- Open Access
- Open Peer Review
Policy implications of marked reversals of population life expectancy caused by substance use
© Rehm et al. 2016
- Received: 4 February 2016
- Accepted: 1 March 2016
- Published: 10 March 2016
Life expectancy has been increasing steadily over the past century in most countries, with only a few exceptions such as during wartimes.
Marked reversal of life expectancy has been linked to substance use and related policies. Three such examples are discussed herein, namely the double reversal of life expectancy trends (first to positive, then to negative) associated with reducing alcohol supply in the then Union of Soviet Socialist Republics (USSR), followed by a rapid increase in availability; the impact of the rapid increase of prescription opioids on white non-Hispanics in the US; and the systemic impact of the violence accompanying the drug war in Mexico on the life expectancy of men. Alcohol policies were crucial to initiate the positive reversal in the USSR, and different substance use policies could have avoided the negative impacts on life expectancy of the described large groups or nations.
Substance use policies can be responsible for abrupt negative changes in life expectancies. An orientation of such policies towards the goals of public health and societal well-being can help avoid such changes.
- Life expectancy
- Marked reversals of trend
- Substance use
- Public health
Life expectancy has increased steadily over the past century, except during mass pandemics, such as the influenza pandemic of 1918/1919, or during World Wars I and II [1–3] (see also: http://vizhub.healthdata.org/le/ accessed March 3, 2016). For most countries, the upward trend has remained uninterrupted since the end of World War II. These gradual upward transitions of life expectancy are based on an environment composed of a complex interplay of a variety of major risk and protective factors , with the balance improving steadily in the overwhelming majority of countries [1–3]. Tobacco, alcohol, and illicit drug use are part of these environments; all three categories of substances are among the top 20 risk factors globally, with most of the burden of disease and mortality attributable to tobacco followed by alcohol, with drugs as a distant third . Thus, substance use has been known to have a negative impact on life expectancy and burden of disease, but usually these impacts are counterbalanced by more positive impact factors.
Abrupt changes of directions in life expectancy have been rare, usually triggered by reversal of mortality rates in mid-adulthood, and linked to specific events, such as the aforementioned pandemic or wartimes . However, substance use policies can also create sudden or relatively abrupt population impacts, as will be illustrated herein with three examples.
These examples are chosen to demonstrate that changes in substance use, unlike changes in other risk factors, can affect population life expectancy not only in the long term but also abruptly, reversing decade-long trends. As shown, this is even true for illicit drugs, which have been linked to much less overall mortality and burden of disease than legal substances such as alcohol and tobacco (see above and ). The cases cited represent dramatic changes in policies and use patterns, where the connections with overall disease burden are striking. However, there is also ample evidence that appropriate incremental changes in policy or their enforcement have had effects on health outcomes [34, 35].
There should be active monitoring of substance-attributable disease burden and mortality. Identifying rapid changes in substance-attributable causes of death above a certain size will prepare the way for adequate policy changes (see , as example for alcohol).
Active and integrated substance use policies should be created, oriented at public health gains as a major goal, and with decriminalization of substance use [33, 37] (see also the UNAIDS recommendations for the United Nations General Assembly Special Session on the World Drug Problem ). Substance use policies must include legal and illegal substances and psychoactive medications, as evidenced by the second example . The public health approach explicitly includes considerations about harm to others attributable to substance use (i.e. second-hand smoke, effects of substance use on road traffic and operating machinery, violence, effects on the family).
Trade agreements and dispute mechanisms – global, regional, and bilateral – need to be changed so that market restrictions on legally traded psychoactive substances for public health purposes cannot be challenged or nullified [40, 41].
Access to treatment and social assistance for heavy users and their families should be improved, which needs to be linked to a reduction of stigmatization. Substance use disorders are the least treated mental conditions, and mental conditions as a whole are less treated than somatic conditions . Improving access to treatment and social assistance would also help in achieving the UN sustainable development goal, specific target 3.5, asking for a strengthening of “prevention and treatment of substance abuse” .
