title: Liver cirrhosis mortality, alcohol consumption and tobacco consumption over a 62 year period in a high alcohol consumption country: a trend analysis.
abstract: BACKGROUND
  The relationship between alcohol consumption and liver cirrhosis mortality has been revealed by data from several different countries. However, the impact of tobacco smoking on liver cirrhosis has not been considered. The aim of this study was to estimate trends in liver cirrhosis mortality and alcohol and tobacco consumption from 1952 to 2013 as well as more recent trends in substance use disorder treatments and hospital treatments of liver diseases in Germany.
  
  
  METHODS
  Data from the National Statistics Office were used. Liver cirrhosis was diagnosed according to the International Classification of Diseases (ICD-6 to ICD-10). Alcohol beverages and tobacco products were estimated according to tax or governmental data. Substance use disorder treatment and hospital treatment data were used. Trends were calculated using Joinpoint regression analyses.
  
  
  RESULTS
  Liver cirrhosis mortality among men increased annually by 8.4% from 1952 to 1960 and increased annually by 2.8% from 1961 to 1976. From 1976 to 1982, liver cirrhosis mortality decreased annually by 4.8%, from 1982 to 2013 liver cirrhosis mortality decreased annually by 1.2%. Among females, liver cirrhosis mortality increased annually by 8.9% from 1952 to 1959 and by 4.3% from 1959 to 1968, but then decreased 1.0% annually from 1968 to 1995. After 1995, liver cirrhosis mortality decreased 1.9% annually through 2013. These reductions in liver cirrhosis mortality were accompanied by decreases in alcohol consumption beginning in 1976. These findings were also accompanied by decreases in the consumption of cigarette equivalents since 1971. Meanwhile, the number of substance use disorder treatments and hospital treatments of liver diseases increased.
  
  
  CONCLUSIONS
  The decrease in liver cirrhosis mortality may have been caused by a decrease in alcohol drinking and tobacco smoking. Smoking may have exerted indirect effects via alcohol consumption as well as direct effects. These trends existed despite largely missing preventive efforts to reduce alcohol consumption and tobacco smoking. Increases in educational attainment in the general population may have contributed to the reductions in alcohol and tobacco consumption. Convincing evidence that the increased provision of substance use disorder treatment significantly contributed to the decrease of liver cirrhosis was not found.
authors.affiliation: Institute of Social Medicine and Prevention, University Medicine Greifswald, Walther-Rathenau-Str. 48, 17475, Greifswald, Germany. ujohn@uni-greifswald.de.
authors.forename: Ulrich
authors.initials: U
authors.lastname: John
authors.affiliation: Institute of Social Medicine and Prevention, University Medicine Greifswald, Walther-Rathenau-Str. 48, 17475, Greifswald, Germany. hanke@uni-greifswald.de.
authors.forename: Monika
authors.initials: M
authors.lastname: Hanke
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000428:Alcohol Drinking / Q000009:adverse effects / Q000453:epidemiology; D005260:Female; D005858:Germany / Q000453:epidemiology; D006801:Humans; D008103:Liver Cirrhosis / Q000209:etiology / Q000401:mortality*; D008297:Male; D008875:Middle Aged; D012907:Smoking / Q000009:adverse effects / Q000453:epidemiology; D019966:Substance-Related Disorders / Q000150:complications / Q000453:epidemiology; D013997:Time Factors; D064424:Tobacco Use / Q000009:adverse effects / Q000453:epidemiology; D055815:Young Adult