Russia’s alcohol problemBMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d5240 (Published 17 August 2011) Cite this as: BMJ 2011;343:d5240
It is 8 in the morning at the square outside Belarus station in central Moscow, but the early hour has not stopped a large number of people from drinking. A man in an ill fitting suit is striding towards the metro entrance, a can of 9% “alcopop” in one hand, briefcase in the other. Several men with heavy luggage, just disembarked from an overnight train, are drinking bottled beers in the morning sunshine around a plastic table, while at an adjacent table a woman smokes a slim cigarette and quaffs a gin and tonic mix from a can. Two bearded tramps are asleep on one of the pavements, an empty vodka bottle by their side, and all around there are kiosks selling beer and shops that sell spirits.
The scene is not unusual in Russia, where alcohol consumption is legendary. Across the country’s vast Eurasian landmass, in cities, towns, and villages, millions of Russians engage in dangerous drinking that several studies have shown has an appalling effect on public health and has contributed to the country’s demographic crisis. Last year, Prime Minister Vladimir Putin became the latest in a long line of Russian leaders to attempt to tackle the problem, pledging to halve alcohol consumption among Russians by 2020. Measures include cracking down on illegal alcohol, increasing minimum prices for alcohol, and a full ban on advertising. Tighter regulation of beer, previously classed as a soft drink in many respects, has also been announced.
Several studies have suggested that alcohol misuse has contributed hugely to death rates over the past two decades, as Russian male life expectancy took an unprecedented plunge for a country not at war. One study by British, French, and Russian researchers that looked at three industrial towns in western Siberia with typical mortality patterns found that over half of all deaths among working age men between 1990 and 2001 were due to alcohol misuse1; this compares with less than 4% of all deaths worldwide.2 The authors of the report suggested that increased alcohol consumption cost the lives of three million Russians.
What is strange for the observer of drinking in Russia is that according to statistics, while Russians are indeed among the heaviest drinkers in the industrialised world, their consumption does not seem to be as far ahead of that in other European countries as is their mortality. According to the World Health Organization’s Global Status Report on Alcohol and Health, Russia is in fourth place in absolute terms when it comes to per capita alcohol consumption, below Moldova, Czech Republic, and Hungary, with 15.8 litres of pure alcohol per person a year.2 The UK, in 17th place, consumes 13.4 litres a year—much less, but not low enough to explain the difference in health problems and death rates caused by alcohol.
Martin McKee, professor of European public health at the London School of Hygiene and Tropical Medicine, is an international expert on alcoholism in Russia and has authored several papers and studies on the subject. He highlights two particularly harmful aspects of the Russian drinking culture. One is the consumption of surrogate alcohols not originally meant for drinking, such as perfumes or surgical spirit, which are often more than twice as strong as vodka. The other is zapoi, meaning a bender. A zapoi is more than just a big night out followed by a sore head the next day, it is an extended drinking binge lasting several days or more, and often planned in advance among friends. During zapoi people cease to function properly and essentially withdraw from society for several days. Professor McKee’s estimate is that 40% of deaths among men of working age in Russia are caused by harmful drinking—just zapoi and surrogate drinking—not including the “ordinary” drinking of vodka. Extrapolated to the whole of Russia, this makes for 170 000 excess male deaths a year, and goes a long way to explaining why the life expectancy for men has hovered around 60 years in the past decade.
“Most Russians don’t drink more than most Europeans,” says Vadim Drobiz, director of the Centre for Federal and Regional Alcohol Market Studies. “The problem is that we have about 20% of people who drink four or five times the average, and this is the danger group.”
What everyone agrees on is the difficulty of finding genuinely reliable statistics on the amount that Russians drink. “We need to exercise considerable care with statistics on consumption as the official data are almost certainly an underestimate,” says Professor McKee. “In particular, we need to consider home produced spirits (samogon) and alcohol that is, at least officially, not sold for drinking.” Mr Drobiz says that, based on his personal research, he estimates that Russians consume about 2.3 billion litres of spirits a year, of which around 800 million litres are legally sold, 700 million are illegally sold, and 800 million are substitutes. The illegally sold spirits tend to be vodka and cognac made legitimately in factories but sold through corrupt schemes without going through the proper taxation channels, he says. The substitutes can be anything, from samogon, moonshine brewed up in the countryside, to all sorts of alcohol containing industrial fluids such as de-icers, eau de cologne, and surgical spirit.
