healthmedicinet

Three main results were found: first, liver cirrhosis mortality decreased starting in 1977 among males and in 1969 among females. This trend was accompanied by decreases in alcohol consumption beginning in 1977. Second, these results were also accompanied by decreases in consumption of cigarette equivalents starting in 1972. Third, liver cirrhosis mortality decreased whereas the number of SUD treatments and hospital treatments for alcohol-related liver disease increased.

The reduction in liver cirrhosis mortality is similar to trends found in other European countries. Data from other countries have also revealed a decrease in liver cirrhosis mortality since the mid-1970s [2]. This trend has been confirmed in additional countries outside of Europe [1] including the United States [3]. This alignment suggests two potential causes for the reduction in liver cirrhosis mortality: a decrease in alcohol consumption and improvement in treatments.

The decrease in pure alcohol consumption over the course of 37 years from 16.62 liters consumed annually per resident aged 15 or older to 11.13 liters consumed annually is accompanied by a decrease in liver cirrhosis mortality of approximately half: from 51.4 per 100,000 male residents aged 15 or older in 1976 to 26.2 in 2013 and from 21.4 per 100,000 female residents aged 15 or older in 1976 to 12.3 in 2013. Earlier evidence showed simultaneous changes in the relationship between alcohol consumption and liver cirrhosis mortality in a dose–response relationship pattern [7].

Potential reasons for the decrease in alcohol consumption might include public health activities aiming to reduce alcohol consumption in the general population, further changes in social norms with regards to alcohol consumption, changes in the economy, mechanisms of the beverage market, changes in educational attainment, and reductions in tobacco consumption. Public health activities designed to reduce alcohol consumption did not take place in a way that might be strong enough to make changes. However, drinking norms may have changed over time, e.g., the acceptability of drinking and driving. Alcohol-free driving was advertised publicly. Additionally, media covering other countries with strict alcohol policies may have had an influence. General health-related norms may also have become more influential in reducing alcohol consumption. An economic recession in 1967 may have added to the decrease in alcohol consumption during this time period [cf. 16, 17]. The increase in the proportion of people attaining the highest level of education may have contributed to improved health consciousness and decreased alcohol consumption. The rate of those with 12 or more years of education among the female population at age 19 was 3.1 % in 1950 and 37.7 % in 2013; among men, the rate of those with 12 or more years of education was 6.1 % in 1950 and 29.8 % in 2013 [18, 19].

The finding that the decline in smoking started 5 years earlier than alcohol consumption and liver cirrhosis mortality suggests an indirect and direct effect of smoking on the decrease in liver cirrhosis mortality may have been active. The presence of indirect effects is supported by evidence concerning alcohol drinking and tobacco smoking [10, 20]. The probability of alcohol dependence increases as more cigarettes per day are smoked [21]. If tobacco smoking becomes less prevalent, the “appetite” for alcohol may decrease [21, 22]. A direct link between tobacco smoking and liver cirrhosis is also suggested by evidence. Cohort data revealed that tobacco smoking may increase the risk of liver cirrhosis independent of the influence of alcohol [11, 12, 23, 24]. Even among those who consumed less than 7 drinks per week, female current smokers had a higher risk for liver cirrhosis than non-smokers [12]. Animal studies suggest independent associations between tobacco smoking and liver cirrhosis [10, 25].

Improvements in SUD treatments might be an additional reason for the decrease in liver cirrhosis over time. In Germany, the number of facilities for treating alcohol dependence increased steadily since 1982. However, data on the adult general population revealed that only 22.8 % of alcohol dependent subjects utilized this treatment [26]. Among those who had taken part in specialized alcohol treatment, no additional subjects had survived 14 years after the baseline interview than among those who did not utilize specialized alcohol treatment services [26]. These findings do not speak in favor of SUD treatment as contributing significantly to the decrease in liver cirrhosis.

The increase in hospital treatments for alcohol-related liver disease since 2000 might be of some relevance for explaining the decrease in liver cirrhosis mortality. One reason for the increase in hospital treatments might be increased detection rates in primary medical care [27]. Fewer individuals may have gotten to a stage of severe impairment, a stage in which cirrhosis develops. Treatments and secondary prevention of liver disease have also likely improved [28] as have the survival rates of patients with liver cirrhosis [29, 30]. However, data from the UK revealed no progress in survival rates during almost five decades through 1999 [31, 32].

The strengths of the present study include the time span of 62 years covered by the data for liver cirrhosis mortality and alcohol and tobacco sales and the data being largely free of bias except the diagnosis of liver cirrhosis as the cause of death. Limitations include that liver cirrhosis may have been underestimated. For example, cases of death that occurred outside the hospital may not have been captured. Data from a previous study revealed that less than half of liver cirrhosis deaths detected by autopsy had been declared in mortality statistics [33]. Additionally, the proportion of alcohol-related liver cirrhosis among all liver cirrhosis cases may have been reduced over time. Changes in liver cirrhosis rates resulting from the obesity epidemic may increase the proportion of non-alcoholic fatty liver disease [34].