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Russia-specific relative risks and their effects on the estimated alcohol-attributable burden of disease

BMC Public Health201515:482

https://doi.org/10.1186/s12889-015-1818-y

Received: 15 August 2014

Accepted: 5 May 2015

Published: 10 May 2015

Abstract

Background

Alcohol consumption is a major risk factor for the burden of disease globally. This burden is estimated using Relative Risk (RR) functions for alcohol from meta-analyses that use data from all countries; however, for Russia and surrounding countries, country-specific risk data may need to be used. The objective of this paper is to compare the estimated burden of alcohol consumption calculated using Russia-specific alcohol RRs with the estimated burden of alcohol consumption calculated using alcohol RRs from meta-analyses.

Methods

Data for 2012 on drinking indicators were calculated based on the Global Information System on Alcohol and Health. Data for 2012 on mortality, Years of Life Lost, Years Lived with Disability, and Disability-Adjusted Life Years (DALYs) lost by cause were obtained by country from the World Health Organization. Alcohol Population-Attributable Fractions (PAFs) were calculated based on a risk modelling methodology from Russia. These PAFs were compared to PAFs calculated using methods applied for all other countries. The 95 % Uncertainty Intervals (UIs) for the alcohol PAFs were calculated using a Monte Carlo-like method.

Results

Using Russia-specific alcohol RR functions, in Russia in 2012 alcohol caused an estimated 231,900 deaths (95 % UI: 185,600 to 278,200) (70,800 deaths among women and 161,100 deaths among men) and 13,295,000 DALYs lost (95 % UI: 11,242,000 to 15,348,000) (3,670,000 DALYs lost among women and 9,625,000 DALYs lost among men) among people 0 to 64 years of age. This compares to an estimated 165,600 deaths (95 % UI: 97,200 to 228,100) (29,700 deaths among women and 135,900 deaths among men) and 10,623,000 DALYs lost (95 % UI: 7,265,000 to 13,754,000) (1,783,000 DALYs lost among women and 8,840,000 DALYs lost among men) among people 0 to 64 years of age caused by alcohol when non-Russia-specific alcohol RRs were used.

Conclusions

Results indicate that if the Russia-specific RRs are used when estimating the health burden attributable to alcohol consumption in Russia, then the total estimated burden will be more than if RRs from meta-analyses are used. Furthermore, additional research is needed to understand which aspects of the Russian style of drinking cause the most harm.

Keywords

Alcohol Russia Eastern Europe Relative risk Risk factor Burden of disease Population-attributable fraction

Background

Alcohol has been shown to cause a considerable burden of disease [1, 2]. Historically, estimates of the alcohol-attributable burden have been based on a conceptual Population-Attributable Fraction (PAF) model that combines Relative Risks (RRs) taken from meta-analyses [3, 4] with alcohol exposure estimates [5, 6]. However, estimates based on this model may not accurately reflect the true proportion of disease caused by alcohol for countries with extreme and varying drinking patterns. For example, consumption patterns found in Russia include long bouts of continuous heavy drinking alternating with days of abstinence [79], which negatively impact on ischemic heart disease (IHD), ischemic stroke and injuries [1013].

Historically, alcohol has had a great impact on health in Russia [14, 15]. Furthermore, the overall health of the Russian population is considered poor by Western European standards, and Russians, and in particular Russian men, have a low life expectancy: the 2012 life expectancy was 63 years for men and 75 years for women [16]. Alcohol has been found to be the most important factor responsible for the low life expectancy for men [15, 1720]. Indeed, when alcohol consumption dropped markedly as a result of the Gorbachev reforms, mortality rates dropped by 11.4 % [18, 21], exemplifying the negative impact of alcohol consumption on the health of the Russian population. Less dramatic, but still visible, were the more recent impacts of alcohol policy on mortality and life expectancy [22].

The production and consumption of alcohol is heavily ingrained in Russian society [7, 23]. Russia and other Eastern European countries consume more alcohol than any other countries in the world [2, 24]. Additionally, Russians consume alcohol in the comparatively most harmful manner, namely irregular very heavy drinking, mostly outside of meals and associated with intoxication (for associations between these patterns of drinking and health see [4, 8, 25, 26]). Russia and surrounding Eastern European countries received pattern of drinking scores (a measure of the way alcohol is consumed, rather than the amount of alcohol that is consumed) of 5, indicating the most detrimental way of drinking [2]. As people in these countries consume alcohol in a very detrimental manner, the application of global RRs may be problematic for these countries.

Accordingly, the 2010 Global Burden of Disease (GBD) study used Russia-specific RRs based on average consumption of alcohol data obtained from a large cohort study in Russia [14] in order to model the burden of disease attributable to alcohol in Russia and countries with similar drinking patterns [1]. To date, there has been no systematic comparison of the resulting estimated burden of disease attributable to alcohol consumption using Russia-specific RRs compared to using the RRs from meta-analyses that combined risk information from multiple countries; however, the most recent World Health Organization (WHO) alcohol burden of disease study for 2012 [2] provides the data to make this comparison. This paper: (i) presents a method used to calculate the alcohol PAFs for Russia based on Russia-specific RR functions, (ii) uses this method to estimate and describe the burden of disease attributable to alcohol in Russia, and (iii) compares this estimated burden of disease to the estimated burden calculated using RRs that combined data from all studies.

Methods

The estimates for the burden of disease attributable to alcohol consumption are limited by inaccuracies in the cause of death [2729], and this error increases for the elderly as pathologies may become more complicated [30, 31]. Accordingly, this study was limited to Russians 0 to 64 years of age.

Estimating the alcohol population-attributable fractions

A PAF is the proportion of mortality or morbidity that would not have occurred if the exposure of every person in the population to a risk factor were at the theoretical minimum risk exposure level [1, 32, 33]. Even though protective effects of alcohol can be observed for ischemic diseases and diabetes for people who consume little alcohol and do not engage in Heavy Episodic Drinking (HED) [10, 34, 35], the PAFs for alcohol use the theoretical minimum risk exposure of lifetime abstention and are calculated for most chronic diseases (except IHD and injuries) (see appendix for methodology) using Formula 1.