There are also huge regional fluctuations in how much people drink. “As a general rule, the further north you go, the more people drink, and the further east you go, the more people drink,” says Alexander Nemtsov, head of department at the Moscow Research Institute of Psychiatry, putting the regional differences largely down to remoteness and harsher climate. He says that studies of drinking habits and, more importantly, medical interventions are not always calibrated to take into account the specifics of different regions.
Professor McKee says that his research shows that alcohol in Russia is an important cause of cardiac death, a finding that has surprised some others in the profession. “In addition to the usual injuries and liver damage, we see this pattern of drinking causing high rates of sudden cardiac death, probably as a result of abnormal heart rhythms,” he says. Although the Russian drinking patterns are unusual, they are replicated in some other areas. “What we see in Russia is also seen in its neighbours, Belarus, Ukraine, and the Baltic states. Although less researched, it is also seen in some heavy drinking cultures elsewhere, such as Glasgow.”
One of the biggest shifts in recent years in Russian drinking habits has been in the consumption of beer. Until the late Soviet period, Russians mainly drank wine and vodka, says Dr Nemtsov. In 1995, when foreign breweries first entered the Russian market en masse, the average Russian consumed 15 litres of beer a year. By 2007, this had risen to 81 litres, a more than fivefold rise in a little more than a decade. “This sort of increase in consumption has never occurred in any society, and will never occur again,” says Mr Drobiz.
Beer in Russia is not classified as an alcoholic drink, and unlike vodka it is sold in the street kiosks which dot town centres across Russia. Worried by the rapid growth in beer drinking—and egged on, some analysts say, by the power of the vodka lobby—the Russian parliament finally passed a bill earlier this year that brings the laws for beer into line with those for other alcoholic drinks. From 2013, beer will not be available in kiosks, will not be available at stations and other transport hubs, and will not be for sale during night hours.
The night ban could change Russian drinking culture substantially. Currently, the kiosks sell beer and alcopops all through the night. Although sales of spirits are banned after 11 pm, the general availability of alcohol seems a far cry from a complaint made by the alcoholic narrator in Venedikt Yerofeyev’s 1970 cult classic novel Moscow-Petushki. Skulking around the streets near Moscow’s Kursk station, he speaks of the frustrating hours at dawn when it was impossible to buy vodka. “The most powerless and shameful time in the lives of my people is the time between sunrise and when the shops open.” There have been no such troubles for citizens of post-Soviet Moscow and other Russian cities, but the ban on all night alcohol sales has been welcomed as likely to reduce drunken and disorderly behaviour on the streets. However, experts say it may not help the real problem drinkers in the Russian provinces. “To get 1 ml of alcohol from beer is much more expensive than to get it from vodka,” says Dr Nemtsov. “This means that people who drink because they want to get drunk will not drink beer. The beer drinking phenomenon is mainly a metropolitan thing; in the villages and the small towns, it’s too expensive.”
Mr Drobiz suggests that in terms of actual amount of beer consumed, the new law could have little effect. He points to neighbouring Belarus, where beer sales were banned in kiosks but consumption did not decrease. “It will leave the kiosks, but there will just be more 24 hour beer bars, to get round it,” he says.
One thing that everybody seems to agree on is that the standard government response of raising prices for alcohol is unlikely to solve the problem. The government has promised to double the minimum price of vodka, from 98 roubles (about £2, €2.4, or $3.4) for a half litre to 200 roubles, within the next three years. But while £2 per bottle sounds extraordinarily cheap (buying a coffee in central Moscow can cost three times this), compared to average salaries in the regions, where many people survive on £200 a month or less, it is not. Indeed, for many, the price of alcohol as a ratio of salary is higher than in Western Europe. “If you raise the price, people will just move on to surrogates, and that is more dangerous,” says Dr Nemtsov. “Raising the price is the worst thing you can do, in fact. You need to tackle the primary reasons why people drink. If you don’t do that, and then take away their ability to buy drink, they will find a way round. The Russian people are very resourceful.” A similar dynamic has occurred in recent years among heroin addicts who, faced with rising costs of the drug and decreased access, have turned in their thousands to desomorphine, a lethal analogue cooked up from codeine based painkillers.
“Changing the law can only do so much,” says Dr Nemtsov. “The main reasons that people in Russia drink are poverty and a lack of cultural or spiritual satisfaction. Everything else—price, access, the popularity of samogon— it’s important, but it’s all secondary.”
Cite this as: BMJ 2011;343:d5240
Competing interests: The author has completed the ICJME unified disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from him) and declares no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.