Trends in Death Associated with Abuse of Volatile Substances, 1971-1999

Tags: St George's Hospital Medical School, VSA Deaths, Northern Ireland, VSA, TOTAL, volatile substances, Scotland and Northern Ireland, plastic bag, volatile substance, death certificates, National Statistics, cleaning fluids, data collection, Age distribution, VSA mortality rates, Cranmer Terrace, Department of Public Health Sciences, the Department of Health, Medical Toxicology Unit, Volatile substance abuse, advertising campaign, St George's Hospital Medical School Department of Public Health Sciences Cranmer Terrace Tooting LONDON, Hospital Medical School
Content: Trends in Deaths Associated With Abuse of Volatile Substances 1971-1998 Department of Public Health Sciences and the Toxicology Unit Department of Cardiological Sciences St George's Hospital Medical School Cranmer Terrace, London SW17 0RE J.C. Taylor M.E. Field-Smith C.L. Norman J.M. Bland J.D. Ramsey H.R. Anderson June 2000 Report No. 13
Published by
St George's Hospital Medical School Department of Public Health Sciences Cranmer Terrace Tooting LONDON SW17 0RE Telephone: 020 8725 5491 e.mail: [email protected]
This report is available on our WEB site where previous reports can be found: http://www.sghms.ac.uk/depts/phs/vsamenu.htm
ISBN 1 8981 8318 X
St George's Hospital Medical School
VSA Deaths 1971-1998
TABLE OF CONTENTS
Page
INTRODUCTION
3
ACKNOWLEDGEMENTS
5
KEY FINDINGS FOR 1998
6
COMMENTARY
7
BIBLIOGRAPHY
17
Figure 1
Flow chart of collection and dissemination of data
18
Figure 2
Number of VSA deaths each year: 1971 - 1998
19
Figure 3
Monthly VSA deaths among children, and adults, showing
effect of 1992 advertising campaign
20
Table 1
Age distribution of deaths: 1971 - 1996, 1997 and 1998
21
Figure 4
Age distribution of deaths: 1971 - 1997 and 1998
22
Figure 5
cumulative distribution of age at death, all ages:
23
1971 - 1997 and 1998
Figure 6
Age distribution of deaths, ages 9-14, 15-19 and 20+:
24
1971 - 1998
Figure 7
Quartiles of age distribution by year of death: 1983 - 1998
25
Table 2
Sex distribution of VSA deaths: 1971 - 96, 1997 and 1998
26
Figure 8
Ratio of males to females: under 18, and 18 plus,
27
1983 -1998
Figure 9
VSA mortality rates, ages 10 to 14 by sex: 1989 - 1998
28
Figure 10
VSA mortality rates, ages 15 to 19 by sex: 1989 - 1998
29
Table 3
Number of deaths in age groups 10-14 and 15-19,
30
all causes, RTAs and VSA: 1998
Table 4
Number of VSA deaths in each Region and Country:
31
1971-1988 and each year to 1998, using GORs
1
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Table 5 Figure 11 Table 6 Figure 12 Table 7 Table 8 Table 9 Table 10 Table 11 Table 12 Figure 13 Figure 14 Figure 15 Figure 16 Figure 17 Table 13
Standardised Mortality Ratios for each Region and Country, 32 adjusted for age and sex: 1989 -1998, using GORs
Map showing Standardised Mortality Ratios for each Region 33 and Country, all ages: 1989 - 1998, using GORs
Substances abused, 1971 - 88 and each year to 1998
34
Substances abused, all ages: 1989 -1998
35
Primary substances abused: 1989 -1998
36
Product abused by substance: 1971 - 1998
37
Product abused by substance: 1998
38
Methods of administration of volatile substances:
39
1971 - 96, 1997 and 1998
Methods of administration of volatile substances
40
by substance:1971 - 96, 1997 and 1998
Mechanism of death: 1971 - 88 and each year to 1998
41
Principal mechanism of death, all ages: 1989 - 98
42
Place of death: percentages for 1998
43
Place where substance was abused: percentages for 1998 44
Place where substance was abused: males and females:
45
1990 - 1998
Place where substance was abused, by year: 1990 - 1998 46
Place where substance was abused, by age: 1990 - 1998
47
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VSA Deaths 1971-1998
INTRODUCTION This is the thirteenth annual statistical summary of data on trends in deaths associated with the deliberate inhalation of volatile substances. Data for 1998 are included here for the first time, together with updated information for earlier years, so Report 13 supersedes all previous reports. There is necessarily a delay of more than twelve months between the end of a calendar year and publication of our annual report. This is to allow time for details to become available from HM Coroners and from the Office for National Statistics (ONS), now called NS or National Statistics, and the General Register Offices for Scotland and Northern Ireland. The terms "glue sniffing" and "solvent abuse", which were commonly used in connection with volatile substance abuse, have for some years been inadequate to describe the problem, hence our adoption of the term "volatile substance abuse". We note that the World Health Organisation has also now adopted the term "volatile substance", but we consider that their term "volatile substance use" is inaccurate since the correct term for deliberate misuse is "abuse". Another term widely used is "inhalant abuse". Our data set includes deaths from 1971 onwards, and our methods of data collection have been stable and systematic since 1983. For some analyses all 3
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cases have been used. For examining some time trends, only the period of stable data collection has been used, whilst for others only the most recent ten years have been included, as appropriate. To examine recent trends 1998 has been compared with the preceding ten years, 1988 -1997.
Our information for England and Wales is provided from the following main sources: HM Coroners to whom we write regularly, ONS, the Medical Toxicology Unit, and press clippings agencies. For Scotland, information is supplied by the Crown Office and General Register Office for Scotland. Details of Northern Ireland deaths are provided by the State Pathologist's Department, HM Coroner for Greater Belfast, the General Register Office for Northern Ireland and the Lord Chancellor's Department. The Deputy Viscount in Jersey, HM Greffier in Guernsey, and the High Bailiff in the Isle of Man supply information for their areas.
Data on all cause mortality and population estimates are supplied by ONS and the General Register Offices for Scotland and Northern Ireland.
The criteria used for classifying deaths and details of how we collect the data may be found in the publications listed on page 17. Figure 1 shows the flow of collection and dissemination of data.