The research leading to these results or outcomes has received funding from the European Community’s Seventh Framework Programme (FP7/2007–2013), under Grant Agreement n° 266813 – Addictions and Lifestyle in Contemporary Europe – Reframing Addictions Project (ALICE RAP – www.alicerap.eu). Participant organizations in ALICE RAP can be seen at http://www.alicerap.eu/about-alice-rap/partner-institutions.html. The views expressed here reflect only those of the authors and the European Union is not liable for any use that may be made of the information contained therein. The funder had no role in the study design, in the collection, analysis and interpretation of data, or in the writing of the report.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Lancaster HO. Expectations of Life: A Study in the Demography, Statistics, and History of World Mortality. New York: Springer-Verlag; 1990.View ArticleGoogle Scholar
- Riley JC. Rising Life Expectancy: A Global History. Cambridge: Cambridge University Press; 2001.View ArticleGoogle Scholar
- Deaton A. The Great Escape – health, wealth and the origins of inequality. Princeton: Princeton University Press; 2013.Google Scholar
- Forouzanfar MH, Alexander L, Anderson HR, Bachman VF, Biryukov S, Brauer M, et al. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;386:2287–323.View ArticlePubMedGoogle Scholar
- Leon DA, Chenet L, Shkolnikov V, Zakharov S, Shapiro J, Rakhmanova G, et al. Huge variation in Russian mortality rates 1984-1994: artefact, alcohol, or what? Lancet. 1997;350:383–8.View ArticlePubMedGoogle Scholar
- Shkolnikov VM, Mesle F, Vallin J. Recent trends in life expectancy and causes of death in Russia, 1970-1993. In: Bobadilla JL, Costello CA, Mitchell F, editors. Premature Death in the New Independent States. Washington, DC: National Academy Press; 1997. p. 34–65.Google Scholar
- Bhattacharya J, Gathmann C, Miller G. The Gorbachev anti-alcohol campaign and Russia’s mortality crisis. Am Econ J Appl Econ. 2013;5:232–60.View ArticlePubMedPubMed CentralGoogle Scholar
- Stuckler D, King L, McKee M. Mass privatisation and the post-communist mortality crisis: a cross-national analysis. Lancet. 2009;373:399–407.View ArticlePubMedGoogle Scholar
- Brainerd E. Economic Reform and Mortality in the Former Soviet Union: A Study of the Suicide Epidemic in the 1990s. Eur Econ Rev. 2001;45:1007–19.View ArticleGoogle Scholar
- Cornia GA, Paniccià R. The transition mortality crisis: evidence, interpretation and policy responses. In: Cornia GA, Paniccià R, editors. The Mortality Crisis in Transitional Economies. Oxford: Oxford University Press; 2000.View ArticleGoogle Scholar
- Velichkovskiĭ BT. The importance of social stress and effective occupational motivation in the forming of life-style, population health, and the development of demographic processes in Russia. Vestn Ross Akad Med Nauk. 2007;5:41–8 [In Russian].Google Scholar
- Lynch JW, Davey Smith G, Kaplan GA, House JS. Income inequality and mortality: importance to health of individual income, psychosocial environment, or material conditions. BMJ. 2000;320:1200–4.View ArticlePubMedPubMed CentralGoogle Scholar
- Neufeld M, Rehm J. Alcohol consumption and mortality in Russia since 2000 – are there any changes following the alcohol policy changes starting in 2006. Alcohol Alcohol. 2013;48:222–30.View ArticlePubMedGoogle Scholar
- Grigoriev P, Andreev EM. The huge reduction in adult male mortality in Belarus and Russia: is it attributable to anti-alcohol measures? PLoS One. 2015;10:e138021.View ArticleGoogle Scholar
- International Narcotics Control Board. Narcotic Drugs. Estimated World Requirements for 2015. Statistics for 2013. New York: United Nations; 2014. http://www.incb.org/documents/Narcotic-Drugs/Technical-Publications/2014/Narcotic_Drugs_Report_2014.pdf. Accessed March 3, 2016.Google Scholar
- Compton WM, Volkow ND. Major increases in opioid analgesic abuse in the United States: Concerns and strategies. Drug Alcohol Depend. 2006;81:103–7.View ArticlePubMedGoogle Scholar
- Kolodny A, Courtwright DT, Hwang CS, Kreiner P, Eadie JL, Clark TW, et al. The prescription opioid and heroin crisis: a public health approach to an epidemic of addiction. Annu Rev Public Health. 2015;36:559–74.View ArticlePubMedGoogle Scholar
- Imtiaz S, Shield KD, Fischer B, Rehm J. Harms of prescription opioid use in the United States. Subst Abuse Treat Prev Policy. 2014;9:43.View ArticlePubMedPubMed CentralGoogle Scholar
- Paulozzi LJ, Ryan GW. Opioid analgesics and rates of fatal drug poisoning in the United States. Am J Prev Med. 2006;31:506–11.View ArticlePubMedGoogle Scholar
- Paulozzi LJ, Budnitz DS, Xi Y. Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiol Drug Saf. 2006;15:618–27.View ArticlePubMedGoogle Scholar
- Case A, Deaton A. Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. Proc Natl Acad Sci U S A. 2015;112:15078–83.View ArticlePubMedPubMed CentralGoogle Scholar
- Ferrari AJ, Norman RE, Freedman G, Baxter AJ, Pirkis JE, Harris MG, et al. The burden attributable to mental and substance use disorders as risk factors for suicide: findings from the Global Burden of Disease Study 2010. PLoS One. 2014;9:e91936.View ArticlePubMedPubMed CentralGoogle Scholar
- Rehm J, Taylor B, Mohapatra S, Irving H, Baliunas D, Patra J, et al. Alcohol as a risk factor for liver cirrhosis – a systematic review and meta-analysis. Drug Alcohol Rev. 2010;29:437–45.View ArticlePubMedGoogle Scholar
- Degenhardt L, Hall W. Extent of illicit drug use and dependence, and their contribution to the global burden of disease. Lancet. 2012;379:55–70.View ArticlePubMedGoogle Scholar
- Xu JQ, Murphy SL, Kochanek KD, Bastian BA. Deaths: Final data for 2013. National vital statistics reports. Hyattsville: National Center for Health Statistics; 2016.Google Scholar
- National Center for Health Statistics. NCHS Fact Sheet. June 2015. NCHS Data on Drug Poisoning Deaths. 2015. http://www.cdc.gov/nchs/data/factsheets/factsheet_drug_poisoning.pdf. Accessed March 3, 2016.
