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

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Indirect evidence is persuasive and remains salient

The problem we are faced with in understanding the massive fluctuations in mortality in Russia is the almost entire absence of valid conventional, individual-level epidemiological data. It is in this context that the indirect evidence, whatever its limitations, remains salient. We would argue, however, that it is also more persuasive than Bobak and Marmot imply (1). First, the cause-specific pattern of mortality decline associated with the anti-alcohol campaign of the mid-1980s is in many

Flaws in contrary evidence

Bobak and Marmot (1) cite as evidence against the link one of the very few studies of alcohol consumption and mortality undertaken in Russia. The Lipid Research Clinics' Russian cohort failed to show an increase in the relative risk of cardiovascular death even in the heaviest drinking category (8).

Balkau (2) has identified several limitations of this study but there are others which together throw doubt on the validity of the findings. From our own experience of analysing this cohort (9), we

Consistency and biological plausibility

We now turn to the issue of whether or not our hypothesis that alcohol has played an important role in the fluctuations in cardiovascular disease in Russia is biologically plausible and consistent with the evidence from other human and animal studies. Bobak and Marmot (1) argue that “Virtually all research conducted in western populations is consistent in finding that alcohol consumption reduces risk of ischaemic heart disease, with only those with very high consumption having an elevated risk

Prevalence and episodes of binging and relative risks

Survey data on alcohol consumption patterns over the period of the collapse of the Soviet Union is fragmentary and not altogether consistent. Nevertheless, Bobak and Marmot do not take issue with the finding that in 1996 a third of Russian men were found to drink a quarter of a litre of vodka or more at one go at least once a month (35). They also do not challenge the Finnish finding that binge drinking has been found to be associated with a 6-fold increased risk of sudden cardiac death in one

Conventional cardiovascular risk factors

We agree that other factors must contribute to the high levels of cardiovascular mortality in Russia but three issues are pertinent. First, it is necessary to consider two phenomena separately, the high level of cardiovascular disease in Russia that has been evident since the mid-1960s and the enormous fluctuations observed since the mid 1980s. Second, even if alcohol is playing a major role, it may be modified by a wide range of other factors, such as diet or the social context in which

Future research directions

Although the evidence that has looked specifically at binge drinking is consistent, we concede that most of it is indirect. Future research should address several questions. First, there is a need to examine the use of the label `ischaemic heart disease'. This work has suggested that if binge drinking is associated with death from heart disease, the link is primarily with sudden cardiac death rather than individuals who suffer the classic symptoms of myocardial ischaemia and die later from

Acknowledgements

This research is funded by the United Kingdom Department for International Development (DfID). However DfID can accept no responsibility for the views expressed.

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