Institute of Internal Medicine, Siberian Branch of the Russian Academy of Medical Sciences, Novosibirsk, Russia and 1 International Centre for Health and Society, Department of Epidemiology and Public Health, University College London, 119 Torrington Place, London WC1E 6BT, UK
* Author to whom correspondence should be addressed: Email: martinb{at}public-health.ucl.ac.ukch
(Received 24 June 2003; first review notified 24 July 2003; in revised form 27 October 2003; accepted 3 November 2003)
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ABSTRACT |
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INTRODUCTION |
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Paralleling the increase in mortality in the early 1990s, income inequalities in Russia also increased considerably (World Bank, 1996), and there was a marked increase in educational differences in mortality over this period. Mortality rates increased more rapidly in men and women with low education than in those with higher education (Shkolnikov et al., 1998
). A cohort study in St Petersburg reported similar findings for men (Plavinski et al., 2003
).
Given the important role of alcohol in Russia and the increase in social inequalities since the collapse of communism, it is of interest to explore whether the social distribution of alcohol consumption in Russia changed during the period of social transformation. To do so, we used three population surveys conducted by the Novosibirsk part of the WHO MONICA Project (World Health Organization, 1987). The surveys coincided with the period of major social changes, and thus offered a unique opportunity to assess changes in health behaviours during this period. Novosibirsk is the third largest Russian city and the industrial centre of Western Siberia, and, as far as data are available, it is typical for Russia in terms of mortality, alcohol intake and social development (Nikitin and Gerasimenko, 1995
; Nemtsov, 2000
; Tchernina, 2000
; Malyutina et al., 2002
).
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SUBJECTS AND METHODS |
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Participants were invited for an interview in a clinic. Several measures of alcohol consumption were available. First, the frequency of drinking in the last year, measured on the following scale: never; less than once a month; 12 times a month; once a week; 24 times a week; 56 times a week; and daily. In the present analyses, we examined the prevalence of frequent drinking (at least twice a week). Second, we analysed a continuous measure of alcohol intake at a typical drinking occasion. The amount was reported in units common in Russia (i.e. bottles of beer and grams of wine and spirits) and then recalculated into grams of ethanol. Third, we analysed the mean consumption of beer, wine and spirits during the 7 days preceding the interview. Finally, we examined the prevalence of binge drinking (at least 80 g of ethanol for men and 60 g for women) at least once a month, estimated by combining the frequency and the typical amount.
Alcohol consumption in men was measured in all three surveys for men but was not measured in women in the 1988/89 survey. The overall levels of drinking by survey were published elsewhere (Malyutina et al., 2001).
We used two principal socio-economic measures: education and marital status. Education was categorized into four groups: primary (8 years or less, mean 6.6 years of schooling); secondary (912 years, mean 10.1 years of school); higher secondary (an additional 13 years of further education, mean 12.6 years of school); and university (a degree, mean 15.7 years of school). Marital status was classified into four groups: married; single (never married); divorced; and widowed.
We calculated age-adjusted means (standard errors) and proportions of alcohol intake indices by education and marital status for each survey, separately for men and women. Within each survey and sex, we calculated P-values for trend by education, using linear regression for continuous variables and logistic regression for binary variables, and P-values for overall differences (heterogeneity) in means or proportions between categories of marital status, using ANOVA for continuous variables and the change in likelihood ratio in logistic regression (with marital status) for binary variables. We also calculated the statistical significance of the changes in the alcohol variables between 1988/89 and 1994/95 (the period of the main societal changes in Russia) among men. (This was not done for women because alcohol intake in women was not assessed in the second survey.) To allow an easier assessment of the changes in differences between socio-economic groups, we present for each survey the difference (for continuous variables) or ratio (for binary variables) between the extreme groups in terms of all-cause mortality rates; i.e. between the highest and the lowest educational group and between married and divorced subjects (Malyutina et al., 2003). We also examined the interactions between survey number and education/marital status. Where appropriate, the significance is reported in the text.
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RESULTS |
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DISCUSSION |
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Potential limitations of the study
Several limitations of this study need to be considered when interpreting the results. First, the study was conducted in Novosibirsk, and is therefore not directly generalizable for the whole of Russia. However, trends in mortality and drinking in Novosibirsk are close to national averages (Nikitin and Gerasimenko, 1995; Nemtsov, 2000
; Malyutina et al., 2001
, 2002
), and Novosibirsk probably represents the social patterns common in Russian urban populations (Tchernina, 2000
).
The study participants were randomly selected from electoral lists and were interviewed and examined at a clinic. The response rates were high and consistent across surveys. The electoral lists in Russia are regularly updated and are considered complete and reliable. There were no dramatic changes in education or marital status between surveys, although there was a tendency towards increasing educational level and the proportion of married men declined slightly. While these changes seem to reflect genuine social trends, we cannot exclude the possibility that the composition of non-responderswith respect to their drinking habitsmay have changed over time. If heavy drinkers have become more likely to participate in the study, and if the increased participation was related to education or marital status, the results would be unreliable. However, there is no indication that this is the case, and a serious selection bias of this study is therefore unlikely.
Second, as with all self-reported measures, it is possible that some measurement bias may have occurred in relation to alcohol consumption. A sub-sample of subjects interviewed in 1994/95 was re-interviewed and provided a blood sample in 2000; both self-reported consumption and serum gamma-glutamyl transferase (GGT) correlated well with the original reported alcohol intake (Malyutina et al., 2002; S. Kurilovitch, unpublished). This does not suggest a systematic bias. Random mis-classification, due to imprecise reporting, would tend to attenuate any underlying differences between educational and marital status groups. Male drinking in Russia has not been associated with social stigma, but drinking by women has been considered socially undesirable (though the attitudes towards female drinking and smoking probably started changing in the 1990s). This would lead to under-estimation of levels of drinking among women. Earlier results on GGT and hangover frequency suggested some under-reporting of alcohol intake in women, but the magnitude of such a bias is small (S.Kurilovitch, unpublished). If the social stigma in women differed by education groups or marital status, differences in drinking may be biased but we have no data with which to assess this possibility.
