A new paradigm for addictions.

AIM: To suggest a new paradigm for addictions. METHODS: Consideration of relevant research findings and thought experiments. RESULTS: Common mental motors leading to addictions are pleasure-seeking and hyperbolic discounting. The important point of the latter is that given two choices of future rewards, commonly one initially prefers the larger one available after a longer waiting time but despite this the smaller and sooner reward will be chosen when it becomes available. These are general biological properties, found at least in human beings, the rat, and the pigeon. If this continues it may create an unconscious habit, difficult to change. Several other risk factors for addictions are known, notably both externalizing and internalizing mental problems. Predisposing factors are likely to interact. CONCLUSIONS: The above suggests a new paradigm for addictions. Pleasure provides temptations, hyperbolic discounting weakens the will. Habits emerge. Addictions seem to be a group of problems of its own kind, not diseases, because diseases do not bring about pleasure, and are not sought for pleasure.

Population Alcohol Consumption as a Predictor of Alcohol-Specific Deaths: A Time-Series Analysis of Aggregate Data.

AIMS: The study examines whether the number of alcohol-specific deaths can be predicted by population total and/or beverage-specific alcohol consumption and if, how precisely. The data are annual series of spirits, wine, beer and total consumption and alcohol-specific deaths in Finland in the years 1969-2015. METHODS: We specify a Auto Regressive Distributed Lags model with cointegrated variables, to be used in prediction. In our model, the number of alcohol-specific deaths is the response variable, and log of spirits consumption and log of non-spirits consumption, are the explanatory variables. The response variable has one added annual lag and the explanatory variables have both four annual added lags in the model. RESULTS: In our data alcohol-specific deaths, log of spirits and log of non-spirits consumption are significantly cointegrated. The precision of the estimated model is good. The prediction results include prediction of the 2008 downturn in alcohol deaths, using the data from the years 1969-2004, forecasting the as yet unknown 2016 alcohol deaths on the basis of known values of alcohol consumption up to 2016, and forecasts of future (2017-2020) alcohol deaths from 2016 on. Forecasted effects of a proposed Finnish alcohol policy change, leading to six percent total consumption increase, are estimated. CONCLUSIONS: The number of alcohol-specific deaths can be predicted with an appropriate time-series regression model on the basis of population consumption. It is important to consider also beverage type because of the improved predictive power. The model is useful in an evaluation of proposed alcohol policy changes.

Does the Tail Wag the Dog? Abstainers, Alcohol Dependence, Heavy Episodic Drinkers and Total Alcohol Consumption.

AIMS: To study total alcohol consumption and its correlates, with an emphasis on the direction of causality. METHODS: The associations among total alcohol consumption, abstaining, alcohol dependence (AD) and heavy episodic drinking were compared in 29 Organization for Economic Cooperation and Development (OECD) countries in 2010. RESULTS: Either total alcohol consumption is determined by the number of abstainers and that of alcohol dependents, or the number of alcohol dependents is determined by total alcohol consumption. The number of non-dependent heavy episodic drinkers does not play a role. CONCLUSION: The number of alcohol dependents and abstainers seemingly determines total alcohol consumption and more efforts should be made to reduce AD. SHORT SUMMARY: The associations between total alcohol consumption, abstaining, alcohol dependence and heavy episodic drinking were compared in 29 OECD countries in 2010. The number of non-dependent heavy episodic drinkers does not play a role. The number of alcohol dependents and abstainers seemingly determine total alcohol consumption.

The Weakness of Stern Alcohol Control Policies.

