Impact of introducing a minimum alcohol tax share in retail prices on alcohol-attributable mortality in the WHO European Region: A modelling study.

Background: Alcohol use and its burden constitute one of the largest public health challenges in the WHO European Region. Raising alcohol taxes is a cost-effective "best buy" measure to reduce alcohol consumption, but its implementation remains uneven. This paper provides an overview of existing tax structures in 50 countries and subregions of the Region, estimates their proportions of tax on retail prices of beer, wine, and spirits, and quantifies the number of deaths that could be averted annually if these tax shares were raised to a minimum level. Methods: Review of databases and statistical reports on taxes and mean retail prices of alcohol beverages in the Region. Affordability was calculated based on alcohol prices, adjusted for differences in purchasing power. Consumption changes and averted mortality were modelled assuming two scenarios. In Scenario 1, a minimum excise tax share level of 25% of the beverage-specific retail price was assumed for all countries. In Scenario 2, in addition to a minimum excise tax share level of 15% it was assumed that per unit of ethanol minimal retail prices were the same irrespective of alcoholic beverages (equalisation). Sensitivity analyses were conducted for different price elasticities. Findings: Alcohol is very affordable in the Region and alcohol taxes have clearly been under-utilized as a public health measure, constituting on average only 5·7%, 14·0% and 31·3% of the retail prices of wine, beer, and spirits, respectively. Tax shares were higher in the eastern part of the Region compared to the EU, where various countries did not have excise taxes on wine. Annually, the introduction of a minimum tax share of 25% (Scenario 1) could avert 40,033 (95% CI: 38,054-46,097) deaths in the WHO European Region (with 753,454,300 inhabitants older than 15 years of age). If a 15% tax share with equalisation were implemented (Scenario 2), 132,906 (95% CI: (124,691-151,674) deaths could be averted. All sensitivity analyses with different elasticities yielded outcomes close to those of the main analyses. Interpretation: Similar to tobacco taxes, increasing alcohol taxes should be considered to be a health-based measure aimed at saving lives. Many countries have hesitated to apply higher taxes to alcohol, but the present results show a clear health benefit as a result of implementing a minimum tax share. Funding: This work was supported by the National Institute on Alcohol Abuse and Alcoholism (1R01AA028224) and the Canadian Institutes of Health Research, Institute of Neurosciences, and Mental Health and Addiction (SMN-13950).

Smoking-Attributable Direct Healthcare Expenditure in Lithuania: A Prevalence-Based Annual Cost Approach.

Introduction: The estimates of the economic burden of smoking provide the basis for a comprehensive assessment of the overall economic impact and evidence for potential public health policy intervention by the government. The aim of this paper is to estimate the smoking-attributable direct healthcare expenditure covered by the Compulsory Health Insurance Fund (CHIF) in Lithuania in 2013. Methods: A prevalence-based and disease-specific annual cost approach was applied to 25 smoking-related diseases or disease categories. Our analysis included only direct government healthcare expenditure (reimbursed by CHIF), including: smoking-attributable outpatient and inpatient care services, medical rehabilitation, reimbursable and publicly procured pharmaceuticals and medical aids, the emergency medical aid (ambulance) service, nursing, and expensive tests and procedures. The smoking-attributable expenditure on the above-mentioned healthcare services was calculated by multiplying the total annual expenditure by the corresponding smoking attributable fractions (SAFs). Results: The total smoking-attributable government expenditure amounted to €37.4 million in 2013. This represented 3% of the total CHIF budget in 2013. Smoking-attributable expenditure on inpatient care and medical rehabilitation services was two times higher for male smokers, than for female smokers. Conclusions: Smoking imposes a significant preventable financial cost within the budget of the Lithuanian healthcare system. A quantitative estimation of smoking related healthcare costs could provide an incentive for the development of smoking cessation services, with additional attention towards male smokers, as well as an important focus on smoking prevention among children and youths.

Burden of smoking in Lithuania: attributable mortality and years of potential life lost.

