Journal of Public Health | Vol. 31, No. 3, pp. 366 –373 | doi:10.1093/pubmed/fdp051 | Advance Access Publication 3 June 2009

The burden of alcohol-related ill health in the United Kingdom Ravikumar Balakrishnan, Steven Allender, Peter Scarborough, Premila Webster, Mike Rayner British Heart Foundation Health Promotion Research Group, Department of Public Health, University of Oxford, Old Road, Headington, Oxford OX3 7LF, UK Address correspondence to Steven Allender, E-mail: [email protected]

A B S T R AC T Background Although moderate alcohol consumption has been shown to confer a protective effect for specific diseases, current societal patterns of alcohol use impose a huge health and economic burden on modern society. This study presents a method for estimating the health and economic burden of alcohol consumption to the UK National Health Service (NHS). Methods Previous estimates of NHS costs attributable to alcohol consumption were identified by systematic literature review. The mortality and morbidity due to alcohol consumption was calculated using information from the World Health Organization Global Burden of Disease Project and routinely collected mortality data. Direct health-care costs were derived using information on population attributable fractions for conditions related to alcohol consumption and NHS cost data. Results We estimate that alcohol consumption was responsible for 31 000 deaths in the UK in 2005 and that alcohol consumption cost the UK NHS £3.0 billion in 2005–06. Alcohol consumption was responsible for 10% of all disability adjusted life years in 2002 (male: 15%; female: 4%) in the UK. Conclusions Alcohol consumption is a considerable public health burden in the UK. The comparison of the health and economic burden of various lifestyle factors is essential in prioritizing and resourcing public health action. Keywords alcohol, burden of disease, economic costs

Introduction The UK Government currently advises that ‘regular consumption of between three and four units a day by men’ and ‘between two and three units a day by women of all ages will not lead to any significant health risk’.1 Consuming in excess of four units on the heaviest drinking day of the week in men, or over three units in women, is not advised, and the Government recommendations on sensible drinking are now based on these daily benchmarks.2 The number of people reporting consumption of harmful levels of alcohol is increasing. In 2006, around a third of men and a fifth of women reported drinking over the weekly recommendations compared with around a quarter of men and ten percent of women in 1988:3,4 some of this difference in consumption is due to changes in the measurement of alcoholic units in health surveys, but these changes were introduced to account for recent increases in average drink size and alcoholic strength of regularly consumed alcoholic beverages.5 There is a clear inverse relationship between

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likelihood of consumption above government guidelines and age, with binge drinking among men 30% higher than average among men aged 16– 24 and 42% higher in women of the same age. Adverse effects of excess alcohol consumption include mortality from injuries and accidents (such as falls and motor vehicle accidents) and chronic disease (such as chronic liver disease).6,7 Alcohol consumption has been shown to provide some protective health benefits, irrespective of the type of alcoholic beverage consumed.8 For example, irregular heavy drinking seems to increase the risk of coronary heart disease (CHD) whereas regular low-to-moderate consumption appears to infer a reduction

Ravikumar Balakrishnan, Specialist Registrar Steven Allender, Senior Researcher Peter Scarborough, Researcher Premila Webster, Honorary Senior Lecturer Mike Rayner, Director

# The Author 2009, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved.

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in CHD risk.9 Similar J-shaped associations exist between alcohol consumption and diabetes, hypertension, congestive heart failure, stroke, dementia and all cause mortality.10 Developing a clear estimate of the burden of alcoholrelated disease to health systems is an essential step in understanding the public health impact of excess alcohol use. Estimates of the comparable attributable burden between alcohol consumption and other unhealthy behaviours can inform policy and resource allocation decisions. Such estimates provide a baseline for planning appropriate action and assessing the impact of future interventions. Full economic costing studies are complex and labour intensive and so are not conducted regularly. A comparable and replicable method for estimating the burden of different behavioural exposures, such as alcohol consumption, has been developed and used previously to assess and compare the health and economic burden of poor diets, low levels of physical activity, smoking and overweight and obesity in the UK (Balakrishnan et al., unpublished data)11 – 13 A relatively easy method for estimating the burden of disease is useful given changes in the patterns of disease and their prevention, treatment and care and also in changes in health-care costs (between 1992 – 93 and 2005 – 06 total NHS expenditure increased from £3114 to £80 billion15). This paper presents a method for estimating the burden of ill-health related to alcohol consumption in the UK and provides a comparison with the burden attributable to other risk factors. This method has the potential to enable policy-makers to compare the ill-health burden attributable to various lifestyle factors and thus prioritize appropriate public health action.

