Daily variations in deaths in Lithuania: the possible contribution of binge drinking.

BACKGROUND: During the early 1990s the countries of the Former Soviet Union experienced a dramatic rise in mortality, especially from cardiovascular diseases. Although still poorly understood there is evidence, particularly from Russia, that this mortality crisis is partly linked to alcohol consumption. In this paper we use data from Lithuania to explore the daily variations of deaths and the probable relationship with binge drinking. METHODS: Computerized death certificates for those aged 20-59 years were analysed according to the day of death, place of death, and cause of death for the years 1988-1997. RESULTS: There is a marked increase in deaths from accidents, violence, and alcohol poisoning at the weekend, suggesting a pattern of binge drinking in Lithuania. There is also a significant increase in ischaemic heart disease (IHD) deaths on Saturdays, Sundays and Mondays. If the analysis is performed separately according to place of death, the day of the week effect is strengthened for cardiovascular deaths outside of hospital; consistent with the idea of a sudden cardiac death. CONCLUSION: The increase in mortality from cardiovascular diseases observed at the weekend in Lithuania is similar to that observed in Moscow and other populations. The relationship with alcohol consumption is supported by the available physiological evidence. We propose that bingeing can be solely responsible for, or acts as a 'catalyst' for, pathophysiological events by increasing blood pressure, cardiac rhythm and coagulability. The increased IHD mortality observed throughout the weekend and on Monday in Lithuania may reflect the influence of alcohol consumption patterns in a population already subject to high psychosocial stress.

Exploring the relationship between alcohol consumption and non-fatal or fatal stroke: a systematic review.

OBJECTIVE: Alcohol consumption has been reported to have both beneficial and harmful effects on stroke occurrence. Several studies have demonstrated a significant association with heavy drinking, but the evidence linking light-to-moderate alcohol consumption still remains unclear. This study, using a systematic review of the published literature, aimed to explore the dose-response relationship between alcohol and stroke, the effect of irregular drinking and the effect of beverage types on the risk of stroke. METHODS: A structured search for English-language published literature since 1966 was made using several electronic databases. This was supplemented using a hand search of references in review articles and additional searches on key authors. From the 153 eligible articles, 41 studies were selected according to study design, categorization of the exposure and outcome measures. FINDINGS: An association between recent alcohol use and stroke was consistently reported. There was also some evidence for a linear positive association for haemorrhagic stroke and alcohol consumption. Inconsistent results emerged on the J-shaped relationship between alcohol and ischaemic stroke, and the association between alcohol and non-fatal or fatal stroke combined. The importance of the pattern of drinking was also demonstrated, indicating a higher risk for irregular drinkers. CONCLUSIONS: There is insufficient evidence to conclude that light-to-moderate alcohol drinking and wine intake have beneficial effects on stroke occurrence. On the contrary, findings from this review suggest the opportunity for a primary prevention regarding heavy drinking and binge drinking. More information regarding the risk of stroke associated with irregular alcohol drinking, and the joint effects of alcohol with other risk factors, would clarify the complex interaction between alcohol and stroke.

What has contributed to the change in life expectancy in Italy between 1980 and 1992?

Life expectancy at birth in southern Europe is known to be greater than expected in comparison with levels of economic development. This has been attributed to the 'Mediterranean diet'. There are, however, concerns that this comparative advantage is being lost. This paper examines the factors underlying changing life expectancy in Italy since 1980. The subjects of this analysis are obtained from data on all deaths in Italy between 1980 and 1992. Change in age specific death rates is calculated from selected causes and, using the method developed by Pollard, the contribution of deaths from different causes and at different ages to changing life expectancy at birth is estimated. Between 1980 and 1992, life expectancy at birth increased by 2.70 years for men and 2.75 years for women. Death rates have fallen among children and those over 40. In contrast, death rates have increased among men aged between 20 and 39 and have increased very slightly among women aged 25-29. Falling death rates from ischaemic heart disease are continuing to contribute to increasing life expectancy. Death rates from lung and breast cancer are rising among women but are compensated for by falling death rates from other cancers. Among men, falling death rates from cancer at younger ages are being offset by increases at older ages. The rising death rate among younger men is almost entirely due to AIDS, with accidents also making a small contribution. Life expectancy in Italy has improved throughout the 1980s, largely driven by falling death rates from cardiovascular diseases. Here are, however, some worrying trends, most notably the rising death rate among young men, due almost entirely to AIDS. The changing pattern of mortality has some similarities with Spain, another Mediterranean country, but there are also important differences.