AIMS: To test the total consumption model claiming that alcohol-related ill health can best be diminished by a policy of severe restrictions and high price. METHODS: The associations between an index measuring the severity of the alcohol policy, total alcohol consumption and number of disability-adjusted life years (DALYs) lost due to alcohol were compared in 30 OECD countries in 2005. RESULTS: No significant correlations were found between alcohol policy index, alcohol consumption and the number of DALYs due to alcohol use. In regression analysis, alcohol policy index and alcohol consumption were not related to alcohol-related DALYs. Excise tax rate was not related to alcohol-related DALYs (25 countries with tax rate data). CONCLUSIONS: These findings suggest that the total consumption model fails. Alcohol-related ill health seems to be mainly due to alcohol dependence, both clinical and subclinical, not to moderate drinking.

Subjective measures of binge drinking and alcohol-specific adverse health outcomes: a prospective cohort study.

AIM: To determine the performance of subjectively defined intoxications, hangovers and alcohol-induced pass-outs in identifying drinkers at risk for adverse health outcomes. DESIGN: Prospective population-based cohort study. SETTING: Working-aged Finnish general population. PARTICIPANTS: A total of 21,204 alcohol-drinking men and women aged 20-24, 30-34, 40-44 and 50-54 years at baseline who participated in the Health and Social Support (HeSSup) postal survey in 1998. MEASUREMENTS: Binge drinking was measured by subjectively defined intoxications/drunkenness, hangovers and alcohol-induced pass-outs. Hazardous drinking was defined according to Finnish guidelines as weekly total intake of >287 g of ethanol for men, and for women > 191 g of ethanol (≥24 and ≥16 standard drinks, respectively). Study participants were followed-up for 7 years for alcohol-specific hospitalizations and deaths. Proportional hazard models and areas under the receiver operating characteristics curves (AUC) were used to analyse the data. FINDINGS: Of the drinkers, 6.5% exceeded the weekly limit for hazardous drinking, and 1.5% experienced the alcohol-specific end-point during the follow-up. Subjective intoxications, hangovers and alcohol-induced pass-outs all predicted future alcohol-specific diagnoses independently of average intake and of several other potential confounders. In identifying baseline hazardous drinking, subjective intoxications had a superior performance in relation to other subjective measures of binge drinking. In identifying future alcohol-specific hospitalizations or death, subjective intoxications had also the best performance, but this was not significantly different from the other binge drinking measures, or average intake. CONCLUSIONS: Subjectively defined intoxications, hangovers and alcohol-induced pass-outs are population-level proxy measures of at-risk drinking patterns.

Under-recording of ethanol intoxication and poisoning in cause-of-death data: causes and consequences.

In the present study we examined how consistently and completely the role of acute alcohol (ethanol) intake as a cause of death is reported on death certificates, how complete and specific the statistical recording of cause-of-death data on acute alcohol-induced deaths is, and how the information ultimately appears in the national mortality statistics. Data on all alcohol-positive deaths with blood alcohol concentration of ≥ 0.5‰ (g/kg) in Finland in 2005 (N = 2348) were reviewed. Overall, a concentration-dependent association was found between forensic-toxicologically determined blood alcohol concentrations and acute alcohol-specific cause-of-death diagnoses. Based on a medico-legal re-evaluation of death certificates, acute alcohol-specific causes were found to be underreported nationally at a rate of 8%. For accidental alcohol poisonings alone, the figure was about 1%. This underreporting was not corrected during recording of the cause-of-death data, though individual corrections and changes were observed. Especially, recording of multiple causes suffers from this underreporting of acute alcohol-specific causes. ICD-10 seems to do well in fulfilling the demands for a specific classification of uncomplicated alcohol poisoning. In combined alcohol-drug poisonings, however, ICD-10 shows a bias towards drugs over alcohol, even when alcohol has been specified and reported as the most toxic component by the medico-legal pathologist. Since the national statistics is based on the underlying causes, this state of affairs is likely to result in the underestimation of the role of acute alcohol intake as a cause of death. This observation of underreporting of acute alcohol-specific causes on death certificates should result in a harmonisation of education and principles and practices used in death certification. To increase the coverage and specificity of mortality statistics, based on the underlying causes of death, the coding of all components of alcohol-drug combinations and their classification according to the most important intoxicant or combination of intoxicants is recommended.

