Suchergebnisse

Introduction: Alcohol is a major contributor to the burden of disease globally. In Europe, there is a long-standing tradition of drinking alcohol, with per capita consumption being the highest in the world, even if it has been declining in recent decades. Changes in per capita consumption are likely to be related to factors operating at societal level, of which globalisation has been one of the most important factors. Since early 2020, the global pandemic of the Coronavirus Disease 2019 (COVID-19) has caused serious disruptions to day-to-day and community life. As a consequence of the pandemic and the measures taken to contain the spread of the virus, patterns and levels of alcohol consumption are expected to change due to reduced alcohol availability, and according to income levels and distress experiences. Surveys are used to assess such short-term trends, but also to identify drinking patterns that cannot be derived from other sources such as alcohol purchases. However, general population surveys usually fail to capture the entire amount of alcohol consumed within a population. This inherently limiting factor of surveys is called underreporting and not well understood to date. Aims and Objectives: The overall aim of this dissertation was to provide a comprehensive and up-to-date assessment of alcohol consumption in Europe using survey data, as well as to compare survey-based annual consumption estimates with per capita consumption data, i.e., sales and other data derived. For this purpose, the following three objectives were of interest: First, to determine and to compare European drinking practices across 19 countries using survey data from 2015 (study I). Second, to examine changes in alcohol consumption during the first months of the COVID-19 pandemic in 21 European countries and whether these changes were associated with income and pandemic-related distress experiences (study II). Third, to estimate the degree of under-reporting of alcohol consumption in surveys and to study possible factors related to under-reporting based on 39 surveys from 23 European countries (study III). Design: All studies are based on individual-level data from cross-sectional pan-European surveys covering the general adult population. In study I, European drinking practices were determined by the means of latent class analysis using key indicators of alcohol consumption (past-year drinking frequency and quantity, risky single-occasion drinking, and preferred alcoholic beverage) derived from nationally representative data from 2015. In a second step, the identified drinking practices were compared across countries. In study II, self-reported changes in drinking frequency, drinking quantity, and the frequency of heavy episodic drinking over the past month were assessed in a large convenience sample collected between April and July 2020. Additionally, past-year alcohol consumption was recorded using the consumption items of the Alcohol Use Disorder Identification Test in order to obtain an estimate of alcohol consumption during the pre-pandemic period. Income and distress experiences were recorded as factors hypothesised to be associated with self-reported changes in consumption. In Study III, nationally representative surveys conducted between 2008 to 2015 were combined and compared with alcohol per capita consumption estimates for the same years and countries, in order to estimate survey-based under-reporting of alcohol consumption at the national level. Per capita consumption estimates were retrieved from sales statistics and corrected for unrecorded and tourist consumption. Data sources: Survey data were obtained from large-scale alcohol surveys covering the majority of European Union countries plus some non-European Union countries. Statistical analyses: To identify European drinking practices (study I), survey-weighted latent class models of key indicators of alcohol consumption, adjusted for respondent's location, were conducted. The resulting class prevalence estimates were then contrasted across locations, and fractional response regression models were calculated for membership probabilities of each class (dependent variable) in explorative analysis, with sociodemographic data and individual alcohol harm experiences serving as independent variables. To identify changes in overall alcohol consumption over the past month during the COVID-19 pandemic (study II), a consumption-change score was calculated by combining the single change indicators (i.e., drinking frequency, drinking quantity, and frequency of heavy episodic drinking; range: -1 to +1). Multilevel linear regressions with the random intercept country of residence were used to test for statistical significance of the consumption-change score (dependent variable), adjusting for sample weights and past-year alcohol consumption, as well as for associations with income group and pandemic-related distress experiences. To quantify the extent to which national surveys assess alcohol per capita consumption (study III), coverage rates were calculated. Coverage is defined by dividing the survey-based annual alcohol consumption estimates by per capita consumption estimates. Using fractional response regressions, differences in coverage rates (dependent variable) across transnational regions, as well as the relative importance of heavy episodic drinking prevalence and indicators of survey methodology were tested. Results: Three latent classes of drinking practices were identified: a 'light to moderate drinking without risky single-occasion drinking' class (prevalence: 