(Formula 1)
$$ PAF=\frac{P_{abs}+{P}_{former}R{R}_{former}+{\displaystyle {\int}_{>0}^{150}}{P}_{current}(x)R{R}_{current}(x)dx-1}{P_{abs}+{P}_{former}R{R}_{former}+{\displaystyle {\int}_{>0}^{150}}{P}_{current}(x)R{R}_{current}(x)dx} $$

where Pabs is the prevalence of lifetime abstainers, Pformer is the prevalence of former drinkers, RRformer is the RR for former drinkers, Pcurrent is the prevalence of current drinkers who consume on average x grams of alcohol, and RRcurrent is the RR given an average daily consumption of x grams of alcohol. The full methods for the calculation of the alcohol PAFs are outlined in Additional file 1 (HED is used in the estimation of the PAFs for injuries and IHD when using the 2010 GBD and 2012 WHO alcohol burden of disease study methodologies).

Mortality, morbidity and population data

Data for 2012 on mortality (deaths and Years of Life Lost (YLL)), morbidity (Years Lived with Disability (YLD)), and Disability-Adjusted Life Years (DALYs) lost (a combination of YLL and YLD) were obtained from the WHO [2]. Population data by age and sex were obtained from the United Nations population division [36].

Indicators of alcohol consumption

Data for the drinking status indicators for 2012, namely lifetime abstainers (those who have not consumed at least one standard drink of alcohol within their lifetime), former drinkers (those who have consumed at least one standard drink of alcohol, but have not done so in the past year), and current drinkers (those who have consumed at least one standard drink of alcohol in the past year), the prevalence of HED, the relative amount of alcohol consumed among drinkers differentiated by sex and age groups (15 to 34, 35 to 64 and 65 years of age and older) were obtained from the Global Information System on Alcohol and Health, which inputs country-specific data (for Russia: [37]) into a regression equation with the following variables: alcohol consumption (from survey data and per capita data), year, Gross Domestic Product (adjusted for purchase power parity), population age structure and the prevalence of people who identify themselves as Muslims (see [2] for more information). This regression method adjusted for inconsistencies between country-specific data for 2012 and data from surveys of the same nature conducted in similar countries, thereby bringing data on the prevalence of HED and the prevalence of different drinking statuses in line with those of other similar countries. This is especially important for Russia, as the data outlined in [37] have been criticized for being substantial underestimates of the prevalence of HED [38, 39].

These survey-based data were triangulated with data on recorded and unrecorded alcohol per capita consumption (estimated based on data obtained from the government of Russia [40] and Nemtsov [21]). Adult per capita consumption of alcohol is considered the best measure of alcohol consumption as surveys often underestimate alcohol consumption [41, 42]. This is especially important for Russia, as the data outlined in [37] have also been criticized for being substantial underestimates the volume of alcohol consumed [38, 39]. The distribution of alcohol consumption among current drinkers by age and sex for Russia in 2012 was estimated using methodology developed by Rehm and colleagues and Kehoe and colleagues [6, 43]. (See Additional file 1 for more details).

Risk relations

For this study we modelled the burden caused by alcohol consumption using RRs specific to Russia (which were based on average consumption) and RRs based on meta-analyses. The RR functions used for Russia were obtained from the study by Zaridze and colleagues [14] for tuberculosis, acute and chronic pancreatitis, pneumonia, stroke (ischemic and hemorrhagic), IHD, liver cirrhosis, suicide, homicide and assaults, injuries of undetermined intent, and other injuries. The RRs for Russia were based on the following weekly alcohol consumption categories (the equivalent daily alcohol consumption figures in pure alcohol are given in parentheses): 1) greater than one half but less than one bottle (>12.68 and < 25.36 grams (g) of pure alcohol per day (the lower bound was not used in our calculations)), 2) one to less than three bottles (equivalent to ≥ 25.36 grams to < 76.08 grams of pure alcohol per day), and 3) three or more bottles (≥ 76.08 grams of pure alcohol per day). The reference category for these RRs was current drinkers who consume less than one half of a bottle of vodka on a weekly basis; to adjust for this we applied the RR for people who consume greater than one half but less than one bottle of vodka a week to people who consume less than one half of a bottle of vodka per week. These Russia-specific categorical RRs were then transformed into a piecewise function and were then used in Formula 1 as RRcurrent to estimate the alcohol PAFs. Data on the RRs for former drinkers were obtained from the meta-analyses used for other countries and data on the RRs for other diseases were obtained from other sources (see Additional file 2). See Additional file 3 for a comparison of the meta-analysis RRs with the Russia-specific RRs.

The study by Zaridze and colleagues calculated data on 48,557 adult deaths for people 15 to 74 years of age, and obtained details of alcohol consumption from proxy information provided by family members. The RRs controlled for age, smoking (“did smoke” or “did not smoke”) and city of residence [14].

Estimating the 95 % uncertainty intervals for the PAFs

The 95 % Uncertainty Intervals (UIs) were estimated using a Monte Carlo-type approach [44]. To estimate the 95 % UIs for each alcohol PAF, we used a set of 2,000 generated lowest level parameters; these sets of parameters were then used to calculate 2,000 alcohol PAFs. The calculated variances of the resulting 2,000 alcohol PAFs were used to estimate the 95 % UIs.

All statistical analyses and modelling were performed using R version 3.1.0 [45].

