Alcohol and Alcoholism Advance Access published online on February 3, 2008
Alcohol and Alcoholism, doi:10.1093/alcalc/agm167
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Hazardous Alcohol Drinking in the Former Soviet Union: A Cross-Sectional Study of Eight Countries
1 European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
2 Centre for the Study of Public Policy, University of Strathclyde, Livingstone, Glasgow, G1 1XH, UK
3 Department of Politics and International Relations, University of Aberdeen, Edward Wright Building, Dunbar Street, Aberdeen AB24 3QY, UK
4 Center of Sociological and Political Studies, Belarus State University, Karl Marx Street, 31, 220030 Minsk, Belarus
5 Centre for Sociological Studies, Moscow State University, 11 Mokhovaya Street, Moscow, 103009, Russia
* Author to whom correspondence should be addressed: London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, United Kingdom. Tel.: +442076127811; Fax: +442076127812; E-mail: Joceline.Pomerleau{at}lshtm.ac.uk
Received 13 July 2005; first review notified 25 January 2005; in revised form 8 September 2005; accepted 10 September 2005
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ABSTRACT |
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Background: Hazardous consumption of large quantities of alcohol is a major cause of ill-health in the former Soviet Union (fSU). The objective of this study was to describe episodic heavy drinking and other hazardous drinking behaviors in eight countries of the fSU. Methods: Data from national surveys of adults conducted in Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia, and Ukraine in 2001 were used (overall sample size 18,428; response rates 71–88%). Heavy episodic drinking, high alcohol intake, drinking alcohol during the working day, and using illegally produced strong spirits were examined. Results: On average, 23% of men and 2% of women were defined as heavy episodic drinkers (
2 l of beer or 750 g bottle of wine or 200 g strong spirits at least once every 2–3 weeks). This was more common in young males, women who are single or who are divorced/separated/widowed, in smokers, and in frequent alcohol drinkers. About half the respondents who drank strong spirits obtained at least some alcohol from private sources. Among drinkers, 11% of males and 7% of women usually took their first drink before the end of working day. Conclusions: Heavy episodic alcohol drinking is frequent in males throughout the region—although prevalence rates may have been affected by underreporting—but is still relatively rare in women. Alcohol policies in the region should address hazardous drinking patterns and the common use of illegally produced alcohol. |
INTRODUCTION |
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Alcohol is an important cause of premature mortality in countries of the former Soviet Union (fSU) (World Health Organization, 2002
), underlying the dramatic fluctuations in life expectancy in the region since the mid-1980s that have been driven by deaths from injuries and violence, cardiovascular disease, and alcohol poisoning (Shkolnikov et al., 2001; McKee, 1999).
Many earlier studies of alcohol and health focused on the average weekly volume of alcohol consumed, reaching a consensus that regular moderate drinking has a cardio-protective effect (Murray and Lopez, 1996; Britton and McKee, 2000). However, more recent research has emphasized the importance of pattern of drinking as this has independent health effects not explained by average levels of consumption (Rehm et al., 2001a; Rehm et al., 2001b; Rehm et al., 1996; Klingemann, 2001; Kauhanen et al., 1997; Bobak et al., 2004; Litvak and Grant, 1997; Leon et al., 1997; Shkolnikov and Nemtsov, 1997). Episodic heavy drinking (sometimes described as binge drinking) has been shown to produce a set of adverse physiological effects affecting the heart that is not seen when the same total amount is consumed over a prolonged period (McKee and Britton, 1998). These effects are consistent with the apparent association between episodic heavy drinking and cardiovascular disease, and particularly with the high rates of sudden cardiac death seen in Russia (Shkolnikov et al., 2004).
While recent studies have compared drinking patterns in selected western European countries, Russia and the Baltic States (Leifman, 2002a; Norström, 2002; Reitan, 2004; Bobak et al., 2004), relatively few studies have so far compared patterns of alcohol consumption in other countries of the fSU. The objective of this study was thus to examine a range of hazardous drinking behaviors (episodic heavy drinking, high total consumption, drinking during the working day, and using illegally produced alcoholic drinks) in eight countries of the fSU, using data from the Living Conditions, Lifestyles and Health (LLH) Project. This project investigated living standards, lifestyle behaviors and health status in the adult populations of Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia, and Ukraine, using standardized methods of data collection that included quantitative cross-sectional surveys of a total of 18,428 individuals (Institute for Advanced Studies, 2005). Correlates of episodic heavy drinking and attitudes to episodic heavy drinking were also examined.