Methods This study was conducted in two parts: first a systematic review was conducted to identify all cost of alcohol studies published between 1998 and 2007 relating to the UK or its constituent countries and second the burden of ill-health due to alcohol consumption in each of the four countries of the UK was calculated by applying population attributable fractions (PAFs) from the World Health Organization’s (WHO) Global Burden of Disease Project to routinely collected UK mortality data and NHS cost data. A systematic literature search was conducted using the search terms ‘cost’, ‘alcohol’ and ‘misuse’ in Medline, CINAHL, EMBASE, Cochrane Library, National Health Service Economic Evaluation Database, EconLit, Science Citation Index, Social Science Citation Index, Index to Scientific and Technical Proceedings and the Health Management and Policy Database from the Health-care

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Management Information Consortium. Studies were included if they related to the cost of alcohol consumption to the NHS in the UK or one of its constituent countries and were published in English between August 1997 and September 2007. The reference lists of all papers were reviewed to identify other potentially relevant studies. Only studies reporting a new analysis of the cost to the NHS in the UK or one of the constituent countries of the UK were included. Studies reporting previous analyses or opinionbased estimates were excluded. The method for calculating the health burden due to alcohol consumption and the direct cost to the NHS involved five steps. (i) Diseases where alcohol consumption is a risk factor were identified from the World Health Report for 2002.16,17 (ii) Data on attributable years of life lost (YLL), years of health life lost to disability (YLD) and disabilityadjusted life years (DALYs) were taken from the World Health Project Report16,17 for WHO EUR-A region (which includes the UK). Data on mortality for the year 2005 was obtained directly from Office of National Statistics for England and Wales (Personal communication, 2006) and the General Register Offices for Scotland and Northern Ireland.18,19 (iii) The proportion of NHS expenditure by disease code in 1992 –93 from the National Health Executive14 was applied to the total cost of the NHS in 2005 – 06 for each of the four countries in the UK14,20 – 22 to provide an estimate of cost per disease. (iv) Gender-specific PAFs were extracted from the Global Burden of Disease Project23 where estimates were calculated against a theoretical population in which all referent individuals consumed no alcohol (England and Wales Office of National Statistics. Personal communication; 2006).17 (v) The burden (in terms of economic cost, mortality and morbidity) of ill-health-related to alcohol was calculated by applying the disease specific PAFs to 2005 –06 disease-specific data.

Results Systematic review

The search strategy generated 597 potentially relevant papers. The majority (583) were rejected on the basis of the title or abstract not meeting the inclusion criteria and a further 11 were rejected after reviewing the full paper. The majority of papers were excluded because they reported on the cost in countries other than the UK or non-NHS costs.

morbidity and mortality as a result of alcohol consumption.

Direct costs of resources expended for treatment due to increased England £1400 – 1700 million 2000 –01 2003 Cabinet Office, Strategy Unit25

morbidity and mortality as a result of alcohol consumption.

2002 Susan and Julian26

associated with alcohol (inpatients only)

Direct costs of NHS service resource use for treatment due to increased Scotland £95.6 million

2001

2001 –02

England and Wales £161 million

Direct cost Year of estimate

Royal College of Physicians24

We estimate that the direct cost to the NHS in the UK for conditions attributable to alcohol consumption was

Year of publication

Direct cost to the NHS

Authors

Table 2 shows estimates of the amount of mortality and morbidity (measured as YLLs, YLDs and DALYs) in the WHO EUR-A region for diseases where alcohol is a contributory causal factor. In 2002 those diseases associated with alcohol consumption were responsible for 56% of all mortality, 64% of YLLs, 36% of YLDs and 50% of DALYs, but note that these diseases have multiple causes, and not all of this burden can be ascribed to alcohol alone. By applying PAFs for alcohol to the alcohol-related diseases in Table 2, we can estimate the amount of morbidity due to alcohol alone. Table 3 shows that 10% (male: 15%; female: 4%) of all DALYs lost in the EUR-A region were directly attributable to alcohol consumption. Alcohol use disorders were the largest contributor to the burden of disease attributable to alcohol consumption, accounting for 4.3% of all DALYs lost followed by liver cancer (1.4%) and motor vehicle accidents (0.9%). Whereas data on DALYs are only available for the EUR-A region, cause-specific mortality data have been obtained for the UK. Applying the PAFs derived from the WHO’s Global Burden of Disease Project to the UK data, we estimate that of the 588 000 deaths in 2005, around 31 000 (5.3%) were directly attributable to alcohol consumption in the UK; equating to 7.8% of male deaths (22 000) and 3.0% of female deaths (9000). The proportion of deaths attributable to alcohol consumption varied between countries of the UK from 6.9% in Scotland to 3.8% in Northern Ireland (online supplementary Table S1).

