Janusz Knepil, Alex Paton.  Alcohol in the body: Elimination of alcohol from blood varies. (Letters to the editor).  British Medical Journal  330(7493):732-733, March 26, 2005.

Summary: In a letter to the editor, Janusz Knepil criticizes an implication made by Alex Paton in his book ABC of Alcohol that elimination of alcohol from blood is always linear with time, i.e., that the kinetics are zero order kinetics. Knepil points out that enzyme activity can be assumed to follow first-order reaction rates except when the rate limiting reaction is saturated. In most non-Asian people the point of saturation for ethanol catabolism occurs at a blood ethanol concentration of 55-65 mmol per liter. Below these concentrations, alcohol elimination will proceed under conditions of first-order kinetics. The characteristics for the individual at a given time may be determined by serial estimation of alcohol and subsequent calculation. Knepil argues that the suggestion that alcohol is always eliminated by zero-order kinetics is misleading and can be dangerous if calculation of ethanol elimination is required, for example, for example, before administration of dimercaprol. Alex Paton replies in the same issue of the journal [see BMJ 330:(7493):732-733, March 26, 2005] stating that he and his colleagues are well aware of the complexities of ethanol metabolism and elimination by the liver and explaining that the ABC of Alcohol is not a biochemical text. It is an introduction for clinicians -- physicians, nurses, counselors, therapists, and social workers -- who have to deal with the practical issues of alcohol misuse, so a certain amount of simplification is required. Paton includes a graph to illustrate one of Knepil's points. It shows the rate of decrease in blood alcohol concentrations in heavy, social, and naive drinkers. The graph shows that elimination of ethanol is much more rapid in habitual heavy drinkers than in people who drink only rarely. Paton says the probable reason is a combination of enzyme induction by ethanol itself and recruitment of other enzyme groups to help deal with the added alcohol load of alcohol. These mechanisms explain the alcohol tolerance of experienced drinkers. NIAAA Glossary Terms:  ethanol metabolism, enzymes, chemical kinetics, BAC level, light AOD use, moderate AOD use, heavy AOD use, social drinking, AOD tolerance, chronic AODE, biochemical mechanism, enzyme induction, inducible enzymes, AOD tolerance, handbook, physician, nurse, counselor, social worker, mental health worker, letter to the editor

Raja A. S. Mukherjee, S. Hollins, Mohammed T. Abou-Saleh, and Jeremy Turk.  Low level alcohol consumption and the fetus: Abstinence from alcohol is the only safe message in pregnancy. (Editorial).  British Medical Journal 330:375-376, February 19, 2005.

Summary: The authors provide examples of the evidence that has led the United States, Canada, Australia, and other countries to advise alcohol abstinence during pregnancy. Fetal alcohol syndrome (FAS) was first reported in the international literature by Smith and Jones in 1973. Before that, Lemoine published a series of 127 cases in France, highlighting the phenotypes of people exposed prenatally to alcohol. Full FAS is characterized by a combination of short stature, neurocognitive deficits, and a specific triad of facial dysmorphology. The term fetal alcohol spectrum disorder (FASD) encompasses the behavioral disorders resulting from exposure of the prenatal brain to the teratogenic effects of alcohol, without development of the full FAS phenotype. Although FASD is difficult to diagnose, it is possible when there is a positive maternal history of alcohol consumption and neurocognitive deficits with or without the facial features in the offspring. The neurocognitive deficits in FAS and FASD include hyperactivity, impulsivity, difficulties with planning and mental organization, concrete thinking, visuospatial problems, lack of awareness of social cues, and difficulties understanding the consequences of ones own behavior. Furthermore, there is evidence of overlap and comorbid presentation with conditions such as attention deficit hyperactivity disorder, autism, and personality disorder. Previously FAS was considered a possible consequence of chronic alcohol consumption occurring in specific high risk populations such as Native American groups. Views later changed to encompass moderate consumption in all populations. Evidence from animals and humans now provides confirmation that behavioral changes may be seen even at low doses of alcohol consumption. There is emerging but not yet conclusive evidence about the exact dose of alcohol that is safe in pregnancy. It is likely that individual differences in alcohol metabolism may protect most women when drinking small quantities, but currently it is not possible to predict who is and is not at risk. In contrast to the position of the British Department of Health that 1-2 units a week in pregnancy is safe, the position adopted increasingly in other countries is that no level of alcohol consumption is known to be safe in pregnancy. A health promotion message about a safe amount of alcohol, although designed to protect the pregnant mother and her developing child, can be dangerous as it can be easily misinterpreted. The uncertain level of individual risk to the developing fetus together with the possibility of misinterpreting a health promotion message mean that the only safe message in pregnancy is abstinence from alcohol. NIAAA Glossary Terms:  prenatal alcohol exposure, fetal alcohol syndrome, pregnancy outcome, fetal alcohol effects, phenotype, health promotion, public policy on AOD, AOD consumption, light AOD use, moderate AOD use, heavy AOD use, AOD abstinence, prenatal care, phenotype, birth defects, craniofacial anomaly, alcohol-related neurodevelopmental disorder,  childhood behavioral problem, behavioral and mental disorder, hyperactive behavior, impulsive behavior, cognitive and memory disorder, spatial processing impairment, visual perception, comorbidity, attention deficit disorder with hyperactivity, autism, personality disorder, ethanol metabolism, editorial

Russell Viner and Robert Booy.  ABC of adolescence: Epidemiology of health and illness (Clinical review).  British Medical Journal 330:411-414, February 19, 2005.

