PATTERNS OF ALCOHOL CONSUMPTION IN BULGARIA
Dina Balabanova and
Martin Mckee*
European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
Received 13 July 1998;
in revised form 23 December 1998;
accepted 8 January 1999
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ABSTRACT
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Alcohol is increasingly being recognized as a major cause of the greater burden of disease and premature death in eastern Europe than in the west. This requires a robust policy response but, in most countries in the region, there is little empirical data on patterns of consumption on which to base such a response. Until now, there has been no information on prevalence of drinking among the Bulgarian population. This paper describes a survey that seeks to address this weakness by describing the pattern of drinking in Bulgaria and its relationship with socio-demographic factors. It uses a multivariate analysis of data on patterns of alcohol consumption from a multi-stage nationwide survey of 1550 adults in Bulgaria, in 1997 which found that overall 50.7% of men and 13.6% of women drink at least weekly. In both sexes, drinking is least common among the elderly and those living in villages. It is also less common among those reporting their financial status as poor. Muslims are less likely to drink than are orthodox Christians. Drinking is most common among those living in cities, with higher education and high incomes. Heavy drinking, defined as 80 g/day or more, is rare among women, but is ascribed to 18.2% of men. Heavy drinking was much more common among men living in Sofia and was less common among those whose financial situation was poor. At the levels of drinking reported, it can be expected that alcohol is making a substantial contribution to the burden of disease and premature mortality in Bulgaria. A coordinated, effective policy response is required. Although some of the legal prerequisites are in place, they are poorly enforced and there is no overall strategy to address this issue.
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INTRODUCTION
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There is a growing recognition of the contribution of alcohol to the large burden of premature mortality in central and eastern Europe, leading to high death rates from accidents, cirrhosis, and heart disease, among others. This requires an effective policy response, which should preferably be based on information on how much is drunk and by whom. Unfortunately, such information is lacking throughout most of this region.
Bulgaria is an example of this problem. Although male age standardized death rates from chronic liver disease and cirrhosis have increased from 9.8/100 000 in 1970 to 33.6/100 000 in 1994 (World Health Organization, 1998
) a recent review noted that there are no studies of prevalence of alcohol consumption among adults in Bulgaria (Harkin et al., 1997
). Indeed, until recently, there has been relatively little information on any of the determinants of health in Bulgaria, a matter of particular concern, because, unlike the situation in other post-transition countries, such as Poland and the Czech Republic, life expectancy at birth in Bulgaria is continuing to fall.
This paper addresses this problem. It reports the results of a nationwide survey undertaken in 1997 that sought, among other things, to assess the current level of alcohol consumption and its determinants in the Bulgarian population.
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METHODS
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Data were collected in a household survey conducted in May 1997 designed to be representative of the population of Bulgaria aged 18 years or higher. A two-stage random sampling procedure was used. Using administrative divisions stratified by region and size as the first sample frame, 200 units were selected, with a probability of selection proportional to their size. In the second stage, 11 respondents were randomly selected from electoral registers in each unit, among whom eight respondents were to be interviewed. The planned sample consisted of 1600 main respondents (8 respondents in 200 clusters) with 600 respondents in reserve. The final sample was 96.9% of the planned sample size, representing 1550 individuals. Face-to-face interviews were conducted using a structured questionnaire drawing on existing survey instruments, such as the World Bank Living Standard Measurement Study (Ainsworth et al., 1992
) and the Health Survey for England (Department of Health, 1995
). The questionnaire collected data on a range of variables related to lifestyle, health status, household income and socio-economic status, health services utilization, total expenditure for health care including informal payments, and ability and willingness to pay for health care.
With respect to drinking, respondents were asked How often do you drink? with possible responses Doesnt drink, Almost every day (57 days/week), Several (14) days per week, At least once a month, At least once every three months, and At least once a year and were asked how much beer, wine or spirits they drank, in g/week, 750-ml bottles/week, and 500-ml bottles/week respectively. These were then converted into g/week using the method described by Anderson et al. (1993). A 750-ml bottle of wine was assumed to contain 80 g of alcohol and a 500-ml bottle of beer 40 g of alcohol.
