BACKGROUND AND AIMS:Separate birth cohorts experience different social and environmental factors, which may lead to differences in psychological and social development and health-related behaviours. We analysed the association between age, birth cohort and body weight, glucose metabolism, diet, and cardiorespiratory fitness (CRF). METHODS AND RESULTS:The sample included two very similarly formed birth cohorts (n = 1238) of the Estonian Children Personality Behaviour and Health Study. Body weight, diet and CRF from 15 to 25 years was analysed by birth cohort using the linear mixed-effects regression model. Differences at ages 15, 18, and 25 years were assessed by independent group t-test. Prevalence of overweight and obesity increased over time across both birth cohorts and sexes. Subjects from the older birth cohort had lower measures of obesity at ages 15 and 18 years. However, in males, the difference either disappeared or was reverse by age 25. The increase per year in measures of obesity was significantly greater among subjects in the older birth cohort, compared to the younger cohort. The older birth cohort had higher daily energy intake (kcal) at ages 15 and 25 years and higher carbohydrate intake (g) at ages 15, 18 and 25 years. CONCLUSION:During profound societal changes, birth cohort effects on body weight and weight gain can rapidly emerge, with sex differences. Relationship between birth cohort and measures of obesity may at least partly be driven by energy intake, especially from carbohydrates.

Abstract Background Despite the national cervical cancer (CC) screening program established in 2006, the CC incidence in Estonia in 2020 was still one of the highest in Europe. To better understand the possible barriers among women, the aim of this study was to describe the inequalities in the Pap smear uptake trend in 2004–2020 and to analyse the associations between different factors in Estonia. Methods Weighted data of 25–64-year-old women (N = 6685) from population-based cross-sectional studies of Health Behaviour among Estonian Adult Population in 2004–2020 was used. Linear trends in uptake of Pap smear over time were tested using the Cochrane-Armitage test. Binary logistic regression with interactions was performed to analyse associations between the uptake of Pap smear and sociodemographic, socioeconomic, health-related and lifestyle factors. Crude and adjusted odds ratios with 95% confidence intervals were calculated. Results Prevalence of lifetime uptake of Pap smear increased in 2004–2020 from 50.6 to 86.7% (P < 0.001). From 2004 to 2020, uptake of Pap smear increased significantly among women aged 25–34, 35–44, 45–54 and 55–64, in both ethnicity groups and among women with basic, secondary and higher education (P < 0.001). The gap in Pap smear uptake increased between Estonians and non-Estonians but decreased between education levels over time. Lower lifetime uptake of Pap smear was associated from sociodemographic factors with younger age, being non-Estonian and single, from socioeconomic factors with lower educational level and unemployment, from health indicators with higher body mass index indicating overweight and obesity, presence of chronic disease and depressiveness, and from lifestyle factors with non-smoking. Conclusions Although Pap smear uptake among 25–64 year old women increased significantly in Estonia in 2004–2020, inequalities were found indicating an opportunity for development of targeted CC prevention strategies.

In order to implement evidence-based strategies, there is a need to assess (1) time trend in leisure time physical activity (LTPA) and (2) the relationship between trend of LTPA and trend of potential explanatory factors in Estonia from 2000 to 2018. Data from 25−64-year-old adults (n = 16,903) were drawn from cross-sectional surveys of Health Behavior among Estonian Adult Population. Joinpoint regression analysis was used to calculate annual percentage changes (APCs) and to identify whether there was a significant change in trends of LTPA. Logistic regression analysis was used to assess associations of LTPA with socioeconomic, health-related and health-behavioral factors. Prevalence of LTPA increased from 26.2% to 44.1% among men and from 28.0% to 40.6% among women from 2000 to 2018 (p < 0.001). Average APC for men was 3.4% (95% CI 2.6−4.3) and for women 2.4% (95% CI 1.4−3.4). Adjusted logistic regression model showed that LTPA was statistically significantly associated with higher education and income, economic inactivity, at-least-good self-rated health (SRH) and non-smoking. Interaction of SRH with study year was significant indicating that the association of at-least-good SRH changed over time (p = 0.016). Health promotion activities should be addressed in particular to adults with lower levels of LTPA, paying attention to the factors associated with LTPA.