Summary: This clinical review discusses adolescent demographics in the United Kingdom, patterns of disease and health risk, mortality, alcohol and other drugs, teenage pregnancy and sexual health, obesity, and chronic illness. The following points are made regarding alcohol and drugs: Road traffic injuries are the leading cause of death in adolescence (27% of deaths in 15-24-year-olds), particularly in young men, with motor vehicle collisions the main contributor. Road traffic injuries in young people are strongly associated with risk factors such as alcohol, depression, social disruption, and stress. Regular alcohol drinking (defined as once a week or more) in the UK rises from 3% of 11-year-olds to 38% of 15-year-olds, with boys and girls nearly equal until age 15. Like smoking and drinking, the prevalence of drug abuse in adolescence increases sharply with age. In 1998, only 1% of 11-year-olds in England had ever tried drugs, compared with 31% of 15-year-olds. The likelihood of having ever used drugs is strongly related to smoking and drinking experience; while few adolescents who are never-smokers or never-drinkers try drugs, up to three quarters of regular smokers who drink at least once a week have tried drugs. Similar risk and protective factors to those for smoking operate for substance use, with depression a particular risk factor. Alcohol abuse disorders in adolescence are not benign conditions; they often continue into adulthood and are associated with later substance abuse, depression, and antisocial behaviors. The recent improvements in mortality seen in young children have not been matched in teenagers, and adolescent morbidity shows worrying trends in key areas such as mental health, sexual health, and cardiovascular risk. As behaviors that both increase and protect against poor health outcomes in later life are laid down in adolescence, increased public health, policy, and clinical focus on the health of young people will have important benefits for the long term health of the population. NIAAA Glossary Terms:  United Kingdom, adolescence, public health, demographic characteristics, prevalence, morbidity, mortality, risk factors, protective factors, underage drinking, underage AOD use, AOD abuse, AOD use pattern, AOD use frequency, AOD nonuse, trend, AODR mortality, traffic accident, drinking and driving, smoking, sexually transmitted disease, obesity, emotional and psychiatric depression, stress, social adjustment, antisocial behavior, cardiovascular disorder, mental health, age differences, teen pregnancy prevention, health related behavior, literature review

Trevor Jackson.  Inside Saatchi & Saatchi (Commentary).  British Medical Journal 330:426, February 19, 2005.

Summary: The author of this commentary describes the £20 million (~US$38 million) marketing campaign by the manufacturer of the Brazilian alcoholic drink Sagatiba (38% proof) aimed at giving the beverage "a chic global presence, a must-imbibe for all the bright young things of the coolest bars in London, Amsterdam, Rome, and Paris." Sagatiba is an "upmarket" type of cachaça, a beverage distilled from sugar cane and normally drunk on street corners in Brazil. It is almost unheard of outside Brazil, which exports only 1% of its cachaça, in contrast to Russia, which exports 50% of its vodka. The manufacturer, also named Sagatiba, has retained the Saatchi & Saatchi advertising agency to promote the beverage in the United Kingdom with emphasis on its "purity" and its status as "a drink for hot, hot people." Initially, the campaign was built around the slogan, "Pure, so you don't have to be," but this proved unsuccessful. The advertising agency then adopted the slogan "Pure spirit of Brazil," and found a model who looks like Brazil's most famous icon, the statue of Christ the Redeemer in Rio de Janeiro. He is photographed, with his arms outstretched, in a bar, a swimming pool, and a nightclub, and on the back seat of a taxi. The ads are now set to appear in glossy style magazines around the world. The author concludes that the advertising campaign offers a fascinating insight into how much time, money, energy, and "a kind of creepy corporate enthusiasm" goes into making people want something they do not need and shows exactly what public health professionals are up against. NIAAA Glossary Terms:  distilled alcoholic beverage, Brazil, United Kingdom, Netherlands, Italy, France, marketing strategy, AOD product advertising, advertising technique, positive advertising, targeted advertising, alcoholic beverage industry, public health, commentary

Carlos Martinez, Stephan Rietbrock, Lesley Wise, Deborah Ashby, Jonathan Chick, Jane Moseley, Stephen Evans, and David Gunnell.  Antidepressant treatment and the risk of fatal and non-fatal self harm in first episode depression: Nested case-control study.  British Medical Journal 330:330:389, February 19, 2005.

Summary: The risks of nonfatal self-harm and suicide in patients taking selective serotonin reuptake inhibitors (SSRIs) were compared with those risks in patients taking tricyclic antidepressants, as well as between different SSRIs and different tricyclic antidepressants, in a nested case-control study. The participants were 146,095 primary care patients with a first prescription of an antidepressant for depression. The main outcome measures were suicide (n = 69) and nonfatal self-harm (n = 1,968). The overall adjusted odds ratio (OR) of nonfatal self-harm was 0.99 (95% confidence interval [CI], 0.86-1.14) and that of suicide 0.57 (95% CI, 0.26-1.25) in people prescribed SSRIs compared with those prescribed tricyclic antidepressants. There was little evidence that associations differed over time since starting or stopping treatment. Some evidence was found that risks of nonfatal self-harm in people prescribed SSRIs, compared with those prescribed tricyclic antidepressants, differed by age group (interaction p = 0.02). The adjusted OR of nonfatal self-harm for people prescribed SSRIs, compared with users of tricylic antidepressants, for those aged 18 or younger was 1.59 (95% CI, 1.01-2.50), but no association was apparent in other age groups. The strongest predictors of nonfatal self-harm were a history of self harm, referral to a psychiatrist, alcohol abuse (OR = 3.58; 95% CI, 3.04-4.21) and drug abuse. The strongest predictors for suicide were a history of nonfatal self-harm, antipsychotic therapy, number of antidepressants prescribed in the previous year, alcohol abuse (OR = 2.31; 95% CI, 0.97-5.49), and referral to a psychiatrist. No suicides occurred in those aged 18 or younger currently or recently prescribed tricyclic antidepressants or SSRIs. In summary, there was no evidence that the risk of suicide or nonfatal self-harm in adults prescribed SSRIs was greater than in those prescribed tricyclic antidepressants, and some weak evidence of an increased risk of nonfatal self-harm for current SSRI use among those aged 18 or younger. However, preferential prescribing of SSRIs to patients at higher risk of suicidal behavior cannot be ruled out. NIAAA Glossary Terms:  suicide, suicidal behavior, risk analysis, risk factors, predictive factor, statistical estimation, AOD abuse, relative risk, antidepressants, emotional and psychiatric depression, serotonin uptake inhibitors, age differences, antipsychotic tranquilizers, psychiatric care, case-control study, primary care, human study