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METHODS |
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Survey methods
Details of the survey methods have been described elsewhere (Gilmore et al., 2004
). In summary, surveys were conducted in each country in the autumn of 2001 using standardized methods. Each sought to include representative samples of the population aged 18 years and over, although a few small regions that are not under the control of central governments or were subject to conflict had to be excluded from sampling in Georgia (3% of population), Moldova (15% of population), and the Russian Federation (2% of population). Individuals in the armed forces and prisoners were excluded from the samples. Other exclusion criteria (with minor variations among countries) included being mentally disabled, institutionalized, hospitalized or homeless, or being unable to respond due to intoxication. The aim was to sample at least 2000 respondents in each country, but to reach 4000 in the Russian Federation and 2500 in Ukraine to reflect the larger and more regionally diverse populations in these two countries.
Samples were selected using multistage random sampling with stratification by region and rural/urban settlement type. Within each primary sampling unit (about 50–200 per country), households were selected by random sampling from a household list (Armenia) or by standardized random route procedures (other countries). One person was chosen from each selected household (the individual whose birthday was closest to the interview date) with some substitution in all countries except Kyrgyzstan and Moldova; for example, if the household was not lived in, the building was ruined (disaster zone), or the selected individual was not in the country at the time of the survey. A prespecified quota control was used in Belarus, Kazakhstan, Moldova, and Ukraine (combination of region, area, gender, age, and/or education level), and sampling repair procedure (based on area, gender, age, and education) in Georgia and Russia. Face-to-face interviews were conducted by trained fieldworkers in the respondents’ homes, primarily in the language of the country and in Russian. Quality control procedures included reinterviews to assess the work of both the interviewers and the interviewers’ supervisors. Response rates varied between 71% and 88% among countries. A description of the survey samples is available elsewhere (Pomerleau et al., 2005).
The questionnaire was developed and piloted in consultation with country representatives using questionnaires from preexisting studies conducted in other countries in transition (McKee et al., 2000; Gilmore et al., 2001; Gilmore et al., 2002; Centre for the Study of Public Policy, 2005). In addition to covering demographic and socioeconomic characteristics, living conditions, lifestyle, use of health services, health status, and health beliefs, it examined the frequency of beer, wine, and strong spirits consumption in all respondents who reported consuming alcohol (categories were: "Daily," "4–5 times a week," "2–3 times a week," "Once a week," "Once every 2–3 weeks," "Once a month," "Once in 2–3 months," "Less often," "Never"). It also investigated the amounts typically drunk at one time in those drinking these types of drinks at least once every 2–3 weeks (see categories in Table 1). Based on this information, usual weekly intake of alcohol was estimated; respondents who reported consuming beer, wine or strong spirits less frequently than once every 2–3 weeks were assumed to have a mean weekly intake of zero gram of alcohol for these types of drinks, respectively. The reported typical amounts of alcohol consumed were converted from liters into grams of pure alcohol per week assuming 1 l beer contained 40 g pure alcohol, a 750-g bottle of wine contained 90 g pure alcohol, and a bottle of 500 ml of vodka or strong spirits contained 215 g pure alcohol, based on data from recent laboratory analyses of drinks sold in Russia (McKee et al., 2005). Those saying they drink more than 2 l beer, 1 l wine or more, and more than half a liter of vodka or strong spirits, were assumed to drink 2.5 liters of beer, 1 liter of wine, and 600 g strong spirits, respectively.
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Alcohol consumption was dichotomized using two different weekly limits of intakes to define high alcohol intake (Rehn et al., 2001): 1) >210 g alcohol in males and >140 g in females; 2) >420 g alcohol in males and 280 g in females (corresponding to a high-risk drinking for acute and chronic harm based on WHO classification (Department of Mental Health and Substance Dependence, Noncommunicable Diseases and Mental Health Cluster, 2000
)).