Objective: Neuropeptide Y affects several physiological functions, notably appetite regulation. We analysed the association between four single nucleotide polymorphisms (SNP) in the NPY gene (rs5574, rs16147, rs16139, rs17149106) and measures of obesity, dietary intake, physical activity, blood pressure, glucose and lipid metabolism from adolescence to young adulthood.& nbsp; Methods: The sample included both birth cohorts of the Estonian Children Personality Behaviour and Health Study at ages 15 (n = 1075 with available complete data), 18 (n = 913) and 25 (n = 926) years. Linear mixedeffects regression models were used for longitudinal association between NPY SNP-s and variables of interest. Associations at ages 15, 18 and 25 were analysed by ANOVA.& nbsp; Results: Rs5574 CC-homozygotes had a greater increase per year in waist-to-hip ratio (WHR) and a smaller decrease in daily energy intake and carbohydrate intake from age 15?25 years; fasting glucose and cholesterol were higher in rs5574 CC-homozygotes. Rs16147 TT-homozygotes had higher body weight and a greater increase in sum of 5 skinfolds, waist circumference, WHR and waist-to-height ratio; however, they had lower carbohydrate intake throughout the observation period. Rs16147 TT-homozygotes and both rs16139 and rs17149106 heterozygotes had higher triglyceride levels. All NPY SNP-s were associated with blood pressure: rs5574 TT-and rs16147 CC-homozygotes had a smaller increase in diastolic blood pressure, while rs16139 and rs17149106 heterozygous had lower blood pressure throughout the study.& nbsp; Conclusion: Variants of the NPY gene were associated with measures of obesity, dietary intake, glucose and lipid metabolism and blood pressure from adolescence to young adulthood.

The severe impact of different forms of violence on health has been demonstrated in a substantial number of studies. At the same time, it has been acknowledged that different forms of violence tend to co-occur, such that many survivors of violence have been exposed to more than one violent event and/or more than one form of violence. Despite mounting evidence concerning the associations between polyvictimization and health, there are still important gaps in this knowledge concerning adult female population’s sexual health, including both physical and mental aspects associated with it. The aim of this study was to evaluate the exposure to emotional, physical, and sexual violence among women and associations with poor self-perceived health, dissatisfaction with life, stress, and worry due to sex life and sexual dysfunction. The term polyvictimization is used in this article to express the exposure to more than one form of violence. We used data from a cross-sectional study carried out in Estonia in 2014 among women aged 16 to 44 years. Responses of 2,333 women were analyzed for this article. Of all the respondents, 27.9% were polyvictimized. Women who had been exposed to all three forms of violence had, after adjusting for confounding factors, the highest risk of reporting poor self-perceived health, limited daily activities due to chronic health problems, feelings of depression, dissatisfaction with life, stress, and worry due to sex life and sexual dysfunction. The results of this study demonstrate that exposure to violence is associated with poorer health outcomes and that the association is stronger among those who have been polyvictimized.

Objectives The aims of the study were (1) to describe trends in the prevalence of monthly alcohol use from 2003 to 2015 and (2) to analyse the associations between alcohol use and family-related and school-related factors, risk behaviours and perceived alcohol availability in Estonia compared with Latvia, Lithuania, Finland and Sweden. Methods The study used nationally representative data of 15-16-year-old adolescents from the European School Survey Project on Alcohol and Other Drugs. Data from Estonia, Latvia, Lithuania, Finland and Sweden collected in 2003, 2007, 2011 and 2015 were utilised (n=57 779). The prevalence of monthly alcohol use including light and strong alcohol use was calculated for each study year. A chi(2) test for trend was used to evaluate statistically significant changes in alcohol use over the study period. A multilevel logistic regression analysis was used for assessing the association between alcohol use and explanatory factors. Marginal ORs with 95% CIs for each country were calculated. Results Monthly alcohol use decreased significantly among boys and girls in all countries from 2003 to 2015. In 2015, the prevalence of monthly alcohol use among boys was 36.1% in Estonia, 44.3% in Latvia, 32.4% in Lithuania, 32.3% in Finland and 22.4% in Sweden. Among girls, it was 39.1%, 45.9%, 35.6%, 31.8% and 29.1%, respectively. In all countries, higher odds of monthly alcohol use were observed among adolescents who skipped school, smoked cigarettes, used cannabis, perceived alcohol to be easy to access and had parents who did not know always/often about their child's whereabouts on Saturday nights. Compared with Estonia, associations between alcohol use and explanatory factors were similar in Latvia and Lithuania but different in Finland and Sweden. Conclusion Results of cross-national comparison of alcohol use and explanatory factors could be effectively used to further decrease alcohol use among adolescents.

