Essays on Societal Cost of Alcohol and Related Issues - A Health Economic Analysis

The consumption of alcoholic beverages has wide effects, for example, causes premature mortality, prevents certain heart diseases, increases crime rates, and affects quality of life. The main problems with alcohol consumption from an economic point of view are lack of information for consumers when making consumption decisions, externalities, and the addictive nature. It is expected that this results in non-optimal consumption levels, causing higher costs than benefits. Studying the effects of alcohol consumption is thus important in order to increase information and to allow interventions and regulations to be implemented targeting market failures, with the overall purpose of improving societal and individual welfare. The aim of this thesis is to study the effect of alcohol consumption on society, calculating the societal cost of consumption, and investigating possible improvements with regard to the estimation methods, data materials, and methodological assumptions. The focus of the latter is on issues related to labour market outcomes. Four research papers are included, together covering the aim. Paper I conservatively estimates the societal cost of alcohol consumption in Sweden, including health and quality of life effects. The costs add up to a net cost of SEK 20.3 billion (0.9% of GDP) in 2002. To this should a partial estimate of reduced quality of life be added, totalling 122,000 QALYs. Sensitivity analyses indicate a sensitivity range of 50% of the net cost. However, even the lowest plausible estimate shows net societal cost of alcohol consumption. Paper II investigates the effect of low alcohol consumption on health, measured as medical care costs and prevalence of alcohol-attributable diseases. It is found that low alcohol consumption increases medical care costs and episodes, with the exception for individuals above 80 years of age. Thus, the protective effect of low alcohol consumption for some diseases can not fully counter the detrimental effect from those diseases where low alcohol consumption increases the risk. Based on the epidemiological literature, low alcohol consumption should therefore not be considered to improve health. Paper III studies a methodological issue in connection to the wage equation; whether failure to account for individuals’ drinking histories causes heterogeneity within commonly pooled consumption groups, potentially causing bias in econometric estimations. By applying a multinomial logit model, it is found that pooled drinking groups (current abstainers and light drinkers) are heterogeneous, and that this might implicate estimation bias due to confounding and misclassification. This study thus argues that it is imperative to account for drinking history when studying the effect of alcohol consumption. Paper IV analyses the effect of women’s alcohol consumption on the likelihood of being long-term absent from work. Drinking history and selection effects are controlled for by applying a Heckman model. Women who are not a long-term light drinker is associated with an increase in the probability of long-term sickness-related absence, except for the insignificant effect of being a current light but former heavy drinker. The strongest effect is found for former drinkers (18%) followed by former abstainers (15%). Surprisingly are both being a long-term abstainer and a long-term heavy drinker associated with an increase of around 10%. Several simulation models were estimated, for example investigating the potential societal gain in productivity if all women were long-term light drinkers. It is found that the effect of alcohol consumption on long-term sickness-related absence is rather small on an individual level, although the added societal effect is substantial. It is shown in this thesis that alcohol consumption has a large societal impact. The societal cost was estimated in Paper I and Paper II – IV have supplied new information, with focus on the possible wage effect of alcohol consumption, in order to improve future estimations. Paper II rejects, based on the epidemiological literature, the possibility that the positive wage effect of low alcohol consumption is mediated through a protective health effect. According to Paper III, drinking history should be controlled for although this can not explain the commonly found inversed U-shaped relationship between alcohol and wages. Paper IV in turn suggests sickness-related absence as a mediator, potentially explaining (parts of) the alcohol – wage effect. Finally, the thesis has shown that the results of cost estimations are sensitive to what type of data is being used. Compared to a society without alcohol, the current Swedish consumption increases long-term sickness-related absence when using epidemiological data (Paper I), and decreases absence when using microdata and econometric methods (Paper IV)

Medical net cost of low alcohol consumption - a cause to reconsider improved health as the link between alcohol and wage?