68.0%, 95% Confidence interval [CI]: 66.7, 69.3), a 'infrequent heavy drinking' class (prevalence: 12.6%, 95% CI: 11.5, 13.7), and a 'regular drinking with at least monthly risk single-occasion drinking' class (prevalence: 19.4%, 95% CI: 18.1, 20.9). In contrast to the former drinking practice of light to moderate drinking, the latter two were characterised by a high average amount of alcohol consumed per drink day, exceeding 100 grams pure alcohol and 60 grams pure alcohol per drink day, respectively. Regional variations in the distribution of drinking practices were observed, with the 'light to moderate drinking without risky single-occasion drinking' class prevailing particularly in southern European countries. In study II, an average decrease in overall alcohol consumption during the first months of the COVID-19 pandemic indicated by a negative consumption-change score was observed (-0.14, 95% CI: -0.18, -0.10). This average decline according to the consumption-change indicator was observed in all countries studied, except Ireland (no change) and the United Kingdom (increase). The most marked decrease was reported in the frequency of heavy episodic drinking (-0.17, 95% CI: -0.20, -0.14). Respondents with low- or average income, as well as those experiencing distress were more likely to increase their alcohol consumption than to decrease it. In study III, the average total alcohol consumption coverage was 36.5% (95% CI: 33.2, 39.8), with large variations in coverage rates between countries. While the prevalence of heavy episodic drinking explained up to 10% of the variance in coverage, there were no systematic variations across European regions or the survey methodologies studied, such as non-response rates. Conclusions: In many European countries, a combination of a light to moderate and risky drinking practices prevailed. With a combined prevalence of 32.0%, almost every third respondent engaged in some form of risky drinking. During the first months of the COVID-19 pandemic, overall alcohol consumption, and particularly heavy episodic drinking, appeared to have declined on average in the countries studied. On the other hand, people with low- or average incomes and those suffering from pandemic-related distress were at increased risk of escalating their alcohol consumption during this period. The results contribute both to an up-to-date assessment of alcohol consumption in Europe, including the identification of populations at increased risk of alcohol-related harm, and to the body of evidence on reducing alcohol availability as an effective measure to lower population-level consumption. Beyond consequences for alcohol policy, benefits and limitations of surveys in the field of alcohol epidemiology are discussed. In light of the substantial and apparently unsystematic under-reporting of alcohol consumption in surveys, a rethinking of this methodology is required. Presenting survey-based data and its limitations in an upfront manner, as well as applying sophisticated statistical methods are two options to address current challenges.:Statement for a publication-based dissertation I Table of contents III List of tables V List of figures VII Abbreviations IX Synopsis XI 1 Introduction 1 1.1 Determinants of alcohol consumption and alcohol-related harm 3 1.1.1 Individual vulnerability factors 4 1.1.2 Societal vulnerability factors 5 1.2 The impact of the COVID-19 pandemic on alcohol consumption 8 1.3 Strengths and limitations of survey research 11 2 Aims and objectives 13 3 Study design and methodology 14 3.1 The Standardised European Alcohol Survey 15 3.1.1 The RARHA SEAS questionnaire 15 3.1.2 Sampling procedure and data pre-processing 16 3.1.3 Calculation of annual alcohol consumption 17 3.1.4 Research ethics 17 3.2 Harmonising Alcohol-related Measures in European Surveys 17 3.2.1 Questionnaires 18 3.2.2 Sampling procedures and harmonising of the questionnaires 18 3.2.3 Research ethics 19 3.3 The Alcohol Use and COVID-19 Survey 19 3.3.1 Survey development and design 19 3.3.2 Survey dissemination 21 3.3.3 Calculation of survey and population weights 22 3.3.4 Research ethics 24 4 Study I – A new perspective on the European drinking culture: a model-based approach to determine variations in drinking practices across 19 European countries 25 4.1 Abstract 25 4.2 Introduction 26 4.3 Methods 27 4.4 Results 30 4.5 Discussion 35 5 Study II – Alcohol consumption during the COVID-19 pandemic in Europe: a large-scale cross-sectional study in 21 countries 38 5.1 Abstract 38 5.2 Introduction 39 5.3 Methods 40 5.4 Results 42 5.5 Discussion 49 6 Study III – Why is per capita consumption underestimated in alcohol surveys? Results from 39 surveys in 23 European countries 53 6.1 Abstract 53 6.2 Introduction 54 6.3 Methods 56 6.4 Results 62 6.5 Discussion 64 7 General discussion 69 7.1 Summary of findings 69 7.2 Strengths and limitations 70 7.3 Implications for future research 72 7.3.1 New impulses for drinking culture research 72 7.3.2 The realisation of multi-country online surveys 73 7.3.3 Consequences of low alcohol consumption coverage in alcohol surveys 74 7.4 Implications for alcohol policy 75 7.4.1 Altered availability of alcohol as a secondary outcome of the COVID-19 pandemic 76 7.4.2 Towards a comprehensive alcohol control policy for Europe 78 7.4.3 Alcohol screening and access to health care in high-risk drinking populations 7.5 Outlook 81 7.6 Conclusion 83 8 References 85 9 Appendix 106 9.1 Appendix A (study I) 106 9.2 Appendix B (study II) 126 9.3 Appendix C (study III) 152 10 Erklärung gemäß §5 der Promotionsordnung 160

