International Health Policy Program -Thailand Thaksaphon Thamarangsi Alcohol and Russian Mortality: a continuing crisis

International Health Policy Program -Thailand 2 Input Alcohol and Russian Mortality: a continuing crisis: David Leon, et al. Addiction, 104, 2009 Alcohol is themain cause of the high rates and rapid fluctuations of premature adult mortality in Russia: Richard Peto (proceeding doc) from the Global Expert Meeting on Alcohol Health and Social Develolment, Sweden 2009 Alcohol and Global BODI focussing on infectious diseases: Jurgen Rehm (proceeding doc) from the Global Expert Meeting on Alcohol Health and Social Develolment, Sweden 2009 WHO alcohol database

International Health Policy Program -Thailand 3 Russia: Why important? High APC Harmful drinking pattern High alcohol attributable health burden

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7 Introduction Life Expectance at birth: Low and fluctuated remarkable gender difference Early childhood and elderly mortalities: stable/decrease Alcohol= most plausible, proximal explanation for the fluctuation, while smoking and health care system help explaining the low LE. Trends in alcohol consumption mirror these fluctuation The decrease in adult per capita consumption by 25%, from 14.2 to 10.5 Litre between 1984 and1987, promotes three more life expectancy years. After consumption volume rebounded back to its former level in five years later, life expectancy also returned to its initial figure. When consumption further increased to 15.0 litres per capita in 2001, moreover, an additional drop in male life expectancy was evident.

International Health Policy Program -Thailand 8 Negative population growth

International Health Policy Program -Thailand 9 Life Expectancy at birth

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International Health Policy Program -Thailand 11 Early childhood and elderly mortality

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International Health Policy Program -Thailand 13 Mortality rates comparison Russia-Western Europe

International Health Policy Program -Thailand 14 Does alcohol consumption mirror mortality? Recorded APC All causes mortality yo M

International Health Policy Program -Thailand 15 Percentage of death and DALYs attributable to alcohol and tobacco by age group: Thailand 2004

International Health Policy Program -Thailand 16 Alcohol-attributable mortality WHO CRA (2002) – Alcohol AF= 18% male and 9% female all age groups – AAF= 31% male and 20% female years Izhevsk (2003-5) – AAF= 43% of male years Thailand (2004) – AAF= 9.82% years (13.98 M, 1.12 F)

International Health Policy Program -Thailand 17 Classic cohort studies tend to underestimate mortality impact of alcohol – Fail to recruit heavy user – Late of death onset: cannot capture heavy use episode – Conventional underestimation of self report Classic alcohol BOD Izhevsk study= case-control – Proxy report – Innovative indicators Surrogate alcohol Zapoi= drinking over 2 days+ escape from normal life Hangover Sleep in clothes from drunkenness Alcohol treatment (compulsory for alcohol problems) Alcohol-attributable mortality: methodology

International Health Policy Program -Thailand 18 Cardiovascular disease CVD= largest single component of total mortality Most Russian are Caucasoid (subject to gain alcohol cardio protective effect) Harmful effect of alcohol to CVD: arrhythmia, blood clotting, and blood pressure High acute alcohol poisoning [17% of M&F (35-69) forensic autopsies had 400 mg%] [+cardio myopathy= chronic effect precipitated by final binge drinking] AAF for hypertension is 10% (Polikina O, et al 2009)

International Health Policy Program -Thailand 19 CVD and non-medical mortality

International Health Policy Program -Thailand 20 Non-beverage alcohols= surrogate alcohols Medicinal alcohol, medicine based alcohol, aftershave, lotions, perfume, shellac, varnish, antifreeze, de-icing fluids, brake fluid, industrial cleaning fluids, solvents, denatured alcohol, glues, gasoline, kerosene, tooth powder, vinegar and shoe polish Izhevsk: prevalence= 8% of years male Largely available, esp medicinal tinctures, with higher content but cheaper price to vodka Alcohol content for most common (i.e. medicinal tinctures, eau- de-colognes, antiseptic)= 60-95% with no significant amount of toxic alcohols Surrogate alcohol rose as by complication from Gorbachev’s anti-alcohol campaign Be clear: what is unrecorded alcohol?

International Health Policy Program -Thailand 21 Recorded- &unrecorded alcohol Unrecorded Legal Home brewed, where permitted Illegal Smuggling (X- border) Homebrewed, where prohibited Counterfeit bev Surrogate Recorded

International Health Policy Program -Thailand 22 Quantifying consumption Survey= underestimation Sale data=production data= cannot capture unrecorded How to quantify homebrew (Samagon in Russia) Innovative approaches – Treml, 1982: retail sales of sugar as a proxy for home-brewed – Nemstov, 2002: Treml approach plus acute alcohol poisoning 1/3 (4.9/15.5) to ½ of APC is unrecorded alcohol

International Health Policy Program -Thailand 23 Drinking behaviour Vodka and other strong spirits are most common drink among men Large hazardous amount on single occasions is common Challenge to the conventional way to define ‘binge drinking’ (X amount of alcohol in single occasion, or public drunkenness) cannot capture or face difficulty with heavy drinking episodes/ intensive drinking bouts, such as zapoi Zapoi prevalence= 12% of male Study show many problems relationship with zapoi drinkers

International Health Policy Program -Thailand 24 Who drinks in Russia? Men have higher drinker prevalence for any beverage type, higher consumption volume/episode, and hazardous drinking Social gradients of hazardous drinking – Education: higher< lower – Marital status: married<single< divorced/separated – Unemployment Bidirectional

International Health Policy Program -Thailand 25 Why do Russians drink? Major events – Collapse of communism>> convulsion – Economic downturn>>Privatization+IMF – Alcohol policy

International Health Policy Program -Thailand 26 Former USSR Russia Latvia UkraineTurkmenistanUzbekistan

International Health Policy Program -Thailand 27 Lesson learned The theory of aggregated consumption volume Benefit and (unexpected) complications of alcohol policy Relationship between SD and Alcohol consumption and Health Innovative methodology