<p>Abstract</p> <p>Background</p> <p>Studies have found a positive effect of low/moderate alcohol consumption on wages. This has often been explained by referring to epidemiological research showing that alcohol has protective effects on certain diseases, i.e., the health link is normally justified using selected epidemiological information. Few papers have tested this link between alcohol and health explicitly, including all diseases where alcohol has been shown to have either a protective or a detrimental effect.</p> <p>Aim</p> <p>Based on the full epidemiological information, we study the effect of low alcohol consumption on health, in order to determine if it is reasonable to explain the positive effect of low consumption on wages using the epidemiological literature.</p> <p>Methods</p> <p>We apply a non-econometrical cost-of-illness approach to calculate the medical care cost and episodes attributable to low alcohol consumption.</p> <p>Results</p> <p>Low alcohol consumption carries a net cost for medical care and there is a net benefit only for the oldest age group (80+). Low alcohol consumption also causes more episodes in medical care then what is saved, although inpatient care for women and older men show savings.</p> <p>Conclusion</p> <p>Using health as an explanation in the alcohol-wage literature appears invalid when applying the full epidemiological information instead of selected information.</p

Equalisation of alcohol participation among socioeconomic groups over time: an analysis based on the total differential approach and longitudinal data from Sweden

<p>Abstract</p> <p>Background</p> <p>Health inequality and its social determinants are well-studied, but the determinants of inequality of alcohol consumption are less well-investigated.</p> <p>Methods</p> <p>The total differential approach of decomposition of changes in the concentration index of the probability of participation in alcohol consumption was applied to 8-year longitudinal data for Swedish women aged 28-76 in 1988/89.</p> <p>Results</p> <p>Alcohol consumption showed a pro-rich inequality, with income being a strong contributor. Overall participation remained fairly constant, but the inequality decreased over time as abstinence became less common among the poor and more common among the rich. This was mainly due to changes in the relative weights of certain population groups, such as a decrease in the proportional size of the oldest cohorts.</p> <p>Conclusions</p> <p>Inequality in participation in alcohol consumption is pro-rich in Sweden. This inequality has tended to decrease over time, due to changes in population composition rather than to policy intervention.</p

Time characteristics of the effect of alcohol cessation on the risk of stomach cancer a meta-analysis

Background: In the Bagnardi et al. (2001) meta-analysis, it was found that alcohol consumption increases the risk of stomach cancer (OR = 1.32 for heavy drinkers). However, it is unknown if drinking cessation reverses this alcohol-elevated risk. Methods: A systematic literature review was performed to provide the information for a meta-analysis where the dose-risk trend was estimated for years since drinking cessation and the risk of stomach cancer. A random effect generalised least squares model for trend estimation was used, employing study characteristics to control for heterogeneity. Results: Nineteen observational studies were identified in the literature review, of which five studies quantified duration of cessation and risk of stomach cancer, giving a total of 1947 cancer cases. No significant effect of drinking cessation on the risk of stomach cancer could be found (OR = 0.99 CI: 0.97-1.02). Conclusions: This result should be interpreted with caution due to the limited number of studies in this area. Recent findings suggest a link between heavy drinking and stomach cancer, especially gastric noncardia, but not for moderate drinking. Since all but one of the included studies in this meta-analysis failed to control for consumption level, the current study could not test if the risk decline following drinking cessation differs between moderate and high consumers

Long-term psychiatric consequences of exposure to trauma in Cambodia: A regional household survey.

The long-term psychiatric consequences of exposure to war and/or mass conflict continue to be of great concern and particularly in Cambodia. The current cross-sectional study examined the relationship between history of trauma and current psychiatric and functional morbidity in 3200 randomly selected adults aged 18-60 in Cambodia. Structured interviews were conducted from November 2011 until May 2012 in two predominantly rural regions purposively selected for differing duration of exposure to the Khmer Rouge occupation. Information was also collected regarding ongoing daily stressors and intimate partner violence. Despite high prevalence rates of conflict/war-related trauma, current rates of psychiatric disorders (depression, post-traumatic stress disorder) were relatively low, suggesting that the effects of trauma and extreme hardship in civilian populations may be modified by contextual factors and/or the passage of time. Poor to fair physical health was, however, reported by nearly 60% of the sample. Daily stressors were more important for current morbidity levels than history of trauma, especially in the region with shorter Khmer Rouge occupation. The results suggest that a focus exclusively on past trauma may overlook the contribution of adverse daily life circumstances towards current levels of well-being in civilian populations affected by war and/or mass conflict

