-Card data sys-
2014 35.9% of the employment in the region (almost 275,000 tem (Thermo Fisher Inc.) using a commercial standard curve of 5
jobs).16 Despite these circumstances, epidemiological studies sug- points from 0.05 to 3 g/L of ethanol in duplicate. In each experi-
gest that the prevalence of alcohol consumption in this region is ment, one negative and two positive controls were included in
lower than the national average (55.6% in the Canary Islands vs. duplicate. A variation coefficient of 10% and an accuracy of 95%
64.4% in mainland Spain for people aged 15e64 years).7 However, were required in all analyses.
these data may not accurately reflect the level of alcohol con- Standard descriptive statistics were calculated for the levels of
sumption in the Archipelago since it only considers the population ethanol in all samples. The distribution of ethanol deviates signif-
permanently residing in the islands, but does not take into account icantly from normality. Hence, nonparametric tests were applied.
the huge “floating” population, mainly tourists, that continuously Spearman's correlation coefficients were used to calculate the as-
visit the Canary Islands. In this sense, it is worthy to mention that a sociations between ethanol concentrations in blood and vitreous
strong relationship between tourism and recreational use of humor. Differences between categorical variables were assessed by
alcohol exists.11,17 c2 test. A value of p < 0.05 (two-tailed) was considered to be sta-
The aim of this work was to prospectively evaluate the preva- tistically significant. Database management and statistical analyses
lence and relevance of ethanol consumption in a highly touristic were carried out with the PASW v 17.0 software (SPSS Inc., Chicago,
region. For this purpose, we measured ethanol levels in all the IL).
victims died in violent deaths which were autopsied at the Institute
of Legal Medicine of Las Palmas, based on the premise that, despite 3. Results and discussion
current laws and educational interventions, alcohol intake con-
tinues to be a relevant factor commonly involved in the violent A total of 139 autopsied subjects involved in violent deaths were
deaths in our region, specifically in traffic crashes. included in our study. Blood was available in 29 subjects, vitreous
humor was available in 13 subjects and blood and vitreous humor
2. Materials and methods were both available in 95 subjects. Two subjects were excluded
from the series because only gastric content samples were taken
The Canary Islands are located 1600 km away from southwest and data about alcohol level were not available. Thus, the series was
Spain, in the Atlantic Ocean, and hardly 100 km from the nearest formed by 137 subjects.
point of the North African coast (southwest of Morocco). The Information on gender and age were not available in some cases,
economy of the Canary Islands is based fundamentally on tourism with a missing percentage of 0.7% for age (1 case corresponding to a
and to a much lesser extent on farming, livestock production, and neonate) and 7.3% (10 cases) for gender. Cause of death was avail-
fishing. The archipelago has a resident population of about 2 able in all cases. These percentages of missing data are similar to
million inhabitants and a visitant population close to 12 million those reported by other authors in similar studies.23,24 Finally, the
people each year (mainly tourists). The archipelago is divided into series was formed by 96 men (70.1%) and 40 women (29.2%), and
two provinces: Las Palmas and Santa Cruz de Tenerife. The Institute showed a mean age of 50.7 ± 14.8 years old (median ¼ 51,
of Legal Medicine of Las Palmas serves a population of 1.1 million range ¼ 0e82 years). There were no differences in age distribution
inhabitants from the province of Las Palmas.18 according to gender (p ¼ 0.843, data not shown).
The universe selected represented 100% of victims (n ¼ 137) of A total of 63 cases were positive for alcohol in blood and/or
violent deaths that were subjected to medico-legal autopsy at the vitreous humor (46.0% of the series). It has drawn our attention that
Institute of Legal Medicine of Las Palmas during 2015. A quantita- half of the subjects which were positive for alcohol, were tourists
tive determination of ethyl alcohol was performed in blood and (Table 1), reflecting the fact that there is a large floating population
vitreous humor samples (n ¼ 232). The sociodemographic charac- on the islands whose alcohol consumption might be relevant.11,17
teristics of the victims were obtained from the forensic reports and The proportion of ethanol positive determinations was higher
were studied in relation to the results of toxicological analyses. The among men (50.0 vs. 37.5%), although this difference was not
42 lez et al. / Journal of Forensic and Legal Medicine 52 (2017) 40e45
M. Almeida-Gonza

Table 1
Description of subjects by demographic characteristics, alcohol and cause of death.