Background: High mortality rates from smoking related diseases are a significant public health issue in Lithuania. Study aims to estimate the number of smoking attributable deaths (SADs) and years of potential life lost in Lithuania in 2013. Methods: Gender, age and disease specific mortality was calculated by applying the smoking attributable fractions (SAFs) to prevalence estimates of current and former smokers among Lithuanian adults aged ≥35 years that are based on the 2005 Lithuanian Health Interview Survey. Mortality data were obtained from the Institute of Hygiene Health Information Centre. Eight years lag was assumed between smoking rates and subsequent mortality. Sensitivity analysis was used to calculate SAFs applying smoking impact ratio method. Results: In 2013, 13.9% of total mortality or 5771 deaths in Lithuania were attributable to smoking (5181 men and 590 women). The two leading causes of SADs were ischaemic heart disease (2861) and lung cancer (1054) that accounted for 67.8% of the smoking attributable mortality. In the same year, smoking accounted for 39 279 years of potential life lost (34 663 years for men and 4615 years for women). Conclusions: Smoking causes a considerable mortality burden in Lithuania, killing nine times more males than females. Therefore reduction of smoking prevalence is an urgent public health need, which calls for implementation of effective and comprehensive tobacco control measures consistent with the World Health Organization Framework Convention on Tobacco Control Articles and Protocols and The Tobacco Products Directive.

Smoking during pregnancy in association with maternal emotional well-being.

OBJECTIVE: The aim of the study was to investigate psychosocial predictors of smoking during pregnancy. MATERIALS AND METHODS: It was a cross-sectional analysis of a prospective birth-cohort study. The participants were 514 mothers of full-term infants. Women completed questionnaires during hospital stay after delivery. Questionnaire included items on sociodemographic characteristics, planning and emotional acceptance of pregnancy, reproductive history, health-related behavior, emotional well-being, and relationships with a partner. RESULTS: Smoking during pregnancy was reported by 14.8% of the participants. Prenatal smoking was associated with secondary or lower education, maternal age less than 20 years, childbirth outside of marriage, history of elective abortion, unplanned pregnancy, lack of positive emotional acceptance of pregnancy by mother and father, emotional distress and alcohol consumption during pregnancy. Smoking during pregnancy remained significantly associated with prenatal alcohol consumption, previous elective abortion, and lack of positive emotional acceptance of pregnancy by mother even after adjustment for maternal age, education, and family structure. CONCLUSIONS: Results support an idea of complexity of the relationships among smoking, alcohol use, and emotional well-being. Lack of positive emotional acceptance of pregnancy by mother and history of elective abortions can be considered as possible associates of smoking during pregnancy and suggest that strengthening of positive attitudes toward motherhood could add to lower smoking rates among pregnant women.

Overturn of the proposed alcohol advertising ban in Lithuania.

BACKGROUND: In response to the dramatic increase in alcohol-related problems in Lithuania, policy measures, including alcohol advertising and availability restrictions combined with taxation increase, were implemented in 2007-08. Simultaneously, a full alcohol advertising ban was adopted to take effect from 1 January 2012. Therefore, the alcohol industry responded with extensive lobbying aiming to revoke this ban, and ultimately they succeeded at the end of December 2011. AIM: To document and analyse actions of stakeholders and events during the alcohol advertising ban cancellation process in Lithuania. METHODS: Policy analysis includes a development of event time-line, description of key stakeholders' actions and a review of policy context. FINDINGS: The alcohol industry in Lithuania used similar tactics as the tobacco industry globally, such as creating strong and diverse opposing groups. The industry successfully exerted pressure to change alcohol control legislation, while non-governmental organizations had the important role of a watchdog, blunting industry's efforts. Unequal power distribution made it difficult to withstand combined local and international lobbying to cancel the ban. CONCLUSION: Given the global nature of the alcohol industry, there is a need for international regulation to limit the influence of vested interests on national lawmaking.

Building an international public health academic partnership: the Alberta-Lithuania experience.

The schools of public health at the University of Alberta and the Lithuanian University of Health Sciences have developed a partnership committed to a variety of collaborations (e.g., faculty/student exchanges and joint projects). Our initial efforts have resulted in the initiation of joint projects, important connections between numerous institutions/academics, and planning for future efforts within and beyond the partnership. The positive potential for such partnerships is significant, and a number of strategies for successful implementation are suggested.