Table 1 Summary of studies included in review with estimates of the cost to the NHS due to alcohol-related ill-health

Mortality and morbidity

Country

Other detail

Some studies were excluded because they reported regional rather than national level costs. Three papers were retained, which reported cost estimates for economic burden of alcohol to the UK health system. We found that there were no studies that presented estimates for the economic burden attributable to alcohol consumption for the UK as a whole (Table 1). The Royal College of Physicians24 estimated that the additional cost to the NHS in England and Wales due to admissions with a main diagnosis directly associated with alcohol in 1992 was £161 million. The Cabinet Office estimated the direct costs in England due to treatment related to alcohol consumption in 2001 between £1.4 and £1.7 billion.25 Susan and Julian26 conducted a similar study for Scotland estimating the burden to be £95.6 million in 2001 – 02.

Extra cost to the NHS due to patients with a main diagnosis directly

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1992

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Table 2 Proportion of mortality, YLLs, YLDs and DALYs by alcohol-related conditions in EUR-A region (which includes the UK) in 2002 Conditions

% of mortality

% of YLLs

% of YLDs

% of DALYs

(n ¼ 3 920 000)

(23 972 000 YLLs)

(27 762 000 YLDs)

(51 734 000 DALYs)

Alcohol-related conditions Cirrhosis of the liver

1.65

3.02

0.67

Epilepsy

0.15

0.37

0.57

0.47

Alcohol use disorders

0.34

0.79

7.35

4.31

Unipolar depressive disorder

1.76

0.04

0.03

14.80

7.96

Ischaemic heart disease

17.14

13.67

1.06

6.9

Cerebrovascular disease

10.56

6.88

3.62

5.16

Mouth and oropharyns cancer

0.61

1.03

0.06

0.51

Oesophagus cancer

0.72

0.95

0.02

0.45

Liver cancer

1.02

1.16

0.02

0.55

Other cancer

18.85

24.78

2.67

12.92

Drowning

0.10

0.30

0.01

1.14

Falls

1.19

1.02

1.33

1.19

Poisoning

0.14

0.48

0.04

0.24

Motor vehicle accidents

1.17

4.18

0.81

2.37

Self-inflicted injuries

1.23

3.46

0.21

1.72

Other intentional injuries

0.12

0.44

0.15

0.29

Other unintentional injuries Total related to alcohol consumption Communicable diseases, maternal/perinatal

0.89

1.64

2.17

1.92

55.91

64.20

35.56

49.86

6.20

6.01

4.00

4.93

conditions and nutritional deficiencies Other cardiovascular diseases

13.42

8.98

1.68

5.06

Digestive diseasesa

2.99

2.51

3.25

2.91

Diabetes mellitus

2.35

1.89

2.35

2.14

Diseases of the genitourinary system

1.59

1.07

1.04

1.06 13.81

Neuropsychiatric disordersb

4.18

3.59

22.63

Musculoskeletal diseases

0.50

0.39

7.58

4.25

Other

12.86

11.36

21.91

15.98

Total

100.00

100.00

100.00

100.00

Among females, alcohol has protective effect against ischaemic heart disease and ischaemic stroke and no effect against haemorrhagic stroke. Numbers may not add exactly to the figures shown in bold due to rounding. a

Excluding cirrhosis of the liver.

b

Excluding alcohol use disorders, unipolar depressive disorder.

£3.0 billion (3.2% of total health-care cost) in 2005 – 06 (Table 4). These costs include £374 million for cirrhosis of the liver and more than £330 million for motor vehicle accidents.