Data were analysed using the Statistical Package for the Social Sciences (SPSS). Most of the variables are self-explanatory. The variable financial situation refers to the question As a whole, how would you assess the financial situation of your household in the last month?. Heavy drinking was defined as consumption of 560 g of ethanol/week or more, equating to 80 g/day or more.
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RESULTS
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Overall, 50.7% of men and 13.6% of women reported drinking alcohol at least weekly and 32.1% of men and 65.1% of women were abstainers (Fig. 1
). Among men, drinking was most common in those aged 3039 years and least common among those over 70 years. Among women, drinking was most common among those aged 4049 years and very uncommon among those aged over 70 years. In both sexes, drinking was more common in cities than in villages, this was especially so for women. To take account of these multiple associations, the probability of drinking weekly was further examined by means of logistic regression. For men, adjusting only for age, drinking was significantly less common in other cities and in villages than in Sofia (Table 1
). Although there is a suggestion that it became more common with increasing education, the association was not significant. There was no association with marital status. Weekly drinking was significantly more frequent in those in the highest income quartile and less frequent in those describing their financial situation as poor. Muslims were significantly less likely to drink than were orthodox Christians. When all variables were included in the model, only age and financial situation remained significant factors.
Among women, a somewhat different pattern was seen (Table 2
). With adjustment only for age, there was a clear urbanrural gradient, with very much lower frequencies in villages. Those with only primary education, a group that included a high proportion of people with learning disabilities, were significantly less likely to drink than those with secondary or university education. Divorced or widowed women were significantly less likely to drink than were married women. There were also clear gradients of increasing drinking with increasing income and better perceived financial status. Many fewer Muslim than orthodox Christian women drank. After adjustment for all variables, urbanrural residence, marital status, and financial situation remained significant factors.
Analysis of factors associated with heavy drinking was confined to men, as only 0.8% of women reported drinking more than 560 g/week, whereas 18.2% of men reported drinking at this level. Again, there was a significant association with age and area of residence, with a much higher frequency among those living in Sofia (Table 3
). After adjustment for age, the only other significant association was with financial status, with low rates among those describing their situation as poor, although the higher frequency among those who were divorced or widowed almost reached significance. Adjustment for all variables increased the urban rural gradient.
Further analyses examined the type of beverage drunk (Fig. 2
). Among men, drinking spirits was most frequent among those aged 3060 years, but beer drinking was more common in those aged 30 50 years. Drinking spirits was much more frequent among those aged under 30 years than among older women.
Most people who drank did not, however, restrict themselves to a single type of beverage, with males, especially, typically drinking at least two types (Fig. 3
).
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DISCUSSION
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Before discussing the results, the limitations of the survey must be considered. Although the overall sample was relatively large, the small size of certain groups reduced the power to detect significant differences. Furthermore, although a quite close match, the sample was not entirely representative of the Bulgarian population. Ethnic minorities were likely to be under-represented, although this is complicated by what is believed to be under-registration in the census. Women and pensioners were over-represented, as were, to a lesser extent, the divorced, although their numbers were likely to have risen since 1992. With these caveats, however, this survey provides information, for the first time, on the socio-economic determinants of alcohol consumption among the Bulgarian population.
Surveys of alcohol consumption are notoriously problematic (Klatsky, 1994
). Difficulties include inaccurate categorization of alcohol intake, as individuals underestimate or distort their consumption (Embree and Whitehead, 1998
) and lack of standardization of measures of consumption. Where heavy drinking is especially frequent, it is intuitively unlikely that those drinking at a level in excess of 100 g/day will be able to recall their consumption with any degree of accuracy, simply because they are likely to be inebriated. Conversely, in a country where heavy drinking is common, it may be that there is less social stigma about admitting to it.
