Susannah Tomkins

Hazardous alcohol drinking and premature mortality in Russia: a population based case-control study

BACKGROUND The reason for the low life expectancy in Russian men and large fluctuations in mortality are unknown. We investigated the contribution of alcohol, and hazardous drinking in particular, to male mortality in a typical Russian city. METHODS Cases were all deaths in men aged 25-54 years living in Izhevsk occurring between Oct 20, 2003, to Oct 3, 2005. Controls were selected at random from the city population and were frequency matched to deaths by age. Interviews with proxy informants living in the same household as cases were done between Dec 11, 2003, and Nov, 16 2005, and were obtained for 62% (1750/2835) of cases and 57% (1750/3078) of controls. We ascertained frequency and usual amount of beer, wine, and spirits consumed and frequency of consumption of manufactured ethanol-based liquids not intended to be drunk (non-beverage alcohol), and markers of problem drinking. Complete information on markers of problem drinking, frequency of alcohol consumption, education, and smoking was available for 1468 cases and 1496 controls. FINDINGS 751 (51%) cases were classed as problem drinkers or drank non-beverage alcohol, compared with 192 (13%) controls. The mortality odds ratio (OR) for these men, compared with those who either abstained or were non-problematic beverage drinkers, was 6.0 (95% CI 5.0-7.3) after adjustment for smoking and education. The mortality ORs for drinking non-beverage alcohol in the past year (yes vs no) was 9.2 (7.2-11.7) after adjustment for age. Adjustment for volume of ethanol consumed from beverages lowered the OR to 8.3 (6.5-10.7), and further adjustment for education and smoking reduced it to 7.0 (5.5-9.0). A strong direct gradient with mortality was seen for frequency of non-beverage alcohol drinking independent of volume of beverage ethanol consumed. 43% of mortality was attributable to hazardous drinking (problem drinking or non-beverage alcohol consumption, or both) adjusted for smoking and education. INTERPRETATION Almost half of all deaths in working age men in a typical Russian city may be accounted for by hazardous drinking. Our analyses provide indirect support for the contention that the sharp fluctuations seen in Russian mortality in the early 1990s could be related to hazardous drinking as indicated by consumption of non-beverage alcohol.

Prevalence and socio-economic distribution of hazardous patterns of alcohol drinking: study of alcohol consumption in men aged 25–54 years in Izhevsk, Russia

Aim To estimate the prevalence of hazardous drinking and its socio-economic distribution among Russian men. Design Participants were an age-stratified, population-based random sample of men aged 25–54 years living in Izhevsk, a city in the Urals, Russia. Interviewers administered questionnaires to cohabiting proxy respondents about behavioural indicators of hazardous drinking derived from frequency of hangover, frequency of drinking beverage spirits, episodes in the last year of extended periods of drunkenness during which the participant withdraws from normal life (zapoi), consumption of alcoholic substances not intended to be drunk (surrogates) and socio-economic position. Logistic regression was used to examine associations between socio-economic position and indicators of hazardous drinking in the past year. Findings Of 1750 men, 79% drank spirits and 8% drank surrogates at least sometimes in the past year; 25% drank spirits and 4% drank surrogates at least weekly and 10% had had an episode of zapoi in the past year. After adjustment for other socio-economic factors, education was strongly associated with indicators of hazardous drinking. Men with the lowest level of education compared to the highest level of education had an odds ratio of surrogate drinking of 7.7 (95% CI 3.2–18.5), of zapoi of 5.2 (2.3–11.8) and of frequent hangover of 3.7 (1.8–7.4). These indicators of hazardous drinking were also independently strongly associated with being unemployed (versus employed) and with levels of household wealth/amenities. Associations of all these variables with daily consumption of beverage spirits were weaker. Conclusion Using a novel range of indicator variables of hazardous drinking, this paper shows that the prevalence of these behaviours is high among working-age men in this Russian city. Moreover, these hazardous behaviours show very clear socio-economic patterns, with particularly high prevalence among those who have had the least education and are not in employment. In contrast, more conventional measures of heavy drinking, based on frequency of consumption of beverage spirits, are less prevalent and show much weaker associations with socio-economic position.