Discussion Main finding of this study

We estimate that, for UK in 2005, 31 000 deaths and £3.0 billion (2005 –06) in direct NHS costs (around 3.2% of total NHS expenditure) could be attributed to alcohol consumption.

What is already known on this topic

Our estimate of attributable mortality for the UK of 5.6% is similar to the 6.1% estimate provided by the WHO for Europe27 and an estimate of 6% from a Canadian study conducted in 2001.28 Our estimate of 25 000 and 1600 deaths for England and Wales, respectively, exceeds those of the Cabinet Office,25 which estimated that deaths in England and Wales related to alcohol ranged from 15 316 to 21 958. The Cabinet Office estimates were based on the data from 2000 and it is possible that a large part of the difference in estimates is due to changes in the underlying mortality patterns between 2000 and 2005. Other estimates

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Table 3 Total DALYs lost and PAFs for alcohol-related ill-health (n and %), by gender, in WHO EUR-A region, 2002 Alcohol-related conditions Male

Female

Total

DALYs lost

PAF

DALYs lost to

% of all

DALYs lost

PAF

DALYs lost to

% of all

DALYs lost

PAF

DALYs lost to

% of all

(n)

DALYs

alcohol

male

(n)

DALYs

alcohol

female

(n)

DALYs

alcohol

DALYs

lost (%)

consumption

DALYs

lost (%)

consumption

DALYs

lost (%)

consumption

Cirrhosis of the liver

611 748

63

385 402

1.41

297 010

49

145 535

0.60

908 758

58

530 936

1.03

Epilepsy

137 854

45

62 034

0.23

107 405

36

38 666

0.16

245 259

41

100 700

0.19

Alcohol use disorders

1 818 348

100

1 818 348

6.65

409 059

100

409 059

1.68

2 227 407

100

2 227 407

4.31

Unipolar depressive disorder

1 474 953

7

103 247

0.38

2 641 965

2

52 839

0.22

4 116 919

4

156 086

0.30

Ischaemic heart disease

2 304 061

2

46 081

0.17

1 265 131

23

237 954

20.16

3 569 191

0

8127

0.02

219 270

26

57 010

0.21

178 630

0

0

0.00

388 199

15

57 010

0.11

Haemoragic stroke Ischaemic stroke

142 287

5

7114

0.03

121 789

216

219 486

20.08

259 190

25

212 372

20.02

Mouth/oropharynx cancer

213 052

41

87 351

0.32

50 554

28

14 155

0.06

263 605

39

101 506

0.20

Oesophagus cancer

186 985

46

86 013

0.31

46 248

36

16 649

0.07

233 233

44

102 663

0.20

Liver cancer

195 489

36

70 376

0.26

86 286

28

24 160

0.10

281 775

34

94 536

0.18

4 515 217

11

496 674

1.82

3 071 643

8

245 731

1.01

7 953 034

9

742 405

1.44

58 435

43

25 127

0.09

15 138

25

3784

0.02

73 572

39

28 911

0.06

Other cancer Drowning Falls

377 092

21

79 189

0.29

237 412

8

18 993

0.08

614 504

16

98 182

0.19

93 616

43

40 255

0.15

32 428

26

8431

0.03

126 044

39

48 686

0.09

Motor vehicle accidents

932 126

45

419 457

1.53

301 066

18

54 192

0.22

1 233 192

38

473 649

0.92

Self-inflicted injuries

667 303

27

180 172

0.66

222 847

12

26 742

0.11

890 150

23

206 913

0.40

Other intentional injuries

106 265

32

34 005

0.12

42 443

19

8064

0.03

148 708

28

42 069

0.08

634 622

32

16

57 624

0.24

994 775

26

1 067 185

4.37

26 534 022

Poisoning

Other unintentional injuries Total related to alcohol

15 654 763

203 079

0.74

360 153

4 200 935

15.37

10 513 085

260 703

0.50

5 268 119

10.18

Table 4 Percentage of total costs (£ millions) in 1992 –93 and 2005 – 06 to the NHS for alcohol-related ill-health by countries in the UK Conditions attributable to alcohol

