Family members were found at 50 066 (83%) of the 60 416 addresses visited. 97% of interviews were completed, yielding information on 48 557 decedents (31 504 men, 17 053 women), of whom 43 082 were cases and 5475 were controls. shows year of death, relationship of interviewee to deceased individual, certified causes of death, and, for controls (97% [5309/5475] of whom were ethnic Russian), their reported habits. Of 2514 male controls, 212 (8%) never drank alcohol, 363 (14%) were in the reference category, and 1939 (77%) were in the higher alcohol consumption categories. Of 2961 female controls, 903 (30%) never drank, 1479 (50%) were in the reference category, and only 579 (20%) were in the higher alcohol consumption categories. Within each category, however, male and female controls had similar consumption patterns. On average, those in the top category drank on 4·8 (SD 1·6) days a week, consuming 5·4 (1·4) half-litre bottles of vodka (or equivalent) a week, with maximum consumption of spirits in 1 day mostly reported as one bottle or two bottles (mean 1·4 [0·6] bottles). On average, those in the other three categories of ever-drinkers (ie, reference, <one bottle, or one to <three bottles) drank on 0·4 (0·6), 0·8 (0·8), or 2·2 (1·2) days a week, consuming 0·1 (0·1), 0·3 (0·3), or 1·5 (0·5) bottles of vodka (or equivalent) a week, with maximum spirits in 1 day 0·2 (0·1), 0·7 (0·3), or 1·0 (0·4) bottles.
Characteristics of deceased men and women, and of interviewees
gives the main results for male mortality at ages 15–74 years in ever-drinkers, subdivided by cause and amount drunk. For neoplastic disease, the trend in risk across categories of ever-drinkers was significant only for upper aerodigestive tract cancer (RR 3·48, 95% CI 2·84–4·27, in the highest alcohol consumption category; trend p<0·0001) and liver cancer (2·11, 1·64–2·70; trend p<0·0001). The trends were not significant for lung cancer (p=0·18) or stomach cancer (p=0·46).
Male relative risk of death at ages 15–74 years, by proxy-reported alcohol intake (other drinkers vs reference drinkers, excluding never-drinkers) and certified cause (other causes vs control diseases)
Six non-neoplastic disease groups were also strongly associated with alcohol in men, with RRs greater than 3·00 in the highest consumption category (all p<0·0001 for the trend in risk). These disease groups were tuberculosis (4·14, 3·44–4·98), pneumonia (3·29, 2·83–3·83), liver disease (6·21, 5·16–7·47), pancreatic disease (6·69, 4·98–9·00), acute ischaemic heart disease (IHD) other than myocardial infarction (3·04, 2·73–3·39), and death from an ill-specified disease (7·74, 6·48–9·25). The latter two groups include some misclassified deaths that were actually from alcohol poisoning.6
Some other causes of death were significantly associated with alcohol, but the RRs were less extreme (eg, stroke [1·28, 1·15–1·43]). There was, however, no significant trend in mortality from acute myocardial infarction (p=0·62); in the heaviest drinkers (three or more bottles per week), acute myocardial infarction accounted for only 178 deaths, whereas acute IHD other than myocardial infarction accounted for 1044 deaths.
In the combined results for all causes of death strongly associated with alcohol in men (ie, liver cancer and anything with RR more than 3·00 in ) there was, of course, a definite and progressive dose-response relation (with RR 3·77, 3·44–4·12, for men in the highest alcohol category), whereas in the combined results for all other diseases the progressive association, although significant, was less strong (1·40, 1·29–1·52).
As expected, reported alcohol consumption was strongly associated with the mortality that was certified as caused by alcohol poisoning, but 41 (3%) of 1610 ever-drinkers who died from alcohol poisoning were in the lowest alcohol category (reference category), and a further 11 were reported as never-drinkers, indicating that proxy information sometimes missed life-threatening alcohol use. Moreover, another 188 (12%) deaths from alcohol poisoning were in men whose usual consumption was, perhaps inaccurately, reported to be less than one bottle per week. Reported alcohol consumption was also strongly associated with the other major groups of external causes of death, including transport accidents (4·20, 3·31–5·34), other accidents (6·07, 5·27–6·98), suicide (8·62, 6·99–10·62), and assault (9·47, 7·96–11·25; all p<0·0001 for the trend in risk).
gives the corresponding results for women. For neoplastic disease, the RR in the highest drinking category appeared to be increased only for liver cancer and upper aerodigestive tract cancer, although no trend in cancer mortality was significantly positive (perhaps because of small numbers). For breast cancer, the trend was significantly negative (p=0·0002), and the relative risks in the two highest alcohol consumption categories were both substantially lower than 1·00.