Objective: One factor potentially contributing to obesity is reward sensitivity. We investigated the association between reward sensitivity and measures of obesity from 9-33 years of age, paying attention to the inner structure of reward sensitivity. Methods: The sample included both birth cohorts (originally n = 1176) of the Estonian Children Personality Behaviour and Health Study. The association between reward sensitivity and measures of obesity was assessed using mixed-effects regression models. Associations at ages 9 (younger cohort only), 15, 18, 25 and 33 (older cohort) years were analyzed by one-way ANOVA. The indirect effect of the gene encoding transcription factor 2 beta (TFAP2B) on obesity through reward sensitivity was tested using mediation analysis. Results: According to linear mixed effects regression models, an increase in scores of Insatiability by Reward and both of its components, Excessive Spending and Giving in to Cravings, significantly increased body weight, body mass index, sum of five skinfolds, waist circumference, hip circumference and waist-to-height ratio from 15 to 25 years of age. Findings were similar at age 9 and 33 years. In contrast, no association between obesity and Openness to Rewards or its facets was observed. The TFAP2B genotype was also associated with fixation to rewards in females, but not with striving towards reward multiplicity. Conclusion: Our results suggest that reward sensitivity is associated with obesity by its reward fixation component. The heterogeneity of the reward sensitivity construct should be taken into account in studies on body composition.

BACKGROUND:To understand better the total burden of interpersonal violence on society, it is useful to assess the prevalence of interpersonal violence among both, men and women. Exposure to multiple forms of interpersonal violence, referred to as polyvictimization, has been associated with more severe health consequences than exposure to any form separately. The aims of this study were to assess the prevalence of emotional, physical and sexual interpersonal violence in childhood, adulthood and at both childhood and adulthood among men and women in Estonia, analyze the patterns of interpersonal violence and socio-demographic correlates of polyvictimization in adulthood by gender. METHODS:The analysis was based on two population-based, cross-sectional, self-administered surveys carried out among men and women in Estonia in 2014. In both surveys, the NorVold Abuse questionnaire was used to measure exposure to interpersonal violence. Men and women aged 18-44 were included to the analysis. RESULTS:Among men 66.6% and among women 54.2% had been exposed to at least one form of interpersonal violence during lifetime. Men had been more often exposed to isolated physical interpersonal violence, among women the distribution of different forms of interpersonal violence was more even and exposure to sexual violence was more common. The prevalence of polyvictimization in adulthood was two times higher among women compared to men and more socio-demographic correlates, were associated with it. Exposure to violence in childhood was associated with polyvictimization in adulthood across gender. CONCLUSIONS:The prevalence of interpersonal violence in Estonia is high among men and women. The most prevalent forms and patterns of interpersonal violence, however, differ by gender, as do the socio-demographic correlates. Screening for interpersonal violence, in childhood and adulthood, and gender-specific interventions are needed, especially for high-risk groups identified in this study. Primary prevention of childhood violence should be a priority, as it was associated with higher risk for exposure to violence later in life across gender.

Background and aims: Fat mass and obesity-associated protein (FTO) variants are among genetic variants frequently associated with obesity. We analyzed the association between FTO rs1421085 polymorphism and obesity, dietary intake, cardiorespiratory fitness (CRF), physical activity, and socioeconomic status (SES) from the age of 9-25 years. Methods and results: The sample included both birth cohorts (originally n=1176) of the Estonian Children Personality Behaviour and Health Study. The association between FTO rs1421085 and obesity, dietary intake, CRF, physical activity, and SES from the age of 15-25 years was assessed using linear mixed-effects regression models. Associations at ages 9 (younger cohort only), 15, 18, and 25 years were assessed by one-way ANOVA. Male C-allele carriers had significantly (p < 0.05) higher body mass index (BMI), sum of 5 skinfolds, body fat percentage, and hip circumference from the age of 15-25 years. Findings were similar at the age of 9 years. In female subjects, waist-to-hip ratio was significantly greater in CC homozygotes. Interestingly, female CC homozygotes had a greater decrease in the rate of change in daily energy intake and lipid intake per year and higher physical activity score at every fixed time point. Moreover, in females, an effect of FTO x SES interaction on measures of obesity was observed. Conclusion: The FTO rs1421085 polymorphism was associated with obesity and abdominal obesity from childhood to young adulthood in males, and with abdominal obesity from adolescence to young adulthood in females. This association is rather related to differences in adipocyte energy metabolism than lifestyle. (C) 2020 The Italian Society of Diabetology, the Italian Society for the Study of Atherosclerosis, the Italian Society of Human Nutrition, and the Department of Clinical Medicine and Surgery, Federico II University. Published by Elsevier B.V. All rights reserved.

