Cardiovascular diseases mortality and alcohol control policy in Lithuania: exploring a possible link

Following decades of decline globally, cardiovascular disease (CVD) mortality rates have been starting to stagnate in most high-income countries, and even increase in some [1]. In 2019, CVDs were responsible for more than 18.6 million deaths globally, 3.5 million of which were in high income countries [1].

Lithuania has been classified by the World Bank as a high-income country since 2012 but the age-standardized CVD mortality rate per 100,000 people is about 2.6 times greater than that of other high-income countries [2]. In fact, the age-standardized CVD mortality rate is higher in Lithuania than the average for all World Bank income classification groups, as well as the global average [2].

CVD mortality can be mostly attributable to biological risk factors, including arterial hypertension, dyslipidemia and diabetes [3‐6], as well as certain health behaviors, such as smoking, unhealthy diet, physical inactivity and alcohol use [7‐9]. The observation that Lithuania possesses one of the highest alcohol per capita consumption in tandem with the fact that alcohol use accounts for the highest proportion of CVD deaths and disability-adjusted life years in Europe attests to the association between alcohol use and CVD mortality [10].

Long-term prospective studies have shown that there is a J-shaped association between CVD morbidity and mortality and alcohol use [11‐13].

A meta-analysis of 83 prospective studies found that among 599,912 current drinkers, increased alcohol consumption was log-linearly associated with a lower risk of myocardial infarction (Hazard Ratio = 0.94, 95% Confidence Interval (CI): 0.91–0.97) [14]. On the other hand, according to the NHANES cohort, alcohol use increased the risk of coronary artery disease by an average of 14% (Odds Ratio = 1.14, 95% CI: 1.04–1.35) among people under 55 years of age [14]. Heavy drinking, defined as consuming more than 4 drinks on any day or more than 14 drinks per week for men and consuming more than 3 drinks on any day or more than 7 drinks per week for women, is associated with a high risk of death from CVD [10]. Heavy alcohol use, especially among middle-aged men, is a common cause of arterial hypertension, non-ischemic dilated cardiomyopathy (alcoholic cardiomyopathy), atrial fibrillation, and stroke (both ischemic and hemorrhagic) [12, 15].

There is a vast amount of literature that suggests alcohol control policy interventions, such as restrictions on the physical availability of alcohol, an increase of excise tax on alcoholic beverages, and alcohol advertising restrictions can reduce not only all-cause mortality [16], but also specifically CVD mortality [17]. Alcohol control policy is often in the spotlight of political and public debate in Lithuania. In fact, the Alcohol Control Law is one of the most frequently amended legal acts in Lithuanian legislative history with around 63 amendments since 1995 [18]. Not surprisingly, there have been fluctuations between a more conservative stance on alcohol and liberalization, which is suspected to be reflected in the alcohol-related harm trends in Lithuania.

The aim of this study was to investigate the CVD mortality rate trends in Lithuania over the past 18 years (2001–2018) and explore a possible link between CVD mortality rate and alcohol control policy implementation.

The current study uses an observational design, based on yearly CVD mortality data. CVD mortality trends were investigated according to the International Classification of Diseases 10th Revision (ICD-10) codes for all CVDs (I00-I99) and three other common CVDs - ischemic heart disease (IHD) (I20-I25), cerebrovascular diseases (I60-I69) and alcoholic cardiomyopathy (ACM) (I42.6) [19]. Population mortality data for 2001–2018 were obtained from Statistics Lithuania [20] and The State Register of Death Cases and Their Causes, Institute of Hygiene [21]. Data of recorded alcohol consumed per capita (RAPC) among males and females aged 15 years and older were obtained from Statistics Lithuania [20].

Overall, mortality rates from all CVD as well as IHD, cerebrovascular diseases and ACM decreased between 2001 and 2018 (Table 1). All CVD mortality rate decreased from 1048.6 per 100,000 population in 2001 to 749.1 per 100,000 in 2018, with an average rate of 925.6 per 100,000. The largest increase and decrease in CVD mortality rate from the previous year was found in 2005 (+ 3.8%) and 2014 (− 5.4%), respectively.

The IHD mortality rate decreased from 684.3 per 100,000 population in 2001 to 474.7 per 100,000 in 2018, with an average rate of 596.9 per 100,000. The largest increase and decrease in IHD mortality rate from to the previous year was found in 2005 (+ 4.7%) and 2017 (− 5.9%), respectively.

The mortality rate from cerebrovascular diseases decreased from 235.6 per 100,000 population in 2001 to 182.8 per 100,000 in 2018, with an average rate of 219.7 per 100,000. The largest increase and decrease in cerebrovascular diseases mortality rate from the previous year was found in 2006 (+ 5.0%) and 2014 (− 8.0%), respectively.

The ACM mortality rate decreased from 5.0 per 100,000 population in 2001 to 1.8 per 100,000 in 2018, with an average rate of 4.7 per 100,000. The largest increase and decrease in ACM mortality rate from to the previous year was found in 2007 (+ 67.2%) and 2018 (− 60.8%), respectively.