Results

In Russia in 2012, the adult per capita consumption of alcohol was 14.8 litres of pure alcohol (23.4 litres of pure alcohol per adult male and 7.6 litres of pure alcohol per adult female), with recorded adult per capita consumption of alcohol being 11.2 litres of pure alcohol and unrecorded adult per capita consumption of pure alcohol being 3.6 litres of alcohol. Table 1 outlines alcohol consumption in Russia for 2012. In that year, more men than women were current drinkers and engaged in HED. Furthermore, more men than women were heavy consumers of alcohol (a daily consumption of greater than 76.08 grams of pure alcohol per day).
Table 1

Alcohol consumption characteristics of the Russian population in 2012

Gender

Alcohol consumption

Age

15 to 34 years of age

35 to 64 years of age

65 years of age and older

Total (15 years of age and older)

Men

Lifetime abstainers

6.6 %

5.4 %

11.5 %

6.5 %

Former drinkers

15.0 %

20.4 %

24.2 %

18.7 %

Current drinkers

78.4 %

74.2 %

64.3 %

74.8 %

 

<12.68 g/day*

23.2 %

22.8 %

22.8 %

22.9 %

 

>12.68 g/day and < 25.36 g/day

12.9 %

12.5 %

11.7 %

12.5 %

 

≥25.36 g/day to < 76.08 g/day

27.5 %

25.9 %

21.5 %

26.0 %

 

≥76.08 g/day

14.9 %

13.1 %

8.3 %

13.3 %

Heavy episodic drinkers**

31.2 %

29.5 %

25.6 %

29.8 %

Women

Lifetime abstainers

14.7 %

16.0 %

32.5 %

18.8 %

Former drinkers

18.4 %

18.5 %

24.7 %

19.7 %

Current drinkers

66.9 %

65.4 %

42.8 %

61.5 %

 

<12.68 g/day

32.7 %

33.8 %

30.2 %

32.8 %

 

>12.68 g/day and < 25.36 g/day

12.6 %

12.5 %

7.5 %

11.6 %

 

≥25.36 g/day to < 76.08 g/day

17.5 %

16.0 %

5.0 %

14.4 %

 

≥76.08 g/day

4.1 %

3.1 %

0.2 %

2.9 %

Heavy episodic drinkers**

11.1 %

10.8 %

7.1 %

10.2 %

Total

Lifetime abstainers

10.6 %

11.1 %

25.9 %

13.2 %

Former drinkers

16.7 %

19.4 %

24.5 %

19.2 %

Current drinkers

72.7 %

69.5 %

49.6 %

67.6 %

 

<12.68 g/day

27.9 %

28.7 %

27.8 %

28.3 %

 

>12.68 g/day and < 25.36 g/day

12.7 %

12.5 %

8.8 %

12.0 %

 

≥25.36 g/day to < 76.08 g/day

22.5 %

20.5 %

10.2 %

19.7 %

 

≥76.08 g/day

9.5 %

7.7 %

2.8 %

7.6 %

Heavy episodic drinkers**

21.2 %

19.4 %

12.9 %

19.1 %

*Measured in grams of pure alcohol per day

**Monthly consumption of at least 60 grams of pure alcohol on at least one drinking occasion

In 2012, for people 0 to 64 years of age, using Russia-specific alcohol RRs, alcohol caused an estimated 231,900 (95 % UI: 185,600 to 278,200) deaths in Russia (70,800 deaths among women and 161,100 deaths among men), and 13,295,000 DALYs were lost (95 % UI: 11,242,000 to 15,348,000) (3,670,000 DALYs lost among women and 9,625,000 DALYs lost among men) due to alcohol consumption. Adjusting these figures for population size results in 187 deaths per 100,000 people (118 and 251 deaths per 100,000 women and men respectively) and 10,694 DALYs lost per 100,000 people (6,091 and 15,023 DALYs lost per 100,000 women and men respectively).

This burden represents 29.4 % of all deaths for this age group (31.2 % and 28.7 % of all deaths for women and men respectively in this age group), and 27.5 % of all DALYs lost (21.9 % of all DALYs lost for women and 30.5 % of all DALYs lost for men). See Tables 2 and 3 for the burden of alcohol consumption by cause for deaths and DALYs lost respectively based on Russia-specific alcohol RRs.
Table 2

Burden of deaths attributable to alcohol consumption in Russia for people 0 to 64 years of age in 2012 based on Russia-specific alcohol RR functions

Cause*

Women

Men

Total

Deaths

% of all deaths AA

Deaths

% of all deaths AA

Deaths

% of all deaths AA

Total

70,800

31.2 %

161,100

28.7 %

231,900

29.4 %

 

Communicable, maternal, neonatal and nutritional disorders

3,510

13.4 %

12,620

16.8%

16,130

15.9 %

  

HIV/AIDS and tuberculosis

1,470

8.5 %

7,950

14.0 %

9,420

12.7 %

  

Lower respiratory infections

1,960

42.8 %

4,550

35.3 %

6,510

37.2 %

  

Neonatal conditions

80

3.3 %

120

3.4 %

200

3.3 %

 

Non-communicable diseases

51,810

29.9 %

84,850

22.8 %

136,660

25.1 %

  

Neoplasms

3,810

6.8 %

8,120

10.1 %

11,930

8.8 %

  

Diabetes mellitus

−280

−13.9 %

−10

−0.5 %

−290

−7.8 %

  

Cirrhosis of the liver

11,750

76.2 %

11,750

50.0 %

23,500

60.4 %

  

Digestive diseases (except cirrhosis)

970

16.1 %

3,210

18.1 %

4,180

17.6 %

  

Neurological disorders

90

4.5 %

210

8.4 %

300

6.7 %

  

Mental and behavioural disorders

3,580

67.1 %

14,850

71.3 %

18,430

70.4 %

  

Cardiovascular and circulatory diseases

31,900

42.0 %

46,720

22.4 %

78,620

27.7 %

 

Injuries

15,510

55.3 %

63,600

55.5 %

79,110

55.5 %

  

Transport injuries

2,120

41.0 %

8,230

47.7 %

10,350

46.1 %

  

Unintentional non-transport injuries**

8,990

57.1 %

35,380

55.8 %

44,370

56.0 %

  