There remains considerable disagreement about how to define episodic heavy drinking (International Center for Alcohol Policies, 1997) and inevitably elements of the definition will be to some degree arbitrary. Several studies (including those using the term binge drinking) have used a threshold of approximately 60 or 80 g pure alcohol drunk on a single occasion while others have used lower values for women (Kauhanen et al., 1997; International Center for Alcohol Policies, 1997; Wechsler and Nelson, 2001; Bergman and Källmén, 2002; Bobak et al., 1999). Other studies have chosen the much higher cutoff value of 160 g pure alcohol (Malyutina et al., 2002; Hansagi et al., 1995). The use of a fixed cutoff point has, however, been criticized as it does not take account of the weight of the person or whether any food was eaten during the drinking episode, and because it may give the impression that consumption below that level is safe. Because this study did not include information on markers of the consequences of heavy drinking, such as frequency of hangovers, getting into trouble with police, or being unable to work because of the effects of alcohol (these could be used to help predict the negative health effects of heavy alcohol use (Shkolnikov et al., 2004)), we examined episodic heavy drinking defined as the consumption of at least 2 l beer (80+ g pure alcohol), 750 g wine (90+ g pure alcohol) or 200 g strong spirits (86+ g alcohol). We also identified respondents whose typical consumption of strong spirits was 300 g or more (129+ g alcohol) as thresholds of 120 g and 160 g pure alcohol have also been used in previous studies performed in Russia and Sweden (Bobak et al., 1999, 2004; Malyutina et al., 2002; Hansagi et al., 1995).
The questionnaire also enquired whether the respondents believed that it is important, quite important, rather unimportant, or unimportant to avoid binge drinking for keeping healthy. Given the key role attributed to episodic heavy drinking in previous research on premature mortality in Russia, the relationship between this behavior and a range of factors was examined. These included age, country, type of living settlement, marital status, religion (Muslim/other), educational achievement, economic situation, employment status ("unemployed and cannot find work" or "employed/studying/housekeeping/on maternity leave/disabled/does not want to work/other situation"), cigarette smoking, frequency of alcohol consumption, and self-perceived health. These factors were selected to identify possible social and economic correlates of episodic heavy drinking.
Statistical analyses
Data were analyzed using the statistical package Stata 6.0 (Stata Corporation, College Station, Texas). As sex is a strong predictor of alcohol intake in the fSU, results are presented separately for men and women (Simpura et al., 1997). Correlates of episodic heavy drinking and of high weekly alcohol intake were examined using multiple logistic regression analyses, adjusting for age and country of residence.
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RESULTS |
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Table 1 shows important between-country variations in the amount of beer, wine, and strong spirits usually drunk on one occasion by respondents who report consuming these types of drinks at least once every 2–3 weeks. A majority of males (75% on average) reported typically drinking between
and 1 l beer at one time (equivalent to about 20–40 g alcohol) and about 38% drink between 1 and 
l (about 40–60 g alcohol). Between 61% (Kyrgyzstan) and 95% (Armenia) of women (83% on overage) typically drank half a liter or less of beer at one time (
20 g alcohol). When drinking wine, a majority of males in all countries but Georgia (77% on average for seven countries and 10% in Georgia) say they usually drink half a bottle of wine or less (60 g alcohol) on one occasion; about half the males from the same seven countries (55% compared with 4% in Georgia) say they normally take only a maximum of one glass. In Georgia, almost two-thirds of males drinking wine at least once every 2–3 weeks say they usually take at least 1 l wine at one time. The amounts of wine generally drunk on one occasion by women are somewhat lower than those reported by men. On average, 39% of women say they usually take less than a glass and another 39% say they take only about a glass. One point to note is the relatively high proportion of Georgian women regularly drinking 1 l wine or more (16%) compared with women from other countries (range from 0% to 3%). When they drink strong spirits, a majority of males (73% on average) reported typically consuming between 100 and 300 g. However, Armenian males tended to report slightly lower intakes with 73% typically drinking 200 g or less of strong spirits. A large majority of women reported consuming 200 g or less of strong spirits (84% taking 200 g on one occasion); intakes tended to be slightly lower in Armenia, Moldova, and Ukraine (82%, 77%, and 70%, respectively, were usually consuming a maximum of 100 g strong spirits at one time, compared to 62% on average for the eight countries).