Why is the death rate from lung cancer falling in the Russian Federation?

Age standardised death rates (European standard population) from lung cancer in the Russian Federation, have been rising since at least 1965, levelled out in the late 1980s and have subsequently decreased. The reasons for this decline are not apparent. This study seeks to identify the reasons for the decline in mortality from lung cancer in the Russian Federation in the 1990s. Changes in age-specific mortality from lung cancer in the Russian Federation between 1990 are described and age-cohort analysis, based on age-specific death rates for lung cancer is undertaken for the period 1965 to 1995. As other work has shown that any recent deterioration in coding of cause of death has been confined largely to the elderly, this suggests that the trend is not a coding artefact. Age-period-cohort analysis demonstrates the existence of a marked birth cohort effect, with two major peaks corresponding to those born around 1926 and 1938. These groups would have reached their early teens during the second world war and the period immediately after the death of Stalin, respectively. The present downward trend in death rates from lung cancer in the Russian Federation is partly due to a cohort effect and it is expected that this will soon reverse, with a second peak occurring in about 2003.

Cancer mortality in Russia and Ukraine: validity, competing risks and cohort effects.

BACKGROUND: The dramatic increase in mortality in Russia and Ukraine in the late 1980s and 1990s has been due to increases in certain causes of death, particularly cardiovascular disease and accidents and violence. In contrast, there has been a slight fall in mortality from cancer. METHODS: This paper presents an analysis of trends and patterns in cancer mortality and examines four possible explanations for its recent fall: changes in data collection; cohort effects; competing mortality from other causes of death; and improvements in health care. RESULTS: All contribute to some extent to the observed changes, with each affecting predominantly different age groups. There is evidence of a significant underrecording of cancer deaths among the elderly especially in rural areas and of significant changes in coding practices in the early 1990s. Competing mortality from cardiovascular diseases and accidents can explain some reduction in male deaths from cancer in middle age. Birth cohort effects can explain some reduction among males after early middle age and among females at all ages. The impact of changes in health care are more difficult to identify with certainty but there is evidence of reduced deaths from childhood leukaemia. IMPLICATIONS: Recent changes in mortality in Russia are complex and their understanding will require a multidisciplinary approach embracing demography, epidemiology and health services research.

Seasonal variation in mortality in Moscow.

BACKGROUND: Seasonal variation in mortality has been investigated in many countries but not, until recently, in Russia. There are some grounds for suspecting that it may differ in Russia from what is seen in western countries. This paper explores patterns of seasonal variation in mortality in Moscow between 1993 and 1995. METHODS: Analysis was based on individual data on deaths occurring in Moscow between January 1993 and December 1995, grouped by four-week period and by calendar month and on mean monthly temperature in Moscow for the same period. Crude, smoothed and deseasonalized trends were inspected. Auto-correlation functions were estimated and deaths were regressed against temperature. RESULTS: As in other northern hemisphere countries, there is a winter excess of deaths but this is much smaller than in many western countries. It is restricted to some causes of death, such as ischaemic heart disease and cerebrovascular disease, and is associated with low temperature. In contrast, there is a marked summer increase in deaths among young people, especially from accidents and other deaths associated with alcohol consumption. Over the three-year period studied, there was an initial underlying increase in alcohol-related deaths that subsequently fell, coinciding with a previously observed increase in life expectancy. CONCLUSIONS: It is possible that the low level of excess winter mortality reflects warmer indoor environments than in the west. The seasonal variation of deaths among young people reinforces evidence of the important role of alcohol in the Russian mortality crisis.