Abstract: Aim: Exploring trends in 1) alcohol-specific mortality and 2) alcohol sales in European countries in the years before and during the COVID-19 pandemic. Method: Complete data on alcohol-specific mortality and alcohol sales were obtained for 14 European countries (13 EU countries and UK) for the years 2010 to 2020, with six countries having mortality data available up to 2021. Age-standardised mortality rates were calculated and descriptive statistics used. Results: When compared to 2019, alcohol-specific mortality rates in 2020 increased by 7.7 % and 8.2 % for women and men, respectively. Increases in alcohol-specific mortality were seen in the majority of countries and continued in 2021. In contrast, alcohol sales declined by an average of 5.0 %. Conclusion: Despite a drop in alcohol consumption, more people died due to alcohol-specific causes during the COVID-19 pandemic in Europe.

Zusammenfassung: Zielsetzung: Ausgehend von der Veröffentlichung der dritten Ausgabe des Buchs "Alkohol: Kein gewöhnliches Konsumgut" haben die Autor_innen die Umsetzung kosteneffektiver alkoholpolitischer Maßnahmen in Deutschland bewertet. Methodik: Aktuelle gesetzliche Regelungen und Praktiken zu Maßnahmen aus vier Bereichen wurden gesichtet: (1) Preispolitische Maßnahmen; (2) Regulation der Verfügbarkeit alkoholischer Getränke; (3) Beschränkungen des Alkoholmarketings; sowie (4) Maßnahmen zur Bekämpfung von Alkohol am Steuer. Ergebnisse: Die Verbrauchssteuern auf alkoholische Getränke sind im europäischen Vergleich eher gering und führen zu keiner nennenswerten Reduktion der Erschwinglichkeit von Alkohol. Alkoholische Getränke können mit nur wenigen Ausnahmen rund um die Uhr und in unterschiedlichen Verkaufsstätten (z. B. in Supermärkten oder Tankstellen) erworben werden. Beschränkungen im Alkoholmarketing gibt es nur im Bereich Jugendschutz und sind auf die Abwendung von Darstellungen eines "missbräuchlichen" Konsums beschränkt. Empfohlene Maßnahmen gegen Alkohol am Steuer sind weitestgehend umgesetzt. Schlussfolgerungen: Kosteneffektive alkoholpolitische Maßnahmen, die die alkoholbedingte Krankheitslast in Deutschland substantiell reduzieren könnten, sind in Deutschland unzureichend implementiert.

