Alcohol Increases Circulatory Disease Mortality in Russia
Alcohol Increases Circulatory Disease Mortality in Russia
Background There is a consensus that the large fluctuations in mortality seen in Russia in the past two decades can be attributed to trends in alcohol consumption. However, the precise mechanisms linking alcohol to mortality from circulatory disease remain unclear. It has recently been argued that a substantial number of such deaths currently ascribed to cardiovascular disorders are misclassified cases of acute alcohol poisoning.
Methods Analysis of routine mortality data and of a case–control study of mortality among working-age (25–54 years) men occurring in the Russian city of Izhevsk, west of the Ural mountains, 2003–05. Interviews were carried out with proxy informants for both the dead cases (N = 1750) and the controls (N = 1750) selected at random from a population register. Mortality was analysed according to indicators of alcohol problems.
Results Hazardous drinking was associated with an increased risk of death from circulatory diseases as a whole [odds ratio (OR) = 4.14, 95% confidence interval (CI) 3.23, 5.31] adjusted for age, smoking and education. The association with alcoholic cardiomyopathy was particularly strong (OR = 15.7, 95% CI 9.5, 25.9). Although there was no association with deaths from myocardial infarction (MI; OR = 1.17, 95% CI 0.59, 2.32), there was a strong association with the aggregate of all other ischaemic heart disease (IHD; OR = 4.04, 95% CI 2.79, 5.84). Stronger associations for each of these causes (other than MI) were seen with whether or not the man had drunk very heavily in the previous week. However, associations also remained when analyses were restricted to subjects with no evidence of recent heavy drinking, suggesting that misclassification of acute alcohol poisonings is unlikely to explain these overall associations.
Conclusion Taken as a whole, the available evidence suggests that the positive association of alcohol with increased cardiovascular disease mortality may be best explained as being the result of a combination of chronic and acute alcohol consumption resulting in alcohol-related cardiac disorders, especially cardiomyopathy, rather than being due to misclassification of acute alcohol poisoning. Further work is required to understand the mechanisms underlying the link between heavy alcohol consumption and deaths classified as being due to IHD (other than MI).
Since the mid-1980s Russia has experienced pronounced mortality fluctuations, particularly among men, driven largely by deaths at working age. A substantial body of research has concluded that variations in alcohol consumption, particularly of spirits in intensive drinking binges, are likely to underlie these temporal changes. In turn, these variations in consumption have been influenced by the social and economic stresses arising from the transition from communism, as well as changes in supply and affordability of alcohol substances being drunk. However, there remains uncertainty around the relative importance of different biological mechanisms that may underlie the association between fluctuations in alcohol consumption and fluctuations in specific causes of death.
The most obvious cause of death associated with alcohol is acute alcohol poisoning. This has been and continues to be an important public health problem in Russia and other parts of the former Soviet Union, currently accounting for ~4% of all deaths among working-age men in Russia. There is a wide range of other pathological mechanisms by which heavy drinking can lead to death. These include deaths from external causes resulting from intoxication (e.g. drowning, fire accidents, road traffic injury and suicide), deaths from tuberculosis, where immune function is impaired, perhaps as a consequence of concomitant malnutrition, deaths from pneumonia (often following aspiration of vomit) and deaths from cirrhosis and pancreatitis due to long-term end organ damage caused by the toxic effects of ethanol and its metabolites. All of these causes have shown clear fluctuations in Russia that were highly correlated with those of mortality from alcohol poisonings and of mortality as a whole.
Circulatory disease has also shown parallel fluctuations over time, with mortality rates broadly following those for more obviously alcohol-related causes. This has been apparent for both mortality from ischaemic heart as well as cerebrovascular disease. Among deaths from cardiovascular disease, alcoholic cardiomyopathy is one cause that is explicitly related to alcohol. This potentially very important cause of death has been often overlooked in previous work, largely because until 2005 it was not routinely tabulated as a cause of death in Russia in official mortality statistics.
A recent review of the link between circulatory disease and alcohol emphasized the variety of different mechanisms that underlie these associations. However, the pattern of fluctuations in ischaemic heart disease (IHD) mortality in Russia provides a challenge to the view that for this particular end point alcohol has a largely cardio-protective effect. Yet, as we have previously argued, there is a range of mechanisms that could explain the increased IHD risk associated with alcohol in the Russian context, not least the particularly adverse effects of heavy, episodic drinking of spirits, a phenomenon that is widespread in Russia and much less important in the West. This is supported by a recent analysis of time-series mortality data. However, a recent article in this journal concluded that the Russian trends in cardiovascular mortality are in fact due to deaths from acute alcohol poisoning being incorrectly classified as due to IHD.
In this article, we report the results of a series of analyses of the association of circulatory disease mortality with alcohol in a case–control study conducted in Russia between 2003 and 2005. These are placed in the context of fluctuations in circulatory disease mortality in Russia over the past 25 years. Improved understanding of this phenomenon is a priority, not least because the very high rates of circulatory disease mortality in Russia importantly contribute to the extraordinarily low life expectancy, especially among men, which in 2008 was just under 62 years.