Risk factors for alcohol-specific hospitalizations and deaths: prospective cohort study.

AIMS: To study the risk factors for hospitalizations and deaths due to alcohol-specific diagnoses. METHODS: Representative samples of men (n = 4431) aged 15-69 at the baseline interviews in September 1969, 1976 and 1984 were pooled. Follow-up was 16.3 years or to the first end-point. The main outcome measure was hospitalization (main cause) or death (underlying or contributory cause) due to an alcohol-specific diagnosis. RESULTS: There were altogether 216 men with either hospitalization or death with an alcohol-specific diagnosis. This outcome was positively associated with smoking, overall alcohol intake, being an ex-drinker and being divorced or widowed. Similar associations and relative risk estimates were found when cases of alcohol dependence were excluded and when focusing on alcohol psychosis or on alcohol-specific diseases of the stomach, liver and pancreas. CONCLUSION: Cigarette smoking, overall alcohol intake, being an ex-drinker and marital status associate with alcohol-specific hospitalizations and deaths and can predict these outcomes.

Alcohol consumption and all-cause mortality among elderly in Finland.

AIMS: To estimate the gender-specific prevalences of alcohol consumption levels and to investigate the association between heavy drinking and all-cause mortality among elderly males. DESIGN: A cohort derived from a nationally representative sample of Finns aged >65 years was followed for six years. Number of subjects was 1569 (72.7% of the original sample, 65.3% females, weighted n=1357). MEASUREMENTS: Alcohol consumption was retrospectively measured by beverage-specific quantity and frequency over a 12-month period. Mortality data were obtained from the official Cause-of-Death Register. Cox proportional hazards models were used to analyse the relative risks (RRs) of death. FINDINGS: The prevalence of heavy drinking (>8 standard drinks per week) was 20.3% in males and 1.2% in females. Over one-tenth (11.4%) of males reported drinking > or =15 standard drinks per week. Relative death risks suggested a J-curved relationship between alcohol consumption levels and mortality. However, significant curvilinear relationship was not found, when using alcohol consumption as continuous variable. The multivariate adjusted RR of death among moderate drinkers (1-7 drinks per week) vs. abstinent subjects was 0.41 (95% CI=.23-.72). Males drinking > or =15 standard drinks per week had a two-fold multivariate adjusted risk of death (RR=2.11, 95% CI=1.19-3.75) compared with abstinent males. The level of alcohol consumption by females was too low for analysis. CONCLUSIONS: Heavy drinking is common among Finnish elderly males but not among females. The present study shows an increased all-cause mortality risk for males drinking, on average, more than two standard drinks per day.

Binge drinking and depressive symptoms: a 5-year population-based cohort study.

BACKGROUND: Only few prospective population studies have been able so far to investigate depression and drinking patterns in detail. Therefore, little is known about what aspect of alcohol consumption best predicts symptoms of depression in the general population. PARTICIPANTS AND DESIGN: In this prospective population-based two-wave cohort study, a cohort of alcohol-drinking men and women (n = 15 926) were followed-up after 5 years. A postal questionnaire was sent in 1998 (response proportion 40%) and again in 2003 (response proportion 80% of the baseline participants) to Finnish adults aged 20-54 years at baseline. MEASUREMENTS: Alcohol consumption was measured by average intake (g/week) and by measures of binge drinking (intoxications, hangovers and alcohol-induced pass-outs). Depressive symptoms were assessed with the 21-item Beck Depression Inventory. In addition, information from hospital discharge register for depression and alcohol abuse were linked to the data. FINDINGS: This study found a positive association between baseline binge drinking and depressive symptoms 5 years later. Adjustment for several possible confounders attenuated the observed relationships only slightly, suggesting that binge drinking contributes independently to the occurrence of depressive symptoms. Binge drinking was related to symptoms of depression independently of average intake. CONCLUSIONS: This study supports the hypothesis that heavy drinking, and in particular a binge pattern involving intoxications, hangovers or pass-outs, produces depressive symptoms in the general population. The frequency of hangovers was the best predictor for depressive symptoms.