Trends and social differences in alcohol consumption during the postcommunist transition in Lithuania.

The aim of the study was to evaluate the trends and social differences in consumption of various types of alcoholic beverages in Lithuania over the postcommunist transition period (1994-2010). The data were obtained from nine nationally representative postal surveys of Lithuanian population aged 20-64 conducted every second year (n = 17154). Prevalence of regular (at least once a week) consumption of beer, wine, or strong alcoholic beverages and the amount of alcohol consumed per week were examined. Regular beer drinking as well as the amounts consumed increased considerably in both genders. The increase in regular consumption of strong alcohol was found among women. Sociodemographic patterning of regular alcohol drinking was more evident in women than in men. In women, young age and high education were associated with frequent regular drinking of wine and beer. Social differences in regular alcohol drinking should be considered in further development of national alcohol control policy in Lithuania.

Recent heavy alcohol consumption at death certified as ischaemic heart disease: correcting mortality data from Kaunas (Lithuania).

AIMS: To assess the proportion of deaths assigned to ischaemic heart disease (IHD) which in fact were caused by the toxic effects of alcohol, and how this may affect the official statistics of mortality from IHD in Lithuania. METHODS: Using the IHD register in Kaunas, Lithuania, and verifying underlying causes of death using standard international methodology, 3061 cases were found in Kaunas city who had died from IHD at age 25-64 during 1993-2007. Out-of-hospital sudden deaths accounted for 2467 cases (81%), including 1498 where forensic autopsy was conducted and post-mortem concentration of alcohol in blood and urine was available. RESULTS: In total, 78.4% of all initial IHD diagnoses were verified, while in 8.7% of deaths the underlying cause of death was corrected into an alcohol-related cause and in 12.9% to other diseases. Alcohol was found in about half (50.3%) of out-of-hospital death cases subjected to autopsy. In 18.0% of cases, the alcohol concentration was 3.5% or higher. Alcohol was more likely to be present in winter months and at weekends. CONCLUSION: A significant number of alcohol-attributable deaths in Lithuania were misclassified as coronary deaths, accounting for almost one-tenth of officially registered deaths from IHD in ages 25-64. A high prevalence of positive post-mortem blood or urine alcohol tests suggests that the proportion of alcohol-related deaths among out-of-hospital IHD deaths may be actually even higher. A similar situation may be present in some other countries where high levels of alcohol consumption and binge drinking patterns are observed.

Trends of smoking prevalence among Lithuanian school-aged children in 1994-2006.

BACKGROUND. Despite much effort spent on antismoking programs in schools in different countries, limited effects have been observed in many cases. Evidence from European countries shows that active tobacco control actions such as ban on tobacco advertising, increase of tobacco taxes could lead to successful results. Our study was aimed to analyze time trends on smoking in Lithuanian school-aged children during the period of 1994-2006 in the context of antismoking policies, which were implemented in Lithuania. MATERIAL AND METHODS. This study was a part of WHO Cross-National Health Behavior in School-Aged Children (HBSC) study carried out in Lithuania. The standardized methods of international HBSC study protocol were applied. Stratified random representative samples of 5428, 4513, 5645, and 5632 students aged 11, 13, and 15 years were included into school-based anonymous questionnaire surveys in 1994, 1998, 2002, and 2006, respectively (spring semester). Questions on frequency of smoking, age of initiation and other questions were included. Response rates of each of these four questionnaire surveys were higher than 90%. RESULTS. Smoking behavior was more common among boys. The prevalence gap in smoking between boys and girls diminished during period of observation. Prevalence of smoking increased significantly among boys during the period of 1994-2002 (11.3%, 19.8%, and 23.6% in 1994, 1998, and 2002, respectively), but started to decline after (17.3% in 2006, P<0.05). Similar trends were observed among girls: 3.6%, 8.5%, 14.6%, and 12.5% of girls reported smoking in cross-sectional surveys of 1994, 1998, 2002, and 2006, respectively. Boys living in rural areas were more frequent smokers than those living in urban areas in 1994-1998 (9.5% vs 13.9%, P<0.05). However, the surveys of 2002-2006 showed opposite changes (25.6% vs 22.1%, P<0.05 and 17.8% vs 16.9%, P>0.05). Urban girls have reported smoking more frequently in comparison with rural girls. CONCLUSIONS. An increase in tobacco smoking among school-aged children was observed in Lithuania during 1994-2002. A decrease in prevalence of smoking was seen during the period of 2002-2006. These trends could be related to the implementation of tobacco control measures in Lithuania.

