1. Alcohol and health of Russian men at working age Evidence from the Izhevsk studies (2003-2010) David Leon London School of Hygiene & Tropical Medicine Symposium "Actual Problems of Demographic Development" Moscow April 2010

2. International 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

3. Summary 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. 4 Izhevsk Family Study 2003-5 and 2008-10

5. Damaging patterns of alcohol consumption

6. 6 Prevalence of problem drinking in working age 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% Zapoi 10%11% Non-beverage alcohol 6% N ~ 1500 * Specified in questionnaire as “Perepivaet”

7. 7 Summary distribution of drinking behaviours in 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% Total 100% N=1345

8. 8 Survey of non-beverage alcohol (surrogate) availability in 17 Russian cities in 2007 Gil et al, Alcoholism : Clinical Experimental Research, 2008 Gil et al, Narkologia, 2009

9. Location of 17 surveyed cities 9

10. 10 Samples bought in Samara in April 2007 253 ml 90% 20 rbs 100 ml 70% 13 rbs

11. Ratio of the volume tank to the average unit cost of ethanol and the cost of one piece 11

12. Conclusion - 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

13. Mortality and alcohol

14. 14 Alcohol poisonings and life expectancy at birth Russia (M+F) 1965-2006 R= - 0.94 Source : VM Shkolnikov

15. 15 Impact 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.

16. Strong association of alcohol with mortality by cause Men 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)

17. Conclusion - 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

18. Drinking and employment 18

19. Cross-sectional associations of employment with drinking behaviour - Izhevsk 19 Drinking pattern Number (%) not in permanent paid employment 2003-52008-9 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%)

20. A causal loop 20 EMPLOYMENT DRINKING Bi-directional association

21. Men in permanent paid employment at baseline 2003-5 21 Drinking behaviour 2003-5 Employment status 2008-9

22. 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 in employment status

23. Conclusion - 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

24. Impact of adult drinking on children

25. Percentage of households with children under 18 years where the working age man was a hazardous drinker : Izhevsk 2008-9 Drinking pattern of man%(N) Non-hazardous77.8(580) Hazardous 22.3(93) Total households with children100.0(703) Age standardised to Izhevsk male city population in 2003 Hazardous drinking as reported by proxy informant Source : K. Keenan (unpublished)

26. Prevalence of psychiatric disorder in children aged 11-14 years and alcoholism in family Novosibirsk Alcoholism in family%(N) No19(74/388) Yes 56(10/18) Source : Goodman R, Slobodskaya H and Knyazev G. Eur Child Adolesc.Psychiatry 14 :28-33, 2005.

27. Conclusion - 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

28. Summary 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

29. Thanks to … 29 Liz AllenMartin McKee Evgueny AndreevAlexey Oralov Diana ElbourneOlga Savenko Sara CookLyudmila Saburova Artyom GilVladimir Shkolnikov Katy KeenanSusannah Tomkins Nikolay KiryanovKeith Tomlin Jim McCambridge