Patterns of smoking in Russia.

BACKGROUND: Tobacco is a leading cause of avoidable death in Russia but there is, as yet, relatively little information in the public domain on who is smoking and how this is changing. This information is important for those seeking to develop effective policies to tackle this issue. OBJECTIVE: To determine the prevalence of smoking in Russia and its association with sociodemographic factors. DESIGN: Cross-sectional survey on patterns of tobacco consumption. SETTING: Data were collected using the New Russia Barometer, a multi-stage stratified-sample survey of the population of the Russian Federation undertaken in the summer of 1996. PARTICIPANTS: Data were available on 1587 individuals (response rate 65.7%). Respondents differed little from the overall Russian population in terms of age, sex, education, and voting intention. MAIN OUTCOME MEASURES: Prevalence of current and past smoking. RESULTS: Smoking is common among males of all ages and in all areas. Of those aged 18-24 years, 65% smoke, rising to 73% in those aged 25-34 and then falling steadily to reach 41% in those aged 65 and older. Among women, smoking is much more common among the young (27% in those aged 18-34) than among the middle-aged and elderly (5% in those aged 55 and older), and more common among those living in urban areas than in rural areas. Smoking is also more common among men and women suffering material deprivation but there is no independent association with education. Among men, but not women, church attendance is inversely associated with smoking. In both sexes, but especially women, heavy drinking and smoking are associated. CONCLUSIONS: Tobacco poses a major threat to the health of future generations in Russia, especially among women. A robust policy response is required.

Down the road to deregulation.

A recent preliminary ruling by the European Court of Justice, that would have ended the Swedish state retail alcohol monopoly on grounds of European law on free movement of goods, highlights the international pressure on countries to deregulate further their alcohol markets. However, those countries that have recently taken the road to deregulation have not been able to prevent the alcohol industry encouraging people to drink more and they are experiencing increased alcohol-related problems. The international debates about tradeable commodities rarely take account of the consequences for public health. Alcohol is one such commodity that is also an important cause of premature death. It is essential that this is not overlooked in the race to promote free trade.

Economic change, crime, and mortality crisis in Russia: regional analysis.

OBJECTIVE: To identify which aspects of socioeconomic change were associated with the steep decline in life expectancy in Russia between 1990 and 1994. DESIGN: Regression analysis of regional data, with percentage fall in male life expectancy as dependent variable and a range of socioeconomic measures reflecting transition, change in income, inequity, and social cohesion as independent variables. Determination of contribution of deaths from major causes and in each age group to changes in both male and female life expectancy at birth in regions with the smallest and largest declines. SETTING: Regions (oblasts) of European Russia (excluding Siberia and those in the Caucasus affected by the Chechen war). SUBJECTS: The population of European Russia. RESULTS: The fall in life expectancy at birth varied widely between regions, with declines for men and women highly correlated. The regions with the largest falls were predominantly urban, with high rates of labour turnover, large increases in recorded crime, and a higher average but unequal distribution of household income. For both men and women increasing rates of death between the ages of 30 and 60 years accounted for most of the fall in life expectancy, with the greatest contributions being from conditions directly or indirectly associated with heavy alcohol consumption. CONCLUSIONS: The decline in life expectancy in Russia in the 1990s cannot be attributed simply to impoverishment. Instead, the impact of social and economic transition, exacerbated by a lack of social cohesion, seems to have played a major part. The evidence that alcohol is an important proximate cause of premature death in Russia is strengthened.

Alcohol and cardiovascular mortality in Moscow; new evidence of a causal association.