Abstract and Introduction
Abstract
Background There is a consensus that the large fluctuations in mortality seen in Russia in the past two decades can be attributed to trends in alcohol consumption. However, the precise mechanisms linking alcohol to mortality from circulatory disease remain unclear. It has recently been argued that a substantial number of such deaths currently ascribed to cardiovascular disorders are misclassified cases of acute alcohol poisoning.
Methods Analysis of routine mortality data and of a case–control study of mortality among working-age (25–54 years) men occurring in the Russian city of Izhevsk, west of the Ural mountains, 2003–05. Interviews were carried out with proxy informants for both the dead cases (N = 1750) and the controls (N = 1750) selected at random from a population register. Mortality was analysed according to indicators of alcohol problems.
Results Hazardous drinking was associated with an increased risk of death from circulatory diseases as a whole [odds ratio (OR) = 4.14, 95% confidence interval (CI) 3.23, 5.31] adjusted for age, smoking and education. The association with alcoholic cardiomyopathy was particularly strong (OR = 15.7, 95% CI 9.5, 25.9). Although there was no association with deaths from myocardial infarction (MI; OR = 1.17, 95% CI 0.59, 2.32), there was a strong association with the aggregate of all other ischaemic heart disease (IHD; OR = 4.04, 95% CI 2.79, 5.84). Stronger associations for each of these causes (other than MI) were seen with whether or not the man had drunk very heavily in the previous week. However, associations also remained when analyses were restricted to subjects with no evidence of recent heavy drinking, suggesting that misclassification of acute alcohol poisonings is unlikely to explain these overall associations.
Conclusion Taken as a whole, the available evidence suggests that the positive association of alcohol with increased cardiovascular disease mortality may be best explained as being the result of a combination of chronic and acute alcohol consumption resulting in alcohol-related cardiac disorders, especially cardiomyopathy, rather than being due to misclassification of acute alcohol poisoning. Further work is required to understand the mechanisms underlying the link between heavy alcohol consumption and deaths classified as being due to IHD (other than MI).
Introduction
Since the mid-1980s Russia has experienced pronounced mortality fluctuations, particularly among men, driven largely by deaths at working age. A substantial body of research has concluded that variations in alcohol consumption, particularly of spirits in intensive drinking binges, are likely to underlie these temporal changes. In turn, these variations in consumption have been influenced by the social and economic stresses arising from the transition from communism, as well as changes in supply and affordability of alcohol substances being drunk. However, there remains uncertainty around the relative importance of different biological mechanisms that may underlie the association between fluctuations in alcohol consumption and fluctuations in specific causes of death.
The most obvious cause of death associated with alcohol is acute alcohol poisoning. This has been and continues to be an important public health problem in Russia and other parts of the former Soviet Union, currently accounting for ~4% of all deaths among working-age men in Russia. There is a wide range of other pathological mechanisms by which heavy drinking can lead to death. These include deaths from external causes resulting from intoxication (e.g. drowning, fire accidents, road traffic injury and suicide), deaths from tuberculosis, where immune function is impaired, perhaps as a consequence of concomitant malnutrition, deaths from pneumonia (often following aspiration of vomit) and deaths from cirrhosis and pancreatitis due to long-term end organ damage caused by the toxic effects of ethanol and its metabolites. All of these causes have shown clear fluctuations in Russia that were highly correlated with those of mortality from alcohol poisonings and of mortality as a whole.
Circulatory disease has also shown parallel fluctuations over time, with mortality rates broadly following those for more obviously alcohol-related causes. This has been apparent for both mortality from ischaemic heart as well as cerebrovascular disease. Among deaths from cardiovascular disease, alcoholic cardiomyopathy is one cause that is explicitly related to alcohol. This potentially very important cause of death has been often overlooked in previous work, largely because until 2005 it was not routinely tabulated as a cause of death in Russia in official mortality statistics.
A recent review of the link between circulatory disease and alcohol emphasized the variety of different mechanisms that underlie these associations. However, the pattern of fluctuations in ischaemic heart disease (IHD) mortality in Russia provides a challenge to the view that for this particular end point alcohol has a largely cardio-protective effect. Yet, as we have previously argued, there is a range of mechanisms that could explain the increased IHD risk associated with alcohol in the Russian context, not least the particularly adverse effects of heavy, episodic drinking of spirits, a phenomenon that is widespread in Russia and much less important in the West. This is supported by a recent analysis of time-series mortality data. However, a recent article in this journal concluded that the Russian trends in cardiovascular mortality are in fact due to deaths from acute alcohol poisoning being incorrectly classified as due to IHD.
In this article, we report the results of a series of analyses of the association of circulatory disease mortality with alcohol in a case–control study conducted in Russia between 2003 and 2005. These are placed in the context of fluctuations in circulatory disease mortality in Russia over the past 25 years. Improved understanding of this phenomenon is a priority, not least because the very high rates of circulatory disease mortality in Russia importantly contribute to the extraordinarily low life expectancy, especially among men, which in 2008 was just under 62 years.
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