Alcohol and health of Russian men at working age

Evidence from the Izhevsk studies (2003-2010)

David LeonLondon School of Hygiene & Tropical

Medicine

Symposium "Actual Problems of Demographic Development"Moscow April 2010

International collaborationInternational collaboration

• Izhevsk State Medical Academy• Udmurt Technical University• Max Planck Institute for Demographic Research,

Germany• London School of Hygiene & Tropical Medicine, UK• Funded by Wellcome Trust, UK

2

SummarySummary

• Damaging patterns of alcohol drinking• Availability of cheap alcohol• Burden of mortality associated with alcohol• Employment and alcohol• Impact of parental drinking on children

4

Izhevsk Family StudyIzhevsk Family Study

2003-5 and 2008-10

Damaging patterns of alcohol Damaging patterns of alcohol consumptionconsumption

6

Prevalence of problem drinking in working age Prevalence of problem drinking in working age men in Izhevsk men in Izhevsk

Over past year 2003-5(aged 25-54)

2008-9 (aged 30-59)

Hangover 2+ / week 4% 3%Drunk* 2+ / week 4% 4%Zapoi 10% 11%Non-beverage alcohol 6% 6%

N ~ 1500

* Specified in questionnaire as “Perepivaet”

7

Summary distribution of drinking behaviours in Summary distribution of drinking behaviours in working age men in Izhevsk working age men in Izhevsk

2003-5(aged 25-54)

2008-9 (aged 30-59)

Abstains 14% 15%Beer, wine, spirits 75% 72%Beer, wine, spirits [problem drinking] 5% 7%

Non-beverage alcohol 6% 6%Total 100% 100%

N=1345

8

Survey of non-beverage Survey of non-beverage alcohol (surrogate) alcohol (surrogate)

availability in 17 Russian availability in 17 Russian cities in 2007cities in 2007

Gil et al, Alcoholism : Clinical Experimental Research, 2008Gil et al, Narkologia, 2009

Location of 17 surveyed citiesLocation of 17 surveyed cities

9

Nenets autonomous district

Kirov regionKomi-Permyatzky autonomous district

Perm region

Ivanovo regionVladimir region

Republic of Mariy ElChuvash republic

Tula region

Rostov regionVolgograd region Saratov region

Tambov region

Republic of Tatarstan

Chelyabinsk region

Sverdlovsk region

Yamalo-Nenetz autonomous district

Khanty-Mansi autonomous district

Tomsk region

Republic of Khakasia

Kemerov region

Krasnoyarsk region

Evenki autonomous district

Irkutsk region

Chita region

Pskov

Korolev

St.-Petersburg

Kotlas

Murashy

Voronezh

Lukoyanov

Tyumen

YekaterinburgSamara

Chelyabinsk

Tver

Izhevsk

Kurgan

Omsk

Tambov

ViborgKhabarovsk territory

10

Samples bought in Samara in April 2007Samples bought in Samara in April 2007

253 ml90%20 rbs

100 ml70%13 rbs

Ratio of the volume tank to the average unit cost of ethanol and the cost of one piece

11

Conclusion - 1Conclusion - 1

• Affordable and easily available sources of alcohol exist outside the regulated market of legal beverage alcohols

• Non-beverage alcohols and illegal spirits are a major source of alcohol in Russia

• Major challenge to attempts to control alcohol consumption

Mortality and alcoholMortality and alcohol

14

Alcohol poisonings and life expectancy at birth Russia (M+F) Alcohol poisonings and life expectancy at birth Russia (M+F) 1965-20061965-2006

0

10

20

30

40

50

60

1965 1975 1985 1995 2005

De

ath

ra

te p

er

10

0,0

00

60

62

64

66

68

70

72

Lif

e e

xp

ec

tan

cy

, y

ea

rs

Life expectancy

Alcohol poisoning per 100,000

R= - 0.94

Source : VM Shkolnikov

15

Impact on male deathsImpact on male deaths

Hazardous drinking accounts for

43% of deaths among working age (25-54) men in Izhevsk

170,000 excess male deaths per year applied to Russia as a whole

[Note : 2009 study from Barnaul suggests more than half of all deaths attributable to alcohol]

Leon et al, Lancet (2007), 369 :2001-2009.