George Davey Smith.  Lifestyle, health, and health promotion in Nazi Germany.  British Medical Journal  329:1424-1425, December 18, 2004.

Summary: This article describes public health campaigns in Nazi Germany during the 1930s and 1940s, a time when several health-related behaviors came under scrutiny in that country, and examines whether the campaigns achieved any benefits. The first case-control study of smoking and lung cancer took place in Nazi Germany in 1939. It found that heavy smoking was strongly associated with lung cancer. Considerable official concern in Germany on the health damaging effects of smoking resulted in establishment of the Bureau against the Dangers of Alcohol and Tobacco in 1939 and the Institute for the Struggle against the Dangers of Tobacco at the University of Jena in 1942, where a second and highly convincing case-control study of smoking and lung cancer was carried out. The Institute was supported by 100,000 reichsmark of Adolf Hitler's personal finances. There was much antismoking health promotion in Nazi Germany. The Hitler Youth and the League of German Girls disseminated antismoking propaganda, and in 1939 Hermann Göring issued an order forbidding military personnel from smoking on the streets and during marches or brief off-duty periods. In 1942 the Federation of German Women launched a campaign against tobacco and alcohol misuse. Smoking was banned for both pupils and teachers in many schools. From July 1943, tobacco use was outlawed in public places for anyone younger than 18 years. It was considered criminal negligence if drivers were involved in crashes while smoking. In 1944, smoking was banned on trains and buses in cities and in many workplaces, public buildings, hospitals, and rest homes. The advertising of smoking products was strictly controlled, and there was discussion on whether people with smoking-related illnesses should receive medical care equal to that of patients with illnesses not seen as self-inflicted. Many leading Nazis, including Hitler, attested to the benefits of not smoking. As one magazine stated, "Brother national socialist, do you know that your Führer is against smoking and thinks that every German is responsible to the whole people for all his deeds and omissions, and does not have the right to damage his body with drugs?" There were also strong campaigns against alcohol consumption. Fruit and vegetable consumption was encouraged, as was the use of wholemeal bread and the avoidance of fat. There was considerable interest in the notion that a poor intrauterine environment would have long term deleterious effects on offspring. A 1942 health manual proclaimed "mothers, you must absolutely avoid alcohol and nicotine during pregnancy and when nursing. They hinder, they harm, they disrupt the normal course of pregnancy. Drink fruit juice." A public health film exhorted the German people that they "can and must maintain their health through a sensible lifestyle." There were clear links between the promotion of particular lifestyles and Nazi notions of "racial hygiene" that found expression in the death camps for Jews, homosexuals, and others. Tobacco and alcohol were considered "genetic poisons," leading to degeneration of the German people. Martin Gumpert, an émigré Jewish physician and campaigner against the Nazi regime, saw the lifestyle campaigns as a cover-up for the dramatic deterioration of health in Germany under the Nazis, and declared that the "abstinent Hitler, who from conviction never takes a drop of alcohol . . . now drives the people at whose head he stands into fatal alcoholism." NIAAA Glossary Terms:  Germany, health promotion, health related behavior, public policy on AOD, AOD use, heavy AOD use, AOD dependence, AOD abstinence, public AOD use, alcoholic beverage, tobacco in any form, smoking, nicotine, case-control study, risk analysis, cancer, lung disorder, lifestyle, diet, public health prevention model, advertising, prenatal care, prenatal alcohol exposure, racism, Jew, homosexual, homicide, historical overview

Barbara Kermode-Scott.  Drug misuse in Canada has increased in the past decade (News article).  British Medical Journal 329:1304, December 4, 2004.

Summary: A new population survey report, A National Survey of Canadians' Use of Alcohol and Other Drugs, finds that the prevalences of alcohol, cannabis, and other drugs use have increased in Canada in the past decade. This is the first major survey since 1994 on the use of alcohol and other drugs among Canadians aged 15 and older. The participants were a national sample of 13,909 Canadians who were interviewed by telephone between December 2003 and April 2004. The survey focused on the impact of alcohol and drug use on physical, mental, and social wellbeing. Overall, 45% of Canadians reported using cannabis at least once during their lifetime and 14% reported using it in the past year, nearly double the rate reported in 1994. Of the past-year users, almost 46% had not used cannabis or had used it only once or twice in the 3 months preceding the interview. However, 18% of past-year users reported daily use. Almost 30% of respondents 15-17 years old and more than 47% of  respondents 18-19 years old said they had used cannabis in the past year. Almost 70% of survey participants between ages 18 and 24 reported having used cannabis at least once. The prevalence of lifetime use of cannabis increased with education and income. People who had never been married were more likely to use cannabis. Michel Perron, chief executive officer of the Canadian Center on Substance Abuse, expressed concern over the rise in cannabis use, especially among young Canadians, saying that cannabis is not a benign substance and that a number of health risks are associated with its use. Note: The report (in PDF) is available at http://www.ccsa.ca/pdf/ccsa-004804-2004.pdf. NIAAA glossary:  AOD use, AOD use pattern, AOD use frequency, underage AOD use, adolescent, young adult, Canada, alcoholic beverage, marijuana in any form, underage AOD use, survey, interview, self-report, prevalence, physical health, mental health, social indicators, human study, report

Anonymous.  Girls binge on alcohol more than boys (News item).  British Medical Journal 329:1304, December 4, 2004.

