The avoidable costs of alcohol abuse in Australia and the potential benefits of effective policies to reduce the social costs of alcohol
4.1 The Arcadian Normals
The Arcadian Normal approach, which is identified as a possible tool for analysis in the Health Canada avoidable cost guidelines, examines best outcomes in comparable countries as an indication of what potentially could be achieved in Australia.
We have been fortunate in this study to be able to use background research undertaken by Dr Jürgen Rehm and his team for a concurrent alcohol avoidable costs study in Canada (Rehm et al., forthcoming). The Canadian study makes a comparison between rates of mortality and years of life lost (YLL) for various causes of death which epidemiological evidence shows to be causally linked, in part or fully, to the consumption of alcohol. The countries chosen for comparison purposes were within plus or minus ten per cent of the Gross Domestic Product Purchasing Power Parity per capita 2002 of Canada. These countries were Australia, Austria, Belgium, Denmark, Finland, France, Germany, Iceland, Italy, Japan, Netherlands, Sweden and the United Kingdom, together with the United States.
To correct for inter-national differences in population age structures, age-standardised mortality rates (SMR) were calculated. As the Rehm study includes Australia as one of the comparator countries, these data could be used in the Australian calculations.
Alcohol has characteristics not shared to any significant extent by tobacco or illicit drugs. Some of its attributable fractions are negative—that is for some health conditions alcohol, when consumed appropriately, can have protective effects. In relation to these conditions (in the Rehm et al. study, diabetes mellitus, ischaemic heart disease and cerebrovascular disease) alcohol consumption reduces mortality. A second important characteristic not shared by alcohol or illicit drugs is that the primary policy objective for alcohol is to reduce abusive consumption, not consumption per se.
For most alcohol-attributable health conditions the Arcadian Normal country is the country which has the minimum SMR. However, this approach does not sensibly translate into lives saved for conditions with negative attributable fractions, since countries having high overall mortality rates (that is, non Arcadian Normal countries) will, as a mathematical reality, usually also have relatively high rates of lives saved. Arcadian Normal countries tend to have relatively low rates of lives saved, simply because similar negative attributable fractions are being applied to lower overall mortality rates.
Thus, the approach adopted here is to use the Arcadian Normal approach in relation only to conditions for which the attributable fractions are positive. Where the fractions are negative, it is assumed that policies can be put in place to preserve the benefits of lives saved.
The Arcadian Normal countries are chosen as those which have the lowest SMRs for individual alcohol-attributable conditions. The difference is calculated between the Australian alcohol-attributable SMR and the relevant Arcadian Normal alcohol-attributable SMR for each of the conditions for which the attributable fraction is positive. In this way, the potential percentage reduction in SMR, and so in alcohol-attributable mortality, can be calculated. The results of this calculation appear in Table 4 below.
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Table 4. Alcohol-attributable deaths, Australia, 2004/05, and estimated potential reductions in deaths
The above table indicates that, according to Arcadian Normal calculations, 47 per cent of male deaths are potentially avoidable, 49 per cent of female deaths, and 48 per cent of total deaths.
The experience gained in these Arcadian Normal calculations has indicated some important
- Arcadian Normal countries for each condition should be determined by reference to the relevant attributable mortality rates (after the application of the relevant attributable fractions) rather than to total mortality for that condition. Countries with a low total mortality rate will not necessarily be experiencing low alcohol-attributable mortality. For example, countries with low overall road traffic accident death rates may have relatively high death rates from alcohol-attributable accidents. In fact, a case could be made out that the Arcadian Normal should be determined by the size of the country-specific attributable fraction, rather than the country-specific attributable mortality, though it is in practice unlikely that such data would be available at the necessary level of country disaggregation.
- The Arcadian Normal approach is, in the main, relevant only to the morbidity and mortality costs of alcohol abuse. It can be used only very indirectly, and so very imperfectly, for other significant alcohol abuse cost areas such as crime and workplace productivity.
- If Arcadian Normal calculations are to include the benefits of the protective effects of alcohol, in terms of lives saved, the analysis should concentrate specifically upon countries’ performance measured in terms of the size of the country-specific negative attributable fractions, rather than the negative mortality rate.
- It has not proved possible in practice to translate Arcadian Normal data into potential cost savings, mainly as result of the issues discussed in points 2 and 3 above.
- Without analyses of the interventions which have enabled the Arcadian Normal countries to achieve that status, the approach does not indicate which policies should be adopted to achieve Arcadian Normal outcomes in Australia.
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