Self-harm and personal violence***

4,400

62.7 %

20,000

60.7 %

24,400

61.0 %

*See Additional file 2 for ICD categories included in each cause

**Includes poisonings, falls, fires, drowning and other unintentional injuries

***Includes self-inflicted injuries and homicide

Table 3

Burden of Disability-Adjusted Life Years lost attributable to alcohol consumption in Russia for people 0 to 64 years of age in 2012 based on Russia-specific alcohol RR functions

Cause*

Women

Men

Total

DALYs

% of all DALYs AA

DALYs

% of all DALYs AA

DALYs

% of all DALYs AA

Total

3,670,000

21.9 %

9,625,000

30.5 %

13,295,000

27.5 %

 

Communicable, maternal, neonatal and nutritional disorders

183,200

8.5 %

620,100

14.3 %

803,300

12.4 %

  

HIV/AIDS and tuberculosis

87,600

9.3 %

434,600

15.0 %

522,200

13.6 %

  

Lower respiratory infections

86,700

29.0 %

172,800

28.9 %

259,500

28.9 %

  

Neonatal conditions

8,900

3.1 %

12,600

3.2 %

21,500

3.2 %

 

Non-communicable diseases

2,541,000

19.8 %

5,487,700

26.4 %

8,028,700

23.9 %

  

Neoplasms

145,400

6.8 %

291,800

10.0 %

437,200

8.7 %

  

Diabetes mellitus

−45,700

−13.7 %

−1,500

−0.5 %

−47,200

−7.8 %

  

Cirrhosis of the liver

494,900

76.1 %

510,000

49.8 %

1,004,900

60.0 %

  

Digestive diseases (except cirrhosis)

43,600

15.1 %

152,900

19.0 %

196,500

17.9 %

  

Neurological disorders

16,600

3.2 %

32,400

8.3 %

49,000

5.4 %

  

Mental and behavioural disorders

637,500

22.3 %

2,698,200

59.7 %

3,335,700

45.2%

  

Cardiovascular and circulatory diseases

1,248,800

41.1 %

1,803,700

22.1 %

3,052,500

27.2 %

 

Injuries

946,000

53.5 %

3,517,100

54.4 %

4,463,100

54.2 %

  

Transport injuries

157,100

41.3 %

552,400

47.5 %

709,500

46.0 %

  

Unintentional non-transport injuries**

555,700

55.4 %

1,890,700

54.6 %

2,446,400

54.8 %

  

Self-harm and personal violence***

233,200

61.5 %

1,074,000

60.2 %

1,307,200

60.4 %

*See Additional file 2 for ICD categories included in each cause

**Includes poisonings, falls, fires, drowning and other unintentional injuries

***Includes self-inflicted injuries and homicide

Furthermore, in Russia in 2012, for people 0 to 64 years of age, alcohol-attributable communicable, maternal, neonatal and nutritional disorders contributed to 7.0 % of all alcohol-attributable deaths and 6.0 % of all alcohol-attributable DALYs lost. Alcohol-attributable non-communicable diseases contributed to 58.9 % of all alcohol-attributable deaths and 60.4 % of all alcohol-attributable DALYs lost, and alcohol-attributable injuries contributed to 34.1 % of all alcohol-attributable deaths and 33.6 % of all alcohol-attributable DALYs lost. Self-harm and personal violence as well as mental and behavioural disorders (the burden of this category stemmed mainly from alcohol use disorders) were impacted the most by alcohol; 61.0 % of all deaths and 60.4 % of all DALYs lost caused by self-harm and personal violence and 70.5 % of all deaths and 42.8 % of all DALYs lost caused by mental and behavioural disorders were attributable to alcohol consumption. Transport injuries, unintentional non-transport injuries, cirrhosis of the liver, cardiovascular and circulatory diseases, and lower respiratory infections were also greatly impacted by alcohol.

Compared to the 231,900 deaths based on country specific data (see above), an estimated 165,600 deaths (95 % UI: 97,200 to 228,100) (29,700 deaths among women and 135,900 deaths among men) were caused by alcohol based on using the alcohol RR functions from the meta-analyses used for other countries. These differences in the estimated numbers of deaths stem primarily from differences in the number of deaths estimated to be caused by injuries, ischemic strokes and IHD attributable to alcohol; there was little observed difference in the mortality burdens for pneumonia, hemorrhagic and other non-ischemic strokes, and cirrhosis of the liver attributable to alcohol. See Table 4 for the number of deaths and DALYs lost by cause attributable to alcohol for men and women using Russia-specific alcohol RR functions and using general alcohol RR functions. See Additional file 4 for the number of YLL and YLD by cause attributable to alcohol consumption for men and women using Russia-specific alcohol RR functions and using general alcohol RR functions.
Table 4

Deaths and DALYs lost attributable to alcohol consumption in Russia in 2012 using Russia-specific alcohol RR functions and general population alcohol RR functions for people 0 to 64 years of age

   

Women

Men

Total

 

Cause*

Deaths

DALYs

Deaths

DALYs

Deaths

DALYs

Russia-specific alcohol RRs

      
 

Communicable, maternal, neonatal and nutritional disorders

      
  

Lower respiratory infection

1,960

86,700

4,550

173,000

6,510

259,700

 

Non-communicable diseases

      
  

Ischemic heart disease

25,520

1,009,600

38,870

1,507,000

64,390

2,516,600

  

Ischemic stroke

2,430

86,500

3,260

116,000

5,690

202,500

  

Hemorrhagic and other non-ischemic strokes

3,400

129,600

3,520

137,000

6,920

266,600

  

Cirrhosis of the liver

11,750

494,900

11,750

510,000

23,500

1,004,900

  

Acute and chronic pancreatitis

970

43,600

3,210

153,000

4,180

196,600

 

Injuries

      
  

Transport injuries

2,120

157,100

8,230

552,000

10,350

709,100

  