Background: From a public health perspective, alcohol taxation should be designed to reduce alcohol affordability and thus alcohol consumption and related harms. Objectives: In this brief report, we estimate alcohol affordability in European Union Member States and associated countries and investigate whether affordability is related to national alcohol excise duties. Method: Beverage-specific affordability for beer, wine, and spirits were estimated based on the number of standard drinks a household could purchase based on their median monthly disposable household income in 2020. To determine the pooled affordability of alcohol, the beverage-specific estimates were weighted by the share of the beverage-specific per capita consumption in total recorded consumption. Pearson and Spearman rank correlations were calculated to establish the association between alcohol affordability and alcohol excise duty rates. All data were retrieved from official sources. Results: On average, a European household can purchase 1,628 standard drinks of alcohol with its monthly income, with affordability being highest in Germany, Austria, France, and Luxembourg. The affordability of spirits, but not that of beer or wine, was inversely correlated with the beverage-specific excise duty rates. Conclusions: Alcohol is affordable in the Member States of the European Union and associated countries, and low levels of excise duties on beer and wine appear to be unrelated to their affordability. Alcohol taxes should be increased to effectively reduce the affordability of alcoholic beverages in order to lower the alcohol-related health burden in Europe.

<b><i>Introduction:</i></b> The year 2020 was marked by the COVID-19 pandemic. Policy responses to COVID-19 affected social and economic life and the availability of alcohol. Previous research has shown an overall small decrease in alcohol use in Denmark in the first months of the pandemic. The present paper focused on identifying which subgroups of individuals had decreased or increased their consumption. <b><i>Materials and Methods:</i></b> Data were collected between May and July 2020 (<i>n</i> = 2,566 respondents, convenience sample). Weights were applied to reflect the actual Danish general population. Variables included the pre-pandemic alcohol consumption, change in alcohol consumption in the past month, socio-demographics, and reported economic consequences. Responses to a single item assessing changes in alcohol consumption in the past month were classified as no change, increase, or decrease in consumption. Regression models investigated how changes in consumption were linked to pre-pandemic drinking levels, socio-demographics (gender, age groups, education), and reported economic consequences. <b><i>Results:</i></b> While 39% of participants reported decreased consumption levels and 34% had stable levels, 27% increased consumption. Characteristics associated with changes in consumption were associated with both increases and decreases in consumption: younger people, those with higher consumption levels before the pandemic, and those with lower education more often both reported increases as well as decreases in consumption. <b><i>Discussion/Conclusions:</i></b> We confirmed that more people decreased rather than increased their alcohol consumption in the first few months of the pandemic in Denmark. Characteristics associated with changes in consumption such as younger age, higher consumption levels, and lower education demonstrated a polarization of drinking since these were associated with both increases and decreases in consumption. Public health authorities should monitor alcohol use and other health behaviours for increased risks during the pandemic.

Zusammenfassung. Zielsetzung: Ziel der vorliegenden Studie war, die Veränderung des Alkoholkonsums während der SARS-CoV-2 Pandemie in Deutschland zu untersuchen und mit derer anderer europäischer Länder zu vergleichen. Methodik: Analyse von soziodemographischen und sozioökonomischen Daten sowie Angaben zur Veränderung des Alkoholkonsums seit der Pandemie in einer europaweiten Onlinebefragung (n=40.064) aus 21 Ländern. Zur Anpassung an die Bevölkerungsverteilung in den Ländern erfolgte eine Gewichtung anhand von Geschlecht, Alter und Bildungsabschluss. Ergebnisse: Seit Beginn der Pandemie wurde im Mittel weniger Alkohol getrunken. Der Rückgang des Konsums ist vor allem auf eine Reduktion der Gelegenheiten zum Rauschtrinken zurückzuführen. Der Alkoholkonsum ist in Deutschland weniger stark als in anderen Europäischen Ländern zurückgegangen. Gründe dafür sind Zunahmen im Alkoholkonsum bei Frauen sowie bei Personen, die negative Auswirkungen in Beruf und Finanzen erlebt haben und bei Personen mit riskanten Konsummustern. Schlussfolgerungen: Um den negativen Folgen des in Teilgruppen verstärkten Alkoholkonsums während der Pandemie entgegenzuwirken, sollte die Verfügbarkeit von Alkohol durch eine sinnvolle Besteuerung reduziert sowie eine Ausweitung routinemäßiger Alkoholscreenings in der allgemeinärztlichen Versorgung umgesetzt werden.