With these caveats, several observations can be made. The first is that the proportion of the population drinking heavily is considerable. Eighteen per cent of Bulgarian men are drinking at a level that equates to 80 g/day, which is associated with a greatly increased risk of many of the manifestations of physical harm due to drinking (Anderson, 1995
). This compares with figures of 3.2% of men in France and 6.7% of both sexes combined in The Netherlands (Harkin et al., 1997
). The results of the survey are equivalent to a mean annual adult consumption of 7.8 l of pure ethanol, which is less than that from official sales figures (9.56 l/person aged 15+ in 1994) (World Health Organization, 1998
), so the survey data are likely to be an underestimate. The number of abstainers is also high. High rates have been reported among certain groups in other Slavic countries, such as Old Believers and Jews in Russia, but these rates are somewhat higher than obtained in a comparable survey undertaken in Russia (Bobak et al., 1999
).
The proportion of Bulgarian men drinking regularly varies according to a number of characteristics, some of which are intuitive and others have implications for policy. For example, the lower frequency of drinking among Muslims, even in a society that was largely secular during the post-war period, is not surprising. This is consistent with the much lower rates of alcohol-related mortality in the Muslim republics of the Russian Federation (Walberg et al., 1998
). The low frequency among old men could be due to increasing numbers of individuals reducing their consumption or abstaining, but it is also possible that there is selective survival, as premature mortality is likely to be high at the levels of consumption recorded by many younger Bulgarians. The urbanrural divide may reflect better access to sales outlets in cities. Although the difference ceases to be significant when all variables are included, the urbanrural trend in measures of central tendency persists, suggesting that it cannot be explained solely by differences in income or education. The association with financial hardship, with twice as many men in the category that perceive their situation as good compared to those describing it as poor, emphasizes the importance of affordability, suggesting that any measure that reduced the relative price of alcohol could lead to a substantial increase in drinking, but also that taxation, if it can be accompanied by effective enforcement, could be a valuable policy instrument.
Among women, the variations are somewhat greater. Regular drinking is very uncommon among elderly women and those living in villages, but is most common in young women living in cities, with higher education and who are more wealthy.
Heavy drinking, however, remains infrequent among women, but very common among men. The overall figure is a matter for considerable concern but, when specific categories are examined, it becomes even more alarming, with about one-third of men in Sofia drinking at a level that is likely to cause physical harm. On the basis of the data available, it is not possible to say whether this represents selective migration to the capital, although this seems a strong possibility.
The survey provides relatively little information on pattern of drinking. This is unfortunate, as there is now a growing body of evidence that pattern, and especially binge drinking, is important in explaining the high level of alcohol-related mortality in this region (McKee and Britton, 1998
). However, a simple tabulation of amount drunk by those reporting that they drink only several days/week shows that about 7% of men report regularly drinking the equivalent of 160 g of alcohol/drinking occasion.
The information on the type of beverage shows that most men drink a variety of products. Women are most likely to drink beer or spirits, singly or in combination. Perhaps surprisingly, given that Bulgaria is a major wine producer, rates of wine drinking are relatively low.
Male death rates from cirrhosis in Bulgaria have more than trebled in a period of 25 years. Although alcohol is only one of the factors accounting for the high level of premature mortality of the Bulgarian population, it seems likely that it is an important one, and one that is amenable to a concerted policy response. Some elements of such a policy are in place, at least formally, such as a legal limit on blood-alcohol concentration for drivers (0.2 g/dl) and bans on advertising in the mass media. There are also legal restrictions of the type of sales outlet, their distribution, and their opening hours. However, as in neighbouring countries, these regulations are poorly enforced. Furthermore, there is no tradition of inter-sectoral working and no mechanisms to deliver an effective policy response.
Hopefully, the findings of this survey will help to stimulate the action needed to develop and implement the co-ordinated response that is needed.
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ACKNOWLEDGEMENTS
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This research was supported by the PHARE ACE Programme 1995. Contract No. P95-3136-S.
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FOOTNOTES
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* Author to whom correspondence should be addressed. 
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