Increased stroke risk is related to a binge-drinking habit.

BACKGROUND AND PURPOSE: Heavy alcohol consumption increases the risk for all strokes, whereas moderate regular alcohol consumption is associated with a lower risk for ischemic stroke. The purpose of this study was to evaluate the effect of different drinking patterns on stroke risk, independent of average alcohol intake. METHODS: A prospective cohort study of 15 965 Finnish men and women age 25 to 64 years who participated in a national risk factor survey and had no history of stroke at baseline were followed up for a 10-year period. The first stroke event during follow-up served as the outcome of interest (N=249 strokes). A binge drinking pattern was defined as consuming 6 or more drinks of the same alcoholic beverage in men or 4 or more drinks in women in 1 session. Cox proportional-hazards models were adjusted for average alcohol consumption, age, sex, hypertension, smoking, diabetes, body mass index, educational status, study area, study year, and history of myocardial infarction. RESULTS: Binge drinking was an independent risk factor for total and ischemic strokes. Compared with non-binge drinkers, the hazard ratio for total strokes among binge drinkers was 1.85 (95% CI, 1.35 to 2.54) after adjusting for average alcohol consumption, age, and sex; the association was diluted after adjustment for other risk factors. Compared with non-binge drinkers, the risk for ischemic stroke was 1.99 (95% CI, 1.39 to 2.87) among binge drinkers; the association remained statistically significant after adjustment for potential confounders. CONCLUSIONS: This study found that a pattern of binge drinking is an independent risk factor for all strokes and ischemic stroke.

Hazardous drinking: prevalence and associations in the Finnish general population.

BACKGROUND: Hazardous drinking, defined as consuming alcohol on a risky level and not meeting the diagnostic criteria of alcohol use disorders (AUDs), has been suggested for a new complementary nondependence diagnosis. This study aimed to investigate the prevalence and associations of hazardous drinking in comparison to AUDs, moderate drinking, and abstinence. METHODS: A national representative sample of Finns was examined in the Health 2000 Survey. For 4477 subjects aged 30 to 64 years (76%, 2341 females), both the quantity frequency data about alcohol consumption and Composite International Diagnostic Interview (CIDI) data concerning AUD diagnoses were available. The nationally recommended limits for hazardous dinking were used (males: 24 drinks, females: 16 drinks/wk). Logistic regression models were used to analyze associations. RESULTS: The prevalence of hazardous drinking was 5.8%. Hazardous drinking was more prevalent among males than females (8.5% vs. 3.1%). It was most prevalent among the subjects aged 40 to 49 years (7.3%), divorced or separated (8.3%), unemployed (8.2%) and subjects living in the southern (Helsinki) region (7.5%). AUDs versus hazardous drinking were more likely to be in males versus females and in the unemployed versus employed. Subjects aged 40 and over had higher odds for hazardous drinking versus AUDs. The odds for hazardous versus moderate drinking were higher for males versus females (adjusted odds ratio = 3.24), for subjects aged over 40 years, unemployed versus employed and cohabiting, divorced/separated or unmarried subjects versus married subjects. CONCLUSION: The high prevalence of hazardous drinking makes it an important public health concern. Hazardous drinkers have different sociodemographic characteristics as compared to people in other alcohol use categories.

What predicts illicit drug use versus police-registered drug offending? Findings from the Finnish "From a Boy to a Man" birth cohort study.