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VSA Deaths 1971-1998
ACKNOWLEDGEMENTS
The register of Volatile Substance Abuse deaths is funded by the Department of Health. For England and Wales we wish to thank all HM Coroners who notify cases to us, the ONS Health Statistics Division for providing death certificates, the Medical Toxicology Unit (formerly the National Poisons Unit), the British Aerosol Manufacturers' Association for giving us access to their information, and the Health and Safety Executive and the Railways Inspectorate for liaison over workplace deaths where necessary. For Scotland, we wish to thank the Crown Office for providing information on Scottish deaths, and the General Register Office for Scotland for providing death certificates. For Northern Ireland, we wish to thank the staff of the State Pathologist's Department for ascertainment, the General Register Office for Northern Ireland for death certificates, HM Coroner for Greater Belfast and the Lord Chancellor's Department for the supply of documents. We wish to thank the Deputy Viscount in Jersey, and HM Greffier in Guernsey whose assistance enables us to include information for the Channel Isles, and the High Bailiff and Coroner of Inquests for the Isle of Man. 5
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VSA Deaths 1971-1998
KEY FINDINGS FOR 1998 · There were 70 deaths associated with volatile substance abuse in 1998. · Over the last ten years, there have been significant falls in the numbers of deaths associated with aerosols and glues, whilst there has been little change in those associated with gas fuels. These are now associated with the majority of deaths. · Concern over butane lighter refills is reinforced by the figures for 1998, when they were associated with 56% of all VSA deaths. (The Cigarette Lighter Refill (Safety) Regulations 1999 under the Consumer Protection Act 1987 came into force on 1 October 1999. The deaths included in this report all occurred before that date.) · VSA deaths continue to be much more common among males than females. Although the proportion of females among the deaths has been rising in recent years, it fell from 23% in 1997 to 16% in 1998. · Death rates continue to be highest in the northern areas of the British Isles. · Volatile substance abuse accounted for one in forty of all deaths in ages 15-19 (inclusive) in the United Kingdom in 1998. · The average age at death increased fairly steadily during the 1990s. The proportion of deaths among persons under 18 years of age fell. The median age at death peaked at 20 years in 1997 and fell to 19 in 1998. It is too early to say whether the upward trend has stopped. · The most common place of abuse for adults was their own home. Most fatal abuses by children occurred in a public place.
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VSA Deaths 1971-1998
COMMENTARY Mortality associated with the abuse of volatile substances (VSA) is related to many factors, including the chemical nature of the substance itself, the product containing it, the method of inhalation and the prevalence of abuse. We have been collecting data on deaths in a systematic way since 1983. New information is added to our database when it becomes available. The purpose of this report is to monitor trends rather than to provide an exhaustive commentary. More detailed analyses of some of the data, such as the substances abused and toxicological aspects, are the subjects of separate papers. GENERAL NOTE When looking at trends and mortality rates in this report it should be remembered that they will be subject to more random variation when the numbers are small. When further cases or additional data for previous years come to light they are added to the data set. Occasionally, if later information on a death previously included puts it outside our criteria, then that death is removed from the data set. Any important revisions are noted in our reports.
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TRENDS IN TOTAL DEATHS PER YEAR The total number of deaths to the end of 1998 was 1762. During 1998 there were 70 deaths. Figure 2 gives the total number of deaths for each year. The annual variation over the ten years from 1989 to 1998 was greater than would be expected by chance1, indicating that real changes in the frequency of VSA deaths have occurred over this period.
During the period following the Department of Health's 1992 advertising campaign, there is no evidence that the changes in annual total deaths are greater than natural variation would produce2.
TIME SERIES analysis reports 8 and 9 included analyses of the monthly number of deaths following the Department of Health's advertising campaign of February 1992 aimed at parents. These showed a sharp drop in deaths among children following the campaign. To ensure that no bias was caused by the earlier omission of the cases notified late, as described above, this analysis has been repeated. It includes data for England, Wales and Scotland, as only these areas received the full campaign. As Figure 3 shows, following the campaign there was a sharp fall in deaths among children, which has persisted. We estimate that the number of deaths in persons under 18 years of age has fallen by 60% from that predicted by the previous trend3. Among adults there was a small fall, estimated to be 21%. This was not
1 chi-squared = 80.32, 9 d.f., P<0.0001 2 chi-squared = 1.63, 5 d.f., P = 0.9 3 P<0.001 95% CI 45% to 71% 8
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statistically significant 4. Thus, the evidence is that there was a large and sudden fall in VSA deaths among children following the campaign, and that this reduction has persisted up to the end of 1998.
There have been other, smaller, campaigns since 1992, aimed either at parents or young people, which may have reinforced the message of the national campaign.
AGE VSA deaths comprise an important proportion of all deaths in young people, as death from any cause in this group is rare. In 1998 the youngest child to die was aged nine. Table 1 shows the age distribution of deaths, with the highest numbers of deaths being aged 14 to 18. This group accounts for 56% of all VSA deaths from 1971 to 1998. Changes in the age distribution are illustrated in several ways. Figure 4 shows a shift in the distribution of deaths in 1998 towards higher ages. Figure 5 shows the cumulative distribution of age at death for the same years, again showing the higher age of deaths in 1998.
Figure 6 shows trends over time in the number of deaths by age group. This shows that the fall in deaths since 1990 was predominantly among young people. Among adults there was a levelling rather than a fall. Figure 7 shows the change in median age. It also shows that the age at death has risen, particularly over the years 1992 to 1994. This is statistically significant5.
4 P=0.1 (95% CI -6% to 42%) 5 t=2.85, P<0.009, Linear regression 9
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VSA Deaths 1971-1998
SEX Table 2 shows the sex distribution of deaths associated with volatile substances. Deaths are far more common amongst males than females. Over the past ten years the majority (87%) of cases have been male. It should not be inferred from this that VSA is much more common among males than females. Studies suggest that the practice of VSA is more nearly equal between the sexes. For example, Chadwick et al, 1991, reported 3.8% of boys and 4.0% of girls in a school sample had ever tried VSA, and 0.6% of boys and 0.7% of girls had abused volatile substances 10 times or more. Although the sex ratio varies from one survey to another, recent surveys are broadly consistent, (see Ives, bibliography).