Availability and Characteristics of Nonbeverage Alcohols Sold in 17 Russian Cities in 2007

BACKGROUND It is known that a range of nonbeverage alcohols including eau-de-colognes and medicinal tinctures are consumed by sections of the Russian population. Research conducted in a city in the Urals (2003 to 2005) showed that consumption of such products is associated with very high mortality from a wide range of causes. However, there have been no systematic attempts to investigate the extent to which such products are available in other cities of the Russian Federation. There is particular interest in establishing this following the introduction of new federal regulations in January 2006 aimed at restricting the availability of these products. METHODS In the first half of 2007, we conducted a survey in 17 cities that spanned the full range of city types in the Russian Federation excluding those in the Far East. In each city, fieldworkers visited pharmacies and other types of retail outlets and purchased samples of nonbeverage alcohols. These were defined as being typically 10 to 15 roubles per bottle, with an ethanol concentration of at least 60% by volume. RESULTS We were able to purchase samples of nonbeverage alcohols in each of the 17 cities we investigated. The majority of the 271 products included were a cheaper and more affordable source of ethanol than standard Russian vodka. Medicinal tinctures, sold almost exclusively in pharmacies, were particularly common with an average concentration of 78% ethanol by volume. Most importantly, the majority of the products were of a sort that our previous research in 2004 to 2005 had established were drunk by working-age men. CONCLUSIONS While the 2006 federal regulations introduced in part to reduce the availability and consumption of nonbeverage alcohols may have had some effect on certain classes of nonmedicinal products, up until June 2007 at least, medicinal tinctures as well as some other nonbeverage alcohols that are consumed appear to have been readily available.

Trends in and predictors of second‐hand smoke exposure indexed by cotinine in children in England from 1996 to 2006

AIMS To explore trends in and predictors of second-hand smoke (SHS) exposure in children. To identify whether inequalities in SHS exposure are changing over time. DESIGN Repeated cross-sectional study with data from eight annual surveys conducted over an 11-year period from 1996 to 2006. SETTING England. PARTICIPANTS Nationally representative samples of children aged 4-15 years living in private households. MEASUREMENTS Saliva cotinine (4-15-year-olds), current smoking status (8-15-year-olds), smoking status of parents and carers, smoking in the home, socio-demographic variables. FINDINGS The most important predictors of SHS exposure were modifiable factors-whether people smoke in the house on most days, whether the parents smoke and whether the children are looked after by carers who smoke. Children from more deprived households were more exposed and this remained the case even after parental smoking status has been controlled for. Exposure over time has fallen markedly among children (59% decline over 11 years in geometric mean cotinine), with the most marked decline observed in the period immediately preceding smoke-free legislation. Declines in exposure have generally been greater in children most exposed at the outset. For example, in children whose parents both smoke, median cotinine declined annually by 0.115 ng/ml compared with 0.019 ng/ml where neither parent smokes (P < 0.05). CONCLUSIONS In the 11 years leading up to smoke-free legislation in England, the overall level of SHS exposure in children as well as absolute inequalities in exposure have been declining. Further efforts to encourage parents and carers to quit and to avoid smoking in the home would benefit child health.

Hazardous alcohol consumption is a major factor in male premature mortality in a typical Russian city: prospective cohort study 2003-2009.

Introduction Russia has experienced massive fluctuations in mortality at working ages over the past three decades. Routine data analyses suggest that these are largely driven by fluctuations in heavy alcohol drinking. However, individual-level evidence supporting alcohol having a major role in Russian mortality comes from only two case-control studies, which could be subject to serious biases due to their design. Methods and Findings A prospective study of mortality (2003–9) of 2000 men aged 25–54 years at recruitment was conducted in the city of Izhevsk, Russia. This cohort was free from key limitations inherent in the design of the two earlier case-control studies. Cox proportional hazards regression was used to estimate hazard ratios of all-cause mortality by alcohol drinking type as reported by a proxy informant. Hazardous drinkers were defined as those who either drank non-beverage alcohols or were reported to regularly have hangovers or other behaviours related to heavy drinking episodes. Over the follow-up period 113 men died. Compared to non-hazardous drinkers and abstainers, men who drank hazardously had appreciably higher mortality (HR = 3.4, 95% CI 2.2, 5.1) adjusted for age, smoking and education. The population attributable risk percent (PAR%) for hazardous drinking was 26% (95% CI 14,37). However, larger effects were seen in the first two years of follow-up, with a HR of 4.6 (2.5, 8.2) and a corresponding PAR% of 37% (17, 51). Interpretation This prospective cohort study strengthens the evidence that hazardous alcohol consumption has been a major determinant of mortality among working age men in a typical Russian city. As such the similar findings of the previous case-control studies cannot be explained as artefacts of limitations of their design. As Russia struggles to raise life expectancy, which even in 2009 was only 62 years among men, control of hazardous drinking must remain a top public health priority.