Summary: A team from the European school survey on alcohol and drugs has found that, for the first time, more girls than boys in the United Kingdom binge on alcohol. Interviews with more than 2,000 pupils revealed that a third of 15 and 16 year old girls admitted at least one binge drinking experience in the last month, compared to a fourth of boys. NIAAA glossary:  binge AOD use, underage drinking, prevalence, gender differences, United Kingdom, survey, interview, human study

Raghav Chawla.  Regular drinking might explain the French paradox (News article).  British Medical Journal 329:1308, 4 December 2004.

Summary: Alcohol specialists meeting in London last week said It's safer to drink some alcohol every day of the week than drink the same amount on a weekend. Binge drinking, especially among younger people, can lead to traffic injuries, violence, and unwanted sex, and habitual binge drinking can lead to serious health problems, said Prof. Morten Grønbæk, director of the Center for Alcohol Research in Copenhagen, Denmark. Scientists and physicians have argued for more than a decade that moderate drinking protects against coronary heart disease (CHD), but a recent study (Addiction 99:323-330, 2004) that examined the effects of alcohol habits on longevity in a large sample (N = 57,000) of middle aged Danes found evidence suggesting that the pattern of drinking may be just as important as intake. Dr Janne Tolstrup, the principal author of the article, said that, for a given total level of alcohol intake, there is an increased risk of mortality for people who drink infrequently compared with those who drink frequently. Last year, researchers in Boston reported an important link between regular drinking and reduced risk of coronary heart disease (New England Journal of Medicine 348:109-118, 2003). Prof. Grønbæk said that article's main conclusion, in terms of cardiovascular disease, was that "it doesn’t really matter how much you drink as long as you drink regularly." Grønbæk warned, however, that this finding has to be put into perspective, because the cardiovascular benefits may be outweighed by the detrimental effects of a high alcohol intake. A link between binge drinking and blood pressure has been reported by researchers at Queen's University, Belfast, Northern Ireland, who found that the drinking patterns of Northern Irish men were entirely different from those of French men (Hypertension 38:1361-1366, 2001). Alun Evans, professor of epidemiology at Queen's University, told the British Medical Journal that in Belfast, 66% of alcohol was consumed on Fridays and Saturdays, whereas in France it was consumed evenly throughout the week. After adjusting for several potential confounders, Evans and his colleagues found that blood pressure was higher among Northern Irish drinkers on a Monday and decreased until Thursday, whereas the French drinkers’ blood pressure remained constant throughout the week. "The French pattern of drinking seems to afford cardioprotection, in contrast to the Northern Irish pattern," Evans concluded. Prof. Grønbæk said policy makers need to take account of this research on the growing problem of binge drinking, especially among young people, and focus prevention efforts more on a daily alcohol intake that should not be exceeded rather than on alcohol intake per week. NIAAA glossary:  binge AOD use, AOD intake per occasion, AODR mortality, AOD use pattern, AOD consumption, heavy AOD use, moderate AOD use, AOD use frequency, prevention of AODR problems, AODR injury, AODR disorder, public policy on AOD, coronary artery disorder, blood pressure, hypertensive disorder, cardiovascular disorder, cardiovascular deterioration, protective drug effect, protective factors, day of week, Northern Ireland, France, international differences, prevention of AODR problems, prevention approach, epidemiology, human study

Andrew Osborn.  Russia fails to ban drinking in public despite soaring alcoholism (News article).  British Medical Journal  329:1202, November 20, 2004.

Summary: The upper house of Russia's parliament -- the Federation Council -- has defeated a bill that would have banned drinking alcoholic beverages in stadiums, parks, schools, hospitals, public transport, and streets. The bill, which in part was aimed at reversing increasing alcoholism rates among children, had been overwhelmingly approved by the lower house. Beer, which sells for about US$0.74 a bottle, is treated almost like a soft drink in Russia and has replaced vodka as the alcoholic drink of choice among young Russians. Drinking on the streets has increased greatly since the collapse of the Soviet Union in 1991, and it is common to see commuters drinking beer in the morning as they ride in Moscow's subway trains, as well as to see children as young as 11 drinking beer with their friends after school. The bill also would have made the sale of beer to persons younger than 18 years illegal, with a fine of ~110 roubles (~US$3.72) for violation, and would have restricted beer advertising on television. Although the Russian parliament is increasingly eager to eliminate many of the excesses that have arisen during the past 13 years in Russian society, the Federation Council determined that the bill went too far. It is now expected that the bill's provisions banning drinking in public places will be eliminated and that provisions to combat alcoholism in children will be retained. NIAAA Glossary Terms:  legislation, legislative process, Russia, public AOD use, AOD dependence, prevalence, underage drinking, beer, fine, AOD product advertising, product advertising regulation, television, AOD price, minimum drinking age, societal AODR problems, U.S.S.R., transportation industry, report

Henry O'Connell, Ai-Vyrn Chin, Conal Cunningham, and Brian A Lawlor.  Recent developments: Suicide in older people.  British Medical Journal 329:895-899, October 16, 2004.