Unintentional injuries (other than transport injuries)**

8,990

555,700

35,380

1,891,000

44,370

2,446,700

  

Self-harm and personal violence***

4,400

233,200

20,000

1,074,000

24,400

1,307,200

 

Total

70,800

3,670,000

161,100

9,625,000

231,900

13,295,000

 

Total (per 100,000 people)

118

6,091

251

15,023

187

10,694

Non-Russia-specific alcohol RRs

      
 

Communicable, maternal, neonatal and nutritional disorders

      
  

Lower respiratory infection

410

18,500

1,940

74,200

2,350

92,700

 

Non-communicable diseases

      
  

Ischemic heart disease

130

−21,900

−5,570

−227,600

−5,440

−249,500

  

Ischemic stroke

−300

−10,300

1,500

52,900

1,200

42,600

  

Hemorrhagic and other non-ischemic strokes

3,880

146,300

5,900

230,600

9,780

376,900

  

Cirrhosis of the liver

10,070

425,800

18,680

811,900

28,750

1,237,700

  

Acute and chronic pancreatitis

360

16,200

2,920

139,600

3,280

155,800

 

Injuries

      
  

Transport injuries

1,440

96,900

15,110

961,200

16,550

1,058,100

  

Unintentional injuries (other than transport injuries)**

2,960

161,500

40,930

2,085,700

43,890

2,247,200

  

Self-harm and personal violence***

1,420

76,800

22,160

1,199,100

23,580

1,275,900

 

Total

29,700

1,783,000

135,900

8,840,000

165,600

10,623,000

 

Total (per 100,000 people)

49

2,959

212

13,798

133

8,545

*See Additional file 2 for ICD categories included in each cause

**Includes poisonings, falls, fires, drowning and other unintentional injuries

***Includes self-inflicted injuries and homicide

When using the alcohol RR functions from the meta-analyses, 10,623,000 DALYs (95 % UI: 7,265,000 to 13,754,000) were lost (1,783,000 DALYs lost among women and 8,840,000 DALYs lost among men) for people 0 to 64 years of age. This compares to an estimated 13,295,000 DALYs lost (95 % UI: 11,242,000 to 15,348,000) (3,670,000 DALYs lost among women and 9,625,000 DALYs lost among men) caused by alcohol consumption for people 0 to 64 years of age when using the Russia-specific alcohol RR functions. These differences in the numbers of DALYs lost stem primarily from differences in the number of DALYs lost caused by injuries, ischemic strokes and IHD attributable to alcohol consumption. See Additional file 5 for the burden of disease modelled for all ages.

Discussion

This study presents data that suggests that modelling the burden of alcohol consumption using RRs based on meta-analyses from all countries may not be appropriate, especially for diseases and injuries where the risk is determined in part by drinking patterns and other factors such as drink-driving laws [12, 13]. Specifically, this study found that the alcohol-attributable burden of transport injuries was moderately higher when non-Russia-specific RRs were used and that alcohol-attributable ischemic disease was markedly underestimated when non-Russia-specific RRs were used. This study also found that the alcohol-attributable burdens of acute and chronic pancreatitis, unintentional injuries (other than transport injuries), self-harm and personal violence were lower when using non-Russia-specific RRs, and that the burdens of hemorrhagic and other non-ischemic strokes, and cirrhosis of the liver were higher when using non-Russia-specific RRs (see Additional file 3 for a comparison of the Russian RRs with categorically transformed RRs from meta-analyses).

Differences in the estimated alcohol-attributable burden using the Russia-specific RRs versus the general RRs were most evident for women, as the protective effect on IHD is more pronounced among women [10]). However, the differences in the estimated alcohol-attributable burden using the Russia-specific RRs versus the general RRs may be diminished if the studies which provide new evidence of the detrimental effects of alcohol on IHD (which have only been recently published) were used in modeling general RRs for IHD [46, 47]. Moreover, results of Mendelian randomization studies on alcohol and IHD have put into question the existence of a beneficial effect (see [48], and the subsequent discussion [49, 50]).

The burden of transport injuries caused by alcohol was less when calculated using the Russia-specific RR functions compared to when the general alcohol RR functions were used. This may be due to the different methodologies used in the two estimates (one based on average consumption and the other based on average and heavy drinking occasions).

When restricting our findings to people 15 to 64 years of age, this study found that 32.4 and 29.3 % of all deaths among women and men respectively were attributable to alcohol consumption. These findings are in contrast to those reported by Leon and colleagues [8] who found that 43 % of all premature deaths among men 25 to 54 years of age were attributable to hazardous drinking as defined by non-beverage alcohol consumption and/or problem drinking, and to Zaridze and colleagues’ findings that 52 % of all deaths among people 15 to 54 years of age were attributable to alcohol consumption [14]. One explanation for part of the observed differences is that in our study alcohol poisoning deaths (which constituted a large percentage of excess deaths in Leon and colleagues’ and Zaridze and colleagues’ studies) could not be modelled using a specific category RR, as data on alcohol poisonings were not available as a separate injury category. Furthermore, the percentage of all deaths attributable to alcohol consumption was greater for women than for men, even though men experienced more deaths attributable to alcohol consumption. The factors that caused women to have such a high relative burden of alcohol consumption should be investigated in future research.

The current results underline the necessity to check on the applicability of global RR functions for individual countries. For Russia and some surrounding Eastern European countries, RR functions may underestimate true risk because of drinking patterns. Additionally, for other countries, prevalences of people with genotypes that influence the risk of alcohol consumption may also lead to incorrect burden estimates when global RR functions are applied [51].