Category All Positive EtOH Negative EtOH p value

n, (%) n, (%) n, (%)

Whole series 137 (100.0) 63 (46.0) 74 (54.0) NA

Gender 0.193
Male 96 (70.1) 48 (50.0) 48 (50.0)
Female 40 (29.2) 15 (37.5) 25 (62.5)
Age (years) 0.164
18 5 (3.6) 0 (0.0) 5 (100.0)
18.1e30 4 (2.9) 2 (50.0) 2 (50.0)
30.1e40 17 (12.4) 8 (47.1) 9 (52.9)
40.1e50 37 (27.0) 18 (48.6) 19 (51.4)
50.1e60 37 (27.0) 15 (40.5) 22 (59.5)
>60 27 (19.7) 17 (63.0) 10 (37.0)
Foreign citizens (tourist) 0.262
Yes 43 (31.4) 22 (51.2) 21 (48.8)
No 94 (68.6) 41 (43.6) 53 (56.4)
Cause of death 0.183
Traffic accident 14 (10.2) 9 (64.3) 5 (35.7)
Violent deatha 34 (24.8) 18 (52.9) 16 (47.1)
Suicide 31 (22.6) 15 (48.6) 16 (51.6)
Otherb 58 (42.3) 21 (36.2) 37 (63.8)

EtOH: ethanol; NA: not applicable.

p values were calculated by X2 test.
Include firearms, sharp weapons, drowning, fights and falls.
Include heart failure, heart attack, ischemic cardiomyopathy, coronary obstruction and other cardiac diseases, head trauma, suffocation, pulmonary edema, gastroin-
testinal bleeding, pneumonia and unknown causes.

statistically significant (Table 1). In general terms, this profile of violent deaths and suicides. Violent deaths include deaths from
consumption fits perfectly with drink habits reported for the gen- precipitation, which cannot be considered as suicides because the
eral population. The global prevalence of alcohol intake is around intentionality of the act is unknown; and suicides include bronco-
43% and the percentage of alcohol consumption is higher among aspiration deaths, that showed the highest BAC (2.37 g/L, data not
men in all regions around the world.1 However, it has to be high- shown). The role of alcohol in suicides and accidental mortality has
lighted that blood alcohol concentration (BAC) and vitreous humor been previously reported.25,26 Moreover, some authors have pub-
alcohol concentration (VHAC) was higher among females (Table 2). lished a dramatical increment of alcohol abuse and dependence
Median BAC among subjects who were positive for alcohol was among female suicides.27 On the other hand, females are more
0.84 g/L in the whole series. This value was 0.61 and 1.65 among likely to meet criteria for lifetime anxiety disorders that are asso-
males and females, respectively. A similar trend was observed for ciated with nonviolent suicide methods.28 Taken together, these
median VHAC (Table 2). Although such differences did not show would explain the fact that the prevalence of positive de-
statistically significant differences, this finding deserves some dis- terminations was lower among women but the median BAC was
cussion. A possible explanation for that observation may be found higher than in men. In our opinion, this is a reflection of the social
in the cause of death. Median values of BAC were higher among reality of our country: women drink less alcohol but the intake level
females for all causes of death (Fig. 1), with especial emphasis on would be associated to suicides and violent deaths due to different

Table 2
Blood and vitreous humor alcohol concentration among subjects who presented positive determination for alcohol, by gender, age, and cause of death.

Category BAC positive BAC p value VHAC positive VHAC p value

n, (%) median, (range) n, (%) median, (range)

Whole series 56 (100.0) 0.84 (0.03e6.04) NA 43 (100.0) 1.66 (0.04e5.54) NA

Gender 0.788 0.221
Male 41 (73.2) 0.61 (0.03e6.04) 32 (74.4) 1.27 (0.03e4.71)
Female 15 (26.8) 1.65 (0.04e5.26) 11 (25.6) 2.28 (0.18e5.54)
Age (years)
18 0 NA 0.534 0 NA 0.699
18.1e30 1 (1.8) 1.65 (1.65e1.65) 2 (4.7) 1.26 (0.86e1.66)
30.1e40 6 (10.7) 0.34 (0.04e3.78) 6 (14.0) 1.11 (0.07e3.55)
40.1e50 17 (30.4) 0.32 (0.04e2.79) 10 (23.3) 1.42 (0.20e3.82)
50.1e60 14 (25.0) 0.84 (0.07e4.14) 11 (25.6) 1.13 (0.03e4.71)
>60 15 (26.8) 1.90 (0.03e6.04) 12 (27.9) 2.55 (0.05e5.54)
Cause of death 0.048 0.432
Traffic accident 9 (16.1) 2.56 (0.03e6.04) 5 (11.6) 2.45 (0.20e3.07)
Violent deatha 14 (25.0) 2.47 (0.06e5.26) 15 (34.9) 2.27 (0.05e5.54)
Suicide 14 (25.0) 0.50 (0.04e4.43) 8 (18.6) 1.94 (0.07e4.41)
Otherb 19 (33.9) 0.31 (0.03e4.14) 15 (34.9) 0.92 (0.03e4.71)