Summary: The authors outline the epidemiology and causal factors (psychological, physical, and social) associated with suicidal behavior in elderly people and summarize the current measures for prevention and management of this neglected phenomenon. Alcohol, among other factors, plays a role in suicides among the elderly. Major depressive disorder has been found to be more common in completed suicides among older people than among younger counterparts and may affect as many as 83% of elderly suicides. The prevalence of completed suicide is, however, relatively low among elderly people with primary psychotic illnesses, personality disorders, anxiety disorders, and alcohol and other substance use disorders. Psychological autopsy studies of elderly suicide victims found that 71-95% had a major psychiatric disorder at the time of death. In the only prospective, non-clinical cohort study of older people to date in which completed suicide was the outcome, self-rated severity of depressive symptoms was the strongest predictor of suicide. Elderly people in the poorest summary score category were 23 times more likely to commit suicide than those with the least depressive symptoms. Other important psychological factors included was found in 35% of elderly men and 18% of elderly women who had committed suicide, with corresponding rates in controls of only 2% and 1%. Physical factors including having more than three physical illnesses and a history of peptic ulcer disease in a population sample of community dwelling residents aged over 85 years predicted increased suicidal feelings. Physical health and disability seem to be associated independently of depression with the "wish to die." This death wish was also associated with the highest comorbidity in a large sample of older patients attending their general practitioner for depression, anxiety, and drinking more than three units of alcohol a day and sleeping 9 or more hours at night. These results have limited generalizability, however, because the people were living in a retirement community. A recent retrospective case-control study found that alcohol use disorders predicted suicide in older people. A history of alcohol dependence or misuseat risk alcohol use. Although several social factors associated with suicide in the elderly cannot be modified, they may give clues to the underlying biological processes involved in suicidal ideation and behavior. For example, the increased vulnerability of elderly men to bereavement and physical illness may be mediated by relatively higher levels of cerebrovascular disease and alcohol use disorders compared with elderly women. NIAAA Glossary Terms: suicide, suicidal ideation, suicidal behavior, risk factors, predictive factors, AOD dependence, AOD abuse, AOD consumption, patient AODU history, alcohol use disorder in the elderly, problematic AOD use, retired, case-control study, prospective study, physical health,  emotional and psychiatric depression, physical disability, anxiety, peptic ulcer, prevalence, literature review, human study, epidemiology

Tiia Anttila, Eeva-Liisa Helkala, Matti Viitanen, Ingemar Kåreholt, Laura Fratiglioni, Bengt Winblad, Hilkka Soininen, Jaakko Tuomilehto, Aulikki Nissinen, and Miia Kivipelto.  Alcohol drinking in middle age and subsequent risk of mild cognitive impairment and dementia in old age: a prospective population based study.  British Medical Journal  329:539, September 2004.

Summary: A prospective population-based study was undertaken in the cities of Kuopio and Joensuu, eastern Finland, to evaluate the relation between midlife and mild cognitive impairment and dementia in old age, and the possible modification of this relation by apolipoprotein E. The participants were 1,464 men and women 65-79 years old who were randomly selected from population-based samples studied in 1972 or 1977. Seventy percent of the original sample (n = 1,018) were re-examined in 1998 (the average follow-up period was 23 years) to determine mild cognitive impairment and dementia in old age. Participants who abstained from alcohol in midlife and those who alcohol consumptiondrank alcohol frequently were both twice as likely to have mild cognitive impairment in old age compared to participants who drank alcohol infrequently. The presence of the apolipoprotein e4 allelle modified the risk of dementia related to alcohol drinking, increasing the risk of dementia with increasing alcohol consumption. Compared with non-carriers who never drank, the odds ratio was 0.6 for carriers who never drank, 2.3 for infrequent drinkers, and 3.6 for frequent drinkers. The overall interaction term "drinking frequency*apolipoprotein e4" was significant (p = 0.04), as were the interactions "infrequent drinking*apolipoprotein e4" (p = 0.02) and "frequent drinking*apolipoprotein e4" (p = 0.03). Non-carriers of apolipoprotein e4 had similar odds ratios for dementia irrespective of alcohol consumption. In summary, alcohol drinking in middle age showed a U-shaped relation with risk of mild cognitive impairment in old age, and risk of dementia increased with increasing alcohol consumption only in individuals carrying the apolipoprotein e4 allele. NIAAA Glossary Terms:  AOD consumption, AOD use pattern, AOD use frequency, AOD nonuse, apolipoproteins, allele, risk analysis, relative risk, odds ratio, dose-response relationship, dementia, cognitive and memory disorder, elderly, middle-aged adult, human study

Jane Burgermeister.  French wine makers face legal action over birth defects (News article).  British Medical Journal 329:368, August 2004.