[Associations between mortality and alcohol consumption in Lithuanian population]. / Lietuvos gyventoju mirtingumo sasajos su alkoholiniu gerimu vartojimu.

UNLABELLED: The objective of the study was to assess alcohol-related mortality that potentially might explain an increasing trend in overall mortality of Lithuanian population, which started after 2000 and peaked in 2005. MATERIAL AND METHODS: An empiric analysis of national mortality and other statistical data as well as their international comparisons. RESULTS: An analysis of available data clearly indicates that a decline in mortality in 1998-2000, i.e. during the beginning of the National Programme of Health, as well as its increase in 2001 and 2005 were predominantly determined by cause-specific deaths of two groups: deaths from diseases of the circulatory system (mainly ischemic heart disease) and alcohol consumption-related deaths (liver cirrhosis, accidental poisoning by alcohol, accidents, etc.). A certain proportion of deaths, which were caused by alcohol, were wrongly assigned to the deaths from diseases of the circulatory system due to uncertainties in filling-in death certificates. By approximate estimates, at least one-quarter of increase in all-cause mortality between 2002-2004 and 2005-2007 could be explained by an increase in alcohol consumption, accounting for additional 880 deaths on average per year. In the year 2007, 12.6% (n=5760) of all deaths were somehow related to alcohol consumption. A comparative analysis demonstrated that mortality and alcohol consumption trends were going in parallel over the last decade. The systemic decline in mortality observed in Lithuania from 1995 stopped in 2000 after a decrease in alcohol taxes, which resulted in an increase in alcohol accessibility and consumption. An average annual increase in alcohol consumption over the period of 2001-2004 was 7%; it increased up to 17% in 2005 and accounted for 12% annual increase on average within 2005-2007. CONCLUSIONS: Negative trends in alcohol-related morbidity and mortality in Lithuanian population most notably registered in 2001 and 2005 were largely influenced by uncontrollable increase in alcohol consumption over the last decade. Economic and commercial arguments in decision-making process that neglected health interest of Lithuanian population (decrease of alcohol taxes in 1999, other factors increasing alcohol accessibility and consumption) were those counteracting the implementation of balanced health policy in the country.

Trends in alcohol consumption among Lithuanian school-aged children in 1994-2006 and new challenges.

UNLABELLED: Alcohol abuse is considered one of the most important risk-taking behaviors among young people in the world. This paper presents the results of the WHO collaborative cross-national study on Health Behavior in School-aged Children (HBSC) carried out in Lithuania and other European countries also in USA, Canada, and Israel in 1994, 1998, 2002, and 2006. OBJECTIVE: The aim of this study was to analyze features and trends in alcohol consumption among the samples of 11-, 13-, and 15-year-old adolescents (school-aged children) in Lithuania during 1994-2006. MATERIAL AND METHODS: Representative samples of 5428, 4513, 5645, and 5632 respondents aged 11, 13, and 15 years were included into school-based questionnaire surveys in 1994, 1998, 2002, and 2006, respectively. The standardized research methods were applied. The students have filled in the questionnaires anonymously in the classroom according to the methodology of international HBSC study. The students were asked about lifestyle habits, alcohol consumption, and episodes of drunkenness. RESULTS: The number of students who had been drunk two or more times has increased by 2.5 times (from 9.8%. to 25.6%) during 1994-2006. A significant increase in alcohol consumption was observed among 15-year-old girls - the percentage of girls who have reported alcohol consumption almost approached the percentage of boys (50.3% and 56.8%, respectively; P=0.006). The reported mean age of the onset of first drinking had shifted by 2 years towards younger age during the period of 1994-2006. The comparison of data from 37 countries, participating in this cross-national study, revealed that the prevalence of alcohol consumption among Lithuanian school children is one of the highest (29.0% of boys and 22.1% of girls) and was in the second worst position on a rating scale when comparing with other 36 countries involved in HBSC study. The results suggest that increased use of light alcoholic beverages can cause an increase in the number of drinking teenagers. Ready-to-drink beverages ("alcopops") at least once per week were used by 15.3% of boys and 17.5% of girls (P=0.216); beer - 16.9% of boys and 5.6% of girls (P<0.001). CONCLUSIONS: A significant shift of the onset of drinking alcohol towards younger age was observed in Lithuania during 1994-2006. In recent years, Lithuanian students as compared to peers from other countries are among those who consume alcohol most frequently.