BACKGROUND: In explaining recent trends in Russian mortality, alcohol drinking has often been put forward as a major factor. However, cardiovascular disease remains the major cause of death in Russia and alcohol is currently viewed as having a protective effect on heart disease. This study explores this apparent paradox by examining daily trends in deaths from cardiovascular disease in Moscow. SUBJECTS: Those dying in Moscow in the years 1993-1995. METHODS: Analysis of daily variation in deaths based on data from Moscow City death certificates. RESULTS: There is a significant increase in deaths from alcohol poisoning, accidents, and violence and cardiovascular diseases on Saturdays, Sundays, and Mondays. This is especially marked for sudden deaths. This pattern is consistent with the known pattern of drinking in Russia, which is more likely to take place in binges than is the case in other countries. CONCLUSION: A possible causative role for alcohol in sudden cardiovascular death is suggested as there are no other obvious explanations for this pattern, which cannot be accounted for by daily variations in traditional risk factors such as smoking or lipids. Although this is inconsistent with the prevailing view in the West that alcohol is seen as cardioprotective, there is considerable supporting evidence from a necropsy study and from studies in other places with a similar pattern of drinking. In countries such as Russia, where patterns of drinking differ considerably from that in the West, binge drinking can be an important cause of sudden cardiac death. This has important implications for estimates of the amount of mortality worldwide attributable to specific risk factors and thus for national and international policy.

Deaths from alcohol and violence in Moscow: socio-economic determinants.

PIP: The authors "examine the association between accidental, violent and alcohol related adult mortality in the Russian capital and socio-economic status characteristics such as educational status, occupational group and marital status.... The probability of death from alcohol related diseases increased as education level decreased, with those men failing to complete secondary education over two and a half times as likely to die from these causes than men with higher education. Blue collar workers were also much more likely to die from these causes than white collar workers. Marriage had a marked protective effect for both men and women." (EXCERPT)^ieng

Health sector reform in the former Soviet Republics of Central Asia.

Health services in the former Soviet Republics of Central Asia face many challenges, not least a rising burden of disease and severe economic constraints. Each government has developed proposals for reform. This paper describes the key elements of the proposals developed in each country. They have many features in common, such as financing based on social insurance, although they also have many differences, reflecting national political, economic and historical circumstances. While most attention so far has concentrated on the design of the proposed systems, it is argued here that there has been inadequate attention to the obstacles to implementation. These stem from the many adverse factors in the context within which reforms are taking place, weaknesses in the process of reform, and failure to involve the groups whose actions will be necessary for success. It is argued that governments and those advising them must place greater emphasis on the challenges of implementation, including the development of a much better understanding of the context within which change must take place.

Huge variation in Russian mortality rates 1984-94: artefact, alcohol, or what?

BACKGROUND: According to published data, between 1984 and 1994 mortality rates in Russia initially underwent a rapid decline followed by an even steeper increase. In 1994, male life expectancy at birth was 57.6 years, having fallen by 6.2 years since 1990. There has been concern that such striking fluctuations in mortality are an artefact, although, among other factors, alcohol consumption has been implicated. METHODS: We analysed the age-specific and cause-specific patterns of mortality decrease and increase by use of data from a newly reconstructed mortality series for Russia so that we could examine the plausibility of various explanations for the mortality trends. FINDINGS: All major causes of death, with the exception of neoplasms, showed declines in mortality between 1984 and 1987 and increases between 1987 and 1994. In relative terms, these tended to be largest for the age-group 40-50 years; surprisingly, they were of the same magnitude among women and men. The largest declines and subsequent increases in proportional terms were observed for alcohol-related deaths and accidents and violence. However, pronounced effects were also seen for deaths from infections, circulatory disease, and respiratory disease. No substantial variations were seen for neoplasms. INTERPRETATION: The stability of mortality from neoplasms in contrast to other causes over the period 1984-94 largely precludes the possibility that the changes in life expectancy are mainly an artefact, particularly one due to underestimation of the population. Although factors such as nutrition and health services may be involved, the evidence is that substantial changes in alcohol consumption over the period could plausibly explain the main features of the mortality fluctuations observed. These results provide a major challenge to public health in Russia and to our understanding of the determinants of alcohol consumption and its role in explaining mortality patterns within and between many other countries.