- National Institute on Drug Abuse. Overdose Death Rates. 2015. www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates. Accessed March 3, 2016.Google Scholar
- National Institute on Drug Abuse. America’s Addiction to Opioids: Heroin and Prescription Drug Abuse. Presented by Nora D. Volkow. 2014. http://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2015/americas-addiction-to-opioids-heroin-prescription-drug-abuse. Accessed March 3, 2016.Google Scholar
- Goldstein PJ. The drugs/violence nexus: a tripartite conceptual framework. J Drug Issues. 1985;15:493–506.View ArticleGoogle Scholar
- Aburto JM, Beltrán-Sánchez H, García-Guerrero VM, Canudas-Romo V. Homicides in Mexico reversed life expectancy gains for men and slowed them for women, 2000-10. Health Aff. 2016;35:88–95.View ArticleGoogle Scholar
- Gamlin J. Violence and homicide in Mexico: a global health issue. Lancet. 2015;385:605–6.View ArticlePubMedGoogle Scholar
- Werb D, Rowell G, Guyatt G, Kerr T, Montaner J, Wood E. Effect of drug law enforcement on drug market violence: a systematic review. Int J Drug Policy. 2011;22:87–94.View ArticlePubMedGoogle Scholar
- Anderson P, Braddick F, Conrod P, Gual A, Hellman M, Matrai S, et al. The New Governance of Addictive Substances and Behaviours. Oxford: Oxford University Press; 2016.Google Scholar
- Babor T, Caetano R, Casswell S, Edwards G, Giesbrecht N, Graham K, et al. Alcohol: no ordinary commodity. Research and public policy. 2nd ed. Oxford: Oxford University Press; 2010.View ArticleGoogle Scholar
- Babor TF, Caulkins JP, Edwards G, Fischer B, Foxcroft DR, Humphreys K, et al. Drug policy and the public good. Oxford: Oxford University Press; 2010.Google Scholar
- Rehm J, Zatonski W, Taylor B, Anderson P. Epidemiology and alcohol policy in Europe. Addiction. 2011;106:11–9.View ArticlePubMedGoogle Scholar
- Global Commission on Drug Policy. Taking control: pathways to drug policies that work. Rio de Janeiro: Global Commission on Drug Policy; 2014.Google Scholar
- Joint United Nations Program on HIV/AIDS (UNAIDS). A public health and rights approach to drugs. Geneva: UNAIDS; 2015.Google Scholar
- U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014.Google Scholar
- Gleeson D, Friel S. Emerging threats to public health from regional trade agreements. Lancet. 2013;381:1507–9.View ArticlePubMedGoogle Scholar
- Room R, Cisneros Örnberg J. The governance of addictions at the international level. In: Anderson P, Bühringer G, Colom J, editors. Reframing Addictions: Policies, Processes and Pressures. Barcelona: The ALICE RAP project; 2014. p. 46–58.Google Scholar
- Kohn R, Saxena S, Levav I, Saraceno B. The treatment gap in mental health care. Bull World Health Org. 2004;82:858–66.PubMedPubMed CentralGoogle Scholar
- United Nations. Sustainable Development Knowledge Platform. Goal 3: Ensure healthy lives and promote well-being for all at all ages. https://sustainabledevelopment.un.org/sdg3.
- Lachenmeier DW, Rehm J. Comparative risk assessment of alcohol, tobacco, cannabis and other illicit drugs using the margin of exposure approach. Sci Rep. 2015;5:8126.View ArticlePubMedPubMed CentralGoogle Scholar