Risk factors for alcohol use among youth and main aspects of prevention programs.

Increasing alcohol consumption becomes more relevant social and health problem among youth. There is no reason to believe that this problem will decrease or be solved in the future. In such situation, it is necessary to build on the experience and conclusions of research performed by other countries. In this article, the risk factors for alcohol consumption among youth and preventive programs, in which family, school, and community play the main role, are analyzed. Such programs may attract the attention of public health specialists and public health politicians and can be not only declared, but also really implemented.

[Smoking habits, attitudes and smoking cessation among sixth-year medical students of Kaunas University of Medicine]. / Kauno medicinos universiteto Medicinos fakulteto studentu rukymo iprociai ir poziuris i rukymo kontrole.

UNLABELLED: The aim of the study was to assess trends of smoking and the relation between smoking behavior of undergraduate medical students and their attitudes towards smoking and treatment of tobacco dependence. METHODS: Data were collected from sixth-year medical students of Kaunas University of Medicine during ten consecutive years. A total of 1518 students completed the anonymous questionnaire; response rate was 83.5%. RESULTS: The daily smoking rate was 19.4% in males and 4.2% in females; 15.9% and 10.4% respectively were irregular smokers, never smoked 41.6% of males and 64% of females. 70% of smokers and 83% of nonsmokers agreed that tobacco smoking is one of the greatest health hazards of modern times; 97.1% of all students considered passive smoking as harmful. More nonsmokers (70%) than smokers (5l%) were aware of addictive nature of tobacco, but there was a little difference in their opinion about support to smokers for quitting: 83.2% of smokers and 87.1% of nonsmokers stated that medical doctors should help smokers to give up smoking and 68% of them thought that doctors had not enough knowledge how to help. Less smokers (55%) than nonsmokers (87%) believed that smoking should be banned in hospitals. CONCLUSIONS: Prevalence of smoking was significantly lower among medical students than in general population. There were no significant changes in smoking prevalence among male medical students during the period of 1995-2004. At the same time smoking prevalence among female medical students increased more than twice. Attitudes of smokers and nonsmokers were significantly different on most items of tobacco, but knowledge of tobacco problem in the undergraduate students was not sufficient. Teaching about tobacco and related issues remains essential in the undergraduate medical course.

[Smoking prevalence among university hospital staff]. / Rukymo paplitimas tarp viesosios gydymo istaigos darbuotoju.

Addiction to smoking was assessed in staff of Kaunas University of Medicine Hospital based on the results of an anonymous questionnaire. A total of 3090 valid questionnaires were collected (56.5% of whole sample). Prevalence of smokers was 13.3% (37.6% men and 9.7% women), former smokers - 6.0% (16.0% men and 3.7% women) and non-smokers - 80.7% (46.4% men and 86.6% women). The 30-39 year old age men and 18-39 year old women groups present the highest prevalence of smoking (48.8% and 14.9%, accordingly). The highest prevalence of tobacco smoke was found among auxiliary personnel men and women (44.9% and 11.3%, accordingly) and the lowest - among doctors (36.4% and 7.6%, accordingly). The received data enable to evaluate smoking prevalence among University Hospital staff and allow smoking control policy measures.