Alcohol policy in adolescence and subsequent alcohol-attributable hospitalizations and mortality at ages 21-54 years – A register-based cohort study
Original article
Context
Early initiation of alcohol use is a powerful predictor of later use in terms of quantity consumed and adverse alcohol consumption habits adopted. In particular heavy alcohol use in adolescence may disrupt brain development and create fertile ground for substance use disorders.
Thus one could consider alcohol policies that target youth consumption to be especially effective in
reducing alcohol-related harm. However the evidence of how exposure to alcohol policies in youth particularly in adolescence when alcohol use is often initiated may shape health in the long-term is scarce.
Stringent alcohol policy environments in the US, Canada, Australia, and Europe have been linked with both less alcohol use and less high-risk alcohol consumption patterns for youth.
But causal inference from cross-sectional studies assessing links between alcohol policies and
alcohol consumption in between-country and other area comparisons is difficult since both
policies and consumption can reflect long-standing cultural factors and attitudes related to
alcohol consumption.
In this sense studies focusing on changing policies can provide more reliable information on policy impacts.
Overall evidence on the short-term impact of changes in alcohol prices and advertising on current alcohol use among youth is unclear or modest perhaps due to the known difficulties in obtaining a reliable measurement of alcohol consumption related to reporting bias and nonresponse in surveys. Moreover as alcohol-related chronic diseases take years to develop and thus tend to occur only at later ages a longer perspective in assessing the impact of alcohol policies experienced in youth is warranted.
Currently evidence on how alcohol policies experienced in youth may be associated with long-term health outcomes is scarce and limited to studies assessing changes in minimum legal alcohol consumption age. These studies have provided comprehensive evidence on how being legally able to purchase alcohol at younger ages is linked with increased rates of later adulthood binge alcohol use as well as increased chronic alcohol-attributable morbidity and mortality rates even decades later.
Besides these few studies on legal alcohol consumption age there have been no efforts to assess how exposure to different alcohol policies in youth is associated with long-term health outcomes.
This study aims to fill this gap in research by means of a 3-decade follow-up among cohorts exposed to either more down-scaled (worsened) or up-scaled (improved) alcohol policies in their adolescence.
Finland’s Alcohol Policy Environment
In 1969 the Finnish alcohol policy reform worsened (down-scaled) numerous previously evidence-based, effective alcohol policies, including a lowering of the minimum legal alcohol consumption age from 21 to 18 and abolishing limits on alcohol sales in rural regions.
Consequently per capita alcohol consumption grew rapidly in the following years.
To remedy this worsening situation with ever-increasing alcohol consumption that followed these changes of down-scaling alcohol policy, the Finnish government introduced alcohol tax increases and a total alcohol advertising ban.
- The government increased the alcohol tax by 28.5% in 1975 with a further 6.1% increase in 1976.
- The advertising ban of 1977 was near-total, exempting advertising in government monopoly stores, bars and restaurants, and professional publications aimed for the hospitality industry. All other forms of advertisement were forbidden including product placements.
However because of rampant inflation in 1975 and government sluggishness to allow the Finnish alcohol monopoly to further raise their prices after the initial increase, the target price level was only reached from the start of 1976. By 1977 the per capita alcohol consumption stabilised for ten years.
Afterwards there were no major alcohol policy changes until Finland joined the European Union in 1995.
Meaning and Conclusions
Using Finnish population register data, the researchers assessed how age of exposure to up-scaled alcohol policies was linked with later-life alcohol-attributable hospitalizations and mortality and
external-cause mortality up to the age of 54 years.
The premise was that being exposed to more expensive alcohol and less alcohol advertising at an earlier age would be beneficial for later health outcomes.
For men below the legal alcohol consumption age when the up-scaled alcohol policies were implemented, all of the studied outcomes (see box to the right) decreased cohort by cohort.
Conversely, alcohol-attributable harms were on a stably higher level for the earlier cohorts who were aged 19 to 25 years at the time of the reform and more likely to have already initiated alcohol use.
For women the results were less conclusive due to the outcomes being rare at ages 21–54 albeit
a similar decline in the hazards of alcohol-attributable harm and external-cause mortality could be observed as with men.
As alcohol-related health harms further increase by age, a prolonged follow-up period could yield more robust associations as shown by a study assessing an earlier change in the Finnish minimum legal alcohol consumption age.
The observed changes in alcohol-attributable and external-cause mortality trends appear to be independent from the general trend of linearly declining other-cause mortality.
This makes the stringent policy changes a plausible driver of this development.
The Outcomes the researchers studied
The alcohol-attributable causes of death and hospitalizations included diseases that were directly linked to alcohol, such as alcoholic liver cirrhosis or alcoholic pancreatic diseases, mental and behavioral conditions affected by alcohol use such as alcohol use disorder and addiction, and accidental alcohol poisoning.
Nearly all deaths and 97.8% of the hospitalizations in the study’s data are chronic alcohol-attributable illnesses.
The alcohol-attributable deaths were identified with the underlying cause of death and the alcohol-attributable hospitalizations were identified using both primary and secondary diagnoses according to data availability for the whole observation period.
The external-cause mortality development also supports the policy inference since alcohol has been strongly linked with accidents, violent victimization, and self-harm in Finland.
