5.12.4. Risk factors

The patterns in mortality from cirrhosis are largely due to changes in the two major recognized causes of this disease, i.e., hepatitis B and C virus (HBV and HCV) infection (see also Chapter 6) and alcohol drinking (Corrao and Aricò, 1998).

In addition to its association with HBV and HCV (see Chapter 6), cirrhosis mortality trends and their variability across countries appear to be mainly related to short-term changes in the patterns of alcohol consumption in several countries. In most countries, changes in alcohol consumption were followed after a few years by comparable changes in cirrhosis mortality. Historically, short-term substantial variation in cirrhosis mortality following sudden changes in alcohol consumption have been described in Paris, France, during World War II, when both alcohol consumption and cirrhosis mortality declined substantially. Thus, earlier excess of cirrhosis mortality in countries of Southern Europe are consistent with the extremely high alcohol consumption in these countries between the 1950s and the 1970s (WHO Statistical Information System, 2006a), and the subsequent favourable trends followed the decline of alcohol consumption observed thereafter (Corrao et al, 1997; La Vecchia, 2001; Ramstedt, 2001). The exceedingly high rates in the countries of Central and Eastern Europe (Hungary, Romania, Slovakia, Slovenia, Croatia) can be related to the prevalence of hepatitis and the quantity of alcohol consumption, but also to the pattern of drinking (out of meal) and to the type of alcohol consumed. In these countries, in fact, a substantial proportion of alcohol derives from fruit (plums, peaches, apricots). Moreover, home-made alcoholic beverages are widespread. There is, however, a lack of data about potentially hepato-toxic chemicals in these alcoholic beverages. Investigations on potential changes in alcohol consumption in those centres are therefore required. Likewise, the marked rises in the mortality from cirrhosis in Ireland and the UK (particularly Scotland) over the last two decades – which remain in any case far from the level reached in central and Eastern European countries – are mainly due to recent rises in alcohol consumption in these populations (Leon and McCambridge, 2006). Although there are suggestions that changes in the type of alcoholic beverages in these countries – with increasing consumption of spirits and wine – may have affected cirrhosis mortality, there is no doubt that total alcohol consumption is a major determinant of the increase of mortality from cirrhosis.