The proportion of females has fallen in 1998, to 15.7%, after a rise in 1997. There appears to have been an increase in the proportion of females over time, and this change appears to have been different for children and adults. Figure 8 shows the ratio of males to females among deaths in persons aged under 18 and adults, for each year since 1983, the period over which the data collection methods have been stable. Regression analysis showed that there was no significant rise in under 18s6, but a significant rise among over 18s7. For all ages, there was a significant rise in the proportion of females over time8, and evidence9 that there was an interaction with age group, i.e. that the rate of change was different in adults than in children. 6 P=0.4 7 P<0.001 8 P<0.0001 9 P=0.02 10
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VSA Deaths 1971-1998
To take into account possible changes in the population at risk, Figures 9 and 10 show the mortality rates per million per year for the 10 -14 and 15 -19 age groups by sex. In both age groups, the mortality rates for females are generally less than those for males, particularly among 15 -19 year olds. However, in 1998 there were no male deaths in the 10 -15 year old group, although there was a 9 year-old male. It should be noted that different scales have been used for Figures 9 and 10.
Table 3 compares the numbers of VSA deaths with those from all causes and those from road traffic accidents (RTAs) at ages 10 -19. In 1998, VSA accounted for 0.4% of all deaths at ages 10 -14 and 2.5% at ages 15 -19. This compares with 16.5% and 25% of deaths associated with road traffic accidents, which are by far the most frequent cause of death in these age groups.
REGIONAL VARIATION Table 4 shows the numbers of deaths by country and region, using Government Office Regions, which were adopted during 1996. Table 5 and Figure 11 show the standardised mortality ratios (SMRs) by region and country, using Government Office Regions.
SMRs are used to compare the regions taking account of any differences in the age and sex distribution of the population. An SMR shows the ratio of the number of deaths actually observed, to the number of deaths expected if the region were like the country as a whole. This is expressed as a percentage, so the whole
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country would have SMR = 100. Regions with an SMR greater than 100 have more deaths than would be expected if the country were uniform, and regions with an SMR of less than 100 have fewer deaths.
For Government Office Regions, the highest SMRs were for North East Region, Scotland, Northern Ireland, and the Region of Yorkshire and the Humber. This regional structure separates London from the rest of south east England. It is interesting that London's SMR is below the national average, although not significantly. Thus there were more deaths than expected in the north of Great Britain and in Northern Ireland, and fewer deaths than expected in the south, particularly in East Anglia and the South West Region of England.
SUBSTANCES ABUSED We classify separately butane which is intended for fuel use, and butane used as a propellant in aerosols. The industry stopped using chlorofluorocarbons (CFCs) as a propellant in aerosols in 1989, with the exception of metered dose inhalers which are being reformulated to use hydrofluorocarbons as a propellant (British Aerosol Manufacturers' Association). This change in the composition of aerosols is part of the move away from substances causing destruction of the ozone layer and towards more "environmentally friendly" products.
Most deaths were associated with only one substance. In 6.0% of cases, two or more substances were involved. Table 6 and Figure 12 show the number of times deaths were associated with each substance. Cases where there was more than
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one substance used appear more than once in this table and graph. The primary substance abused is shown in Table 7.
Over the period 1988 to 1998 there has been a significant change in the substance abused10.
Inspection of Table 7 suggests that numbers of gas-fuel related deaths have not changed much between 1989 and 1998, and year to year variation is not significant11. The frequency of aerosol-related death has decreased considerably, and this is statistically significant12. The frequency of glue-related death has also decreased, and this is also statistically significant13. As the total number of deaths has fallen, butane now accounts for a much greater proportion of deaths, although the absolute number of butane deaths shows no significant change.
PRODUCTS ABUSED Within the broad substance categories a wide variety of products has been abused. Table 8 shows products abused by substance for 1971 to 1998 and gives types of products linked to deaths showing them as percentages of substances used rather than as percentages of the total number of deaths. Thus deaths can appear more than once in this table.
10 chi-squared = 64.88, 27 d.f., P< 0.0001, fire extinguishers, others and not knowns combined (The significance tests in this section ignore the fact that a few people appear more than once in Table 8, having abused more than one substance). 11 chi-squared = 5.68, 9 d.f., P = 0.8 12 chi-squared = 68.01, 9 d.f., P < 0.0009 13
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VSA Deaths 1971-1998
Since 1971 gas cigarette lighter refills have been linked to 80.5% of fatal abuses of gas fuel, and 33.9% of all substances fatally abused. Deodorants and antiperspirants were involved in 41.8% of fatal abuses of aerosols, and 7.7% of all substances. pain relief sprays were used in 18.1% of fatal abuses of aerosols, accounting for 3.3% of all fatal abuses. 48.7% of the fatal abuses of glue since 1971, 8.3% of all fatal abuses, have been associated with contact adhesives. Table 9 gives the same information for 1998 alone. Butane lighter fuel related deaths accounted for 54.8% of deaths, considerably more than the long-term average of 33.8% shown in Table 8.
The movement away from CFCs in accordance with the Montreal Protocol has meant that some products are no longer appearing in association with VSA deaths. There have been no deaths associated with pain relief sprays since 1994, and none with text (or typewriter) correction fluid or fire extinguishers since 1995.
METHOD OF ADMINISTRATION Methods of administration of volatile substances are shown in Table 10. Table 11 gives this information by substance and shows that, where this is recorded, the predominant method of abuse of fuel gases, (mainly butane lighter refills), is by discharging them directly into the mouth. As expected, most glues had been abused by inhalation of the fumes/vapours from plastic bags.
13 chi-squared = 33.79, 9 d.f., P < 0.00001 14
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MECHANISM OF DEATH We give priority to indirect mechanisms of death: plastic bag suffocation where the deceased has been found with a plastic bag over the head, inhalation of gastric contents, and trauma, which includes causes such as hanging and drowning. We only record a death as due to direct toxic effects if none of these priorities can be applied.
Table 12 and Figure 13 show the numbers of deaths due to each mechanism. Overall, 53.3% were due to direct toxic effects and this figure has not changed much over time. The proportions of deaths attributable to suffocation by plastic bag and trauma have fallen in recent years in line with the decline in the number of deaths associated with glues.
PREVIOUS HISTORY OF SOLVENT ABUSE There are obvious difficulties in distinguishing absolutely between the first occasion, and, for example, the second or third occasion on which VSA has taken place. In 1998, for 48 cases (68.6%) there was evidence of a previous history of solvent abuse. For the remaining people (31.4%), there was no evidence of their having indulged in VSA before. For a few of these we have strong evidence that death occurred on the occasion of first abuse. However, an absence of evidence should not lead to the assumption that death occurred on the first occasion.