Background: Sexual violence against women is a major public health issue and a breach of human rights. Although various consequences of sexual violence on health have been described in a large number of scientific publications, very little is known about this topic in Estonia. The aim of this study was to examine the prevalence of sexual violence and associations between exposure to sexual violence and risky health and sexual behaviours among women in Estonia. Methods: A population-based cross-sectional study was carried out in Estonia in 2014. Self-reported data regarding selected indicators of risky health and sexual behaviours were collected from 1670 women, aged 18–44 years, via a self-administered questionnaire. To measure the prevalence of sexual violence, questions from the NorVold Abuse Questionnaire were included. Chi-square and multivariate logistic regression were used to analyse the data. Results: Of the respondents, 22.7% ( n =379) reported being exposed to sexual violence during their lifetime, and over half of these women had had these experiences before the age of 18. Statistically significant associations were found between sexual violence and smoking (adjusted odds ratio (AOR) 1.32, 95% CI 1.03–1.70), alcohol consumption (AOR 1.52, 95% CI 1.18–1.95), illicit drug use (AOR 2.21, 95% CI 1.70–2.89), sexual intercourse for money or other material reward (AOR 3.51, 95% CI 1.62–7.61), concurrent sexual relationships (AOR 2.64; 95% CI 1.80–3.86), and being diagnosed with sexually transmitted infections (AOR 1.48, 95% CI 1.09–2.01). Conclusions: In Estonia, sexual violence against women is widespread and is associated with several risky health and sexual behaviours. Efforts should be made, both among the general public and professionals, to raise awareness regarding the prevalence and negative impact of sexual violence. Women who have been exposed to sexual violence are in need of professional medical, legal and psychological help free from prejudice to help them recover from such traumatic events.

Abstract Background Poor self-rated health (SRH) and smoking have consistently been shown to be related to mortality. The aim of this study was to explore SRH and smoking among physicians and general population with higher education in Estonia in 2002 and 2014 and to analyse the association of SRH with smoking and sociodemographic factors. Methods This study was based on cross-sectional postal surveys among physicians and general population with higher education in Estonia n in 2002 and 2014. Calculation of age-standardized prevalence of SRH and current smoking with 95% confidence intervals (CI) was performed. Multivariate logistic regression analysis was used to measure association between SRH (at-least-good vs less-than good) and smoking status, study year, age group, ethnicity, and marital status. Fully adjusted odds ratios (OR) with 95% CI were computed. Results Age-standardized prevalence of at-least-good SRH was 71.3 and 80.6% among male physicians, 68.4 and 83.1% among female physicians, 45.4 and 67.4% among men with higher education, and 44.7 and 63.1% among women with higher education in 2002 and 2014, respectively. Age-standardized prevalence of current smoking was 26.0 and 15.6% among male physicians, 10.2 and 5.9% among female physicians, 38.7 and 22.2% among men with higher education, and 20.9 and 16.4% among women with higher education in 2002 and 2014, respectively. There was no significant gender difference in at-least-good SRH, but prevalence of current smoking was significantly higher among men in both study groups in 2002 and 2014. Compared to year 2002, odds to have at-least-good SRH was higher in 2014 (OR = 1.64; 95% CI 1.16–2.31 among male and OR = 2.36; 95% CI 2.02–2.75 among female physicians, OR = 1.49; 95% CI 1.07–2.07 among men and OR = 2.40; 95% CI 1.84–3.13). Odds to have at-least-good SRH was significantly higher among non-smokers (except female physicians), in the youngest age group, and among Estonians. Conclusions This study gave an overview of differences in SRH and smoking between two target groups with higher education in two timepoints highlighting the importance of addressing smoking cessation counselling and health promotion campaigns in the population by different subgroups in Estonia.