1992/93 (%

consumption

NHS total

PAF

England

Wales

Scotland

Northern Ireland

Total cost for the UK,

costs)a

Total NHS

Cost

Total NHS

Cost

Total NHS

Cost

Total NHS

Cost

attributable to

costs

attributable

costs

attributable

costs

attributable

costs

attributable

alcohol

2005 –06

to alcohol

2005 –06

to alcohol

2005– 06

to alcohol

2005 –06

to alcohol

Cirrhosis of the liver

0.68

58.42

545.53

318.72

29.05

16.97

50.78

29.67

15.86

9.27

Epilepsy

0.74

41.06

590.92

242.62

31.47

12.92

55.00

22.58

17.18

7.05

374.63 285.18

Alcohol use disorders

1.00

100.00

798.84

798.84

42.54

42.54

74.36

74.36

23.22

23.22

938.96

Unipolar depressive disorder

0.00

3.79

0.08

0.00

0.00

0.00

0.01

0.00

0.00

0.00

0.00

Ischaemic heart disease

2.58

0.23

2064.85

4.70

109.96

0.25

192.20

0.44

60.03

0.14

5.53

Hemorrhagic stroke

1.26

14.69

1008.51

148.11

53.71

7.89

93.87

13.79

29.32

4.31

174.09

Ischaemic stroke

1.89

24.77

1511.95

272.17

80.51

23.84

140.73

26.72

43.95

22.10

284.83

Mouth/oropharynx cancer

0.00

38.51

0.01

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

Oesophagus cancer

0.09

44.02

71.52

31.48

3.81

1.68

6.66

2.93

2.08

0.92

37.00

Liver cancer

0.04

33.55

28.33

9.50

1.51

0.51

2.64

0.88

0.82

0.28

11.17

Other cancer

3.89

9.33

3121.62

291.40

166.23

15.52

290.56

27.12

90.75

8.47

342.51

Drowning

0.00

39.30

0.01

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

Falls

0.94

15.98

750.31

119.88

39.96

6.38

69.84

11.16

21.81

3.48

140.91

0.11

38.63

90.81

35.08

4.84

1.87

8.45

3.26

2.64

1.02

41.23

Motor vehicle accidents

0.92

38.41

739.30

283.95

39.37

15.12

68.81

26.43

21.49

8.25

333.76

Self-inflicted injuries

0.97

23.24

778.74

181.02

41.47

9.64

72.48

16.85

22.64

5.26

212.77

Other intentional injuries

0.00

28.29

0.01

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

Other unintentional injuries

0.70

26.21

561.66

147.20

29.91

7.84

52.28

13.70

16.33

4.28

173.01

Total £ (millions) Total NHS expenditure £ (millions)

15.79 31 060.3

12 663.0 80 185.2

Numbers may not add exactly to the figures shown in bold due to rounding. a

NHS Executive.14

2540.3

674.33 4270.0

135.3

1178.7 7463.6

236.5

368.1 2331.0

73.9

2985.9 94 249.8

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Poisoning

371

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of deaths attributable to alcohol in UK vary widely from 5000 to 40 000.29,30 Britton and McPherson30 found a reduction in mortality due to alcohol but noted that this protective effect was only experienced in men aged 55 and over and women aged 65 and over. This study used moderate drinking as the referent whereas abstinence was the referent in this study. What this study adds

Our estimates of £3.0 billion (2005 – 06) of UK NHS cost for alcohol consumption equates to 3.2% of total NHS expenditure. Our systematic review identified three other studies that estimated the cost of alcohol consumption to the NHS. These estimates ranged from £1.4 to £1.7 billion (2001 prices) for England25 (equating to between 2.0 and 2.5% of total NHS cost) and £ 95.6 million (2001 –02 prices) for Scotland26 (9% of total NHS expenditure). While our estimates are higher than these previous estimates they are comparable when considered as a proportion of total NHS costs suggesting the differences may reflect an overall increase in health-care costs in the intervening period. NHS costs increased from £31 billion in 1992 – 93 to £80 billion in 2005 –06.14,15 Change in treatment modalities and their associated increased cost may also explain some of these differences. Limitations of this study

