摘要：Objectives. We describe the relative burden of alcohol-attributable death among American Indians/Alaska Natives (AI/ANs) in the United States. Methods. National Death Index records were linked with Indian Health Service (IHS) registration records to identify AI/AN deaths misclassified as non-AI/AN. We calculated age-adjusted alcohol-attributable death rates from 1999 to 2009 for AI/AN and White persons by sex, age, geographic region, and leading causes; individuals of Hispanic origin were excluded. Results. AI/AN persons had a substantially higher rate of alcohol-attributable death than Whites from 2005 to 2009 in IHS Contract Health Service Delivery Area counties (rate ratio = 3.3). The Northern Plains had the highest rate of AI/AN deaths (123.8/100 000), and the East had the lowest (48.9/100 000). For acute causes, the largest relative risks for AI/AN persons compared with Whites were for hypothermia (14.2) and alcohol poisoning (7.6). For chronic causes, the largest relative risks were for alcoholic psychosis (5.0) and alcoholic liver disease (4.9). Conclusions. Proven strategies that reduce alcohol consumption and make the environment safer for excessive drinkers should be further implemented in AI/AN communities. Excessive alcohol consumption is a leading preventable cause of death in the United States and has had a greater health impact on American Indians and Alaska Natives (AI/ANs) than on other racial groups. 1 Alcohol-related mortality is a useful measure of the burden of alcohol for a population and has been used in many settings. 2–5 Rates of specific causes of alcohol-related mortality such as hypothermia 6 and alcoholic liver disease 7 have been higher among AI/AN populations than among other racial groups. Cultural, socioeconomic, and alcohol availability differences between these 2 groups have contributed to disparities in alcohol-related mortality. In several settings, higher rates of alcohol-related mortality have been associated with lower socioeconomic status. 8,9 AI/AN alcohol-related mortality rates 10 and patterns of alcohol use 11 also vary by tribe and region. Methods to measure alcohol-related mortality have developed over time. 2,12,13 These methods have evolved because of concerns that alcohol-related mortality was being underreported on death certificates. Methods based solely on underlying cause of death may underestimate the overall impact of alcohol on mortality. 3 A chart review by a medical panel resulted in a 600% increase in the number of alcohol-related deaths over those found by the original death certifiers when both underlying and contributory causes of death were considered. 14 In the United Kingdom, extending the definition of alcohol-related mortality to include deaths with alcohol as a contributory cause increased the percentage of deaths attributable to alcohol by almost 70%. 15 Misclassification of AI/AN race varies by cause of death. Between 1996 and 1998, 91% of deaths in Montana determined to be AI/AN on the basis of the Indian Health Service (IHS) registration file were classified as such on the death certificate, whereas 98% of alcohol-related deaths determined to be AI/AN were classified as such on the death certificate. 16 In Washington State, a similar linkage for 1985 to 1990 found that younger age at death, underlying cause of death being alcohol related, and underlying cause of death not being cancer were associated with more consistent classification of AI/AN race on death certificates. 17 Alcohol consumption is related to alcohol-related mortality, 5 and the price of alcohol is associated with consumption. An increase in price tends to decrease consumption and alcohol-related problems. 18 When the price of alcohol decreases, alcohol-related mortality can increase significantly, as was the case in Finland in 2004. 8 One effective way to increase the price of alcohol is to increase alcohol taxes. 19 Of the 64% of AI/AN tribes that permitted alcohol consumption in 2006, three quarters had no alcohol tax. 20 Reducing access to alcohol, particularly in remote Alaska, has been associated with lower alcohol-related injury death rates. 21 Environmental strategies, such as road engineering and lighting improvements, have also been successful in reducing alcohol-related injury death in AI/AN communities. 6 Alcohol detoxification centers have housed intoxicated people on cold nights to help prevent hypothermia deaths. We investigated differences in alcohol-attributable death rates among AI/AN populations in the United States using the best available classification of AI/AN race.