Smoking surveys among physicians have proved useful in highlighting the importance of physicians as healthy life style exemplars and role models in tobacco control and smoking cessation. The aim of this study was to give an overview of smoking behaviour among Estonian physicians from 1982 to 2014.

BACKGROUND:Previous reports have shown that physicians who smoke underestimate the effects of smoking on health and this influences their practice. This study was designed to investigate the views of Estonian physicians on the role of smoking in smoking-related diseases.METHODS:Cross-sectional postal surveys were sent to all practising physicians in Estonia in 1982, 2002 and 2014 providing data from 3504, 2694, and 2865 physicians respectively. Data analysis involved calculation of the prevalence of smoking with 95% confidence intervals and calculation of the prevalence of agreement with a causal role of smoking in ischaemic heart disease (IHD), lung cancer and chronic bronchitis. Logistic regression was used to analyse associations between agreement with the statements that smoking is a cause of IHD, lung cancer, chronic bronchitis and study year, smoking status, age group and ethnicity. Fully adjusted odds ratios with 95% confidence intervals were calculated.RESULTS:The age-standardized prevalence of current smoking among men decreased from 39.6% in 1982 to 14.2% in 2014, and among women from 12.4 to 5.1%, respectively. Compared with 1982, the proportion of physicians agreeing with statements that smoking is a major cause or one of the causes of IHD, lung cancer, or chronic bronchitis was significantly higher in 2002 and 2014. Past and never smokers were more likely to admit a causal role of smoking in lung cancer than smokers. Agreement with a causal role of smoking in IHD and chronic bronchitis was significantly higher among never and past smoking women only. Compared with non-Estonians, the odds ratio indicating agreement with all three statements was significantly higher among Estonians.CONCLUSION:From 1982 to 2014, physicians' attitudes towards the health risks of smoking improved in Estonia. However, their assessment of a causal role of smoking in smoking-related diseases was related to their own smoking habits and ethnicity. A further decline in smoking among Estonian physicians would require special efforts targeted at physicians. Societal pressure from a national policy could support a further decline in the social acceptability of smoking in Estonia and developments in medical education could provide continuing evidence-based information about the effects of smoking to Estonian physicians.

Background: Sexual violence (SV) is a hidden but widespread violation of human rights and a public health concern. The consequences of SV on mental health can be as serious and long-lasting as the impact on physical and sexual health. The aim of this study is to analyse the associations between the experience of SV and self-perceived health, mental well-being and current use of antidepressants among women in fertile age in Estonia. Methods: Population-based cross-sectional study was carried out in 2014 in Estonia. From the Population Registry a random sample stratified by age (age groups 16–17, 18–24, 25–34 and 35–44 years) of the female population was taken. The total sample size was 5233 women and the response rate was 47%. Out of 2368 respondents, 484 (20%) reported SV experience during their lifetime. Respondents were categorized in two groups by SV experience: with or without SV experience. X-square test and logistic regression analysis were used. Results: Women who had experienced SV were more likely to report bad/very bad health (odds ratio OR = 1.7, 95% CI 1.4–2.1) and more feelings of hopelessness, despondency and depression (OR = 1.7, 95% CI 1.3–2.2). Although women who had experienced SV reported more feelings of depression, no association was found with the use of antidepressants during the last year prior to the study (OR 1.0, 95% CI 0.6–1.8). Conclusions: Our study shows that SV is associated with bad/very bad self-reported health and feelings of depression, hopelessness and despondency. Despite of these findings, there was no association between SV and the use of antidepressants. One of the reasons for that may be current insufficient access to psychological help and stigmatization of the use of antidepressants. Higher risk for health and mental-health problems among SV survivors has to be acknowledged and appropriate help provided.

Self-rated health (SRH) and socioeconomic position (SEP) as important determinants of health differences are associated with health and economic changes in society.