BAC: blood alcohol concentration; VHAC: vitreous humor alcohol concentration; NA: not applicable.
p values were calculated by Kruskal-Wallis test.
Include firearms, sharp weapons, drowning, fights and falls.
Include heart failure, heart attack, ischemic cardiomyopathy, coronary obstruction and other cardiac diseases, head trauma, suffocation, pulmonary edema, gastroin-
testinal bleeding, pneumonia and unknown causes.
lez et al. / Journal of Forensic and Legal Medicine 52 (2017) 40e45
M. Almeida-Gonza 43

of different age groups (p ¼ 0.041, Table 3). In Spain, it is illegal to

drive a motor vehicle with BAC higher than 0.5 g/L, and it entails
criminal responsibility to do it with BAC greater than 1.2 g/L. Ac-
cording to that, BAC was divided into four categories as follows:
negative, positives until 0.5 g/L, 0.5e1.2 g/L, 1.2e3 g/L and >3 g/L.
We observed a predominance of levels higher than 1.2 g/L in males
aged 60 years, but the same was not seen among females (Table 3).
Similar trend has been reported by other authors.23 It has to be
highlighted that 10 of 14 males older than 60 years showed positive
BAC. Among them, 4 died by drowning, and 3 of those showed BAC
>1.2 g/L. This is consistent with data published by other authors
who reported that the number of drowning fatalities has the
highest rate between ages 51e70 years.24 As stated, alcohol con-
sumption is a preliminary condition for accidental drowning
deaths,30 a fact also observed in the present series. Moreover, two
other positive older men died in traffic accidents and two of them
committed suicide.
The majority of subjects included in the present study died by
other causes (42.3%), which include heart failure, heart attack,
ischemic cardiomyopathy, coronary obstruction and other cardiac
diseases, head trauma, suffocation, pulmonary edema, gastroin-
testinal bleeding, pneumonia and unknown causes. However, the
highest proportion of alcohol positive determinations was found
among those subjects who died in a traffic accident (64.3%), sug-
Fig. 1. Box plot showing blood alcohol concentration (BAC) in males and females ac- gesting a clear and worrying association between alcohol intake
cording to the cause of death. Only subjects with detectable levels of blood alcohol and driving (Table 1). Moreover, BAC was statistically higher among
were included. The lines inside the boxes represent the medians, the boxes cover the those people who died in a traffic accident (median BAC ¼ 2.56 g/L,
25e75th percentiles, and the minimal and maximal values are shown by the ends of
the bars.
p ¼ 0.048; Table 2). This value contrasts with that observed among
people who died by other causes (median BAC ¼ 0.31). In Spain,
during 2014, a total of 91,570 traffic accidents were counted. In
risk factors inherent to females, such as anxiety and other social those, 1688 persons died (Ministerio del Interior, 2014), a data that
problems.29 Only one alcohol positive woman died in a traffic ac- puts Spain in the European average and which is among the lowest
cident, showing a BAC ¼ 2.558 g/L. worldwide according to data reported by the World Health Orga-
Subjects older than 60 years old showed the highest proportion nization.31 Among the dead people in traffic accident in Spain,
of ethanol positive determinations (63.0%, Table 1). The proportion alcohol was positive (>0.3 g/L) in 67.1%, according to official data
of positive cases was around 50% for all age ranges, with a slight provided by the Spanish Government.32 As stated above, this data
increment in subjects at 50.1e60 years old. There were not positive fits to that provided in our series (64.3% of positive determinations
determinations among autopsied subjects younger than 18 years. It among subjects died in a traffic accident), reinforcing the impor-
has to be highlighted that 3 of 5 subjects younger than 18 years old tance of alcohol in road crashes. For decades, alcohol seems to be a
committed suicide (mainly hanging), 1 subject was a neonate and causal factor of considerable importance in traffic accidents.
the other one was a 4 years old child who died drowned. This Although the causal role of alcohol in accidents varies across
pattern agrees with that reported in the Spanish population, where different drinking cultures and historical periods, depending on
the prevalence of daily consumption of alcoholic beverages in the consumption levels and drinking patterns, it is indisputable in view
population aged 15e64 years is higher as age increases.7 Median of the data reported worldwide, that accident mortality rates are
values of BAC and VHAC were also higher in the subgroup of people influenced by per capita alcohol consumption.33
older than 60 years (1.90 and 2.55 g/L, respectively; Table 2). In our study, alcohol concentration was available in blood and
Although these differences were not statistically significant, when vitreous humor in 95 subjects. As expected, a clear correlation
BAC was categorized, the distribution of BAC was different in males between determinations in both types of samples was observed