The prevalence of episodic heavy drinking is shown in Table 2. On average, 23% of men reported episodes of heavy drinking at least once every 2–3 weeks, but with large variations among countries (range 11–33%). In males, episodic heavy drinking was more frequently observed for strong spirits: on average, one in five males reported consuming at least 200 g strong spirits (86+ g pure alcohol) on one occasion (highest prevalence rates observed in Belarus, Kazakhstan, and Russia). Drinking large quantities of wine at any given time was particularly high in Georgia where 26% of the male respondents reported typically drinking at least one bottle of wine (
90+ g pure alcohol) on one occasion. Women were about 13 times, on average, less likely to report episodic heavy drinking than males, with prevalences varying from less than 1% (Armenia) to 4% (Russia and Kazakhstan). Drinking large amounts of alcohol on each occasion was slightly more common with strong spirits, with 2% of women consuming more than 200 g (86 g pure alcohol) on a typical occasion (highest prevalence as in males in Kazakhstan, Russia, and Belarus), and 1% consuming more than 300 g (highest prevalence rates also in Russia, Kazakhstan, and Belarus). In parallel with the results observed in men, drinking large quantities of wine at one go rather than strong spirits was slightly more common in women from Georgia.
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Table 3 describes the proportion of respondents classified as having high total intakes of alcohol. Mean intakes have been reported elsewhere (Pomerleau et al., 2005
). On average, 15% of male respondents had a weekly intake of pure alcohol greater than 210 g (range 7–19%) and 6% (range 3–7%) had an intake greater than 420 g. In women, alcohol consumption was much lower with median intakes of zero gram in all countries (result not shown). The proportion of women taking more than 140 g pure alcohol per week was on average only 2% (range 1–3%), and about 1% on average reported consuming more than 280 g per week.
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Correlates of episodic heavy drinking were examined using logistic regression analyses adjusting for age and country of residence. Results are described in Table 4. Age, country, smoking status, and the frequency of alcohol consumption were strong correlates of episodic heavy drinking in both males and females. A significantly lower likelihood of episodic heavy drinking was observed in older individuals (males age 60+ years and females aged 50+ years), but a higher likelihood was observed in middle-aged men (30–49 years), in smokers, and in those consuming alcohol more frequently (P-value for trend <0.0001 in males). Males and females from Armenia, Kyrgyzstan, and Moldova, and females from Georgia and Ukraine were significantly less likely to be episodic heavy drinkers compared to their Russian counterparts. In males, those who reported being single, unemployed, or with a bad self-reported health were less likely to be episodic heavy drinkers compared with, respectively, males who were married, with an occupation (employed, studying, retired, other) and those who rated their health as good. Males who believed that they could live better if the Communist system were restored had a higher odds of episodic heavy drinking compared to those who did not agree with this statement. In women, variations by marital status and economic situation were observed. Women who reported an average economic situation tended to be less likely to be episodic heavy drinkers. In contrast, women who were single or separated/divorced/widowed had a greater than 70% higher odds of episodic heavy drinking than married women.
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A large majority of respondents in all countries except Armenia believed that it is important or quite important to avoid episodic heavy drinking to keep healthy (Table 5); this represented on average 78% of males and 81% of females in these seven countries. In comparison, only 28% of Armenian males and 30% of Armenian females shared the same belief.
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Among respondents who reported drinking vodka or other strong spirits (Table 6), the proportion of those only obtaining legally produced drinks from a legitimate outlet was lowest in Georgia (14% of males and 22% of females) and highest in Kazakhstan (73% of males and 82% of females). Other respondents reported obtaining only illegally produced drinks (more than half the respondents in Georgia), or a combination legally and illegally produced beverages. The likelihood of getting vodka and other strong spirits only from a proper company was lower among the male more frequent spirits drinkers in all countries except Georgia, and in the female more frequent spirits drinkers from Belarus and Russia (country-specific tests for trend all <0.005).