Between 2001 and 2018, the average RAPC in Lithuania was 13.0 l of pure alcohol per capita among those aged 15 years and older, which varied from 10.5 l in 2001 to 14.7 l in 2011 and 2012. During a period from 2001 to 2009, the RAPC increased by 32.4%, while it decreased by 23.8% from 2012 to 2018.

The Joinpoint regression analyses determined that one joinpoint, or critical year, was the ideal number of joinpoints for all CVD groups and all age groups. The results of the sex specific Joinpoint regression analyses are summarized in Table 2 for the overall age group, and in Table 3 for the 25–64 year-old age group.

The CVD mortality rates significantly decreased on average by 1.6% (95% CI -2.0; − 1.2) among men and by 2.1% (95% CI -2.5; − 1.8) among women per year (Fig. 1a). 2006 was identified as the critical year for all CVD. The CVD mortality rates did not change significantly for both men and women from 2001 to 2006. However, significant decreases in CVD mortality rates were observed from 2006 to 2018 for both men and women by an average of 2.4% (95% CI -2.7; − 2.0) and 2.7% (95% CI -3.0; − 2.3), respectively.

The mortality rates from IHD, cerebrovascular diseases and ACM significantly decreased for both men and women between 2001 and 2018. The IHD, cerebrovascular diseases and ACM mortality rates decreased each year by an average of 1.6% (95% CI -2.1; − 1.1), 1.2% (95 CI -1.7; − 0.6) and 4.5% (95% CI -7.3; − 1.6) among men and by 2.0% (95% CI -2.6; − 1.4), 1.8% (95% CI 2.4; − 1.3) and 6.6% (95% CI -10.7; − 2.2) among women, respectively (Fig. 1b, c and d). The critical year points for IHD, cerebrovascular diseases and ACM were respectively 2005, 2008 and 2007. The mortality rates for IHD, cerebrovascular diseases and ACM significantly decreased after their respective critical year points (Fig. 1b and c). IHD mortality rate decreased each year after 2005 by an average of 2.1% (95% CI -2.5; − 1.7) among men and 2.3% (95% CI -2.8; − 1.9) among women, and cerebrovascular diseases mortality rate decreased each year after 2008 by an average of 2.0% (95% CI -2.7; − 1.3) among men and 2.8% (95% CI -3.5; − 2.1) among women. The mortality rate for ACM increased significantly between 2001 and 2007 among men by an average of 9.4% (95% CI 2.0; 17.2) per year but significant changes were not observed among women for the same time period. However, ACM mortality rate decreased significantly after 2007 among men and women by an average of 11.3% (95% CI -14.3; − 8.2) and 14.6% (95% CI -19.3; − 9.6), respectively.

Among 25–64 year-old men and women, CVD mortality decreased significantly on average by 1.7% (95% CI -2.6; − 0.8) and 2.6% (95% CI -3.2; − 2.1) per year, respectively, from 2001 to 2018 (Fig. 1a). 2006 was identified as the critical year for all CVD among the 25–64 year-old population. CVD mortality rates increased significantly between 2001 to 2006 by 4.8% (95% CI 1.9; 7.8) in men and by 3.9% (95% CI 2.2; 5.7) in women, but significantly decreased on average by 4.3% (95% CI -5.0; − 3.5) and 5.2% (95% CI -5.7; − 4.8), respectively, between 2006 and 2018 (Table 3).

Between 2001 and 2018, mortality from IHD among both men and women aged 25 to 64 years decreased significantly on average by 1.9% (95% CI -2.8; − 1.0) and 2.2% (95% CI -3.0; − 1.3) per year, respectively (Fig. 1b). 2006 was identified as the critical year for IHD among the 25 to 64 year-old population. Mortality from IHD increased significantly between 2001 and 2006 among men and women by 3.6% (95% CI 0.8; 6.6) and 5.4% (95% CI 2.6; 8.4) per year, respectively, and decreased significantly on average by 4.1% (95% CI -4.9; − 3.3) and 5.2% (95% CI -5.9; − 4.4), respectively, from 2006 to 2018.

Between 2001 and 2018, mortality from cerebrovascular diseases among both men and women aged 25 to 64 years decreased significantly on average by 1.8% (95% CI -3.0; − 0.6) and 3.8% (95% CI -5.2; − 2.3) per year, respectively (Fig. 1c). 2007 and 2010 were identified as the critical year for cerebrovascular diseases among 25 to 64 year-old men and women, respectively. Mortality from cerebrovascular diseases trends among men and women 25 to 64 years old were without significant changes until their respective joinpoints, after which cerebrovascular diseases mortality decreased significantly by an average of 3.9% (95% CI -5.2; − 2.6) and 6.6% (95% CI -9.2; − 3.9) per year, respectively.