PLACE WHERE SUBSTANCE WAS ABUSED Figure 14 shows the place of death. For 1998, 41.4% of cases were recorded with
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VSA Deaths 1971-1998
death having occurred in hospital or as dead on arrival at hospital, and 35.7% at home.
Figure 15 shows where substances were abused. In 1998 the most common place for abuse remains the home (52.9%), with a further 10% of abuses in the home of a friend. In 25.7% of the deaths the substance was abused in a public place such as a park, shopping centre or the street. Comparing 1998 with previous years there was no significant change in place of abuse14.
Figure 16 shows the place of abuse by sex. There was a significant difference between the sexes in the place of abuse15. Males are more likely to die than females as a result of abuse in a public place or at work, whilst more females than males die at home or at the home of a friend. Figure 17 shows the place where the substance was abused for 1990 to 1998. There was a significant change over time16. This is explained by a decline in deaths associated with abuse in a public place.
The relationship between age and place of abuse is shown in Table 13. Fatal abuse in the home was proportionately much more likely for adults than for children. The place of abuse was proportionately more likely to have been a public place for children. Back to contents
14 chi-squared = 2.67, 4 d.f, P = 0.6, combining "workplace" with "other" 15 chi-squared = 17.31, 4 d.f., P = 0.002, combining school with institution and workplace with other 16 chi-squared = 53.39, 32 d.f., P = 0.01
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BIBLIOGRAPHY
1.
Anderson HR, Dick B, MacNair RS, Palmer JC, Ramsey JD. An investigation of 140 deaths
associated with volatile substance abuse in the United Kingdom 1971-81. Hum Toxicol
1982;1:207-221.
2.
Anderson HR, MacNair RS, Ramsey JD. Deaths from the abuse of volatile substances: a
national epidemiological study. Br Med J 1985;290:304-307.
3.
Anderson HR, Bloor K, MacNair RS, Ramsey J. Recent trends in mortality associated with the
abuse of volatile substances in the UK.
Br Med J 1986;293:1472-1473.
4.
Ramsey J, Anderson HR, Bloor K, Flanagan RJ. An introduction to the practice, prevalence and
chemical toxicology of volatile substance abuse. Hum Toxicol 1989;8:261-269.
5.
Anderson HR. Increase in deaths from deliberate inhalation of fuel gases and pressurised
aerosols. Br Med J 1990;301:41.
6.
Chadwick O, Anderson HR, Bland JM, Ramsey J. Solvent abuse: a population-based
neuropsychological study. Springer-Verlag New York 1991
7.
Flanagan RJ, Ruprah M, Meredith TJ, Ramsey JD. An introduction to the clinical toxicology of
volatile substances. drug safety 1990;5(5):359-383.
8.
Ramsey JD, Anderson, HR, Taylor J, Flanagan RJ. Volatile substance abuse (solvent abuse).
Proceedings of the International Symposium on Forensic Toxicology, June 15-19, 1992. US
Department of Justice, Federal Bureau of Investigation.
9.
Esmail A, Anderson HR, Ramsey JD, Taylor J, Pottier A. Controlling deaths from volatile
substance abuse in under 18s: the effects of legislation. Br Med J 1992;305:692.
10. NIDA Research Monograph 148. Epidemiology of Inhalant Abuse: An International Perspective. 1995. National Institute of Drug Abuse. US Government Printing Office.
11. Advisory Council on the Misuse of Drugs. Volatile Substance Abuse. 1995; London HMSO. ISBN 0 11 341141 3.
12. Esmail A, Warburton B, Bland JM, Anderson HR, Ramsey J. Regional variations in deaths from volatile solvent abuse in Great Britain. Addiction 1997;92:1765-1771.
13. Bland JM, Taylor J: Deaths due to volatile substance misuse are greatly underestimated (letter). Br Med J 1998;316:146.
14. Taylor JC, Bland JM, Anderson HR: Authors overestimated number of teenagers dying from misusing volatile substances (letter). Br Med J 1998;316:312.
15. Ives R, Tasker T: Volatile substance abuse: a report on survey evidence. 1999; London. Health Education Authority. ISBN 07521 1606 1.
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VSA Deaths 1971-1998
FIGURE 1
Volatile Substance Abuse Deaths Collection and Dissemination of Data Press clippings agences
HM Coroners Crown Office, Scotland Lord Chancellor's Dept, NI
Office for National Statistics General Register Office, Scotland General Register Office, N Ireland
Deputy Viscount, Jersey HM Greffier, Guernsey High Bailiff, Isle of Man
VSA MORTALITY MONITORING
State Pathologist's Dept, NI Medical Toxicology Unit
St George's Hospital Medical School Department of Public Health Sciences
Department of Health Talks to interested groups
Regular published reports
Relevant charities
DruDgrsucgope scop
ad hoc statistics publications & liaison
Articles in scientific journals
St George's Hospital Medical School
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VSA Deaths 1971-1998
FIGURE 2
VSA Deaths by Year 1971 to 1998 : All ages ( n = 1762)
Number of Deaths
152 150 137
122 117 116 113
102 100
82 85 63
85
79
76
73
74 70
65
50
46
31
21 17
988 2432
0
71 73 75 77 79 81 83 85 87 89 91 93 95 97 98
Year
Data collection methods stable from 1983
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St George's Hospital Medical School Figure 3
VSA Deaths 1971-1998 St. George's Hospital Medical School
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VSA Deaths 1971-1998
TABLE 1
Age Distribution of Deaths 1971-1996, 1997 and 1998
AGE
1971-1996 1997
1998
TOTAL CUMULATIVE
No. % No. % No. % No. No.