Table 3
Distribution of blood alcohol concentration (BAC) levels by age groups in both male and female subjects.

BAC levels n Malea n Females

Negatives 0 <0.5 0.5e1.2 1.2e3 >3 Negatives <0.5 0.5e .2 1.2e3 >3
% % % % % 0 % % % %

Age (years)
18 2 100.0 0.0 0.0 0.0 0.0 2 100.0 0.0 0.0 0.0 0.0
18.1e30 0 0.0 0.0 0.0 0.0 0.0 3 66.7 0.0 0.0 33.3 0.0
30.1e40 8 37.5 37.5 12.5 0.0 12.5 7 85.7 0.0 0.0 0.0 14.3
40.1e50 28 53.6 35.7 3.6 7.1 0.0 6 33.3 16.7 0.0 50.0 0.0
50.1e60 25 60.0 16.0 8.0 0.0 16.0 10 60.0 10.0 10.0 20.0 0.0
>60 14 28.6 7.1 7.1 28.6 28.6 10 50.0 30.0 0.0 10.0 10.0
Total 77 50.6 23.4 6.5 7.8 11.7 38 60.5 13.2 2.6 18.4 5.3
The distribution of blood alcohol concentration levels was different in males of different age groups (X2 test, p ¼ 0.041).
44 lez et al. / Journal of Forensic and Legal Medicine 52 (2017) 40e45
M. Almeida-Gonza

(Pearson correlation coefficient ¼ 0.951, p < 0.0001). Blood has a subgroup of subjects who presented the highest number of positive
lower water content than vitreous humor, so the expectation is that determinations, although women showed higher BAC, a fact
the blood:vitreous alcohol ratio will be less than unity. In our series, possibly associated to the cause of death. The proportion of
median BAC and median VHAC were 0.812 g/L and 0.780 g/L, drowning people who were positive to alcohol is of concern,
respectively (data not shown). Then, blood:vitreous alcohol ratio especially in a tourist area like the Spanish Archipelago of the Ca-
was 1.041. In cases where the ratio of blood alcohol to vitreous nary Islands. Finally, it has to be highlighted the worrying associ-
humor alcohol concentration exceeds 1.0, the most likely expla- ation between alcohol intake and traffic victims, since this
nation is that death occurred before diffusion equilibrium had been subgroup of patients showed the highest BAC and data indicated
attained, which might have forensic significance.34 We explored that people drives shortly after drinking alcohol. The present re-
the association between BAC:VHAC ratio and cause of death, sults would be of relevance to Public Health Authorities, providing
finding socially relevant results. As shown in Fig. 2, BAC:VHAC ratio information on addictive behaviors and road safety in our region.
was around 1.0 for all causes of death except for people who died in
traffic accident (BAC:VHAC ratio ¼ 1.27), and this difference was Conflict of interest
statistically significant (Kruskal-Wallis test, p ¼ 0.036). This data
suggest that people drives shortly after drinking alcohol, which The authors state they have no conflict of interest.
supposes a higher risk of having a fatal accident on the road.
Despite of its social interest, a number of limitations should be Ethical approval
considered in the present study. First, the series is limited to the
year 2015 and the number of subjects included in the study is None declared.
relatively low. Anyhow, similar epidemiological and demographical
studies have been published including similar numbers of sub- Acknowledgements
jects.24 Moreover, our results agree with other authors worldwide,
and we humbly think that the data reported from our series is a The authors thank Mrs. María de los Reyes Su
arez Hanna for her
reflection of the reality of our society. Second, the present study technical assistance.
could not assess different physiological and behavioral responses
produced by alcohol consumption in different individuals. This is of Funding sources
particular interest in suicidal victims, where the intention of
committing suicide is not always clear (except in cases of hanging This research did not receive any specific grant from funding
or cutting veins). This fact would change the assigned cause of agencies in the public, commercial, or not-for-profit sectors.
death. Nevertheless, this point was discussed with forensic
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