<b><i>Introduction:</i></b> Unrecorded alcohol, that is, alcohol not reflected in official statistics of the country where it is consumed, contributes markedly to overall consumption of alcohol. However, empirical data on unrecorded alcohol consumption are scarce, especially in high-income countries. This study measures the contribution of unrecorded alcohol in 7 member states of the European Union. <b><i>Methods:</i></b> Two categories of unrecorded consumption were assessed in general population surveys (reducing alcohol related harm Standardized European Alcohol Survey; <i>n</i> = 11,224): home-made alcohol and cross-border shopping. Country-specific logistic regressions were used to link respondent characteristics to odds of acquisition of unrecorded alcohol. Total <i>per capita</i> alcohol consumption was estimated under different assumptions of calculating unrecorded alcohol consumption. <b><i>Results:</i></b> Individuals with higher drinking levels were more likely to acquire unrecorded alcohol in all 7 countries. In some countries, male sex and more affluent social class were also positively linked to acquisition of unrecorded alcohol. There was a substantial contribution of unrecorded alcohol to overall consumption in 5 out of 7 member states (Croatia, Finland, Greece, Hungary, Portugal), but not in Poland or Spain. In Greece, up to two-thirds of all alcohol consumed was estimated to be unrecorded.<b><i> Conclusion:</i></b> Unrecorded alcohol contributes to overall consumption even in high-income countries, and thus needs to be monitored. In monitoring, as many categories of unrecorded alcohol as possible should be clearly defined (e.g., surrogate alcohol) and included in future surveys.

Introduction: Unrecorded alcohol, that is, alcohol not reflected in official statistics of the country where it is consumed, contributes markedly to overall consumption of alcohol. However, empirical data on unrecorded alcohol consumption are scarce, especially in high-income countries. This study measures the contribution of unrecorded alcohol in 7 member states of the European Union. Methods: Two categories of unrecorded consumption were assessed in general population surveys (reducing alcohol related harm Standardized European Alcohol Survey; n = 11,224): homemade alcohol and cross-border shopping. Country-specific logistic regressions were used to link respondent characteristics to odds of acquisition of unrecorded alcohol. Total per capita alcohol consumption was estimated under different assumptions of calculating unrecorded alcohol consumption. Results: Individuals with higher drinking levels were more likely to acquire unrecorded alcohol in all 7 countries. In some countries, male sex and more affluent social class were also positively linked to acquisition of unrecorded alcohol. There was a substantial contribution of unrecorded alcohol to overall consumption in 5 out of 7 member states (Croatia, Finland, Greece, Hungary, Portugal), but not in Poland or Spain. In Greece, up to two-thirds of all alcohol consumed was estimated to be unrecorded. Conclusion: Unrecorded alcohol contributes to overall consumption even in high-income countries, and thus needs to be monitored. In monitoring, as many categories of unrecorded alcohol as possible should be clearly defined (e.g., surrogate alcohol) and included in future surveys. ; J.R. acknowledges funding from the Canadian Institutes of Health Research, Institute of Neurosciences, Mental Health and Addiction (Canadian Research Initiative in Substance Misuse Ontario Node grant number SMN-13950).