Female relative risk of death at ages 15–74 years, by proxy-reported alcohol intake (other drinkers vs reference drinkers, excluding never-drinkers) and certified cause (other causes vs control diseases)
The non-neoplastic disease groups that were most strongly associated with alcohol in men were even more strongly associated with alcohol in women, each with an RR of more than 3·00 not only in the heaviest drinkers but also in women drinking one to three bottles of vodka (or equivalent) per week (and each with p<0·0001 for trend). The same findings were seen for each main group of external causes, including transport accidents, other accidents, suicide, and assault. As in men, reported alcohol consumption in women was strongly associated with mortality from alcohol poisoning, but in the 424 female ever-drinkers certified as dying from alcohol poisoning, 51 (12%) were in the lowest alcohol category (reference category), and another 41 (10%) were reported to have usually consumed less than one bottle of vodka (or equivalent) per week. Again, the RR was substantially less extreme for acute myocardial infarction than for other acute IHD, and in the top two alcohol consumption categories, only 64 women died from acute myocardial infarction compared with 463 from other acute IHD.
subdivides the results for all men more narrowly by age (15–54 years and 55–74 years) and groups the causes as alcohol poisoning, accidents and violence, diseases strongly associated with alcohol in this study, other non-control diseases, and control diseases. (The strongly associated diseases were liver disease, liver cancer, upper aerodigestive cancer, and other disease groups with RR more than 3·00 for men with usual consumption three or more bottles of vodka per week [tuberculosis, pneumonia, acute IHD other than myocardial infarction, non-neoplastic pancreatic disease, and ill-specified disease].) The relative risks comparing never-drinkers with reference drinkers are consistent with families under-reporting moderate alcohol use more in men who had died from accidents, violence, and diseases strongly associated with alcohol than in men who had died from other diseases. This finding is particularly clear for men aged 55–74 years, in whom the ratio of reported never-drinkers to reference drinkers was 1·1 ([88+371]/[87+317]) for men who had died of accidents, violence, and diseases strongly associated with alcohol, compared with only 0·4 ([560+98]/[1266+223]) in men who had died of other diseases (p<0·0001 for difference in ratios).
Male dose-related excess mortality in ever-drinkers as a proportion of all mortality in male ever-drinkers and never-drinkers, by age and underlying cause of death
gives corresponding results for women. Discrepancies between never-drinkers and reference drinkers are less extreme than in men, but are still apparent, particularly at ages 55–74 years. The ratio of never-drinkers to reference drinkers at these ages was 0·9 (742/832) for female deaths from accidents, violence, and the diseases strongly associated with alcohol, and only 0·5 (2623/4868) for female deaths from other diseases, again consistent with variable under-reporting of moderate alcohol use.
Female dose-related excess mortality in ever-drinkers as a proportion of all mortality in female ever-drinkers and never-drinkers, by age and underlying cause of death
The relative risks in ever-drinkers (which compare the three higher alcohol consumption categories with the reference category) might be more directly indicative of real associations. Even in ever-drinkers, however, substantial misclassification of real alcohol consumption patterns is inevitable. If some alcohol-associated deaths are included in the reference category, then uncorrected calculation of alcohol-dose-related excess mortality in the other three alcohol consumption categories will underestimate the real excess mortality. Exact correction for this is impossible, but approximate correction for it is made in by multiplying the uncorrected excess mortality from each cause by a common factor, calculated within each age range to ensure that the corrected dose-related excess is 100% for the deaths from alcohol poisoning. At ages 15–54 years, the alcohol dose-related excess accounted for 6712 (48%) of 13 968 male deaths in the uncorrected calculations, and 8182 (59%) of 13 968 in the corrected calculations. Of the corrected excess, 90% ([1163+3756+2432]/8182 deaths) was from alcohol poisoning, accidents, violence, and the eight disease groups that are strongly related to alcohol; of the remaining 10% (831/8182 excess deaths in men at ages 15–54 years), much was from vascular disease. The corrected alcohol dose-related excess accounted for 3944 (22%) of 17 536 deaths in older men, 1565 (33%) of 4751 deaths in women aged 15–54 years and 1493 (12%) of 12 302 deaths in older women.