Frequency and intensity of alcohol consumption : New Evidence from Sweden

There is an increasing body of evidence that the intensity in which alcohol is drunk is of greater concern than the frequency or overall quantity consumed. This paper provides an extensive analysis of the demand for alcohol as measured by total quantity, frequency, and intensity. A unique large sample of cross-sectional data from Sweden 2004–2011 allows reduced-form alcohol demand equations to be estimated for beer, wine, and spirits, split by alcohol drinking pattern (average vs. binge drinkers) and gender. Results find a negative beer excise rate effect for participation and frequency, and positive effect for intensity. The effect was stronger for binge drinkers. Generally, the results also show a positive socioeconomic (income and education) gradient in frequency demand and a negative gradient in the intensity demand. Female wine drinkers show a positive socioeconomic gradient in both frequency and intensity. The findings highlight the complexity of this policy space. Tax increases appear to reduce frequency but raise intensity consumed. The more educated and higher earners drink more in total, but less intensely when they do and this is likely to explain in part why poor health is concentrated amongst lower socioeconomic status individuals

How the risk of liver cancer changes after alcohol cessation: A review and meta-analysis of the current literature

<p>Abstract</p> <p>Background</p> <p>It is well established that drinking alcohol raises the risk of liver cancer (hepatocellular carcinoma). However, it has not been sufficiently established as to whether or not drinking cessation subsequently reduces the risk of liver cancer and if it does reduce the risk how long it takes for this heightened risk to fall to that of never drinkers. This question is important for effective policy design and evaluation, to establish causality and for motivational treatments.</p> <p>Methods</p> <p>A systematic review and meta-analysis using the current available evidence and a specific form of Generalised Least Squares is performed to assess how the risk of liver cancer changes with time for former drinkers.</p> <p>Results</p> <p>Four studies are found to have quantified the effect of drinking cessation on the risk of liver cancer. The meta-analysis suggests that the risk of liver cancer does indeed fall after cessation by 6-7% a year, but there remains a large uncertainty around this estimate both statistically and in its interpretation. As an illustration it is estimated that a time period of 23 years is required after drinking cessation, with a correspondingly large 95% confidence interval of 14 to 70 years, for the risk of liver cancer to be equal to that of never drinkers.</p> <p>Conclusion</p> <p>This is a relatively under researched area and this is reflected in the uncertainty of the findings. It is our view that it is not possible to extrapolate the results found here to the general population. Too few studies have addressed this question and of the studies that have, all have significant limitations. The key issue amongst the relevant studies is that it appears that current drinkers, abstainers and former drinkers are not composed of, or effectively adjusted to be, similar populations making inferences about risk changes impossible. This is a very difficult area to study effectively, but it is an important topic. More work is required to reduce both statistical uncertainty and tackle the various study limitations this paper highlights and until this is done, the current result should be considered preliminary.</p

The Arabidopsis (ASHH2) CW domain binds monomethylated K4 of the histone H3 tail through conformational selection

Chromatin post‐translational modifications are thought to be important for epigenetic effects on gene expression. Methylation of histone N‐terminal tail lysine residues constitutes one of many such modifications, executed by families of histone lysine methyltransferase (HKMTase). One such protein is ASHH2 from the flowering plant Arabidopsis thaliana, equipped with the interaction domain, CW, and the HKMTase domain, SET. The CW domain of ASHH2 is a selective binder of monomethylation at lysine 4 on histone H3 (H3K4me1) and likely helps the enzyme dock correctly onto chromatin sites. The study of CW and related interaction domains has so far been emphasizing lock–key models, missing important aspects of histone‐tail CW interactions. We here present an analysis of the ASHH2 CW‐H3K4me1 complex using NMR and molecular dynamics, as well as mutation and affinity studies of flexible coils. β‐augmentation and rearrangement of coils coincide with changes in the flexibility of the complex, in particular the η1, η3 and C‐terminal coils, but also in the β1 and β2 strands and the C‐terminal part of the ligand. Furthermore, we show that mutating residues with outlier dynamic behaviour affect the complex binding affinity despite these not being in direct contact with the ligand. Overall, the binding process is consistent with conformational selection. We propose that this binding mechanism presents an advantage when searching for the correct post‐translational modification state among the highly modified and flexible histone tails, and also that the binding shifts the catalytic SET domain towards the nucleosome