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Table 7 indicates that 11% of males and 7% of women who report consuming any alcohol usually take their first drink before the end of the working day, but this varied between countries; the highest proportions were observed in Armenia (19% of males and 12% of females) and Moldova (15% of males and 9% of females). In males from all countries but Belarus and in females from Armenia, Moldova, and Ukraine, more frequent drinkers were significantly more likely to start drinking early in the day (country-specific tests for trend all <0.05).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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While most studies of episodic heavy drinking in countries of the fSU to date have focused on Russia and the Baltic States, this study provides information from eight countries representing more than four-fifths of the fSU population. The LLH surveys have several important advantages, including their use of standardized methods of data collection, sampling the general adult population of each country, relatively high overall response rates, being undertaken in respondents’ homes, and high response rates for questions related to alcohol consumption (e.g., 99.95% for overall frequency of consumption; >99.8% for the frequency of beer, wine, and strong spirits consumption). Their generalizability is thus an important strength. However, because the surveys were based on self-reported information, like all such surveys they are likely to have been affected by reporting bias. The tendency for individuals to underestimate their alcohol consumption is well known (Beaglehole and Jackson, 1992
; Nemtsov, 2003; Laatikainen et al., 2002; Leifman, 2002b) and can be expected to have affected estimates of drinking prevalence and amounts consumed in this study. In addition, heavy drinkers are generally less likely to participate in surveys and some individuals unable to give consent were intoxicated and thus excluded from the study. Furthermore, those who drink frequently to intoxication are unlikely to be able to recall accurately how much they consumed. It is also important to consider the fact that the degree of underreporting may vary among countries even if similar measurement techniques and standardized questions are used; cross-country comparisons thus need to be made very cautiously (Leifman, 2002b; Embree and Whitehead, 1998). Another limitation is that our data do not distinguish lifelong abstainers and ex-drinkers. In addition, data on the usual amounts consumed were available only for those drinking at least once every 2–3 weeks; this may have resulted in the exclusion of quite significant proportions of heavy less regular drinkers. Moreover, LLH data did not permit the assessment of whether respondents might be drinking different types of alcoholic beverages in combination, thus potentially leading to an underestimation of heavy alcohol use. Even though the overall sample size in each country is relatively large, the small size of certain subgroups reduced the power to detect significant differences, and data were only collected on individuals aged 18 years and over, which precludes the exploration of hazardous drinking in adolescents.
Our study confirms the widespread use of privately made drinks with about half the respondents obtaining some or all of their alcohol from private sources. However, these surveys were undertaken before the nature of these products became well understood; furthermore, the questions did not explore the types of product consumed. One study in a typical Russian city found that 1 in 12 men of working age was drinking surrogate alcohols, a range of products comprising aftershaves, medicinal tinctures, and technical liquids such as fire lighting fluid (Tomkins et al., 2007). Although officially not intended for consumption, these products are sold in the clear knowledge that they would be drunk. Thus, the aftershaves are simply 95% ethanol and very few contain any scent. Where other substances are present, such as lemon extracts, they are described as "flavors" (McKee et al., 2005). Very recent work has shown how consumption of these products is specifically associated with premature death from many alcohol-related disorders, even after adjustment for other alcoholic drinks (Leon et al., 2007).
While recognizing the many limitations of this research, these results suggest that occasional heavy drinking is frequent in males from the region covered by the surveys, even though a large majority of male respondents in most countries appeared to understand the adverse consequences of such drinking for their health. Based on our definition of episodic heavy drinking (80 g alcohol from beer, 90 g alcohol from wine, or 86 g alcohol from strong spirits in one drinking occasion at least once every 2–3 weeks), 23% of males and 2% of females were, on average, engaging in episodes of heavy drinking at least once every 2–3 weeks. In males, the highest prevalence of episodic heavy drinking tended to be in Belarus, Russia, Kazakhstan (consuming spirits) and Georgia (mainly consuming wine), and lowest in Kyrgyzstan (country with the highest proportion of Muslim respondents). In women, the highest prevalence was in Russia and Kazakhstan, and lowest in Armenia. Eleven percent of males and 1% of females reported drinking large amounts of spirits (129 g alcohol at least once every 2–3 weeks); the highest proportions were once again observed in Belarus, Russia, and Kazakhstan. Interestingly, Armenian respondents, who were the least concerned about the health consequences of episodic heavy drinking, were also relatively less likely to engage in this drinking pattern. This deserves further investigation including that in the perceived definition of what constitutes "binge" drinking. In particular, future research should ask about episodes of zapoi, a Russian term used to describe a binge lasting several days during which the individual concerned is unable to function (Leon et al., 2007).