A case–control analysis of socio-economic and marital status differentials in alcohol- and non-alcohol-related mortality among working-age Russian males

BACKGROUND We examined the role of socio-economic status (SES) and marital status in premature mortality among working-age Russian males. Life expectancy among this group dropped sharply following the collapse of the Soviet Union and has yet to recover despite the relative economic and political stability of the last decade. METHODS We employed individual-level data from a large-scale, population-based, case-control study (n = 3500). Adjusting for age group, hazardous drinking and smoking status, we estimated mortality odds ratios to determine the impact of SES and marital status on premature mortality due to all, alcohol- and non-alcohol-related causes of death. RESULTS Results revealed clear protective effects of SES and marital status against premature mortality. Although the effects for marital status were significant across alcohol- and non-alcohol-related causes of death, the effects of SES were largely limited to non-alcohol-related causes of death. When heavy drinkers were excluded from the analysis, however, SES was found to protect against premature mortality for alcohol-related causes. CONCLUSION While hazardous drinking is known to be a leading cause of premature mortality among working-age Russian males, it is unwise to ignore other factors. Given the substantial social and economic impacts in Russia of the dissolution of the Soviet Union, it is important to examine the health effects of SES and marital status and other social forces in the nation. Our results reveal that while Russia has a very different past in terms of medicine, public health and economic institutions, it currently faces public health threats that follow similar patterns to those found in Western nations.

Identifying the determinants of premature mortality in Russia: overcoming a methodological challenge

BackgroundIt is thought that excessive alcohol consumption is related to the high mortality among working age men in Russia. Moreover it has been suggested that alcohol is a key proximate driver of the very sharp fluctuations in mortality seen in this group since the mid-1980s. Designing an individual-level study suitable to address the potential acute effects of alcohol consumption on mortality in Russia has posed a challenge to epidemiologists, especially because of the need to identify factors that could underlie the rapid changes up and down in mortality rates that have been such a distinctive feature of the Russian mortality crisis. In order to address this study question which focuses on exposures acting shortly before sudden death, a cohort would be unfeasibly large and would suffer from recruitment bias.MethodsAlthough the situation in Russia is unusual, with a very high death rate characterised by many sudden and apparently unexpected deaths in young men, the methodological problem is common to research on any cause of death where many deaths are sudden.ResultsWe describe the development of an innovative approach that has overcome some of these challenges: a case-control study employing proxy informants and external data sources to collect information about proximate determinants of mortality.ConclusionThis offers a set of principles that can be adopted by epidemiologists studying sudden and unexpected deaths in other settings.

Treating iron deficiency in patients with gastrointestinal disease: Risk of re-attendance in secondary care

Background Patients with gastrointestinal disease may have comorbid iron deficiency anaemia (IDA) and an increased risk of hospitalisation and re-attendance in hospital. The purpose of this study was to determine if oral and intravenous (IV) treatment of IDA in patients with gastrointestinal disease attending hospital were associated with differential rates of subsequent re-attendance. Methods and findings Data from the Clinical Practice Research Datalink (primary care) and Hospital Treatment Insights (secondary care) databases in England were used to conduct this retrospective cohort study. Patients with a coded gastrointestinal disease and IDA who attended hospital (inpatient or outpatient) and were dispensed oral or IV iron between 01/01/2010-31/10/2013 were included. Elective and emergency re-attendances in secondary care within 30 days of the initial attendance were determined. Demographics, medical diagnoses and treatments were extracted. Re-attendance rates following oral or IV iron were compared using chi-square tests and a step-wise logistic regression model to adjust for confounders. 2,844 patients contributed 6,294 initial attendances; 80% of patients received oral iron, 14% received intravenous iron, and 6% received both. Of initial attendances recording oral iron, 77% resulted in re-attendance in hospital, compared to 34% of those recording IV iron (unadjusted odds ratio [OR]: 0.16; adjusted OR: 0.52 [95% CI: 0.44–0.61]). Initial attendances using IV treatment were more likely to result in elective re-attendance (84%) than those recording oral treatment (43%) (p<0.001). Median length of stay in hospital tended to be shorter for patients using IV iron (1.4 days; interquartile range 0.5–3.6 days; oral iron: 5.1 days; interquartile range: 2.2–9.6 days). Conclusions Patients with gastrointestinal disease and IDA who received IV iron were less likely to re-attend hospital, more likely to re-attend electively, and tended to have a shorter length of stay in hospital. The mode of IDA treatment could have a real-world impact on healthcare utilisation.