Limitations

There are limitations to the Russia-specific RRs from Zaridze and colleagues’ study. First, these RRs are step functions, in contrast to continuous risk functions which are used for other countries. Second, the measurement of alcohol consumption for Zaridze and colleagues’ study was by proxy (in 2001–2005) and was measured years after the mortality of the individuals (1990–2001). Third, the data for Russia-specific RRs are based on one large study and, as a consequence, some RRs were not significant [14] and, thus, were not used. Fourth, the Russia-specific RRs are solely for mortality and not morbidity, whereas meta-analyses have recently started to assess morbidity separately [3]. Fifth, the Russia-specific alcohol RRs use only average alcohol consumption and use the reference category of ever-drinkers with weekly consumption of less than one half bottle of vodka. The use of this reference category may lead to a minor underestimation of the risk of mortality from alcohol-related diseases as we treated this category as lifetime abstainers within the alcohol PAF. The use of the RR for consumption of between less than one bottle but greater than one half of a bottle of vodka a week to all current drinkers that consumed less than one bottle of vodka a week should not cause an overestimation of the alcohol-attributable burden of IHD, as the protective effects of alcohol on IHD occur at moderate alcohol consumption [10]. Finally, Russia-specific RRs were measured for people who died from 1990 to 2001. This timeframe includes the Russian mortality crisis (from 1990 to 1994) where Russia experienced a 40 % increase in the crude mortality rate and alcohol poisoning also increased [52, 53]. Therefore, the RRs may not reflect the current situation in Russia as some 100 % alcohol-attributable mortalities, such as alcohol poisonings, have since decreased [53].

The estimates for the burden of disease attributable to alcohol consumption have general limitations. First, mortality and morbidity data contain inaccuracies, even when obtained from the most reliable sources [2729], with the measurement of the burden of morbidity being commonly subject to more error than the burden of mortality [54]. For Russia and similar countries, the estimates of YLD are very provisional and uncertain in nature, making estimates of the alcohol-attributable DALYs lost for Russia presented in this study less accurate than the estimates presented for alcohol-attributable mortality [55, 56]. Specifically, the databases which result from the collection of morbidity data from polyclinics and hospitals (the sources of most morbidity data) are problematic in terms of their diagnostic accuracy [55]. Additionally, even data collected in Russia in a systematic manner and on a large scale (such as cancer registries) have problems with accuracy and detail [55]. Second, the estimates presented are based on RR functions that were adjusted for age and smoking status, and in some cases for a variety of other risk factors, which may introduce bias [33, 57, 58]. Third, the estimates for alcohol consumption are cross-sectional, and past alcohol consumption would be a better risk measure for chronic diseases such as cancer and liver cirrhosis which develop over time [3]; however, for diseases such as liver cirrhosis, changes in alcohol consumption have been observed to have an immediate impact on mortality [18, 59].

Conclusions

Russia-specific RRs produce different estimates of the alcohol-attributable burden of disease when compared to estimates obtained using the RRs from meta-analyses of global data. Further investigation into the reasons for these differences should be undertaken, as country-specific RRs may be needed in cases where countries have very detrimental drinking patterns.

Abbreviations

BAC: 

Blood alcohol content

DALYs: 

Disability-adjusted life years

GBD: 

Global burden of disease

HED: 

Heavy episodic drinking

IHD: 

Ischemic heart disease

PAFs: 

Population-attributable fractions

YLL: 

Years of life lost

RR: 

Relative risk

UIs: 

Uncertainty intervals

WHO: 

World health organization

YLD: 

Years lived with disability

Declarations

Acknowledgements

This work was supported by the World Health Organization as provided to the World Health Organization-Pan American Health Organization Collaborating Centre for Addiction and Mental Health located at Toronto, Canada.

Authors’ Affiliations

(1)
Social and Epidemiological Research department, Centre for Addiction and Mental Health (CAMH)
(2)
WHO/PAHO Collaborating Centre in Addiction and Mental Health, CAMH
(3)
Institute of Medical Science (IMS), University of Toronto
(4)
Dalla Lana School of Public Health (DLSPH), University of Toronto
(5)
Institute of Clinical Psychology and Psychotherapy
(6)
Department of Psychiatry, University of Toronto

