Russia: lessons for alcohol epidemiology and alcohol policy

In The Lancet, David Zaridze and colleagues1Zaridze D Lewington S Boroda A et al.Alcohol and mortality in Russia: prospective observational study of 151 000 adults.Lancet. 2014; (published online Jan 31.)http://dx.doi.org/10.1016/S0140-6736(13)62247-3PubMed Google Scholar present additional important information about alcohol epidemiology: a large prospective observational study of 151 000 adults in three Russian cities, followed up for mortality for up to 11 years. The results corroborate findings of previous studies, including a large retrospective case-control study2Zaridze D Brennan P Boreham J et al.Alcohol and cause-specific mortality in Russia: a retrospective case-control study of 48 557 adult deaths.Lancet. 2009; 373: 2201-2214Summary Full Text Full Text PDF PubMed Scopus (265) Google Scholar from the same team, indicating that mortality in Russia, especially for men, is very strongly affected by alcohol consumption. For example, risks of death at age 35–54 years were 16% (15–17), 20% (18–22), and 35% (31–39) for male smokers who reported consuming less than 1, 1–2·9, or 3 or more bottles of vodka per week, respectively. In fact, the time series of alcohol consumption per head and of all-cause mortality for men have been almost parallel for most of the past 60 years.3Leon DA Chenet L Shkolnikov V et al.Huge variation in Russian mortality rates 1984–94: artefact, alcohol, or what?.Lancet. 1997; 350: 383-388Summary Full Text Full Text PDF PubMed Scopus (638) Google Scholar, 4Nemtsov AV A contemporary history of alcohol in Russia. Södertörns högskola, Stockholm, Sweden2011Google Scholar, 5Neufeld M Rehm J Alcohol consumption and mortality in Russia since 2000—are there any changes following the alcohol policy changes starting in 2006?.Alcohol Alcohol. 2013; 48: 222-230Crossref PubMed Scopus (88) Google Scholar What, then, is specific about the Russian experience, and how does Russia contribute to our understanding of the alcohol-attributable burden of disease? The adverse effect of heavy drinking, and particularly of heavy episodic drinking,6Gmel G Rehm J Kuntsche E Binge drinking in Europe: definitions, epidemiology, and consequences.Sucht. 2003; 49: 105-116Crossref Scopus (145) Google Scholar, 7Gmel G Kuntsche E Rehm J Risky single occasion drinking: bingeing is not bingeing.Addiction. 2011; 106: 1037-1045Crossref PubMed Scopus (141) Google Scholar is clearly shown by Russian research studies.1Zaridze D Lewington S Boroda A et al.Alcohol and mortality in Russia: prospective observational study of 151 000 adults.Lancet. 2014; (published online Jan 31.)http://dx.doi.org/10.1016/S0140-6736(13)62247-3PubMed Google Scholar, 2Zaridze D Brennan P Boreham J et al.Alcohol and cause-specific mortality in Russia: a retrospective case-control study of 48 557 adult deaths.Lancet. 2009; 373: 2201-2214Summary Full Text Full Text PDF PubMed Scopus (265) Google Scholar, 3Leon DA Chenet L Shkolnikov V et al.Huge variation in Russian mortality rates 1984–94: artefact, alcohol, or what?.Lancet. 1997; 350: 383-388Summary Full Text Full Text PDF PubMed Scopus (638) Google Scholar, 4Nemtsov AV A contemporary history of alcohol in Russia. Södertörns högskola, Stockholm, Sweden2011Google Scholar The exponential nature of the relation between average alcohol consumption and mortality8Rehm J Roerecke M Reduction of drinking in problem drinkers and all-cause mortality.Alcohol Alcohol. 2013; 48: 509-513Crossref PubMed Scopus (92) Google Scholar is well portrayed in large Russian population samples such as Zaridze and colleagues’ study,1Zaridze D Lewington S Boroda A et al.Alcohol and mortality in Russia: prospective observational study of 151 000 adults.Lancet. 2014; (published online Jan 31.)http://dx.doi.org/10.1016/S0140-6736(13)62247-3PubMed Google Scholar in which substantial numbers of people report drinking three or more half-litre bottles of vodka per week. Yet the exponential curves for dose-response relations between average volume of alcohol consumption and the mortality risk of various diseases,9Rehm J Baliunas D Borges GLG et al.The relation between different dimensions of alcohol consumption and burden of disease—an overview.Addiction. 2010; 105: 817-843Crossref PubMed Scopus (785) Google Scholar which are usually derived from meta-analyses of all epidemiological studies, cannot fully explain the attributable fractions noted in studies based on large population samples from Russia. Consequently, when modelling Russia and surrounding countries with similar drinking patterns, the usual methods9Rehm J Baliunas D Borges GLG et al.The relation between different dimensions of alcohol consumption and burden of disease—an overview.Addiction. 