Alcohol policies experienced in adolescence are crucial in determining later-life health.”
Luukkonen J, Einiö E, Tarkiainen L, Martikainen P, Remes H. Alcohol policy in adolescence and subsequent alcohol-attributable hospitalizations and mortality at ages 21-54 years – A register-based cohort study. Epidemiology. 2025 Apr 4. doi: 10.1097/EDE.0000000000001857. Epub ahead of print. PMID: 40185681.
For men, there were no notable differences between the cohorts who were over 18 years old
when the up-scaled alcohol policies took place which could suggest that despite their still young age the improved alcohol policies had no impact on those who had reached the legal alcohol consumption age before the reform.
The incremental decline in the cohort-wise alcohol-attributable harm after the policy change suggests that exposure to improved alcohol policies already matters for persons who are below the legal alcohol consumption age. In fact, the researchers estimated the policies to be more effective the younger the persons were at the time of reform – consistent with the hypothesis that alcohol exposure at younger ages could be more detrimental.
However the cohort comparison cannot distinguish between the potential roles between age of exposure or cumulative amount of exposure to up-scaled alcohol policies but age of exposure does seem to play a role as the researchers observed stable risks for alcohol-attributable harm for the cohorts who were legal adults by the time of the reform.
Survey-based alcohol consumption habit studies corroborate the study’s findings in showing changing alcohol consumption bheaviour among young people in the 1970s and early 1980s. The proportion of abstainers among people aged 15-29 years old notably increased from 1976 to 1984 and the share of minors consuming alcohol at least once per month was notably less frequent in 1979 than 1973.
The study results support the hypothesis that alcohol policies experienced in adolescence are
potentially crucial in determining later-life health – a finding in line with prior evidence of
adolescence being an especially vulnerable period for initiating addictive behaviours.
As compared to other studies assessing associations with minimum legal alcohol consumption age and long-term alcohol-related health outcomes, the results are similar in that up-scaled alcohol policies around the time of reaching the legal alcohol consumption age were protective from later-life alcohol-attributable harm.
Same Is True For Earlier Cohorts
To further show how the earlier down-scaling of Finnish alcohol policies was linked with the
later health of adolescents exposed to them, the researchers expanded the inspection to birth cohorts 1944–1964 whom the researchers followed up between ages 27 to 54.
They show effects of the 1969 down-scaling of alcohol policies and the improved (up-scaled) alcohol policies from 1975 onwards. The findings demonstrate that better alcohol policies at the time of adolescence were linked with less alcohol-attributable harm, which is observable for both the earliest cohorts who were already adults when the down-scaled reform of 1969 was implemented and for the most recent cohorts who were exposed to the later up-scaled alcohol policies.
Strength and significance of the findings
Given the difficulties in measuring alcohol consumption in adolescence and that alcohol’s health harm tends to occur at later ages, a longer perspective in assessing their impact is warranted.
With the total population data used in this study that covers several decades of reliable outcome data, the researchers have estimated such long-term links.
The incremental cohort-wise decline in alcohol-attributable harm for the cohorts exposed to the
more up-scaled alcohol policy environment in adolescence is solid descriptive evidence.
In general studies about policy changes can provide the most valuable evidence of how the
policies work in practice.
The researchers assessed how age of exposure to up-scaled (improved) alcohol policies in the
form of tax increases and alcohol advertising ban was linked with later-life alcohol-attributable
health outcomes up to the age of 54 years.
The findings show that more up-scale (improved) alcohol policies at vulnerable ages were associated with decreased long-term alcohol-attributable hospitalizations and mortality, as well as with mortality due to external causes.
While the results were more robust among men, similar estimates of decreases in alcohol-attributable harm and external-cause mortality were also observed among women.
The results are consistent with the hypothesis that alcohol policies experienced in adolescence may leave a permanent imprint on alcohol consumption patterns and have substantial health implications in adulthood.
Abstract
Background
Little is known about how alcohol policies experienced in adolescence are associated with later health.
The researchers assess whether age of exposure to up-scaled alcohol policies is linked with later alcohol-attributable hospitalizations and mortality. The researchers take advantage of an alcohol advertising ban and alcohol tax increases introduced in 1975–1977 with relatively stable alcohol policies before and after.
Methods
The researchers used Finnish register data on birth cohorts 1950–1964 (1,175,878 individuals) to assess cohort-wise hazard ratios for the first incidence of alcohol-attributable hospitalization and mortality, and mortality due to external and other causes at ages 21–54 years.
Results
Men who were aged 19 to 25 at the time of the up-scaled alcohol policy reform had similar risks for alcohol-attributable hospitalization and mortality to the reference group of those aged 18 – legal minimum age for alcohol consumption – at the time of reform.
For those underage at the time, hospitalization and mortality rates were incrementally smaller cohort by cohort. For example, men who were 17 at the time of the reform had lower hazard ratios of alcohol-attributable hospitalization [0.91] as did those who were 13 [0.85].
The findings were similar for external-cause mortality, and similar yet more uncertain for women. In contrast, mortality from other causes declined continuously from cohort to cohort.
Conclusions
The study findings are consistent with the hypothesis that up-scaled alcohol policies in adolescence reduce high-risk alcohol consumption patterns extending into adulthood and manifesting as lower alcohol-related harm to health.