摘要：Objectives. We assessed the impact on suicide mortality of a new national policy in Slovenia that limits the availability of alcohol. Methods. We obtained monthly total, male, and female suicide counts in Slovenia between January 1997 and December 2005 and then employed autoregressive integrated moving average (ARIMA) techniques to model the effect of the alcohol policy (implemented in March 2003). Results. There was a significant decrease in the total number of monthly suicides following the policy's implementation. Subsequent analyses revealed this association to be caused solely by the impact on male suicides. Specifically, there was an immediate and permanent reduction of 3.6 male suicides per month (95% confidence interval = −0.4, −6.9), or approximately 10% of the preintervention average. The policy had no statistically significant effect on female suicides. Conclusions. Our results show the effectiveness of this specific policy in reducing male suicides in Slovenia and also hint at the potential of public policy in reducing the public health burden of alcohol-related harm more generally. In the late 1990s, Slovenia's level of alcohol consumption was among the highest in Europe, at over 14 L of ethanol per adult per annum. 1 During the same period, the standardized death rate from suicide—approximately 30 per 100 000 residents—was higher than in any western European nation. 2 Recognizing the high levels of alcohol consumption and related harm, Slovenian public health experts and others lobbied for a new national policy. 3 After considerable effort in the face of opposition, the Slovenian National Assembly passed new legislation 4 in January 2003 that aimed to reduce alcohol-related harm by restricting alcohol's availability. Although implementation of such policies provides scholars with unique scientific opportunities, the empirical literature contains few studies of the effects of these natural experiments on violence. Research on alcohol and suicide at the population level often finds an association between the two, although the strength of this relationship varies by nation depending on the drinking culture. In general, the association is weak or absent in central and southern European nations but significant in northern Europe. 5 , 6 Ramstedt, for example, examined gender- and age-specific associations between alcohol and suicide in several western European nations. 6 Grouping countries into low-consumption (Finland, Norway, Sweden), medium-consumption (Austria, Belgium, Denmark, Ireland, Netherlands, United Kingdom, former West Germany), and high-consumption (France, Italy, Portugal, Spain) nations, he found that yearly changes in per capita alcohol consumption were related to yearly changes in gender- and age-specific suicide rates. Further, results showed that suicide rates were more responsive to changes in alcohol consumption in “dry” (low-consumption) than in “wet” (medium- and high-consumption) drinking cultures. Although still few in number, population-level studies of alcohol and suicide in eastern Europe are growing, probably because of the strong association between alcohol and violence in the region, especially in Slavic nations. 7 – 12 Pridemore and Chamlin found a positive association between heavy drinking and suicide in Russia between 1956 and 2002 for both total and gender-specific rates. 9 In Belarus, Razvodovsky found an association between alcohol and suicide, which was stronger for spirits than for beer and wine. 10 , 11 Landberg, in a study similar to Ramstedt's in aim and method, examined the association between drinking and suicide in 7 eastern European nations. 7 The results showed a significant association between alcohol and suicide in each nation, but they also revealed that the sizes of the effects were stronger in countries in which spirits were the preferred form of alcohol (Belarus, Poland, Russia) than in nations in which nonspirits (wine or beer) were preferred (Bulgaria, former Czechoslovakia, former German Democratic Republic, Hungary). These studies have reached similar conclusions about the population-level association between alcohol and suicide: it is stronger (1) for spirits than for beer and wine and (2) in countries in which the drinking pattern is characterized by binge drinking. Research in western Europe, which has focused less on beverage preference than on “wet” and “dry” drinking cultures, has shown that the association is usually stronger in dry cultures. 