[Changing life expectancy in the 1980's. Why was Denmark different from Sweden?]. / Udviklingen i middellevetid i 1980'erne Hvorfor var Danmark forskellig fra Sverige?

The aim of the present study was to identify the contribution from specific causes of death to the changes in life expectancy at birth in Denmark relative to Sweden in different age groups during the 1980s and to compare the difference in life expectancy between the two countries in 1990. Mortality data from WHO mortality tapes grouped in smaller series of clinically meaningful categories were used to calculate the contribution of each of these categories at each ten year age group to the difference in life expectancy at birth in each country between 1979 and 1990 and between the two countries. During the period from 1979 to 1990 life expectancy increased in both Denmark and Sweden. However, Sweden experienced the greatest increase in life expectancy (more than two years) while it increased less than one year in Denmark. In both countries a decrease in cardiovascular disease mortality contributed most to the increase in life expectancy among males as well as females. Both among males and females the less favourable development in Denmark was mainly caused by differences in mortality trends related to cardio-vascular diseases, respiratory and non-respiratory cancer. Over a short period of time two Nordic countries experienced remarkable, but different changes in mortality. These findings suggest that mortality rates are sensitive to even minor differences in social and cultural factors across countries and over short time periods.

Informing the market: the strengths and weaknesses of information in the British National Health Service.

Many countries are experimenting with planned (or quasi-) markets to discover if they can efficiently deliver health care in keeping with societal objectives. This paper examines the information requirements of this approach. Information is necessary in order to compare the performance of providers, to support billing, and to monitor access to care. It should be accurate, unambiguous, and resistant to manipulation. We draw on a project to find out how information on hospitalisation could be used in contracting in the British National Health Service. We conclude that the existing British system fails to provide robust measures of how many patients are treated, for what conditions, and with what treatments. We identify some promising remedies, others that are more difficult, and some which may be impossible to implement in any planned market, given the uncertainty of clinical practice.

What happened to life expectancy in Spain in the 1980s?

BACKGROUND: Life expectancy at birth in Spain improved between 1972 and 1982, by 2.5 years for males and 3.2 years for females. This slowed considerably in the following decade, with increases of only 0.5 and 1.7 years respectively. OBJECTIVE: To determine the causes of death that have been responsible for the failure by Spain to maintain in the 1980s and 1990s the rate of improvement in life expectancy seen during the 1970s. DESIGN: Data from WHO mortality tapes grouped in a series of clinically meaningful categories were used to calculate the contribution of each category, in five year age groups, to the changing life expectancy at birth in the two periods. SETTING: Spain. RESULTS: The trend in life expectancy at birth in Spain over this 20 year period can be considered to have two components, both with important consequences for public health policy. Underlying trends include a steady negative contribution from respiratory cancer in men and a reduction in cardiovascular disease. More recent trends include a considerable deterioration in deaths among young adults, most notably from accidents and, possibly, AIDS. CONCLUSION: The failure to maintain the rate of earlier gains in life expectancy in Spain can be attributed largely to a few conditions, although these may indicate less obvious underlying problems. These findings have important consequences for prioritising public health policies.

Changing life expectancy in central Europe: is there a single reason?

BACKGROUND: During the 1980s, at a time that life expectancy at birth in western Europe has increased by 2.5 years, it has stagnated or, for some groups, declined in the former socialist countries of central and eastern Europe. METHODS: A study was carried out to ascertain the contribution of deaths at different age groups and from different causes to changes in life expectancy at birth in Czechoslovakia, Hungary and Poland between 1979 and 1990. RESULTS: Improvements in infant mortality have been counteracted by deteriorating death rates among young and middle-aged people, with the deterioration commencing as young as late childhood in Hungary but in the thirties or forties in Czechoslovakia and Poland. The leading contributors to this deterioration are cancer and circulatory disease but, in Hungary, cirrhosis and accidents have also been of great importance. CONCLUSIONS: The patterns observed in each country differ in the age groups affected and the causes of death. Further work is required to explain these differences.