Summary: State prosecutors in Lille, France, are investigating possible legal action against alcoholic beverage manufacturers for failing to warn pregnant women about the risk of birth defects in children who are exposed prenatally to alcohol. The investigation was opened in response to complaints from three mothers in Roubaix, just north of Lille, whose children were born with fetal alcohol syndrome (FAS), an irreversible condition characterized by physical abnormalities, mental impairment, and behavioral problems. An estimated 0.3% of the 700,000 babies born each year in France have FAS. The inquiry could lead to manufacturers facing charges of placing the lives of others at risk, trying to mislead consumers, and wounding without intent. Benoit Titran, the lawyer representing the three mothers, said alcoholic beverage manufacturers have not done enough to inform pregnant women about the risks of drinking, despite evidence showing that a fetus can be harmed by even moderate maternal drinking, and despite the manufacturers own knowledge of the risks of prenatal alcohol exposure. Mr. Titran, whose father is a pediatrician at Roubaix Hospital and a specialist in FAS, claimed that two glasses a day or a peak consumption of five glasses in an evening are sufficient to cause FAS and that even if signs of the syndrome are not immediately apparent, they will show up later as learning problems. He called for prominent warning labels on alcoholic beverage containers about the risks of drinking during pregnancy and noted that bottles of French wine exported to the United States already have such warnings, as required by U.S. law. Mr Titran said that the Lille inquiry was only the first step, and that many other measures are needed to warn women about the risks of drinking during pregnancy. The French minister of health, Philippe Douste-Blazy, has said that he will press for the introduction of warnings about the effects of alcohol during pregnancy. NIAAA Glossary Terms:  France, fetal alcohol syndrome, prenatal alcohol exposure, pregnancy outcome, birth defects, AODR mental disorder, behavioral and mental disorder, developmental disorder, alcohol-related neurodevelopmental disorder, mental retardation, warning label, legal liability, alcoholic beverage industry, wine, United States, report

Susan Mayor.  Researcher objects to drinks industry representative sitting on alcohol research body (News article).  British Medical Journal  329:71, July 2004.

Summary: Prof. Robin Room, an alcohol researcher at the University of Stockholm and director of the Center for Social Research on Alcohol and Drugs in Stockholm, has criticized the appointment of Jean Coussins to the United Kingdom’s Alcohol Education and Research Council (AERC) because he fears a potential conflict of interest. Ms. Coussins is CEO of the Portman Group, which was established in 1989 by UK alcoholic beverage producers mainly to promote responsible drinking. Ms. Coussins was appointed by the secretary of state for culture, the government department that oversees the AERC's work. The AERC's aims are to increase awareness of alcohol issues, reduce alcohol-related harm in society, and encourage best practice. To achieve these aims, it funds research, education, and training for people working on alcohol-related issues. The AERC was established in 1982 to administer the Alcohol Education and Research Fund, a charitable foundation established with assets from a levy on pubs that was originally designed to compensate owners who lost their licenses because of a decision early in the 20th century to reduce the number of pubs. Because of this source of the money, three members of AERC's board have always been nominated by the alcoholic beverage industry, an arrangement Room says has seemed unproblematic. However, Room believes the appointment of Ms Coussins — who replaces one of the current industry representatives — is a potential problem because of the Portman Group’s lobbying role and previous stance on alcohol research. He noted that the group had been exposed in 1995 for offering money to scholars for negative views on a WHO report, Alcohol Policy and the Public Good. Room added that the AERC's reputation and its ability to function as a scientific funding agency acting in the public interest would be severely compromised if Coussins remains on its board. Griffith Edwards, emeritus professor of addiction at the Institute of Psychiatry, London, and editor of Addiction, agreed, saying that Coussins represents a group "committed to traducing science" that has lobbied government intensively on behalf of the alcoholic beverage industry, arguing that the problem is drunkenness, not drinking. Edwards said the Portman Group has "advocated education, which doesn’t work, and voluntary codes of practice, which are difficult to enforce. They have also put out grossly misleading statements saying that there is no scientific evidence for a public health approach to alcohol use." Dr. Noel Olsen, the AERC's chairman, said discussions on the issue will take place over the next few months between the council and relevant government departments and alcohol organizations to determine whether it is right for industry to have seats on the council, and whether the Portman Group's representation on the council is appropriate. Olsen added that the UK government "rightly or wrongly, has decided that their alcohol strategy will be a partnership between industry, government, and alcohol organizations." The Portman Group said on its website that it is a principal provider of responsible drinking advice in the UK and supports the government, media, industry, and consumers with research, educational materials, and campaigns. (Jean Coussins responded in a letter to the editor. See next record.) NIAAA Glossary Terms:  advocacy, conflict, moderate AOD use, societal attitude toward AOD, alcoholic beverage industry, government agency, United Kingdom, prevention through education, public health prevention model, voluntary participation, public-private cooperative prevention

Jean Coussins.  The Portman Group does not represent alcohol industry (Letter to the editor).  British Medical Journal  2004;329:404,  August 2004.

Summary: In a letter to the editor, Ms. Jean Coussins,  chief executive of the Portman Group, responds to Professor Robin Room's objection to her appointment to the United Kingdom’s Alcohol Education and Research Council (AERC) and his concern about a potential conflict of interest (see the previous record). Ms. Coussins makes five arguments: (1) The Portman Group is not a trade association or lobby group, does not represent the alcohol industry, and has no commercial purpose. Its role is to promote responsible drinking by consumers and responsible marketing by producers. (2) Ms. Coussins was not nominated to the AERC by the alcohol industry or any organization related to it. She was invited to apply by the Department for Culture, Media and Sport (DCMS) and does not occupy one of the three places on the AERC that are traditionally reserved for industry nominees. This was made abundantly clear in discussions with the DCMS and the AERC's chairman. (3) No concern was registered by Prof. Room or any other alcohol researcher when one of the industry representatives on the AERC was also the chairman of the Portman Group for two of the years he served on the Council, which makes Prof. Room's concern about the Portman Group's chief executive puzzling. (4) The Portman Group has co-funded a number of research projects with the AERC and at the AERC's invitation, again without any apparent cause for concern. (5) All members of the AERC are appointed as individuals and are committed as trustees to upholding the Council's independence and integrity. Ms. Coussins declares that she fully intends to do this, whatever the source of any pressure. NIAAA Glossary Terms:  letter to the editor, conflict, harm reduction, moderate AOD use, research funding, public-private cooperative prevention

Rebecca Coombes.  Ads: The new tobacco? (News article).  British Medical Journal  328:1572, June 2004.