For sensitivity analyses, alcohol use was crudely split into lower (<one bottle per week, including never drinkers) and higher usual consumption categories, and the analyses of were then repeated. With this crude split, the uncorrected dose-related excess for alcohol poisoning was only 72% (1466/2048), but correction (as in ) automatically increased this to 100%, and made dose-related excess mortality at ages 15–54 years 50% (7045/13 968) for men and 27% (1305/4751) for women, and at ages 55–74 years made it 22% (3827/17 542) for men and 10% (1275/12 302) for women. These corrected percentages are similar to those shown in , and were not materially affected by finer stratification for potential confounders (amount smoked, year of death, years since death, marital status, relationship to informant, ethnicity, education, occupation, socioeconomic status, or recent change in socioeconomic status) or by inclusion in the controls of all cancers not strongly related to alcohol (data not shown).
Non-beverage alcohol use was strongly correlated with other alcohol use but, given vodka consumption, was no more common in those dying from strongly alcohol-related causes than in those dying from other causes. For men who died at ages 15–39 years and were drinkers of less than one, one to less than three, or three or more bottles of vodka (or equivalent) per week, the respective proportions of deaths with non-beverage alcohol use reported were 1% (18/1306), 6% (70/1106), and 20% (250/1257) for the strongly alcohol-related causes and 1% (3/313), 5% (8/168), and 28% (34/120) for the other causes. These findings suggest that for a given amount of ethanol consumption its source was not strongly predictive of cause of death. For women, the corresponding percentages were based on much smaller numbers: 2% (8/405), 6% (9/153) and 20% (38/192) for strongly alcohol-related causes and 0% (0/240), 0% (0/23) and 39% (9/23) for other causes, respectively.
shows the regional mortality trends (1990–2001) in mortality from all causes, from the main causes strongly associated with alcohol use in this study (approximately as in ), and from the other causes. Because of the changes in Russian death coding in 1999, the strongly alcohol-related causes had to include chronic heart disease and exclude liver cancer (see panel 2
). In both sexes and all age-groups there was a much sharper increase during 1992–94 in mortality from the strongly alcohol-related causes than from other causes. Fluctuations in these alcohol-related causes were the main determinants of the large fluctuations in all-cause mortality in the study areas, particularly at ages 15–34 years and 35–54 years. Thus, at these ages, the ratio of mortality from the strongly alcohol-related causes to mortality from all other causes fluctuated sharply, and was at a maximum in 1994. This was true for the whole study region () and for the individuals in our study (data not shown).
Mortality from all causes, from causes strongly related to alcohol, and from other causes in the Altay and Tomsk regions of Russia, 1990–2001
Panel 2. Russian cause of death coding
The strongly alcohol-related causes included in our analyses of regional time trends differ slightly from those used in all of our other analyses, because they had to be defined from Russian cause of death codes,6
which changed in 1999 but still differed from the International Classification of Diseases, 10th revision.18
The Russian codes included (for years 1990–98; then 1999–2001) were:
45–46 and 52; then 56–57 and 65 (upper aerodigestive tract cancer [liver cancer was unavailable])
9–13 and 43; 9–15 and 54 (tuberculosis)
103–07 and 110–14; 148–56 and 160–64 (pneumonia, etc)
30 and 122–23; 41–43 and 173–75 (liver disease, not cancer)
126; 178 (pancreatic disease, not cancer)
92–97; 122–32 (heart disease, other than myocardial infarction [acute and chronic were not separable])
158–59; 226–28 (ill-specified disease)
73, 75, and 160–75; 97, 98, and 239–55 (external causes, including alcoholic psychosis and poisoning)