Alcohol is Implicated in the Fluctuations in Cardiovascular Disease in Russia Since the 1980s

Abstract

Recently in this Journal, Bobak and Marmot challenged the sence of valid conventional, individual-level epidemiologiview that alcohol might be a major factor in the Russian cal data. It is in this context that the indirect evidence, mortality crisis of the 1990s (1). While conceding that whatever its limitations, remains salient. We would argue, alcohol may play a part in the dramatic increase in deaths however, that it is also more persuasive than Bobak and from external causes, they argue that evidence that it has Marmot imply (1). First, the cause-specific pattern of mortalcontributed to the similarly dramatic rise in cardiovascular ity decline associated with the anti-alcohol campaign of disease is weak. They make four main points. First, they the mid-1980s is in many respects the mirror image of the contend that any evidence that does exist to link the two increase seen in the 1990s (3). The fluctuations in mortality is indirect, with no direct evidence from Russia that heavy were observed in most of the former Soviet Republics, all drinking is associated with cardiovascular disease. Second, of which were subject to the anti-alcohol campaign and they argue that estimates of alcohol consumption are too which, as White has shown in great detail (4), was highly low to produce the observed effects. Third, the observed effective in reducing access to alcohol, contrary to what mortality changes would require not only that the prevaBobak and Marmot (1) suggest. lence of drinking changed but also that the relative risk of While the fluctuations in mortality were similar in shape death increased, an idea they deem unlikely. Fourth, the in nearly all Soviet Republics, the magnitude was least in biological mechanisms underlying the proposed relationship those with significant Muslim populations, where alcohol are unclear. In an accompanying Editorial, Balkau (2) was consumption is known to be less (5). There was also variacritical of Bobak and Marmot’s (1) conclusions but we betion among Russian regions where change in deaths directly lieve that, in addition to the issues raised by Balkau (2), attributable to alcohol and to cardiovascular diseases bethere are several others which may help to resolve this tween 1991 and 1994 are also closely correlated (6). Interestcontroversy. At the outset, however, we should emphasise ingly, Poland, which also has a culture of vodka drinking, that we agree with Bobak and Marmot (1) that this question experienced a short lived decline in cardiovascular disease can only be finally resolved when evidence from well-conin the early 1980s during martial law when access to alcohol ducted epidemiological studies in Russia becomes available. was restricted, coinciding with an interruption in the previously increasing death rate from cirrhosis (7).