Finally, the direction of the association between drinking and marital status is not clear. Usually it is thought that socio-economic factors determine life styles. However, heavy drinking has a number of negative consequences, including strained family relationships, and it is likely that the high levels of drinking seen in divorced men actually led to divorce (Caces et al., 1999; Leonard and Rothbard, 1999
). This problem should not occur with education; this is a stable characteristic which is very unlikely to be changed by alcohol.
Education and drinking
Among men, we found an inverse educational gradient in drinking. Previous studies in Russia reported inconsistent results. In a Russian national sample interviewed in 1996, there was a weak and insignificant inverse educational gradient in prevalence of frequent drinking and binge drinking among men and a stronger gradient in women (Bobak et al., 1999). The difference between this and the present study is probably due to the quota sampling approach adopted in the 1996 study, possibly leading to selective non-response in some groups. The educational gradient may also be stronger in urban areas and thus appear weaker in a national sample. Another urban community-based study in the Russian city of Taganrog found a clear inverse gradient in heavy drinking, similar to the present study (Carlson and Vagero, 1998
). In the St Petersburg cohort, weekly alcohol intake was also strongly inversely associated with education (Plavinski et al., 2003
).
In the west, the association between alcohol and socio-economic position is more complex. While the the average intake is usually higher in higher social groups, alcohol-related harm is more common in lower socio-economic groups (Crum et al., 1992; Thun et al., 1997
; Marmot and Feeney 1999
; Ferrieres et al., 2001
). This paradox is most likely to be explained by a more risky drinking pattern (e.g. binge or heavy drinking) in lower socio-economic groups (Marmot and Feeney, 1999
).
The pattern seen in our Russian data is consistent with the general pattern of higher levels of unhealthy behaviours in lower socio-economic groups, with the difference that all and not just some drinking indices in males were inversely associated with education. In women, the lack of a clear relation between education and mean alcohol intake in the last week and prevalence of frequent drinking was probably due to low statistical power.
Marital status and drinking
In western populations, alcohol consumption is, in general, higher in unmarried subjects (Leonard and Rothbard 1999; Power et al., 1999
) but the available data from Russia are inconsistent. We found that levels of drinking were, in general, highest in divorced and, particularly in the most recent survey, widowed men. This contrasts with the above mentioned study in a national sample, in which the prevalence of frequent drinking and binge drinking was similar in divorced and married subjects (Bobak et al., 1999
). As with education, the difference between the two studies is most likely to be due to different sampling methods. However, the Taganrog study mentioned above also found only small differences in prevalence of heavy drinking by marital status, although heavy drinking in men was associated with marriage problems (Carlson and Vagero, 1998
). It is possible that the relationship between marital status and alcohol in Russia may differ by urbanization, geography or calendar period.
It has been proposed that marriage is, in general, associated with better health and that unmarried subjects are more likely to be engaged in unhealthy behaviours, such as smoking, heavy drinking and poor diet (Hajdu et al., 1995; Robles and Kiecolt-Glaser, 2003
). With respect to drinking, our data provide only a partial support for this proposition. Divorced men had high rates of frequent drinking and a high mean dose per drinking occasion, but there were no differences in the proportion of binge drinkers by marital status. Data on women were also inconsistent. Overall, we found no overwhelming evidence of a high risk of heavy drinking in unmarried persons.
Trends in drinking by education and marital status
Among men, the absolute differences by education in all drinking indices increased between the mid 1980s and the mid 1990s. The relative differences remained stable or even decreased. Trends in differences by marital status in men followed a similar patternthe absolute differences between divorced men and the others widened, but the relative differences tended to narrow.
Given these results, we were interested in whether alcohol could have contributed to the widening of educational differences in mortality that occurred in Russia in the early 1990s (Shkolnikov et al., 1998). As an illustration, we have calculated the possible effect of binge drinking on the all-cause mortality rate ratio between men with primary vs university education, assuming an approximately double all-cause mortality in binge drinkers compared with non-binge drinkers (an assumption consistent with results of the Novosibirsk cohort; Malyutina et al., 2002
), and using the prevalence rates of binge drinking in the first and last survey. Under these assumptions, binge drinking alone would have led to a mortality rate ratio (primary vs university) of 1.14 in the first survey and 1.23 in the last survey. This is a modest contribution, compared with the dramatic increase in Russian mortality differentials reported in the literature (Shkolnikov et al., 1998
; Plavinski et al., 2003
).
The contribution of alcohol to educational differentials could be substantially larger, however. Firstly, the heavy drinking pattern may have become more harmful than what could be captured by the dichotomous criterion of binge drinking (e.g. drinkers seem to consume much larger doses per drinking session). Secondly, heavy drinking may interact with other factors and the population-attributable risk fraction could thus be larger. On the other hand, the estimated modest contribution of alcohol to the increase in educational gradient is consistent with the St Petersburg cohort in which the changes in male all-cause mortality between the 1980s and the 1990s in each educational stratum were similar in men with low and high alcohol intakes (Plavinski et al., 2003).
There are no data on trends in mortality differentials by marital status in Russia, though it is commonly assumed that unmarried and especially divorced men in the former communist countries have an increased risk of mortality (Hajdu et al., 1995; Watson 1995
). As with education, however, our data suggest that the widening of differences in alcohol intake between unmarried and married men was not large enough to result in dramatic changes in mortality differentials.
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ACKNOWLEDGEMENTS |
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