Although these data do not provide information about changes in patterns of consumption over time, this was looked at in a study of trends in episodic heavy drinking in an urban population of Russia (Novosibirsk) between 1985 and 1995 (Malyutina et al., 2001). It suggested that episodic heavy drinking, defined as consuming at least 80 g alcohol at a single occasion at least once a month, changed in men aged 25–64 years from 36% in 1985–86 to 52% in 1988–89 and to 51% in 1994–95. In women it increased from 0.4% in 1985–86 to 5% in 1994–95. This highlights the importance of tackling the development of this situation frequently over the coming years.
Compared to other European countries, the proportions of men and women reporting a high alcohol intake were not particularly excessive (Rehn et al., 2001). In Austria, for example, 41% of men and 8.5% of women consume more than 210 g alcohol per week. In Ireland, 27% of men and 21% of women report consuming more than 210 g and more than 140 g alcohol, respectively (our findings indicate 15% in males and 2% in females). However, as discussed above, our results may have been affected by underreporting.
Although the LLH questionnaire did not include a standard instrument to capture problem drinking, one indicator is whether an individual starts drinking early in the day (Mayfield et al., 1974). In this study, 11% of male drinkers and 7% of female drinkers reported drinking alcohol before the end of the working day, and more frequent drinkers are more likely to start drinking before they finished working. Problem drinking should be examined in more detail in future studies in the region using instruments such as the AUDIT questionnaire (Babor et al., 1992; Department of Mental Health and Substance Dependence, Noncommunicable Diseases and Mental Health Cluster, 2000).
A better understanding of the factors associated with different patterns of drinking in this region is needed. In this study, we observed that the likelihood of episodic heavy drinking was higher in those who smoked. Bobak et al. (1999) reported a similar association in their survey in the Russian Federation. Some researchers have suggested that former Soviet citizens with positive recollections of the Soviet period place a lower emphasis on health-promoting activities than those who welcomed the new system (Cockerham et al., 2002), possibly because of the Soviet rejection of individual responsibility for health (Shkolnikov and Meslé, 1996). This agrees with our finding that men who believe that they could live better if the Communist system were restored are more likely to be episodic heavy drinkers. A similar finding was not observed in women, however, and caution is needed when interpreting this relationship as it is based on only one self-reported question.
In our study, episodic heavy drinking was not associated with educational achievement and economic situation. However, contrary to what was observed by Bobak et al. (1999), the unemployed seemed less prone to episodes of heavy drinking. Single women and those who were separated, divorced, or widowed were more likely to engage in episodes of heavy drinking, consistent with other evidences of a change in traditional gender roles in post-Soviet society. Finally, respondents in poorer health were less likely to be episodic heavy drinkers, although the difference reached significance only in men. This is contrary to previous findings that Russian men with the worst self-rated health were almost five times as likely as those with a very good rated health to be episodic heavy drinkers (Bobak et al., 1999). One interpretation is that sicker men may have adopted less hazardous drinking behaviors.
In conclusion, the findings described in this study indicate that heavy episodic alcohol drinking is frequent among men throughout the region covered by the LLH surveys, but so far it is relatively infrequent among women. They also confirm that the use of homemade alcohol is common even though its use may have been underreported. While drinking patterns need to be explored in more detail in the region using internationally agreed tools and definitions, our results emphasize the importance of developing effective policies to reduce harmful patterns of drinking in the region, in line with the goals of the European Alcohol Action Plan (World Health Organization Regional Office for Europe, 2000). These will need to address both overall consumption and damaging drinking patterns, while taking into account the consumption of alcohol from illicit sources.
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ACKNOWLEDGEMENTS |
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The LLH Project was funded by the European Community under the FP5 horizontal program "Confirming the International Role of Community Research" (INCO2-Copernicus; Contract No: ICA2-2000-10031, Project No: ICA2-1999-10074). However, the European Community cannot accept any responsibility for any information provided or views expressed. The authors have no conflict of interest. We are grateful to all members of the LLH Study teams who participated in the coordination and organization of data collection for this working paper.
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