Between 2001 and 2018, mortality from ACM among men and women aged 25 to 64 years decreased significantly on average by 4.1% (95% CI -7.1; − 1.1) and 6.3% (95% CI -10.7; − 1.7) per year, respectively (Fig. 1d). 2007 was identified as the critical year for ACM among the 25 to 64 year-old population. Mortality from ACM increased significantly between 2001 and 2007 among both men and women by an average of 10.5% (95% CI 2.6; 19.0) and 12.2% (95% CI 1.2; 24.4), respectively. The ACM mortality rate for men and women then decreased significantly from 2007 to 2018 by an average of 11.3% (95% CI -14.4; − 8.1) and 15.1% (95% CI -20.0; − 9.8), respectively.

Figure 1 shows that changes in the mortality rates trends for all CVDs, IHD, cerebrovascular diseases and especially ACM coincided with the alcohol policies enacted on the January 1, 2008, January 1, 2009, April 1, 2014 and March 1, 2017 in Lithuanian.

Our study determined the age-standardized mortality rates from 2001 to 2018 for all CVD, IHD, cerebrovascular diseases and ACM to identify any potential links between the implementation of selected most effective alcohol control policies and changes in CVD mortality rates among Lithuanians. All CVD mortality significantly decreased from 2001 to 2018 in both sexes in Lithuania, however the declining trends were more prominent in women than in men. We identified 2005, 2006, 2007, 2008 and 2010 as critical years in CVD mortality rate trends, after which a significant decrease was observed.

The largest AAPC increase (+ 3.8%) in all CVD mortality rates was found between 2004 and 2005, among all ages. As described by Miščikienė et al. (2020) [18], alcohol policies on taxation and advertising were loosened in 2001 and 2002, and further loosened in 2004 as part of legal harmonization with the European Union. This could have contributed to the increased affordability of alcohol beverages and consequently higher alcohol attributable burden.

Among the different CVD groups investigated, the changes in ACM mortality rate trends coincided best with the selected alcohol policy enactment dates. Direct link was observed when analyzing mortality from cerebrovascular diseases in the study population; mortality trends started to decrease significantly in average per year by 2.0% in men and by 2.8% in women after the implementation of alcohol control policies in 2008.

The analysis suggests that there might be a close relation between the implemented alcohol control policies and ACM mortality (especially in men), which is consistent with findings from Russia, a country with a similar experience in the field of alcohol control as Lithuania [26].

As we cannot exclude the supporting effects of the alcohol control policies on the overall declining trends in CVD, we cannot conclude that there was an effect either. The alcohol control policies which were anticipated to be highly impactful did not coincide with rapid declines of CVD mortality in women and men aged at least 15 years or among the 25 to 64 years-old population.

The misalignment between the critical year points identified in this study and the policy implementation time points may be partly explained by recent improvements in the CVD risk profile of Lithuanians, which may have also contributed to the decreased mortality rates between 2001 and 2018.

During the analyzed period, many changes occurred in the CVD risk profile of the Lithuanian population. In 2006, the National Programme for the Screening and Preventive Management of the High Cardiovascular Risk Individuals (40–54 years-old men and 50–64 years-old women) was launched in Lithuania and the prevalence of CVD risk factors has reduced since. The percentage of smoking cessation has increased significantly and a decreasing trend in smoking prevalence, especially among men was estimated [27, 28]. The prevalence of dyslipidemia and arterial hypertension has declined [29, 30], and a significant reduction in the prevalence of metabolic syndrome was identified among women [31]. The previous studies have confirmed that CVD prevention programs can reduce CVD mortality in the long term [32‐34].

Furthermore, significant efforts have been made during the last two decades to improve the diagnosis, management, and treatment of acute myocardial infarction, including pre-hospital and treatment procedures during hospitalization and outpatient care [35, 36]. Nowadays, cardiac reperfusion rates used as a measure of the effectiveness of acute myocardial infarction treatment in Lithuanian hospitals are similar to those in Western and Northern European countries [37‐39]. Also, the clinical diagnosis of patients with CVD has improved due to the application of the newest examination methodologies and diagnostic tools. All the above-mentioned measures could have played a role in a declining trend in CVD mortality.

Long-term behavioral changes were also observed during 2001 to 2018 in the Lithuanian population. Nutrition habits have improved: the consumption of animal fat declined, while the use of vegetable oil and consumption of fresh vegetables increased [40]. Based on the Health Interview Survey carried out by Statistics Lithuania, the prevalence of daily smoking in men decreased from 42.1% in 2005 to 29.9% in 2019 and remained stable in women (9.8% in 2005 and 9.7% in 2019) [41].

Our study showed that all CVD mortality, including IHD, cerebrovascular diseases and ACM, has declined in Lithuania over the past two decades, and declining trends were more prominent in women than in men, especially among individuals 25–64 years of age. Among the different CVD groups investigated, the onset of the declining ACM mortality rate trend coincided best with the selected alcohol policy enactment dates. Future studies are needed to estimate the impact of the alcohol control policies implemented in Lithuania on CVD mortality rates using more targeted statistical methods.