OBJECTIVES:Our study aimed to explore the association between the use of effective contraceptive methods and access to different contraceptive services, as well as to describe accessibility-related obstacles when using contraceptive services and satisfaction with those services.METHODS:From a population-based cross-sectional study carried out in 2004 (response rate 53.8%), the data of 16- to 24-year-old women requiring contraception (N = 868) were analysed. Factors associated with the use of effective contraceptive methods and, specifically, hormonal methods, were explored using multiple logistic regression analysis.RESULTS:Effective contraception was used by 75.1% of the respondents. The use of effective contraceptive methods was associated with school-based sexuality education (adjusted prevalence odds ratio 2.69; 95% confidence interval 1.32 - 5.50), visiting a youth-friendly clinic (YFC) (1.82; 1.03-3.23) or a private gynaecologist (2.08; 1.11-3.92). The use of hormonal methods was additionally associated with being a native Estonian speaker and visiting a family doctor. More than half of the respondents reported some obstacle in accessing contraceptive services. The highest satisfaction ratings were given to YFCs.CONCLUSIONS:Steps to promote the use of services that are youth-friendly and associated with better uptake of effective contraceptive methods are needed among all 16- to 24-year-old women.

Background: There is little comparative information available on the occurrence of respiratory infections (RI) in infants with different degrees of maturity at birth. We aimed to determine the rate and characteristics of RI during the first two years of life in very low gestational age (VLGA) infants compared with the control cohort of full-term (FT) infants and to identify the risk factors for unfavourable outcomes of RI. Methods: The study was a part of a population-based prospective cohort study of VLGA infants born at 22-31 gestational weeks in 2007 in Estonia. At the corrected age of 2 years, surviving 155 VLGA infants were compared with their individually matched FT controls. Perinatal variables were recorded prospectively whereas episodes and characteristics of RI were assessed retrospectively by parental interviews. A logistic regression model was used to test risk factors for unfavourable outcomes (wheezing, recurrent wheezing, and hospitalisation) of RI. Results: The frequency of RI was similar in VLGA and FT infants. However, wheezing as well as recurrent wheezing due to RI was more frequent in VLGA than in FT infants, 34% vs. 21% (OR: 1.9; 95% CI: 1.1-3.2) and 14% vs. 5% (OR: 3.3; 95% CI: 1.4-7.1), respectively. During RI, VLGA infants also needed more hospitalisations (33% vs. 18%; OR: 2.3; 95% CI: 1.3-3.9). There was no significant difference between VLGA infants without bronchopulmonary dysplasia (BPD) compared with FT infants in wheezing and recurrent wheezing. BPD was the main risk factor for all unfavourable outcomes of RI. Conclusions: The frequency of RI in VLGA and FT infants is similar but BPD is more likely than prematurity in itself to predispose VLGA infants to a more severe clinical course of RI.

Background Smoking behaviour is determined by different social contexts (family, peer, school) providing adolescents with important role models. Methods This study was based on the WHO study of Health Behaviour School-Aged Children conducted in 2009/2010 in Estonia. The target group were 13- and 15-years-old adolescents (N = 2799), 1347 boys and 1452 girls. Cigarette smoking of adolescents was determined in 4-step scale: every day, at least once a week, less than once a week and do not smoke. Social …

Aims Alcohol can induce diverse serious pathologies, yet this complexity may be obscured when alcohol-related deaths are classified according to a single underlying cause. We sought to quantify this issue and its implications for analysing mortality data. Design, Setting and Participants Cross-sectional study included 554 men aged 25–54 in Estonia undergoing forensic autopsy in 2008–09. Measurements Potentially alcohol-related pathologies were identified following macroscopic and histological examination. Alcohol biomarkers levels were determined. For a subset (26%), drinking behaviour was provided by next-of-kin. The Estonian Statistics Office provided underlying cause of death. Findings Most deaths (75%) showed evidence of potentially alcohol-related pathologies, and 32% had pathologies in two or more organs. The liver was most commonly affected [60.5%, 95% confidence interval (CI) = 56.3–64.6] followed by the lungs (18.6%, 95% CI = 15.4–22.1), stomach (17.5%, 95% CI = 14.4–20.9), pancreas (14.1%, 95% CI = 11.3–17.3), heart (4.9%, 95% CI = 3.2–7.0) and oesophagus (1.4%, 95% CI = 0.6–2.8). Only a minority with liver pathology had a second pathology. The number of pathologies correlated with alcohol biomarkers (phosphatidylethanol, gamma-glytamyl transpeptidase in blood, ethylglucuronide, ethylsulphate in urine). Despite the high prevalence of liver pathology, few deaths had alcoholic liver disease specified as the underlying cause. Conclusion The majority of 554 men aged 25–54 undergoing forensic autopsy in Estonia in 2008–09 showed evidence of alcohol-related pathology. However, the recording of deaths by underlying cause failed to capture the scale and nature of alcohol-induced pathologies found.