Summary: Success in banning tobacco advertising in the United Kingdom has encouraged campaigners to take on advertising of other products — notably "junk food," alcohol, and cars. Alcohol, as well as fatty food, is regularly being referred to as "the new tobacco" in the advertising trade press. The Advertising Association has voluntarily offered to tighten regulations governing the advertising of alcohol in the wake of public concern about binge drinking and an associated rise in weekend urban violence. But there is disagreement in the advertising industry on how to respond -- whether to accept that restrictions are inevitable or try to head off onerous restrictions by engaging in "serious and constructive" dialogue with the government on such matters as dissociating sex and alcohol in advertising that might appeal to adolescents. The British Medical Association has been the most prominent body to call for a ban on alcohol advertising, but Andrew Brown, director general of the Advertising Association, calls the BMA's arguments "a standard response" with little evidence to support them. "If you look at the expenditure figures in advertising," said Brown, "the heaviest area is in beers and spirits, but these sections are in decline. The least is spent in the area of white wine, but this is the area showing growth. The debate has raged about alcopops, but these products are in a big sales decline; it is a fashion that has had its day."  A spokesman for the pressure group Sustain dismissed industry claims of working in partnership with the government to improve health, saying the industry has done nothing. "I think they are canny and know the pressure won't just go away," he said, "but they will fight tooth and nail. They strongly deny they are part of the problem, so how can they be part of the solution?" NIAAA Glossary Terms:  advertising, advertising effect, advertising technique, targeted advertising, binge AOD use, alcoholic beverage industry, beer, distilled alcoholic beverage, white wine, lobbying, advocacy, trend, tobacco in any form

George J Addis.  Alcohol evidence and policy: Decimalise measure of alcohol (Letter to the editor).  British Medical Journal,  328:1203, May 2004.

Summary: A letter to the editor comments on an editorial (British Medical Journal harm reduction strategy for England. The author argues that expressing alcohol intake as " 328:905-906, April 2004) about the alcoholunits of alcohol" was really intended to suit imperial measure, and is too complex and vague to be of any practical use to drinkers. He believes that most people could manage the concept of actual milliliters of alcohol in each glass and keep a running total. Ideally, a simple pharmacokinetic chart could be provided linking milliliters consumed, body mass index, and liver function to failing a breath analysis test. NIAAA Glossary Terms:  letter to the editor, advocacy, harm reduction policy, AOD intake per occasion, measure of AOD volume and strength, ethanol, alcoholic beverage, product label, standard drink, pharmacokinetics, body mass index, breath alcohol analysis

Neil Pearce, Sunia Foliaki, Andrew Sporle, and Chris Cunningham.  Genetics, race, ethnicity, and health.  British Medical Journal  328:1070-1072, May 2004.

Summary: The authors of this article argue that the common assumption that ethnic or racial differences in health have genetic causes is based on confusion between genetics, race, and ethnicity. A common misconception is that the phenotype is determined by the genotype. Although genetic factors do have a large influence on health, people develop throughout their lives through constant interaction between their genes and the environment. This means that except for a few rare diseases, such as cystic fibrosis, Duchenne's muscular dystrophy, and Huntington's disease, diseases are not purely hereditary even if they are genetic. It is often assumed that diseases are genetic because they run in families, but this often reflects a common environment and lifestyle rather than a genetic influence. Race is commonly defined in terms of biological differences between groups that are assumed to be genetic, but human races have never been pure, and little human genetic variation is explained by race. Only 7 percent of all human genetic variation lies on the average between major human races. Although there are genetic differences between races, very few differences have been found that directly relate to health. For example, a New Zealand alcoholism study found that the alcohol dehydrogenase 2-2 (ADH2-2) gene, which is believed to protect against alcoholism, was relatively common in Maori people but was absent in New Zealand Europeans. Yet alcohol-related health problems are more common among the Maori, which suggests that social, economic, cultural, and political factors outweigh the hypothesized protective genetic factor. The fact that racial categorization based on genetic criteria is inaccurate and misleading changes interpretation of the causes of high mortality and morbidity in indigenous peoples, which primarily relate to issues of ethnicity, rather than of race or genetics. The construct of ethnicity includes biology, history, cultural orientation and practice, language, religion, and lifestyle, all of which can affect health. The lack of major systematic genetic differences between ethnic groups, together with the extensive differences in lifestyle (diet, alcohol, housing, smoking, etc), means that ethnic differences in mortality and morbidity to some extent provide evidence against the importance of genetic factors and for the importance of environmental factors such as access to health care. NIAAA Glossary Terms:  racial differences, ethnic differences, hereditary vs environmental factors, gene, alcohol dehydrogenases, morbidity, mortality, AOD dependence, genetic theory of AODU, AODR disorder, AODR mortality, physical health, lifestyle, diet, ethanol, housing, smoking, health care availability and access, sociocultural norms, history, language, spirituality and religion, lifestyle, literature review

Serge P Marinkovic, Lisa M Gillen, and Stuart L Stanton.  Managing nocturia.  British Medical Journal 328:1063-1066, May 2004.

