Re: How much did alcohol really contribute to the mortality changes?
EDITOR: The deductions of Bobak and Marmot are highly likely to be
correct: “there is no direct evidence that alcohol caused the mortality
fluctuations” (1) reported annually in Russia (2). Except for such deaths
as the relatively small proportion (in Russia) due to alcoholic liver
disease, alcohol poisoning and transport accidents, alcohol rarely
compromises health in a direct fashion.
For most people, alcohol is self-administered as a psychotropic drug,
whose patterns of use interact with the social environment in which it is
used. Psychological and social harms associated with drinking accumulate,
typically, over a long period of time before they are seen as a “problem”
(3). Family breakdown, job loss, homelessness and public order offences
do not appear overnight, but patterns related to alcohol use are
discernible over populations, especially at times of wider change (4).
For example, when the old South West Thames health region asked me to
review HIV and drinking behaviour in 1991, we knew that alcohol did not
cause AIDS - but alcohol use was a significant factor in the spread and
progress of HIV-related disease. Currently my department is involved in
localised studies of domestic violence and of youth suicide: these health
problems are not directly caused by alcohol, but they do appear to relate
to cumulative histories of drinking in individuals and in groups. The
“underlying social problems” mentioned (1) interact with alcohol
histories, and socially isolating adult experiences like divorce, a
criminal record or homelessness may be predisposing to many pathologies
down the road....
That long term health impact of different alcohol histories was
tracked for decades by George Vaillant. He observed (5): “Alcohol abuse
-- unrelated to unhappy childhood -- consistently predicts unsuccessful
aging, in part because alcohol damages future social supports.”
1 Bobak M, Marmot M. How much did alcohol really contribute to the
mortality changes ? BMJ eletters/327/7421/964 13 November 2003.
2 Men T, Brennan P, Boffetta P, Zaridze D. Russian mortality trends
for 1991-2001: analysis by cause and region. BMJ 2003; 327: 964-966.
3 Caan W. Alcohol on the mind. In: Caan W, de Belleroche J (eds)
Drink, Drugs and Dependence. From science to clinical practice. London:
Routledge, 2002; 51-68.
4 Caan W. Coming together on alcohol and drugs: a capital idea.
Journal of Mental Health 2001; 10: 477-479.
5 Vaillant GE. Aging Well: Surprising Guideposts to a Happier Life
from the landmark Harvard Study of Adult Development. Boston: Little and
Brown, 2003 (paperback edition).
Competing interests: No competing interests