1. 1 Explanations of the East European Health Crises and Implications for Health and Social Policy

2. 2Conclusions Most current male deaths at working age in CIS are avoidable by reducing smoking and alcohol Huge opportunity to prevent future epidemic of smoking-related disease in women in CIS Improvements in health services important for secondary prevention

3. 3 What is the problem ?

4. 4 Probability of a 20 year old living to age 60 years in 2003 Source : www.mortality.org, calculations by VM Shkolnikov, Max Planck Institute

5. 5 Making the diagnosis - 1 Sharp fluctuations in mortality in CIS

6. 6 Gradual improvement in life expectancy in EU 1980-2005 EU - F EU - M Source : WHO HFA

7. 7 Sharp fluctuations in life expectancy in CIS 1980-2005 CIS-F CIS - M Source : WHO HFA

8. 8 Alcohol poisonings and life expectancy at birth Russia (M+F) 1965-2006 R= - 0.94 Source : VM Shkolnikov

9. 9 Driver of fluctuations Alcohol is the most likely factor  Very strong correlation of alcohol poisoning with life expectancy for males AND females  Gorbachev anti-alcohol campaign  Causes most affected are those directly linked to alcohol  Fluctuations least in CIS countries with lowest burden of alcohol-related mortality Smoking did not fluctuate and could NOT produce these effects Diet, exercise – little evidence

10. 10 Making the diagnosis - 3 The major problem is at working ages

11. 11 Mortality increase is at working ages (Males in Ukraine – typical of CIS) 25-64 years 75+ years 0-14 years Mortality relative to 1981 Source : WHO HFA

12. 12 Working age mortality Not pensioners, children or infants even though they are socially and economically most vulnerable The problem must be behaviours that are common at working ages There is an iceberg of ill health and disability among people who are the wealth generators of society

13. 13 Making the diagnosis - 4 Non-communicable diseases and injuries are dominant

14. 14 Deaths in Russia, aged 25-64 years, 2005 % distribution by cause of death Source : WHO HFA Men Women

15. 15 Heart disease, injuries & cancer Alcohol key driver of injuries, poisonings & violence (and possibly “heart disease”) Smoking key modifiable factor for cancer and heart disease Primary prevention essential and feasible Improved treatment important as well - but essential to reduce number of people seeking treatment through prevention

16. 16 Smoking

17. 17 Smoking causes more deaths from cardiovascular disease than cancer Deaths attributed to smoking among all men in 2000, Russia All cancers = 77,000 Cardiovascular disease = 148,000 Source : http://www.deathsfromsmoking.net/

18. 18 Smoking prevalence Very high prevalence in men – even among those who are higher educated Low, but rapidly increasing smoking in women A tragedy as this is one of very few areas where the CIS has an advantage over the West Prevalence of smoking in Russia Perlman et al. 2007

19. 19 What can be done about smoking ? Signing and ratifying FCTC  Commitment  Information  Experience of active lobbying  Pooling knowledge and resources Policy priorities  Increasing taxation  Smoking in public places  Restrictions on advertising  Access to nicotine replacement therapy

20. 20 Alcohol

21. 21 Alcohol in the former Soviet Union Climate too cold for grapes (except in South), so alcohol prepared initially from honey and later distilled from grain Long cold winters offer few other distractions One of very few consumer goods that could be produced Explicit use of alcohol as tool of state policy (under Czars and Communists)  To raise money  To keep population from revolting

22. 22 Frequency of heavy drinking among men 2 litre or more of beer 750 grams bottle of wine or more 200 grams or more of vodka or strong spirits (among those sober enough to answer question and/or remember) All respondents

23. 23 What is being drunk? Evidence from a typical Russian city The drinks  Vodka  Surrogate spirits  Alcohol containing medicines  Samogon (moonshine) 8% of healthy controls drink substances not intended for drinking! How is alcohol drunk  Heavy episodic consumption  Zapoi – a Russian word meaning getting so drunk that you withdraw from social interaction for several days 12% of controls report zapoi

24. 24 Vodka: a selection

25. 25 Samogon

26. 26 Surrogate spirits

27. 27 Alcohol containing medicines

28. 28 How much ethanol?

29. 29 What is going on? In Russian cities, a significant number of people drink surrogate alcohols Probably different in rural areas, where the equivalent is samogon (home produced) Surrogates twice as strong and 1/3 the price – i.e. six times cheaper for a given volume of alcohol Observed effects may be that once someone crosses threshold to regular surrogate consumption, price barrier essentially disappears However, where home produced spirits drunk, possibility of additional toxic organ damage

30. 30 What can be done? Reduce initiation of hazardous drinking, especially among young people Prevent hazardous drinking, especially among young people Restrict the sale of surrogate alcohols Reduce the risk of harm to those who have been drinking

31. 31 Reduce initiation of hazardous drinking, especially among young people Price  Price is an important determinant of consumption  higher prices (taxes) reduce consumption Access  Fewer sales outlets, shorter opening hours  Controls on sales to young people: but must be detected and deterred Education  Traditional negative messages are not effective  some other approaches, such as motivational Interviewing, are promising.

32. 32 Restrict the sale of surrogate alcohols This is emerging as a key issue Legislation already in place in Russia since January 2006 The challenge now is to implement and police the restrictions comprehensively

33. 33 Reduce the risk of harm to those who have been drinking Training for people who serve alcohol Sanctions against sales outlets identified as serving to people already drunk (fines/ closure) Training for police  Enforcement of drink-driving laws  Care of people found drunk