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Alcohol and premature death in Estonian men: a study of forensic autopsies using novel biomarkers and proxy informants

Inge Ringmets1*, Jana Tuusov23, Katrin Lang1, Marika Väli23, Kersti Pärna1, Mailis Tõnisson23, Anders Helander4, Martin McKee5 and David A Leon6

Author Affiliations

1 Department of Public Health, University of Tartu, Ravila 19, 50411 Tartu, Estonia

2 Institute of Pathological Anatomy and Forensic Medicine, University of Tartu, Ravila 19, 50411 Tartu, Estonia

3 Estonian Forensic Science Institute, Tallinn, Estonia

4 Alcohol Laboratory, Department of Laboratory Medicine, Karolinska Institutet, C1:74, Clinical Chemistry, Karolinska University Laboratory Huddinge, S-141 86 Stockholm, Sweden

5 ECOHOST, London School of Hygiene & Tropical Medicine, University of London, 15-17 Tavistock Place, London WC1H 9SH, UK

6 Department of Non-communicable Diseases Epidemiology, London School of Hygiene & Tropical Medicine, University of London, Keppel St, London WC1E 7HT, UK

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BMC Public Health 2012, 12:146  doi:10.1186/1471-2458-12-146

Published: 27 February 2012



Alcohol makes an important contribution to premature mortality in many countries in Eastern Europe, including Estonia. However, the full extent of its impact, and the mechanisms underlying it, are challenging issues to research. We describe the design and initial findings of a study aimed at investigating the association of alcohol with mortality in a large series of forensic autopsies of working-age men in Estonia.


1299 male deaths aged 25-54 years were subject to forensic autopsy in 2008-2009. The routine autopsy protocol was augmented by a more systematic inspection of organs, drug testing, assay of liver enzymes and novel biomarkers of alcohol consumption (EtG, EtS and PEth), together with proxy interviews with next of kin for deaths among men who lived in or close to a major town.


595 augmented autopsies were performed. Of these, 66% were from external causes (26% suicide, 25% poisoning). 17% were attributed to circulatory system diseases and 7% to alcoholic liver disease. Blood alcohol concentrations (BAC) of ≥ 0.2 mg/g were found for 55% of deaths. Interviews were conducted with proxy informants for 61% of the subjects who had resided in towns. Of these, 28% were reported in the previous year to have been daily or almost daily drinkers and 10% had drunk non-beverage alcohols. Blood ethanol and the liver enzyme GGT were only associated with daily drinking. However, the novel biomarkers showed a more graded response with recent consumption. In contrast, the liver enzymes AST and ALT were largely uninformative because of post-mortem changes. The presence of extremely high PEth concentrations in some samples also suggested post-mortem formation.


We have shown the feasibility of deploying an extended research protocol within the setting of routine forensic autopsies that offer scope to deepen our understanding of the alcohol-related burden of premature mortality. The most unique feature of the study is the information on a wide range of informative alcohol biomarkers, several of which have not been used previously in this sort of post-mortem research study. We have demonstrated, for the first time, the epidemiological value and validity of these novel alcohol biomarkers in post-mortem samples.