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Liver cirrhosis mortality rates in Britain

2006; Elsevier BV; Volume: 367; Issue: 9526 Linguagem: Inglês

10.1016/s0140-6736(06)68836-3

1474-547X

David Morrison, Allan Boyd, Tricia Richardson,

Birth, Development, and Health

David Leon and Jim McCambridge provided a lucid description of the substantial increase in liver cirrhosis mortality in the UK.1Leon DA McCambridge J Liver cirrhosis mortality rates in Britain from 1950 to 2002: an analysis of routine data.Lancet. 2006; 367: 52-56Summary Full Text Full Text PDF PubMed Scopus (350) Google Scholar Their reanalysis identified even greater differences between mortality in Scotland and England and in the rest of Europe.2Leon DA McCambridge J Liver cirrhosis mortality rates in Britain, 1950 to 2002.Lancet. 2006; 367: 645Summary Full Text Full Text PDF PubMed Scopus (34) Google ScholarEven within Scotland there are large geographic inequalities in deaths from alcoholic liver disease (ICD 10 code K70). During 2002–04, 31% of all deaths from alcoholic liver disease in Scotland occurred in Greater Glasgow, which contains less than a fifth of the Scottish population. The standardised mortality ratio (SMR) for these deaths in residents aged 45 years and older during this period was 193 (95% CI 179–207), whereas the all-Scotland SMR was 100.These geographic inequalities seem to be strongly determined by socioeconomic status. We examined SMRs for alcoholic liver disease within Greater Glasgow by deprivation category (DEPCAT). This scale ranks an area's relative socioeconomic status from 1 (most affluent) to 7 (most deprived) by means of four census variables (social class IV and V, male unemployment, overcrowding, and car ownership). The SMR for death by alcoholic liver disease in 2002–04 was 54 (95% CI 38–71) in residents of DEPCAT areas 1 and 2 (affluent) and 300 (274–326) in residents of DEPCAT areas 6 and 7 (deprived). Explanations involving “area effects” (such as local death record coding practices) are unlikely to account for some areas within Greater Glasgow having half the national rate of alcohol deaths, while others have three times it.Total alcohol consumption is not strongly related to social class in Scotland, although more recent surveys confirm Leon and McCambridge's observation that binge drinking increases in men and women along the social class scale from I (professional) to V (unskilled).3Erens B Alcohol consumption.in: Shaw A McMunn A Field J The Scottish Health Survey 1998: 1. Scottish Executive Health Department, Edinburgh2000Google Scholar However, overall alcohol consumption, binge drinking, and harmful drinking are not more common in Scotland than in England.3Erens B Alcohol consumption.in: Shaw A McMunn A Field J The Scottish Health Survey 1998: 1. Scottish Executive Health Department, Edinburgh2000Google Scholar Thus, the strong association between socioeconomic status and death from alcoholic liver disease is not satisfactorily explained by alcohol consumption alone. Other risk factors—which might include poor nutrition or early life programming4Eriksson JG The fetal origins hypothesis—10 years on.BMJ. 2005; 330: 1096-1097Crossref PubMed Scopus (49) Google Scholar—need to be better understood. Although the prevalence of hepatitis C is twice as great in Scotland as in the rest of the UK (1% vs 0·5%),5Scottish ExecutiveHepatitis C: proposed action plan in Scotland. Scottish Executive, Edinburgh2005Google Scholar our analysis describes only alcoholic disease.Although we support policies to reduce overall alcohol consumption, the excess cirrhosis deaths in Scotland cannot be attributed to alcohol consumption alone. A better understanding of the large contributory effects of socioeconomic non-alcohol cofactors is needed. A corollary is that policies to reduce the harm of alcohol, and to reduce geographic inequalities, might need to be directed largely at these cofactors.We declare that we have no conflict of interest. David Leon and Jim McCambridge provided a lucid description of the substantial increase in liver cirrhosis mortality in the UK.1Leon DA McCambridge J Liver cirrhosis mortality rates in Britain from 1950 to 2002: an analysis of routine data.Lancet. 2006; 367: 52-56Summary Full Text Full Text PDF PubMed Scopus (350) Google Scholar Their reanalysis identified even greater differences between mortality in Scotland and England and in the rest of Europe.2Leon DA McCambridge J Liver cirrhosis mortality rates in Britain, 1950 to 2002.Lancet. 2006; 367: 645Summary Full Text Full Text PDF PubMed Scopus (34) Google Scholar Even within Scotland there are large geographic inequalities in deaths from alcoholic liver disease (ICD 10 code K70). During 2002–04, 31% of all deaths from alcoholic liver disease in Scotland occurred in Greater Glasgow, which contains less than a fifth of the Scottish population. The standardised mortality ratio (SMR) for these deaths in residents aged 45 years and older during this period was 193 (95% CI 179–207), whereas the all-Scotland SMR was 100. These geographic inequalities seem to be strongly determined by socioeconomic status. We examined SMRs for alcoholic liver disease within Greater Glasgow by deprivation category (DEPCAT). This scale ranks an area's relative socioeconomic status from 1 (most affluent) to 7 (most deprived) by means of four census variables (social class IV and V, male unemployment, overcrowding, and car ownership). The SMR for death by alcoholic liver disease in 2002–04 was 54 (95% CI 38–71) in residents of DEPCAT areas 1 and 2 (affluent) and 300 (274–326) in residents of DEPCAT areas 6 and 7 (deprived). Explanations involving “area effects” (such as local death record coding practices) are unlikely to account for some areas within Greater Glasgow having half the national rate of alcohol deaths, while others have three times it. Total alcohol consumption is not strongly related to social class in Scotland, although more recent surveys confirm Leon and McCambridge's observation that binge drinking increases in men and women along the social class scale from I (professional) to V (unskilled).3Erens B Alcohol consumption.in: Shaw A McMunn A Field J The Scottish Health Survey 1998: 1. Scottish Executive Health Department, Edinburgh2000Google Scholar However, overall alcohol consumption, binge drinking, and harmful drinking are not more common in Scotland than in England.3Erens B Alcohol consumption.in: Shaw A McMunn A Field J The Scottish Health Survey 1998: 1. Scottish Executive Health Department, Edinburgh2000Google Scholar Thus, the strong association between socioeconomic status and death from alcoholic liver disease is not satisfactorily explained by alcohol consumption alone. Other risk factors—which might include poor nutrition or early life programming4Eriksson JG The fetal origins hypothesis—10 years on.BMJ. 2005; 330: 1096-1097Crossref PubMed Scopus (49) Google Scholar—need to be better understood. Although the prevalence of hepatitis C is twice as great in Scotland as in the rest of the UK (1% vs 0·5%),5Scottish ExecutiveHepatitis C: proposed action plan in Scotland. Scottish Executive, Edinburgh2005Google Scholar our analysis describes only alcoholic disease. Although we support policies to reduce overall alcohol consumption, the excess cirrhosis deaths in Scotland cannot be attributed to alcohol consumption alone. A better understanding of the large contributory effects of socioeconomic non-alcohol cofactors is needed. A corollary is that policies to reduce the harm of alcohol, and to reduce geographic inequalities, might need to be directed largely at these cofactors. We declare that we have no conflict of interest. Liver cirrhosis mortality rates in Britain – Authors' replyWe agree with Alastair Smith that more light could be thrown on determinants of liver cirrhosis if reliable data differentiating alcohol-related and non-alcohol-related cirrhosis were available. The problem lies in the questionable validity of these distinctions for routine data on cause of death, particularly when making comparisons between countries and across time. Full-Text PDF