References

  1. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2224–60.View ArticlePubMedPubMed CentralGoogle Scholar
  2. World Health Organization. Global status report on alcohol and health. Geneva, Switzerland: World Health Organization; 2014.Google Scholar
  3. Rehm J, Baliunas D, Borges GL, Graham K, Irving HM, Kehoe T, et al. The relation between different dimensions of alcohol consumption and burden of disease - an overview. Addiction. 2010;105(5):817–43.View ArticlePubMedPubMed CentralGoogle Scholar
  4. Rehm J, Room R, Monteiro M, Gmel G, Graham K, Rehn N, et al. Alcohol Use. In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, editors. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. Geneva, Switzerland: World Health Organization; 2004. p. 959–1109.Google Scholar
  5. Rehm J, Klotsche J, Patra J. Comparative quantification of alcohol exposure as risk factor for global burden of disease. Int J Methods Psychiatr Res. 2007;16(2):66–76.View ArticlePubMedGoogle Scholar
  6. Rehm J, Kehoe T, Gmel G, Stinson F, Grant B, Gmel G. Statistical modeling of volume of alcohol exposure for epidemiological studies of population health: the example of the US. Popul Health Metr. 2010;8:3.View ArticlePubMedPubMed CentralGoogle Scholar
  7. Nemtsov AV. A Contemporary History of Alcohol in Russia. Stockholm, Sweden: Södertörns högskola; 2011.Google Scholar
  8. Leon DA, Saburova L, Tomkins S, Andreev E, Kiryanov N, McKee M, et al. Hazardous alcohol drinking and premature mortality in Russia: a population based case–control study. Lancet. 2007;369(9578):2001–9.View ArticlePubMedGoogle Scholar
  9. Tomkins S, Collier T, Oralov A, Saburova L, McKee M, Shkolnikov V, et al. Hazardous alcohol consumption is a major factor in male premature mortality in a typical Russian city: prospective cohort study 2003–2009. PloS one. 2012;7(2):e30274.View ArticlePubMedPubMed CentralGoogle Scholar
  10. Roerecke M, Rehm J. Irregular heavy drinking occasions and risk of ischemic heart disease: a systematic review and meta-analysis. Am J Epidemiol. 2010;171(6):633–44.View ArticlePubMedGoogle Scholar
  11. Sundell L, Salomaa V, Vartiainen E, Poikolainen K, Laatikainen T. Increased stroke risk is related to a binge drinking habit. Stroke. 2008;39(12):3179–84.View ArticlePubMedGoogle Scholar
  12. Taylor B, Irving HM, Kanteres F, Room R, Borges G, Cherpitel C, et al. The more you drink, the harder you fall: a systematic review and meta-analysis of how acute alcohol consumption and injury or collision risk increase together. Drug Alcohol Depend. 2010;110(1–2):108–16.View ArticlePubMedPubMed CentralGoogle Scholar
  13. Taylor B, Rehm J. The relationship between alcohol consumption and fatal motor vehicle injury: high risk at low alcohol levels. Alcohol Clin Exp Res. 2012;36(10):1827–34.View ArticlePubMedPubMed CentralGoogle Scholar
  14. Zaridze D, Brennan P, Boreham J, Boroda A, Karpov R, Lazarev A, et al. Alcohol and cause-specific mortality in Russia: a retrospective case–control study of 48,557 adult deaths. Lancet. 2009;373:2201–14.View ArticlePubMedPubMed CentralGoogle Scholar
  15. Zaridze D, Lewington S, Boroda A, Scélo G, Karpov R, Lazarev A, et al. Alcohol and mortality in Russia: prospective observational study of 151,000 adults. Lancet. 2014;pii: S0140-6736(13):62247–3.Google Scholar
  16. World Health Organization. Global Health Observatory. Geneva, Switzerland: World Health Organization; 2014.Google Scholar
  17. Zaridze D, Maximovitch D, Lazarev A, Igitov V, Boroda A, Boreham J, et al. Alcohol poisoning is a main determinant of recent mortality trends in Russia: evidence from a detailed analysis of mortality statistics and autopsies. Int J Epidemiol. 2009;38:143–53.View ArticlePubMedGoogle Scholar
  18. Leon DA, Chenet L, Shkolnikov V, Zakharov S, Shapiro J, Rakhmanova G, et al. Huge variation in Russian mortality rates 1984–1994: artefact, alcohol, or what? Lancet. 1997;350(9075):383–8.View ArticlePubMedGoogle Scholar
  19. Rehm J, Sulkowska U, Manczuk M, Boffetta P, Powles J, Popova S, et al. Alcohol accounts for a high proportion of premature mortality in central and eastern Europe. Int J Epidemiol. 2007;36:458–67.View ArticlePubMedGoogle Scholar
  20. Rehm J. What can we learn from Russia about alcohol epidemiology and alcohol policy? Lancet. 2014;383(9927):1440–2.View ArticlePubMedGoogle Scholar
  21. Nemtsov AV. Alcohol-related harm losses in Russia in the 1980s and 1990s. Addiction. 2002;97:1413–25.View ArticlePubMedGoogle Scholar
  22. Neufeld M, Rehm J. Alcohol consumption and mortality in Russia since 2000 – are there any changes following the alcohol policy changes starting in 2006. Alcohol Alcohol. 2013;48(2):222–30.View ArticlePubMedGoogle Scholar
  23. Rehm J. Russia: lessons for alcohol epidemiology and alcohol policy. The Lancet. in press.Google Scholar
  24. Shield K, Rylett M, Gmel GS, Gmel G, Kehoe-Chan T, Rehm J. Global alcohol exposure estimates by country, territory and region for 2005 – a contribution to the Comparative Risk Assessment for the 2010 Global Burden of Disease Study. Addiction. 2013;108(5):912–22.View ArticlePubMedGoogle Scholar
  25. Rehm J, Sempos C, Trevisan M. Average volume of alcohol consumption, patterns of drinking and risk of coronary heart disease - a review. J Cardiovasc Risk. 2003;10(1):15–20.View ArticlePubMedGoogle Scholar
  26. Trevisan MT, Schisterman E, Mennotti A, Farchi G, Conti S. Drinking pattern and mortality: the Italian risk factor and life expectancy pooling project. Ann Epidemiol. 2001;11:312–9.View ArticlePubMedGoogle Scholar
  27. James G, Patton RE, Heslin S. Accuracy of cause-of-death statements on death certificates. Publ Health Rep. 1955;70(1):39–51.View ArticleGoogle Scholar
  28. Nashelsky MB, Lawrence CH. Accuracy of cause of death determination without forensic autopsy examination. Am J Forensic Med Pathol. 2003;24(4):313–9.View ArticlePubMedGoogle Scholar
  29. Shojania KG, Burton EC, McDonald KM, Goldman L. Changes in rates of autopsy-detected diagnostic errors over time: a systematic review. J Am Med Assoc. 2003;289(21):2849–56.View ArticleGoogle Scholar