A large part of the variation in the estimates may be methodological. Differing timescales, sources of cost data, weighting methods for calculating cost, diseases attributed to alcohol and the portion of each disease attributed to alcohol are just some of the factors that could affect the comparability of estimates. For example, the 1992 estimate for England and Wales of £161 million (1992 prices) derived by the Royal College of Physicians24 updates a study31 published in 1985 which estimated the NHS costs for 1983. The 1985 study used estimates from earlier case– control studies making comparisons over the intervening time with our estimate for 2005 problematic. This paper presents direct costs of ill-health related to alcohol consumption and so underestimates the total cost of alcohol to the UK. Other indirect costs such as sickness absenteeism, production losses due to alcohol-related premature mortality, morbidity or informal care, non-fatal alcohol-related injuries, crime, etc., were not included in this estimate. These indirect costs would be substantial: an estimate for England and Wales for 2001 –02 suggests that alcohol-related crime caused around £11.7 billion in costs and lost productivity due to alcohol was estimated at

£6.4 billion.25 In Scotland, the overall societal cost of alcohol consumption was reported to be more than £1 billion in 2001 –02.28 The method presented here is limited to analysis of the conditions for which the WHO Burden of Disease study has calculated PAFs, but it is conceivable that other conditions with some proportion attributable to alcohol were not included in this analysis. A further limitation is the retrospective nature of these analyses: this method provides a picture of the past burden of alcohol consumption and so ignores trends in alcohol consumption or other changes as a result of new treatment. Another limitation is the use of cost data extrapolated from 1992 –93 because current NHS cost data by disease category are unavailable. Here, the percentage of total NHS costs for a disease category (e.g. coronary heart disease) was calculated using data from 1992 – 93,14 and it was assumed that these percentages were appropriate for application to the total NHS costs from 2005 –06.15 Although the total NHS budget has more than doubled in this time, it was thought that the proportion of costs due to each disease category would remain relatively stable. There is some evidence that the costs by disease category that are predicted by this method are accurate (Balakrishnan et al., unpublished data),11 – 13 for example it was shown that 2001 –02 costs for coronary heart disease and cancer calculated using this method were very similar to estimates of direct NHS cost of these disease produced for the Wanless32 report in 2002. One of the strengths of this method is that it provides a consistent methodology for comparing the health and economic costs attributable to different risk factors (online supplementary Table S2). The method presented here has also been applied to estimate the burden of ill-health related to poor nutrition, physical inactivity, smoking, overweight and obesity. After adjusting these previous cost estimates to 2005–06 prices, the direct cost of alcohol ranks behind poor nutrition (£8.0 billion), smoking (£5.2 billion) and overweight and obesity (£4.3 billion) but ahead of physical inactivity (£1.4 billion) (Balakrishnan et al., unpublished data).11 – 13 If the aim of public health intervention is the reduction of the burden of disease, our analysis suggests that nutrition should be a higher priority than smoking, overweight and obesity or alcohol consumption. However, this interpretation does not account for the degree to which the burden of disease associated with these risk factors is avoidable, which depends upon the effectiveness of interventions aimed at reducing the risk factors in the general population. The method reported here provides a useful metric for comparing the size of the burden of different risk factors in the UK and allows for an estimation of the potential benefits of

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public health interventions, but decisions regarding distribution of health-care resources towards tackling risk factors should be based upon evidence of the cost-effectiveness of interventions.

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12 Rayner M, Scarborough P. The burden of food related ill health in the UK. J Epidemiol Community Health 2005;59:1054 – 57. 13 Allender S, Rayner M. The burden of overweight and obesity-related ill health in the UK. Obesity Rev 2007;8:467– 73. 14 NHS Executive. Burdens of Disease: A Discussion Document. London: Department of Health, 1996.

Conclusion

15 Department of Health. Resource Accounts 2005 –06. London: The Stationery Office, 2006.

Alcohol consumption is a considerable public health burden in the UK accounting for 5% (31 000) of all deaths in 2005. The estimated direct cost to the NHS in 2005–06 was £3.0 billion. Estimating the burden of ill-health related to alcohol consumption is an important component for making a business case for public health intervention and also provides one metric to track the effects of future interventions.

16 World Health Organization. World Health Report 2002. Geneva: WHO, 2003. 17 World Health Organization. Comparative Quantification of Health Risks: Global and Regional Burden of Disease Attributable to Selected Major Risk Factors. Geneva: WHO, 2004. 18 General Register Office for Scotland. Deaths Registered by Cause and Area of Residence. Edinburgh: GRO, 2006. 19 General Register Office for Northern Ireland. Statistics and Research Agency. Northern Ireland: GRO, 2006.

Funding The work presented in this paper is supported by a research grant from the British Heart Foundation.

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