%
7 9 10 11 12 13 14 15 16 17 18 19 20-24 25-34 35-44 45-54 55-64 65-74 75 & over
0 0.0 1 0.1 4 0.2 6 0.4 23 1.4 59 3.6 166 10.3 238 14.7 222 13.7 176 10.9 132 8.2 88 5.4 247 15.3 161 10.0 45 2.8 24 1.5 21 1.3 4 0.2 1 0.1
TOTAL 1618 100.0
1 1.4 0 0.0 0 0.0 0 0.0 0 0.0 3 4.1 0 0.0 4 5.4 13 17.6 7 9.5 5 6.8 3 4.1 15 20.3 13 17.6 5 6.8 3 4.1 2 2.7 0 0.0 0 0.0 74 100.0
0 0.0 1 1.4 0 0.0 0 0.0 0 0.0 0 0.0 2 2.9 5 7.1 11 15.7 6 8.6 8 11.4 4 5.7 10 14.3 18 25.7 2 2.9 3 4.3 0 0.0 0 0.0 0 0.0
1
1
0.1
2
3
0.2
4
7
0.4
6
13
0.7
23
36
2.0
62
98
5.6
168 266 15.1
247 513 29.1
246 759 43.1
189 948 53.8
145 1093 62.0
95 1188 67.4
272 1460 82.9
192 1652 93.8
52 1704 96.7
30 1734 98.4
23 1757 99.7
4 1761 99.9
1 1762 100.0
70 100.0 1762 St George's Hospital Medical School
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VSA Deaths 1971-1998
FIGURE 4
Age Distribution of Deaths All ages : 1971-1997 and 1998
60
(888)
Values in brackets are numbers of deaths
(34) 50
40
Percentage
30
20 (261*) 10 (2**) 0 10-14
15-19
1971-1997 1998
(262)(10)
(11) (125)
20-24 Age Group
25-29
(12) 8 (154) 30+
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VSA Deaths 1971-1998
FIGURE 5 100
Cumulative Distribution of Age at Death All ages : 1971-1997 and 1998
75
Cumulative Percentages
50
25
0
7
9
11 13 15 17 19 25- 45- 65-
1971-1997 1998
Age at Death
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VSA Deaths 1971-1998
FIGURE 6 100
Age Distribution of Deaths All age groups : 1971 - 1998
90
80
70
Number of Deaths
60
50
40
30
20
10
0 71 73 75 77 79 81 83 85 87 89 91 93 95 9798 Year
7-14 15-19 20+
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VSA Deaths 1971-1998
FIGURE 7 30
Quartiles of Age Distribution by Year of Death: 1983 - 1998
25
Age at Death
20
15 This graph shows the three quartiles of age. 25% of ages are less than the 25th centile. 50% are less than the median and 75% are less than the 75th centile. 10 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 Year of Death 75th centile Median age 25th centile
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St George's Hospital Medical School TABLE 2
VSA Deaths 1971-1998
Sex Distribution of Deaths 1971-1996, 1997 and 1998
1971-1996 1997 SEX No. % No.
1998 % No.
TOTAL % No. %
Male 1415 87.5 57 77.0 59 84.3 1531 86.9 Female 203 12.5 17 23.0 11 15.7 231 13.1 TOTAL 1618 100.0 74 100.0 70 100.0 1762 100.0 St George's Hospital Medical School
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St George's Hospital Medical School FIGURE 8
VSA Deaths 1971-1998
Male : Female ratio
Ratio of Males to Females Under 18 and 18 plus: 1983 - 1998
60
50
40
30
20
10
0
83
85
87
89
91
93
95
97 98
Year
< 18 18 +
NOTE: For 1984 there were no deaths of females aged 18 plus St George's Hospital Medical School
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VSA Deaths 1971-1998
FIGURE 9
VSA Mortality Rates 1989 to 1998 Males and females aged 10 - 14
10
8
Rate per million per year
6
4
2
0 89 90 91 92 Rates quoted are for the UK Males Females
93 94 Year
95 96 97 98 NOTE: There were no male deaths in this age group in 1998, but one aged 9
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VSA Deaths 1971-1998
FIGURE 10 50
VSA Mortality Rates 1989 to 1998 Males and females aged 15 - 19
40
Rate per million per year
30
20
10
0
89 90 91 92 93 94 95 96 97 98
Rates quoted are for the UK
Year
Males
Females
Return to Contents
Return to Commentary 29
St George's Hospital Medical School TABLE 3
VSA Deaths 1971-1998
Numbers of deaths in age groups 10-14 and 15-19 All causes, RTAs and VSA : 1998 England and Wales, Scotland and Northern Ireland
CAUSE OF DEATH
Ages 10-14 No.
% of all cause deaths
Ages 15-19 No.
% of all cause deaths
All causes
Male
343
215 Female
558 TOTAL
100.0 100.0 100.0
927 433 1360
100.0 100.0 100.0
Road Traffic Accidents
Male
61
31
Female
92
TOTAL
17.8 243
26.2
14.4
97
22.4
16.5 340
25.0
Volatile Substance
Abuse
Male
0
2
Female
2
TOTAL
0.0
30
3.2
0.9
4
0.9
0.4
34
2.5
St George's Hospital Medical School
Sources of data for deaths from all causes and from RTAs (ICD codes E810-
E819):
England and Wales:
Office for National Statistics Series DH2 - Mortality
Statistics: Cause 1998
General Register Office for Scotland Report of the Registrar
Scotland:
General for Scotland 1998
Northern Ireland: General Register Office for Northern Ireland
Report of the Registrar General for Northern Ireland 1998
Return to Contents
Return to Commentary 30
St George's Hospital Medical School
VSA Deaths 1971-1998
TABLE 4
Number of VSA Deaths in Each Region and Country 1971-1988 and each year to 1998 (using Government Office Regions)
REGION or COUNTRY