Strong association of alcohol with mortality by causeStrong association of alcohol with mortality by causeMen aged 25-54 years, Izhevsk, 2003 - 5Men aged 25-54 years, Izhevsk, 2003 - 5

Cause of death

Hazardous drinker

(proxy report)

OR (95% CI)

Circulatory disease 4.1 (3.2,5.3)

Acute alcohol poisoning 18.9 (10.7,33.3)

All causes 5.5 (4.5,6.6)

Conclusion - 2Conclusion - 2

• Alcohol has a major role in explaining fluctuations in mortality in Russia over past 25 years

• Alcohol appears to explain important part of cardiovascular excess in Russia > requires rethinking prevention strategies

• Alcohol and smoking may account for most of difference in mortality between Russia and Western countries

Drinking and employmentDrinking and employment

18

Cross-sectional associations of employment Cross-sectional associations of employment with drinking behaviour - Izhevskwith drinking behaviour - Izhevsk

19

Drinking pattern

Number (%) not in permanent paid employment

2003-5 2008-9

Abstains 39/239 (16.3%) 47/219 (21.5%)

Beverage only – not problematic

170/1383 (12.3%) 144/1080 (13.3%)

Beverage only – problematic

35/109 (32.1%) 32/104 (30.8%)

Non-beverage drinker 63/140 (45.0%) 38/95 (40.0%)

A causal loopA causal loop

20

EMPLOYMENT

DRINKING

Bi-directional association

Men in permanent paid employment at Men in permanent paid employment at baseline 2003-5baseline 2003-5

21

Drinking behaviour 2003-5

Employment status 2008-9

22

Baseline alcohol consumption of men in permanent paid

employment at baseline (2003-5)

Odds Ratio (95% CI) of no longer being in permanent paid

employment at follow-up (2008-9)

Adjusted for age

Adjusted for age, education, marital status, cars, central

heating

Abstains 1.06 (0.58, 1.93) 0.95 (0.52, 1.74)

Beverage only – not problematic 1.00 [ref] 1.00 [ref]

Beverage only – problematic 2.56 (1.18, 5.60) 2.42 (1.09, 5.36)

Non-beverage drinker 4.08 (2.23, 7.48) 3.62 (1.92, 6.81)

Baseline alcohol consumptions predicts change Baseline alcohol consumptions predicts change in employment status in employment status

Conclusion - 3Conclusion - 3

• Strong evidence that drinking predicts loss of permanent paid employment

• Only very weak evidence that loss of permanent paid employment predicts initiation of hazardous drinking

23

Impact of adult drinking on Impact of adult drinking on childrenchildren

Percentage of households with children under 18 Percentage of households with children under 18 years where the working age man was years where the working age man was

a hazardous drinker : Izhevsk 2008-9a hazardous drinker : Izhevsk 2008-9

Drinking pattern of man % (N)

Non-hazardous 77.8 (580)

Hazardous 22.3 (93)

Total households with children 100.0 (703)

Age standardised to Izhevsk male city population in 2003Hazardous drinking as reported by proxy informantSource : K. Keenan (unpublished)

Prevalence of psychiatric disorder in children Prevalence of psychiatric disorder in children aged 11-14 years and alcoholism in family aged 11-14 years and alcoholism in family

NovosibirskNovosibirsk

Alcoholism in family % (N)

No 19 (74/388)

Yes 56 (10/18)

Source : Goodman R, Slobodskaya H and Knyazev G. Eur Child Adolesc.Psychiatry 14 :28-33, 2005.

Conclusion - 4Conclusion - 4

• More attention needs to be given to the impact of drinking behaviour on other people

• Studying harm to others within the family is a priority :– Psychological damage to children– Domestic violence

• Need to reduce the (non-genetic) inter-generational transmission of drinking behaviour through appropriate social, psychological and medical interventions

SummarySummary

• Alcohol has a major impact on health and the workforce participation of the most economically important section of Russian society

• Negative impact of heavy drinking in Russian society extends far beyond the drinker – including damaging effects on the next generation

• Policies to reduce this problem need to be integrated and extend beyond the health sector and include the police, courts and social services

Thanks to …Thanks to …

29

Liz Allen Martin McKeeEvgueny Andreev Alexey Oralov Diana Elbourne Olga Savenko Sara Cook Lyudmila Saburova Artyom Gil Vladimir Shkolnikov Katy Keenan Susannah Tomkins

Nikolay Kiryanov Keith TomlinJim McCambridge