BACKGROUND: Reducing the alcohol-attributable cancer burden in the WHO European Region is a public health priority. This study aims to estimate the number of potentially avoidable cancers in countries of the WHO European Region in 2019 for three scenarios in which current excise duties on alcoholic beverages were increased by 20%, 50%, or 100%. METHODS: Mean prices and excise duties for beer, wine, and spirits in the Member States of the WHO European Region in 2020 were used as the baseline scenario. We assumed that increases in excise duties (20%, 50%, and 100%) were fully incorporated into the consumer price. Beverage-specific price elasticities of demand, with lower elasticities for heavy drinkers, were obtained from a meta-analysis. Model estimates were applied to alcohol exposure data for 2009 and cancer incidence and mortality rates for 2019, assuming a 10-year lag time between alcohol intake and cancer development and mortality. FINDINGS: Of 180,887 (95% Confidence interval [CI]: 160,595-201,705) new alcohol-attributable cancer cases and 85,130 (95% CI: 74,920-95,523) deaths in the WHO European Region in 2019, 5·9% (95% CI: 5·6-6·4) and 5·7% (95% CI: 5·4-6·1), respectively, could have been avoided by increasing excise duties by 100%. According to our model, alcohol-attributable female breast cancer and colorectal cancer contributed most to the avoidable cases and deaths. INTERPRETATION: Doubling current alcohol excise duties could avoid just under 6% (or 10,700 cases and 4,850 deaths) of new alcohol-attributable cancers within the WHO European Region, particularly in Member States of the European Union where excise duties are in many cases very low. FUNDING: None.

<b><i>Introduction:</i></b> Prevention of cancer has been identified as a major public health priority for Europe, and alcohol is a leading risk factor for various types of cancer. This contribution estimates the number of cancer cases that could have potentially been averted in 2018 in 4 European countries if an increase in alcohol excise taxation had been applied. <b><i>Methods:</i></b> Current country and beverage-specific excise taxation of 4 member states of the WHO European Region (Germany, Italy, Kazakhstan, and Sweden) was used as a baseline, and the potential impacts of increases of 20, 50, and 100% to current excise duties were modelled. A sensitivity analysis was performed, replacing the current tax rates in the 4 countries by those levied in Finland. The resulting increase in tax was assumed to be fully incorporated into the consumer price, and beverage-specific price elasticities of demand were obtained from meta-analyses, assuming less elasticity for heavy drinkers. Model estimates were applied to cancer incidence rates for the year 2018. <b><i>Results:</i></b> In the 4 countries, &#x3e;35,000 cancer cases in 2018 were caused by alcohol consumption, with the highest rate of alcohol-attributable cancers recorded in Germany and the lowest in Sweden. An increase in excise duties on alcohol would have significantly reduced these numbers, with between 3 and 7% of all alcohol-attributable cancer cases being averted if taxation had been increased by 100%. If the 4 countries were to adopt an excise taxation level equivalent to the one currently imposed in Finland, an even higher proportion of alcohol-attributable cancers could be avoided, with Germany alone experiencing 1,600 fewer cancer cases in 1 year. <b><i>Discussion/Conclusion:</i></b> Increasing excise duties can markedly reduce cancer incidence in European countries.

Abstract

Aims
The aims of the article are (a) to estimate coverage rates (i.e. the proportion of 'real consumption' accounted for by a survey compared with more reliable aggregate consumption data) of the total, the recorded and the beverage-specific annual per capita consumption in 23 European countries, and (b) to investigate differences between regions, and other factors which might be associated with low coverage (prevalence of heavy episodic drinking [HED], survey methodology).


Methods
Survey data were derived from the Standardised European Alcohol Survey and Harmonising Alcohol-related Measures in European Surveys (number of surveys: 39, years of survey: 2008–2015, adults aged 20–64 years). Coverage rates were calculated at the aggregated level by dividing consumption estimates derived from the surveys by alcohol per capita estimates from a recent global modelling study. Fractional response regression models were used to examine the relative importance of the predictors.


Results
Large variation in coverage across European countries was observed (average total coverage: 36.5, 95% confidence interval [CI] [33.2; 39.8]), with lowest coverage found for spirits consumption (26.3, 95% CI [21.4; 31.3]). Regarding the second aim, the prevalence of HED was associated with wine- and spirits-specific coverage, explaining 10% in the respective variance. However, neither the consideration of regions nor survey methodology explained much of the variance in coverage estimates, regardless of the scenario.


Conclusion
The results reiterate that alcohol survey data should not be used to compare or estimate aggregate consumption levels, which may be better reflected by statistics on recorded or total per capita consumption.