5 , 6 However, the dry drinking cultures in Europe are usually in countries in which spirits are the beverage of choice and binge drinking is more common. In eastern European studies, more attention is given to the consumption of spirits than of wine and beer, 7 , 8 , 10 , 11 and binge drinking is common in the region, especially in Slavic countries. The impact of alcohol policies on violence—and on suicide specifically—has received less empirical attention. A few recent studies, however, have examined the Soviet anti-alcohol campaign in the mid- to late 1980s. 13 Although assessments of the campaign's long-term public health effects are mixed, 14 studies provide evidence of short-term success in reducing alcohol consumption and alcohol-related harm, including suicide. Research by Värnik et al., 15 for example, found that the alcohol policy in Estonia led to a 40% reduction in suicides in which alcohol was present in the blood of the victim (i.e., blood alcohol content [BAC]–positive suicides), with men and women equally affected. Once the campaign ended, the number of BAC-positive suicides began to increase. A similar analysis by Nemtsov examined alcohol consumption and suicide in Russia between 1965 and 1999. 16 Nemstov found that the antialcohol campaign was accompanied by a substantial decline in suicides. In related studies, Nemtsov found that violent deaths (including suicide) decreased 33% during the campaign. 17 , 18 Slovenia is a small central European country with a historically high rate of alcohol consumption. Its history, geography, and culture have resulted in an eclectic mix of alcohol beverage preferences. Slovenia's geographic location provides an ideal climate for viticulture, and the country produces wines from 3 growing regions. 19 , 20 In addition, the region's historical connections with the Austro-Hungarian Empire contribute to a tradition of beer brewing and heavy beer drinking. Spirits are also commonly consumed in Slovenia. The most common is made of fermented fruit juices and is often offered as a sign of hospitality and consumed with meals. In short, Slovenia possesses a wet drinking culture, and alcohol has historically been—and continues to be—an important part of the culture. 21 Alcohol consumption increased in Slovenia in the 1980s, and in 1997 the country had the highest level of consumption in its reference group of European nations (Bulgaria, Czech Republic, Estonia, Hungary, Latvia, Poland, Romania, and Slovakia). In 1997, the annual rate of alcohol consumption was more than 14 L per adult. 1 , 22 Unregistered consumption is also high, likely exceeding 5 L per person per annum. 23 By recent estimates, 13% of Slovenian adults are heavy drinkers and 21% of the population consumes more than a relatively safe amount of alcohol per day (10 g for adult women, 20 g for adult men). 24 , 25 Slovenia's annual suicide rate of more than 30 per 100 000 residents is also among the highest in the world. 26 This high rate is not new. When Slovenia was part of Yugoslavia, its suicide rate surpassed that of other Yugoslav republics. The annual suicide rate in all of Yugoslavia in 1982, for example, was 16 per 100 000, but the Slovenian rate was 33 per 100 000. 27 The annual mean suicide rate in Slovenia between 1985 and 1996 was 31.5 per 100 000. 25 The rate among men during this period fluctuated around 50 per 100 000 and was several times that among women, which was more stable and in the low teens. 28 On January 28, 2003, the Slovenian National Assembly passed legislation limiting the availability of alcohol products in an attempt to reduce consumption and alcohol-related harm. 3 The law established a minimum age of 18 years for drinking and purchasing alcoholic beverages and limited where and when alcohol products can be purchased. For example, stores and gas stations are prohibited from selling any alcohol between 9 pm and 7 am , the sale of distilled spirits is prohibited from a store's opening time until 10 am , workplaces must be alcohol free, and alcohol is no longer allowed to be sold from vending machines. 4 Preliminary data suggest that this new alcohol policy may have had an impact on alcohol-related harm. Between 2003 and 2005, there was a 12% reduction in registered alcohol consumption in Slovenia, from 11.7 L to 10.3 L per adult per annum. 29 This was accompanied by a 12% decrease in alcohol-related traffic accidents 29 and an 11% reduction in absences from work because of illness. 30 There was also a steep drop in the standardized death rate for liver diseases and cirrhosis between 2002 and 2005, from 29.5 per 100 000 to 21.9 per 100 000. 30 Because alcoholic liver disease and cirrhosis are chronic conditions, immediate decreases in their rates in response to policy or other interventions may seem counterintuitive. There is substantial evidence of such effects, however, from Slovenia's Eastern European neighbors during the Soviet antialcohol campaign in the 1980s as well as German-occupied Paris in 1942. 31 Given Slovenia's high rates of alcohol consumption and suicide, as well as the intriguing decreases in alcohol-related harm following implementation of the new law, scholars are provided with a rare natural experiment for examining the impact of a national alcohol policy on suicide mortality. We assessed the impact of a national alcohol policy on suicide mortality in Slovenia using interrupted time-series techniques.