2010; 105: 817-843Crossref PubMed Scopus (785) Google Scholar, 10Rehm J Kehoe T Gmel G Stinson F Grant B Gmel G Statistical modeling of volume of alcohol exposure for epidemiological studies of population health: the US example.Popul Health Metr. 2010; 8: 3Crossref PubMed Scopus (156) Google Scholar for estimating burden of alcohol-attributable disease in the comparative risk assessment of the last Global Burden of Disease study had to be abandoned, and region-specific relative risks from the earlier Russian case-control study of Zaridze and colleagues2Zaridze D Brennan P Boreham J et al.Alcohol and cause-specific mortality in Russia: a retrospective case-control study of 48 557 adult deaths.Lancet. 2009; 373: 2201-2214Summary Full Text Full Text PDF PubMed Scopus (265) Google Scholar used instead (for estimation of global and regional burden of disease attributable to various risk factors in 2010 see Lim and colleagues’ work;11Lim SS Vos T Flaxman AD et al.A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010.Lancet. 2012; 380: 2224-2260Summary Full Text Full Text PDF PubMed Scopus (8779) Google Scholar and the Institute for Health Metrics and Evaluation website). On its own, the overall volume of alcohol consumed in Russia, albeit high, cannot explain the high alcohol-attributable mortality; it is the combination of high overall volume with the specific pattern of episodic binges that is necessary to explain the high level and fluctuating trends of total and alcohol-attributed mortality in Russia. The study by Zaridze and colleagues1Zaridze D Lewington S Boroda A et al.Alcohol and mortality in Russia: prospective observational study of 151 000 adults.Lancet. 2014; (published online Jan 31.)http://dx.doi.org/10.1016/S0140-6736(13)62247-3PubMed Google Scholar depicts this theory: even in the highest-drinking group of men, with an average reported consumption of about five half-litre bottles of vodka per week, almost 3 days per week with abstinence were reported. Since the prevalence of smoking in men was so high, varying from 68·9% in the lowest alcohol intake group to 89·4% in the highest alcohol intake group, Zaridze and colleagues limited their main analyses to the effects of drinking among smokers. So perhaps, particularly at older ages, some of the alcohol effect reported could be attributable to an interaction between the effects of smoking and of alcohol consumption. Attributing the effect of alcohol to episodic heavy drinking patterns does not mean that alcohol policy directed at the population level to reduce overall availability does not work in Russia.12Anderson P Chisholm D Fuhr D Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol.Lancet. 2009; 373: 2234-2246Summary Full Text Full Text PDF PubMed Scopus (776) Google Scholar On the contrary, as analysis of the experiment of Mikhail Gorbachev’s 1984 alcohol restrictions indicated, reduction of alcohol availability rapidly led to less episodic heavy drinking and to greatly decreased mortality, especially for alcohol-attributable causes of death in men.3Leon DA Chenet L Shkolnikov V et al.Huge variation in Russian mortality rates 1984–94: artefact, alcohol, or what?.Lancet. 1997; 350: 383-388Summary Full Text Full Text PDF PubMed Scopus (638) Google Scholar, 4Nemtsov AV A contemporary history of alcohol in Russia. Södertörns högskola, Stockholm, Sweden2011Google Scholar A more recent example is provided by the Russian alcohol policy reforms of the first decade of the 21st century, where a decrease since 2006 in the availability of alcohol was again associated with substantially decreased alcohol consumption and mortality.5Neufeld M Rehm J Alcohol consumption and mortality in Russia since 2000—are there any changes following the alcohol policy changes starting in 2006?.Alcohol Alcohol. 2013; 48: 222-230Crossref PubMed Scopus (88) Google Scholar In other words, the fact that alcohol consumption has such a huge effect on mortality opens a door for interventions to decrease the high mortality rate in Russia, especially for men—by implementing alcohol policy that reduces the availability of alcohol, such as via price increases. Since the average life expectancy from birth for men in Russia is still only 64 years, ranking among the lowest 50 countries in the world, more effective alcohol and tobacco policy measures are urgently needed. I declare that I have no conflicts of interest. Alcohol and mortality in Russia: prospective observational study of 151 000 adultsThis large prospective study strongly reinforces other evidence that vodka is a major cause of the high risk of premature death in Russian adults. Full-Text PDF Open Access

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