AIMS: To study whether drug offenders differ in childhood and in early adulthood from those who only report using illicit drugs. DESIGN: Prospective nationwide birth cohort study. Baseline survey in 1989, follow-up data collection from self-reports, police and military registers in late adolescence and early adulthood. PARTICIPANTS: Two-thousand nine hundred and forty six Finnish boys born in 1981. Information about self-reported drug use at age 18 or police-registered drug offending at age 17-20 was available from 79.3% (n = 2,336) of the subjects. MEASUREMENTS: At age 8, psychopathology was assessed using the parent and teacher Rutter scales and child self-reports (Child Depression Inventory). ICD-10 psychiatric diagnoses at early adulthood according to the military register were based on a medical examination. FINDINGS: Childhood psychopathology did not predict self-reported drug use at age 18. Both conduct and hyperactivity problems at age 8 predicted drug offences at age 16-20. The predictive association with drug offences was strongest with severe level (over 90th percentile cut-off point) of conduct (OR 5.5, 95% CI 2.9-10.5) and hyperactivity problems (OR 5.0, 95% CI 2.7-9.3). Also moderate level of conduct (OR 2.9, 95% CI 1.7-4.9) and hyperactivity problems (OR 3.1, 95% CI 1.9-5.1) predicted drug offending. Having a psychiatric diagnosis in early adulthood associated with both self-reported use (OR 4.1, 95% CI 2.4-6.8) and drug offending (OR 13.2, 95% CI 8.3-21.2). CONCLUSIONS: Drug offending is part of a life-course-persistent deviance, whereas for self-reporters, psychiatric problems arise later in life. Accordingly, the preventive needs, and the age period for intervention are different for boys with divergent illicit drug use involvement.

Childhood and current determinants of heavy drinking in early adulthood.

AIMS: To explore the association of parental education, childhood living conditions and several adversities with heavy drinking in early adulthood, and to analyze the effect of the respondent's current circumstances on these associations. METHOD: The analyses were conducted in a sample of 1234 adults aged 18-29 years participating in the Finnish Health 2000 Survey (65% of the original representative two-stage cluster sample, N = 1894). The outcome measure was heavy drinking measured by g/week for pure alcohol (for men >or=280 g/week and for women >or=140 g/week). RESULTS: 8% of young adult men and 5% of women were heavy drinkers. In both genders, parental alcohol problems and other childhood adversities, poor own education, and unemployment status increased the risk of heavy drinking. The impact of childhood on heavy drinking was partly independent and partly mediated by adult characteristics, in particular, for both genders, low level of education. CONCLUSIONS: Childhood adversities are associated with heavy drinking in early adulthood among both genders. Childhood social circumstances as well as low educational level and unemployment should be taken into account in planning preventive policies to tackle the harms caused by excessive alcohol use at the individual and population level.

Alcohol consumption, abstaining, health utility, and quality of life--a general population survey in Finland.

AIMS: To examine the associations between alcohol consumption and utility-based health-related quality of life (HRQoL), subjective quality of life (QoL), self-rated health (SRH), and mental distress. METHODS: Representative general population survey in Finland, with 5871 persons aged 30-64 years. HRQoL was measured with two health utility instruments (15D and EQ-5D), QoL and SRH were measured with RATING scales, and mental distress with a General Health Questionnaire (GHQ-12). Past alcohol problems were diagnosed with a structured psychiatric interview known as the composite international diagnostic interview (CIDI). Alcohol consumption was examined with a self-report questionnaire. RESULTS: Negative associations between alcohol and well-being were observed on several measures for women consuming more than 173 g and men more than 229 g per week. Former drinkers scored worst on most measures, even in comparison to the highest drinking decile. For men, all statistically significant associations between moderate drinking and well-being disappeared when sociodemographic factors and former drinkers were controlled for. For women, moderate alcohol use associated with better SRH and EQ-5D as compared to abstainers. However, the possible health utility benefits associated with moderate alcohol consumption were of clinically insignificant magnitude. CONCLUSIONS: Failure to separate former drinkers and other abstainers produces a significant bias favoring moderate drinkers. As the possible health utility benefits of moderate alcohol use were clinically insignificant, it suffices to investigate mortality, when estimating the public health impact of moderate alcohol consumption using quality-adjusted life years.