Alcohol is the main cause of the high rates and rapid fluctuations of premature adult mortality in Russia Richard Peto CTSU, University of Oxford, UK Source: David Zaridze et al in Moscow, with collaborators in Lyon and Oxford

UK & US (& China): prospective studies find smoking causes far more deaths than drinking does Russia is different

Female Male Accidents, violence & suicide NB. 5/1000 means ~10% die at 35-54

Female Male “Vascular” (mostly a peculiarly Russian ICD group, I-24: IHD, not MI)

The large apparent fluctuations in Russian vascular mortality may be due mainly to fluctuations in alcoholic heart damage or poisoning mis-certified as vascular disease

Russia, : adverse trends in mortality are NOT seen for - lung cancer mortality - other cancer mortality - childhood mortality (0-4) - mortality in old age (75-9)

Frozen social history: Russian Federation in 1988 and in 2003 Female population by birth year

↑ Born 1917

↑ Born 1917 ↑ Born

↑ Born 1917 ↑ Born ↑ Born

↑ Born 1917 ↑ Born ↑ Born ↓

1953 Russian secret police report to new Soviet leadership just after Stalin died: numbers each year between 2 world wars they had exiled, imprisoned or executed Great Terror, : 700,000 executed

↑ Born 1917 ↑ Born ↑ Born ↓

↓1988 ↑ 1994

Russia, destructive consumption of alcohol and all-cause mortality at ages 15-34, and Lancet 2009; 373: 2201

Visit, in , addresses of 60K deaths at ages in in 3 typical cities For 50K deaths (30K men, 20K women), we found family still there; interview 97% about smoking & drinking habits of deceased Controls: 6K of these deaths that were from diseases we thought unlikely to be much related to smoking or drinking (not perfect, but now confirmed by prospective data) Lancet 2009; 373: 2201

B=0.5 litre bottle of vodka (20 UK shots) Habits of ever-drinkers (few “never”): <0.5 (reference), 0.5-1, 1-3, 3+ B/week Get RR for top vs reference category (NB mean in top category ~1B/day) Lancet 2009; 373: 2201

8 diseases: Russian male RRs for ~1 bottle of vodka per day 2.1 x liver cancer 3.5 x upper aerodigestive cancer 3.3 x pneumonia 4.1 x respiratory TB 6.2 x liver disease 6.7 x pancreatic disease 3.0 x non-MI acute IHD 7.7 x ill-specified disease RR=3.8 ( ) for all 8 diseases RR=1.4 ( ) for other diseases

Medical & non-medical causes of death: Russian male RRs for ~1 bottle of vodka/day 2 x any medical cause 4 x road traffic accident 6 x any other accident 8 x suicide 10 x murder

Male mortality in Russian study regions, (“strongly alcohol-related” = non-medical causes & 8 selected diseases)

All-cause mortality, Russia and UK (to 2007): males

All-cause mortality, all Russia and UK (to 2007): females

Alcohol is the main cause of the high rates and rapid fluctuations of premature adult mortality in Russia What about the rest of the former USSR?

Alcohol is the main cause of the high rates and rapid fluctuations of premature adult mortality in Russia (especially at ages 15-54)

Ice fishermen sip vodka at a lake in Moscow Russian president Dmitry Medvedev spearheads Kremlin offensive against spirit blamed for 500,000 deaths a year: hopes shock ads & price hikes will dampen love for vodka With sensationalist adverts, steep price rises & bombastic rhetoric, Russia is pulling out all the stops. guardian.co.uk 21 June 2010guardian.co.uk

With sensationalist adverts, steep price rises and bombastic rhetoric, Russia is pulling out all the stops to curb a national love affair with vodka that is estimated to cause 500,000 deaths a year, especially among men. A series of haunting ads broadcast round the clock on state-run television show in graphic detail the damage that the drink can do. The ads follow on from government plans to double vodka prices to 200 roubles (£4.30) over the next three years, on top of new minimum price stipulations which have already sharply driven up the cost of a bottle. The new offensive is being spearheaded by President Dmitry Medvedev, who has repeatedly warned of the "national calamity" that vodka inflicts on a country with a falling population and low life expectancy.Dmitry Medvedev guardian.co.ukguardian.co.uk Monday 21 June 2010