19711988
YEAR 89 90 91 92 93 94 95 96 97 98 TOTAL
ENGLAND: North East North West Yorkshire and the Humber East Midlands West Midlands East of England London South East South West
51 11 12 4 4 4 4 4 5 5 4 108 115 14 18 13 15 8 9 7 9 14 14 236 67 12 18 16 9 8 7 5 11 11 4 168 40 12 9 9 5 7 3 9 5 4 10 113 77 12 19 8 3 8 6 9 3 4 5 154 54 7 7 7 6 4 6 1 4 11 5 112 118 11 19 10 10 8 10 8 6 7 3 210 88 12 15 13 11 5 5 12 9 4 6 180 43 4 12 9 7 3 3 6 5 5 3 100
TOTAL ENGLAND
653 95 129 89 70 55 53 61 57 65 54 1381
WALES SCOTLAND NORTHERN IRELAND CHANNEL ISLANDS ISLE OF MAN
37 2 7 1 6 6 1 1 3 0 3
67
135 12 12 21 7 9 9 8 14 5 10 242
26 4 4 10 2 6 2 1 3 3 3
64
20010002100
6
0000110
2
TOTAL UK
853 113 152 122 85 76 65 73 79 74 70 1762 St George's Hospital Medical School
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Return to Commentary
31
St George's Hospital Medical School
VSA Deaths 1971-1998
TABLE 5
Standardised Mortality Ratios for each Region and Country 1989 - 1998 adjusted for age and sex (using Government Office Regions)
Deaths
95% confidence
REGION or COUNTRY Observed Expected SMR
interval
ENGLAND:
North East
57
39.7
144
North West
121
105.5
115
Yorkshire & the
101
77.7
130
Humber
East Midlands
73
63.1
116
West Midlands
77
81.8
94
East of England
58
79.2
73
London
92
112.2
82
South East
92
119.1
77
South West
57
71.2
80
TOTAL ENGLAND
728
748.5
WALES
30
44.5
67
SCOTLAND
107
80.0
134
NORTHERN IRELAND
38
29.0
131
106 to 181 94 to 135 105 to 155 89 to 142 73 to 115 54 to 92 65 to 99 61 to 93 59 to 101 43 to 92 108 to 159 89 to 173
WHOLE OF UK*
100
Crude Mortality Rates per million population per year
Males Females
2.66
0.45 1.53
Both
St George's Hospital Medical School
Sources of population data: England and Wales: Scotland: Northern Ireland:
Office for National Statistics General Register Office for Scotland General Register Office for Northern Ireland
*Channel Isles and Isle of Man are not included
Return to Contents
Return to Commentary 32
St George's Hospital Medical School
FIGURE 11
Standardised Mortality Ratios 1989-1998 (all ages) for each Region and Country (Government Office Regions)
VSA Deaths 1971-1998
134
144
131
115
130
116 94 73 67 82
80
77
Return to Contents
St George's Hospital Medical School Return to Commentary 33
St George's Hospital Medical School
VSA Deaths 1971-1998
TABLE 6
Substances Abused 1971 - 1988 and each year to 1998 (n=1863)
1971 -88
YEAR 89 90 91 92 93 94 95 96 97 98 TOTA L
GAS FUELS
No. 276 57 63 49 48 44 46 48 48 51 53 783 % 30.6 47.5 38.9 38.6 54.5 51.8 66.7 60.0 59.3 66.2 73.6
AEROSOL No. 191 25 34 30 11 12 2 8 12 10 7 342 S % 21.2 20.8 21.0 23.6 12.5 14.1 2.9 10.0 14.8 13.0 9.7
GLUES
No. 197 14 27 18 12 11 10 13 5 7 4 318 % 21.8 11.7 16.7 14.2 13.6 12.9 14.5 16.3 6.2 9.1 5.6
FIRE EXT No. 23 4 16 6 5 1 0 1 0 0 0 56 % 2.5 3.3 9.9 4.7 5.7 1.2 0.0 1.3 0.0 0.0 0.0
OTHER
No. 208 19 21 23 12 17 11 10 16 9 5 351 % 23.1 15.8 13.0 18.1 13.6 20.0 15.9 12.5 19.8 11.7 6.9
NOT
No. 7 1 1 1 0 0 0 0 0 0 3 13
KNOWN
% 0.8 0.8 0.6 0.8 0.0 0.0 0.0 0.0 0.0 0.0 4.2
TOTAL
No. 902 120 162 127 88 85 69 80 81 77 72 1863
% 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
St George's Hospital Medical School
NOTE:
All substances are included in this table, so numbers of substances are
greater than numbers of deaths.
Return to Contents
Return to Commentary 34
St George's Hospital Medical School
VSA Deaths 1971-1998
FIGURE 12
Substances Abused 1989 - 1998 (all ages)
Numbers of Deaths
70
60
50
40
30
20
10
0 89 90 91 92 93 94 95 96 97 98
Gas fuels
Year
Aerosols
Glues
Other (inc Fire Ext.)
Return to Contents
Return to Commentary 35
St George's Hospital Medical School
VSA Deaths 1971-1998
TABLE 7
Primary Substances Abused 1989 to 1998 (n=909)
89 90 91 92 93 94 95 96 97 98 TOTAL
GAS FUELS
No. 54 62 49 48 41 45 47 48 51 52 497 % 47.8 40.8 40.2 56.5 53.9 69.2 64.4 60.8 68.9 74.3 54.7
AEROSOL No. 24 31 27 11 11 2 5 11 8 6 136 S % 21.2 20.4 22.1 12.9 14.5 3.1 6.8 13.9 10.8 8.6 15.0
GLUES
No. 12 23 16 10 10 8 13 5 6 4 107 % 10.6 15.1 13.1 11.8 13.2 12.3 17.8 6.3 8.1 5.7 11.8
FIRE EXT No. 4 16 6 5 1 0 1 0 0 0 33 % 3.5 10.5 4.9 5.9 1.3 0.0 1.4 0.0 0.0 0.0 3.6
OTHER
No. 18 19 23 11 13 10 7 15 9 5 130 % 15.9 12.5 18.9 12.9 17.1 15.4 9.6 19.0 12.2 7.1 14.3
NOT
No. 1 1 1 0 0 0 0 0 0 3
6
KNOWN
% 0.9 0.7 0.8 0.0 0.0 0.0 0.0 0.0 0.0 4.3 0.7
TOTAL
No. 113 152 122 85 76 65 73 79 74 70 909 % 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 St George's Hospital Medical School
Return to Contents
Return to Commentary
36
St George's Hospital Medical School
VSA Deaths 1971-1998
TABLE 8
Product Abused by Substance 1971 - 1998
PRODUCT
PERCENTAGE
% OF ALL
of
SUBSTANCES
No.