  30. Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2095–128.View ArticlePubMedGoogle Scholar
  31. Lozano R, Murray CJL, Lopez AD, Satoh T. Miscoding and misclassification of ischaemic heart disease mortality. Global program on evidence for health policy discussion paper 12. Geneva, Switzerland: World Health Organization; 2001.Google Scholar
  32. Rothman KJ, Greenland S, Lash TL. Modern Epidemiology. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.Google Scholar
  33. Rockhill B, Newman B. Use and misuse of population attributable fractions. Am J Public Health. 1998;88:15–9.View ArticlePubMedPubMed CentralGoogle Scholar
  34. Patra J, Taylor B, Irving H, Roerecke M, Baliunas D, Mohapatra S, et al. Alcohol consumption and the risk of morbidity and mortality from different stroke types - a systematic review and meta-analysis. BMC Public Health. 2010;10(1):258.View ArticlePubMedPubMed CentralGoogle Scholar
  35. Baliunas D, Taylor B, Irving H, Roerecke M, Patra J, Mohapatra S, et al. Alcohol as a risk factor for type 2 diabetes - a systematic review and meta-analysis. Diabetes care. 2009;32(11):2123–32.View ArticlePubMedPubMed CentralGoogle Scholar
  36. United Nations. World Population Prospects: The 2012 Revision. In. New York, USA; 2013.Google Scholar
  37. Perlman FJ. Drinking in transition: trends in alcohol consumption in Russia 1994–2004. BMC Public Health. 2010;10 (691).Google Scholar
  38. Nemtsov A. Alcohol consumption level in Russia: a viewpoint on monitoring health conditions in the Russian Federation (RLMS). Addiction. 2003;98:369–70.View ArticlePubMedGoogle Scholar
  39. Nemtsov A. Alcohol consumption in Russia: is monitoring health conditions in the Russian Federation (RLMS) trustworthy? Addiction. 2004;99:386–7.View ArticlePubMedGoogle Scholar
  40. Rosstat (Russian Federal Government Statistics Service). Central Statistics Database. In. Moscow, Russia; 2015. Avaliable at: (http://www.gks.ru/free_doc/doc_2012/rus-eng12.pdf).
  41. Shield K, Rehm J. Difficulties with telephone-based surveys on alcohol in high-income countries: the Canadian example. Int J Methods Psychiatr Res. 2012;21(1):17–28.View ArticlePubMedPubMed CentralGoogle Scholar
  42. Stockwell T, Zhao J, Macdonald S. Who under-reports their alcohol consumption in telephone surveys and by how much? An application of the ‘yesterday method’ in a national Canadian substance use survey. Addiction. 2014; Epub ahead of print.Google Scholar
  43. Kehoe T, Gmel Jr G, Shield K, Gmel Sr G, Rehm J. Determining the best population-level alcohol consumption model and its impact on estimates of alcohol-attributable harms. Popul Health Metr. 2012;10(1):6.View ArticlePubMedPubMed CentralGoogle Scholar
  44. Gmel GJ, Shield KD, Frick H, Kehoe T, Gmel G, Rehm J. Estimating uncertainty of alcohol-attributable fractions for infectious and chronic diseases. BMC Med Res Methodol. 2011;11:48.View ArticlePubMedPubMed CentralGoogle Scholar
  45. R Development Core Team. R: A Language and Environment for Statistical Computing (version 3.1.0). In. Vienna, Austria: R Foundation for Statistical Computing; 2014.Google Scholar
  46. Roerecke M, Rehm J. Chronic heavy drinking and ischaemic heart disease: a systematic review and meta-analysis. Open Heart. 2014;1:e000135.View ArticlePubMedPubMed CentralGoogle Scholar
  47. Roerecke M, Rehm J. Cause-specific mortality risk in alcohol use disorder treatment patients: a systematic review and meta-analysis. Int J Epidemiol. 2014;43(3):906–19.View ArticlePubMedGoogle Scholar
  48. Holmes MV, Dale CE, Zuccolo L, Silverwood RJ, Guo Y, Ye Z, et al. Association between alcohol and cardiovascular disease: Mendelian randomisation analysis based on individual participant data. BMJ. 2014;349:g4164.View ArticlePubMedPubMed CentralGoogle Scholar
  49. Roerecke M, Rehm J. Alcohol and ischaemic heart disease risk-finally moving beyond interpretation of observational epidemiology. Addiction. 2015; Epub ahead of print.Google Scholar
  50. Knott CS, Coombs N, Stamatakis E, Biddulph JP. All cause mortality and the case for age specific alcohol consumption guidelines: pooled analyses of up to 10 population based cohorts. BMJ. 2015;350:h384.View ArticlePubMedPubMed CentralGoogle Scholar
  51. Roerecke M, Shield KD, Higuchi S, Yoshimura A, Larsen E, Rehm MX, et al. Correcting estimates of alcohol-related oesophageal cancer burden in Japan: a systematic review and meta-analyses. Bull World Health Org. In press.Google Scholar
  52. Bhattacharya J, Gathmann C, Miller GJ. The Gorbachev anti-alcohol campaign and Russia’s mortality crisis. Am Econ J Appl Econ. 2013;5(2):232–60.View ArticlePubMedPubMed CentralGoogle Scholar
  53. Shkolnikov VM, Cornia GA, Leon DA, Meslé F. Causes of the Russian mortality crisis: evidence and interpretations. World Dev. 1998;26(11):1995–2011.View ArticleGoogle Scholar
  54. Nolte E, McKee M, Gilmore A. Morbidity and mortality in the transition countries of Europe. In: United Nations, editor. The new demographic regime Population challenges and policy responses. New York, USA: United Nations; 2005. p. 153–76.Google Scholar
  55. Jaakkola JJ, Cherniack M, Spengler JD, Ozkaynak H, Wojtyniak B, Egorov A, et al. Use of health information systems in the Russian federation in the assessment of environmental health effects. Environ Health Perspect. 2000;108(7):589.View ArticlePubMedPubMed CentralGoogle Scholar
  56. National Center for Health Statistics. Vital and health statistics: Russian Federation and United States, selected years 1980–93. Vital Health Stat. 1995; 5(9).Google Scholar
  57. Korn EL, Graubard BI. Analysis of Health Surveys. New York, NY: John Wiley & Sons Inc; 1999.View ArticleGoogle Scholar
  58. Flegal KM, Williamson DF, Graubard BI. Using adjusted relative risks to calculate attributable fractions. Am J Public Health. 2006;96(3):398.View ArticlePubMedPubMed CentralGoogle Scholar
  59. Zatonski W, Sulkowska U, Manczuk M, Rehm J, Lowenfels AB, La Vecchia C. Liver cirrhosis mortality in Europe, with special attention to central and eastern Europe. Eur Addict Res. 2010;16:193–201.View ArticlePubMedGoogle Scholar

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