Summary: Management of nocturia (frequent urination at night time) is reviewed. The authors searched Medline for 1980-2003 using the key words "nocturia" and "nocturnal polyuria" and selected 22 references. Though common, nocturia has received little attention in the medical literature. With no accepted distinction between normal and abnormal urination, physicians tend to overlook nocturia as a possible source of medical problems associated with resultant loss of sleep. Patients tend not to report the condition to their doctors until it becomes unbearable or their quality of life during daytime hours is severely compromised. Nocturia contributes to fatigue, memory deficits, depression, increased risk of heart disease, and gastrointestinal disorders, as well as traumatic injury through falls. The review covers causes, effects, patient assessment, nocturnal polyuria, low nocturnal bladder capacity, and treatment options. Multiple factors may cause nocturia in both men and women, including behavioral patterns, diuretic medications, caffeine, alcohol, or excessive fluids before bedtime, and pathological conditions such as prostatic disease, diabetes mellitus or diabetes insipidus, lower urinary tract obstruction, anxiety, or sleep disorders. Nocturia may also result from stroke, cardiovascular disease, peripheral edema, and myeloneuropathy. In general older people, especially those 65 or older, are affected more than younger adults. Many people with nocturia, especially elderly men, also experience concomitant lower urinary tract problems such as frequency, urgency, weak stream, and incontinence, which are symptoms often attributed to benign prostatic obstruction. Age, childbirth, and menopause are often suggested to contribute to nocturia in women. NIAAA Glossary Terms:  urinary system disorder, urination, sleep disorder, behavior, diuretics, caffeine, ethanol, prostate, diabetes, anxiety, stroke, cardiovascular disorder, edema, myelin sheath, neuropathy, aging, childbirth, menopause, literature review

Martin Plant.  The alcohol harm reduction strategy for England (Editorial).  British Medical Journal 328:905-906, April 2004.

Summary: This editorial critically reviews a report from the prime minister's strategy unit on dealing with increasing alcohol problems in England. The author's criticisms include the following: (1) Although an interim report had much to commend it, the final document has been neutered on issues such as sex, children of problem drinkers, and pregnancy. (2) The report focuses on harm minimization, which seems to accept the current high level of alcohol problems rather than setting out to reduce them substantially. (3) The report states that "There is no direct correlation between drinking and the harm experienced or caused by individuals," an assertion that is contradicted by a vast literature. (4) Much of the report is hard to read and contains many ambiguous or misleading statements. (5) The report's strategy for England is based on the four elements of education and communication, identification and treatment, alcohol-related crime and disorder, and supply and industry responsibility, but given the poor record of education and communication, as the interim report stated more clearly, they should be treated as purely experimental and not as an effective or major arm of policy. (6) The biggest single part of the strategy document is devoted to crime and disorder, and although though some useful initiatives are cited, too much is left to voluntary discretion whereas mandatory and evaluated local action programs would be much better. (7) The section on treatment is written as if evidence is sparse whereas the international literature on effectiveness of treatment is extensive. (8) Action to be carried out in cooperation with the beverage alcohol industry is logical and necessary, but much of what is set out is based on encouraging the industry to adopt better practices on issues such as advertising and cheap drink promotions; these steps are needed, but they should rapidly become mandatory if full compliance is lacking. (9) While it is apparent that big increases in the price of alcohol are not politically realistic, this does not justify the report's curt dismissal of the possible role of taxation to prevent the future rise of alcohol consumption and its associated problems. NIAAA Glossary Terms:  harm reduction policy, United Kingdom, AOD consumption, societal AODR problems, AODR interpersonal and societal problems, AODR crime, AODR disorder, alcoholic beverage industry, public-private cooperative prevention, advertising, marketing strategy, AOD price, sales and excise tax

Jenny Shaw, Tim Amos, Isabelle M Hunt, Sandra Flynn, Pauline Turnbull, Navneet Kapur, and Louis Appleby.  Mental illness in people who kill strangers: Longitudinal study and national clinical survey.  British Medical Journal  328:734-737, March 2004.

Summary: A longitudinal study and a national clinical survey were carried out to establish changes over time in the frequency of homicides committed by strangers and to describe the personal and clinical characteristics of perpetrators of stranger homicides. The participants were people convicted of homicide in England and Wales between 1996 and 1999. Stranger homicides increased between 1967 and 1997, both in number and as a proportion of all homicides, but no increase was found in the number of perpetrators placed under a hospital order after homicide, whether all homicides or stranger homicides only. Twenty-two percent (358 of 1,594) of homicides were stranger homicides. The perpetrators In these cases were more likely to be male and young. The method of killing victims who were strangers to the perpetrator was more likely to be by hitting, kicking, or pushing (36%; 130 of 358, compared with 14%; 145 of 1,074, for victims who were known). Perpetrators were less likely to have a history of mental disorder (34%, n = 80 {nu} 50%, n = 142), a history of contact with mental health services (16%, 37 of 234 {nu} 24%, 200 of 824), and psychiatric symptoms at the time of the offence (6%, n = 14 {nu} 18%, n = 143). They were more likely to have a history of drug misuse (47%, n = 93 {nu} 37%, n = 272); alcohol (56%, n = 94 {nu} 41%, n = 285) or drugs (24% n = 44 {nu} 12%, n = 86) were more likely to have contributed to the offense. In conclusion, stranger homicides have increased in England and Wales, but the increase is not the result of homicides by mentally ill people and therefore cannot be attributed to the "care in the community" policy. Stranger homicides are more likely to be related to alcohol or drug misuse by young men. NIAAA Glossary Terms:  homicide, England, Wales, risk factors, friend, mentally ill, gende