SUBSTANCE GROUP
n = 1863
GAS FUELS
Lighter fuel refill canisters
630
80.5
33.8
Domestic gas (bottled)
94
12.0
5.0
Propane gas cylinder
16
2.0
0.9
Acetylene
3
0.4
0.2
natural gas
1
0.1
0.1
Unspecified butane
39
5.0
2.1
TOTAL for GAS FUELS
783
100.0
42.0
AEROSOLS
Deodorant / Antiperspirant
143
41.8
7.7
Pain relief spray
62
18.1
3.3
Air freshener
41
12.0
2.2
Hair spray
27
7.9
1.4
Cleaning fluids
15
4.4
0.8
Insect spray
7
2.0
0.4
Paint spray
8
2.3
0.4
Aerosol glue
3
0.9
0.2
Other aerosols
36
10.5
1.9
TOTAL for AEROSOLS
342
100.0
18.4
GLUES
Contact adhesives
155
48.7
8.3
Bicycle tyre repair glue
10
3.1
0.5
Model glue
3
0.9
0.2
Other glues
150
47.2
8.1
TOTAL for GLUES
318
100.0
17.1
OTHER
Typewriter correction fluid
113
32.2
6.1
Chloroform
26
7.4
1.4
Dry cleaning fluids
20
5.7
1.1
Petrol
31
8.8
1.7
Plaster remover
17
4.8
0.9
Domestic cleaning fluids
16
4.6
0.9
Industrial solvents / degreasers
15
4.3
0.8
Anaesthetic agents
20
5.7
1.1
Carbon tetrachloride
11
3.1
0.6
Paint thinners and strippers
14
4.0
0.8
Alkyl nitrites
6
1.7
0.3
Brake cleaner
3
0.9
0.2
Ether
4
1.1
0.2
Benzene
1
0.3
0.1
Petroleum spirits (excl. petrol)
1
0.3
0.1
Miscellaneous products
53
15.1
2.8
TOTAL for OTHER
351
100.0
18.8
Fire Extinguishers
56
100.0
3.0
Substance not known
13
100.0
0.7
St George's Hospital Medical School
Return to Contents
Return to Commentary 37
St George's Hospital Medical School
VSA Deaths 1971-1998
TABLE 9
Product Abused by Substance 1998
PRODUCT
PERCENTAGE
% OF ALL
of
SUBSTANCES
No.
SUBSTANCE GROUP
n= 72
GAS FUELS
Lighter fuel refill canisters
40
75.5
55.6
Domestic gas (bottled)
8
15.1
11.1
Propane gas cylinder
1
1.9
1.4
Acetylene
1
1.9
1.4
Natural gas
0
0.0
0.0
Unspecified butane
3
5.7
4.2
TOTAL for GAS FUELS
53
100.0
73.6
AEROSOLS
Deodorant / Antiperspirant
5
71.4
6.9
Pain relief spray
0
0.0
0.0
Air freshener
2
28.6
2.8
Hair spray
0
0.0
0.0
Cleaning fluids
0
0.0
0.0
Insect spray
0
0.0
0.0
Paint spray
0
0.0
0.0
Aerosol glue
0
0.0
0.0
Other aerosols
0
0.0
0.0
TOTAL for AEROSOLS
7
100.0
9.7
GLUES
Contact adhesives
2
50.0
2.8
Bicycle tyre repair glue
0
0.0
0.0
Model glue and plastic cement
0
0.0
0.0
Other glues
2
50.0
2.8
TOTAL for GLUES
4
100.0
5.6
OTHER
Typewriter correction fluid
0
0.0
0.0
Chloroform
0
0.0
0.0
Dry cleaning fluids
0
0.0
0.0
Petrol
3
60.0
4.2
Plaster remover
0
0.0
0.0
Domestic cleaning fluids
0
0.0
0.0
Industrial solvents / degreasers
0
0.0
0.0
Anaesthetic agents
0
0.0
0.0
Carbon tetrachloride
0
0.0
0.0
Paint thinners and strippers
1
20.0
1.4
Alkyl nitrites
0
0.0
0.0
Brake cleaner
0
0.0
0.0
Ether
0
0.0
0.0
Benzene
0
0.0
0.0
Petroleum spirits (excl. petrol)
0
0.0
0.0
Miscellaneous products
1
20.0
1.4
TOTAL for OTHER
5
100.0
6.9
Fire Extinguishers
0
100.0
0.0
Substance not known
3
100.0
4.2
St George's Hospital Medical School
Return to Contents
Return to Commentary 38
St George's Hospital Medical School TABLE 10
VSA Deaths 1971-1998
Methods of Administration of Volatile Substances 1971-1996, 1997 and 1998
METHOD
1971-1996 1997
1998
No. % No. % No. %
TOTAL No. %
Directly into mouth Sniffed from container Sniffed from cloth or sleeve Sniffed from plastic bag Plastic bag over head Mask or padding over face Other Not known
427 26.4 106 6.6 176 10.9 260 16.1 186 11.5 42 2.6 24 1.5 397 24.5
22 29.7 2 2.7 4 5.4 7 9.5 10 13.5 1 1.4 1 1.4 27 36.5
31 44.3 480 27.2 7 10.0 115 6.5 2 2.9 182 10.3 3 4.3 270 15.3 7 10.0 203 11.5 1 1.4 44 2.5 0 0.0 25 1.4 19 27.1 443 25.1
TOTAL
1618 100.0 74 100.0 70 100.0 1762 100.0 St George's Hospital Medical School
Return to Contents
Return to Commentary
39
St George's Hospital Medical School
VSA Deaths 1971-1998
TABLE 11 Methods of Administering Volatile Substances by Substance 1971-1996, 1997 and 1998
METHOD
1971-1996 1997
1998
No. % No. % No. %
TOTAL No. %
GAS FUELS Directly into mouth Sniffed from container Sniffed from cloth or sleeve Sniffed from plastic bag Plastic bag over head Mask or padding over face Other Not known TOTAL for GAS FUELS AEROSOLS Directly into mouth Sniffed from container Sniffed from cloth or sleeve Sniffed from plastic bag Plastic bag over head Mask or padding over face Other Not known TOTAL for AEROSOLS GLUES Directly into mouth Sniffed from container Sniffed from cloth or sleeve Sniffed from plastic bag Plastic bag over head Mask or padding over face Other Not known TOTAL for GLUES OTHER Directly into mouth Sniffed from container Sniffed from cloth or sleeve Sniffed from plastic bag Plastic bag over head Mask or padding over face Other Not known TOTAL for OTHER "Other" includes fire extinguishers Return to Contents
