How much did alcohol really contribute to the mortality changes?
The Russian mortality crisis is a unique and fascinating phenomenon.
The paper by Men at al is very helpful in mapping the mortality trends and
drawing attention to the problem. We agree that there is an urgent need
for more research into the causes of the mortality crisis. Men et al
proposed that the mortality crisis is linked to the social changes during
transformation, and they speculated that alcohol is an important, or
indeed the major proximal cause of mortality in Russia.
We agree that alcohol played an important role in the changes in
changes in mortality from external causes and other causes directly
related to alcohol. However, the contribution of alcohol to the overall
mortality rates, both long-term and short-term, is less clear.
First, there is no direct evidence that alcohol caused the mortality
fluctuations. The evidence is largely indirect, based on the temporal
coincidence of mortality changes with Gorbatchov’s anti-alcohol campaign
and the collapse of the Soviet Union, and on loose extrapolations from
western data. The trends in drinking are uncertain. For example, the most
often cited estimates of alcohol consumption, by Nemtsov, are partly
derived from mortality rates; this can explain why these estimates
agree well with mortality trends. Other estimates should also be
considered. For example, the well designed and carefully executed MONICA
surveys in Novosibirsk showed a decline in heavy drinking over the period
of the steep increasing mortality in the early 1990s. Data from St
Petersburg  also showed a slight decline in proportion of heavy
drinkers between the 1980s and 1990s (calculations available on request).
Second, the mortality fluctuations were roughly similar in men and
women but there is overwhelming evidence that alcohol consumption has been
low in women.[2,4-6] If these data are correct, alcohol cannot explain the
mortality changes in women.
Third, if alcohol was responsible, then the mortality increase should
be steeper in drinkers, or the prevalence of heavy drinking should have
increased between the 1980s and 1990s. The St Petersburg data  suggest
that neither of these happened. The prevalence of heavy drinking declined
from 19% in the 1980s to 15% in the 1990s; the increase in mortality was
identical in heavy drinkers and others (48% and 49%, respectively); and
the relative risk of heavy drinkers vs. the others also remained identical
(1.43 in 1980s and 1.42 in the 1990s; calculations avaialble on request).
Leaving aside short-term mortality fluctuations, the evidence on long
-term effects of heavy and binge drinking does suggest some effect on
total and cardiovascular (CVD) mortality  but the relative risks are
too small to explain much of the high CVD mortality in Russian men and the
contribution would be negligible in women.
Alcohol as the major proximal cause of the mortality crisis would be
a simple explanation, and it would provide a reasonably specific target
for policy measures (though it is debatable whether measures focused on
alcohol can be effective without addressing the underlying social problems
first). The alcohol hypothesis might well turn out to be correct. However,
the evidence available at present does not justify such a conclusion.
1 Nemtsov A. Estimates of total alcohol consumption in Russia, 1980-
1994. Drugs & Alcohol Dependence 2000; 58:133-143.
2 Malyutina S, Bobak M, Kurilovitch S, Ryizova E, Nikitin Y, Marmot
M. Alcohol consumption and binge drinking in Novosibirsk, Russia, 1985-95.
Addiction 2001; 96:987-995.
3 Plavinski SL, Plavinskaya SI, Klimov AN. Social factors and
increase in mortality in Russia in the 1990s: prospective cohort study. Br
Med J 2003; 326:1240-1242.
4 Bobak M, McKee M, Rose R, Marmot M. Acohol consumption in a
national sample of the Russian population. Addiction 1999; 94:857-866.
5 Carlson P, Vagero D. The social pattern of heavy drinking in Russia
during transition. Evidence from Taganrog 1993. Eur J Public Health 1998;
6 Palosuo H, Uutela A, Zhravleva I, Lakomova N. Observations on the
use of alcohol in Helsinki and Moscow in the 1990s. In: Simpura J, Levin
BM, (Eds). Demystifying Russian drinking. Comparative studies from the
1990s. Helsinki: STAKES, 1997: 149-174.
7 Malyutina S, Bobak M, Kurilovitch S, Gafarov V, Simonova G, Nikitin
Y et al. Relation between heavy and binge drinking and all-cause and
cardiovascular mortality in Novosibirsk, Russia: a prospective cohort
study. Lancet 2002; 360:1448-1454.
Competing interests: No competing interests