352 53.2 18 2.7 11 1.7 35 5.3 73 11.0 12 1.8 11 1.7 150 22.7 662 100.0
22 43.1 1 2.0 0 0.0 0 0.0 7 13.7 1 2.0 0 0.0 20 39.2 51 100.0
31 59.6 3 5.8 0 0.0 0 0.0 6 11.5 1 1.9 0 0.0 11 21.2 52 100.0
405 52.9 22 2.9 11 1.4 35 4.6 86 11.2 14 1.8 11 1.4 181 23.7 765 100.0
42 14.1 10 3.4 68 22.9 56 18.9 33 11.1 10 3.4 2 0.7 76 25.6 297 100.0
0 0.0 0 0.0 4 50.0 3 37.5 0 0.0 0 0.0 0 0.0 1 12.5 8 100.0
0 0.0 1 16.7 1 16.7 1 16.7 0 0.0 0 0.0 0 0.0 3 50.0 6 100.0
42 13.5 11 3.5 73 23.5 60 19.3 33 10.6 10 3.2 2 0.6 80 25.7 311 100.0
7 2.5 10 3.5 3 1.1 135 47.7 47 16.6 6 2.1 1 0.4 74 26.1 283 100.0
0 0.0 1 16.7 0 0.0 4 66.7 0 0.0 0 0.0 0 0.0 1 16.7 6 100.0
0 0.0 1 25.0 0 0.0 1 25.0 0 0.0 0 0.0 0 0.0 2 50.0 4 100.0
7 2.4 12 4.1 3 1.0 140 47.8 47 16.0 6 2.0 1 0.3 77 26.3 293 100.0
26 7.1 67 18.3 94 25.7 34 9.3 32 8.7 14 3.8 10 2.7 89 24.3 366 100.0
0 0.0
0 0.0
26 6.8
0 0.0
2 40.0
69 18.2
0 0.0
1 20.0
95 25.0
0 0.0
1 20.0
35 9.2
3 33.3
1 20.0
36 9.5
0 0.0
0 0.0
14 3.7
1 11.1
0 0.0
11 2.9
5 55.6
0 0.0
94 24.7
9 100.0
5 100.0 380 100.0
St George's Hospital Medical School
Return to Commentary
40
St George's Hospital Medical School TABLE 12
VSA Deaths 1971-1998
Mechanism of Death 1971-1988 and each year to 1998
YEAR 71-88 89 90 91 92 93 94 95 96 97
98 TOTAL
DIRECT TOXIC EFFECTS
No. 444 70 95 60 46 35 33 40 42 37 38 940 % 52.1 61.9 62.5 49.2 54.1 46.1 50.8 54.8 53.2 50.0 54.3 53.3
INHALATION No. 119 13 19 18 15 14 16 9 15 12
9 259
of VOMIT
% 14.0 11.5 12.5 14.8 17.6 18.4 24.6 12.3 19.0 16.2 12.9 14.7
PLASTIC BAG No. 127 13
6
8
6
9
3
7
7 10
7 203
% 14.9 11.5 3.9 6.6 7.1 11.8 4.6 9.6 8.9 13.5 10.0 11.5
TRAUMA
No. 122 15 29 26 17 16 11 15 13 10 11 285 % 14.3 13.3 19.1 21.3 20.0 21.1 16.9 20.5 16.5 13.5 15.7 16.2
OTHER
No. 13
1
1
2
1
1
2
0
2
4
1
28
% 1.5 0.9 0.7 1.6 1.2 1.3 3.1 0.0 2.5 5.4 1.4
1.6
NOT KNOWN No. 28
1
2
8
0
1
0
2
0
1
4
47
% 3.3 0.9 1.3 6.6 0.0 1.3 0.0 2.7 0.0 1.4 5.7
2.7
TOTAL
No. 853 113 152 122 85 76 65 73 79 74 70 1762 % 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 St George's Hospital Medical School
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Return to Commentary
41
St George's Hospital Medical School FIGURE 13
VSA Deaths 1971-1998
Numbers of Deaths
Principal Mechanisms of Death 1989 - 1998
100 90 80 70 60 50 40 30 20 10 0 89 90 91 92 Direct Toxic Effects Inhalation of Vomit Plastic Bag Trauma
93 94 95 96 97 98 Year St George's Hospital Medical School
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42
St George's Hospital Medical School
FIGURE 14
Place of Death Percentages for 1998 Home 38.4%
VSA Deaths 1971-1998 Home of friend 2.7%
N/K 4.1% Workplace 1.4% Hospital/DOA 38.4%
Public place 13.7% St George's Hospital Medical School
Return to Contents
Return to Commentary 43
St George's Hospital Medical School
VSA Deaths 1971-1998
FIGURE 15 Place Where Substance was Abused Percentages for 1998
Home 53.4%
0.0% Not known 9.6%
Workplace 2.7% Institution 1%
Public place 24.7%
Home of friend 8.2% St George's Hospital Medical School
Return to Contents
Return to Commentary 44
St George's Hospital Medical School
VSA Deaths 1971-1998
FIGURE 16 Place Where Substance Was Abused Males and females 1990 - 1998 (n = 796) 60
50
40
Percentage
30
20
10
0 Home Friend's Public Inst'n Work Other N/K Place of Abuse
Males (n=618)
Females (n=107)
St George's Hospital Medical School
Return to Contents
Return to Commentary 45
St George's Hospital Medical School
VSA Deaths 1971-1998
FIGURE 17 Place Where Substance Was Abused Males and females 1990 - 1998 (n = 796) 70
60
50
Percentage
40
30
20
10
0
Home Friend's 1990 1991 1992 1993 1994 1995 1996 1997 1998
Public Inst'n Work Other N/K Place of Abuse St George's Hospital Medical School
Return to Contents
Return to Commentary 46
St George's Hospital Medical School
VSA Deaths 1971-1998
TABLE 13
Place of Abuse by Age 1990 - 1998
Age group
Home Home of Public Institution/ Other TOTAL Friend Place School/ Workplace
Under 10
No. 0
0
2
0
% 0.0
0.0
100.0
0.0
0
2
0.0 100.00
10 - 14
No. 30
14
44
5
% 30.6
14.3
44.9
5.1
5
98
5.1 100.00
15 - 19
No. 135
52
166
17
% 36.3
14.0
44.6
4.6
2
372
0.5 100.00
20 - 24
No. 81
4
26
7
% 66.9
3.3
21.5
5.8
3
121
2.5 100.00
25 - 44
No. 103
6
25
8
% 72.0
4.2
17.5
5.6
1
143
0.7 100.00
45 and over No. 21
0
3
2
% 75.0
0.0
10.7
7.1
2
28
7.1 100.00
TOTAL
No. 370
76
266
39
13
764
% 48.4
9.9
34.8
5.1
1.7 100.0
St George's Hospital Medical School
NOTE:
For 32 deaths the place of abuse was not known.
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47

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