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��ࡱ�>��	�����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������[�����bjbj����4�ΐΐJi,�������nnnnn�������8�4�$�+6(>>>����*�*�*�*�*�*�*$F-��/.�*!n������*nn>>�*s#s#s#��n>n>�*s#��*s#s#s#>����`�Iv}��e �s#o*�*0+s#0"Z0s#s#0n�#���s#������*�*s#���+������������������������������������������������������������������������0���������(4:Some aspects of alcohol consumption in Russia: 1970-2014
Sergei V. Jargin
People�s Friendship University of Russia, Clementovski per 6-82, 115184 Moscow, Russia
E-mail:  HYPERLINK "mailto:sjargin@mail.ru" sjargin@mail.ru
Abstract
There is abundant literature about alcohol consumption and alcoholism in Russia. The problem is immense; but nevertheless there is a tendency to exaggerate it, which is visible for inside observers. Such exaggeration tends to veil shortcomings of the health care system, with responsibility for the low life expectancy especially among men shifted onto the patients, that is, self-inflicted diseases caused by excessive alcohol consumption. The purpose of this review is to draw attention to this and other problems related to the alcohol consumption, such as the instable quality of alcoholic beverages, which have sometimes caused poisonings even after consumption in moderate doses, and offences against alcoholics and people with alcohol-related dementia aimed at appropriation of their immobile or other properly. 
Key words: alcoholism, alcohol-related dementia, Russia
Alcohol consumption in the former Soviet Union (SU) has been a theme of extensive research and publication despite the difficulties of obtaining valid statistics. The fact that the state, at various times, encouraged alcohol sales is known to the international community (1). Veiled propaganda of alcohol consumption was recognizable during the 1960-1980s (before the start of the anti-alcohol campaign in 1985) and took place also earlier (2, 3). Some editions such as the extremely popular �Book about delicious and healthy food� re-edited several times (4), praised gustatory and medicinal properties of alcoholic beverages, which was accompanied by appetizing illustrations with bottles standing on a richly covered table, seen and admired by many children. The most efficient tool of the alcohol propaganda was creation by certain mass media and films of an attractive image of a drunkard, suitable for self-identification: carefree, cheerful and manly. The carrier of this notion was, for example, the most popular magazine �Crocodile�, whose feuilletons and caricatures were formally directed against alcohol but, in fact, romanticized alcohol consumption and the reckless drunken atmosphere. The �Crocodile� and other mass media created and poetized alcoholic stereotypes: vodka-i-seliodka (consumption of vodka with salty herring), butylka-na-troikh (a bottle for three) etc. Association of harmless pastimes such as the fishing trips or domino play with alcohol consumption was maintained by numerous pictures and cartoons. In the same way acted the most popular Soviet-time films with participation of the famous actor Yuri Nikulin, who personified the image of a charismatic drunkard; more details are in (2). Alcohol consumption at workplaces was not only tolerated but also visibly encouraged among workers, students and intelligentsia. Some Soviet festivals were associated with drinking, the best example being the New Year: eating and drinking started well before midnight; then, at midnight, sparkling wine was consumed, and then followed a continuation, until the daybreak in many cases. Other festivals associated with alcohol consumption were the Women�s Day on March 8 and professional holidays such as the Builder�s Day on the second Sunday of August, when many people related to a corresponding profession became inebriated. Birthdays and other personal events were regularly celebrated in many working teams. Parties at workplaces were often initiated or indirectly inspired by the management, which was common also in medical, educational and scientific institutions. In such institutions, technical or medicinal alcohol was consumed, which was knowingly tolerated by the management. It was known and seen that the management purloined alcohol themselves. Moreover, in workers�, students� and other companies, the ringleaders could be observed, who manipulated others towards drinking in excess. Non-drinkers were sometimes stigmatized. 
Treatment and prevention of alcoholism was inefficient, while placebos and persuasion were the usual methods (5). Aversion (emetic) therapy and repeatedly induced teturam-alcohol reactions were applied (6). Correctional centers, the so-called work-and-treatment prophylactoriums, were in fact a form of detainment for 1-2 years for alcoholics evading treatment, violating community order or working discipline (according to the official definition); while loopholes were left for the patients to obtain alcohol e.g. over the fence. The prophylactoriums were criticized as contradictory to human rights (6). There was business with teturam preparations for the implantation, having a placebo effect at best (7, 8): patients or their relatives were persuaded about efficacy and paid for the implantation. Finally, the so-called ultra-rapid psychotherapy or stress-therapy of alcoholism, known in the former SU as the �coding�, should be mentioned. The method was started during the anti-alcohol campaign; it was criticized as unethical (9) because of mystification, intimidating verbal suggestion, painful and unpleasant manipulations: spraying the throat with ethyl chloride, massage of the trigeminal nerve branches, sudden backwards movements of the patient�s head by the therapist (9-11). Certain modifications of the method included general anesthesia (12). The method is used in the former SU for treatment of alcohol and drug addiction now as before (13).
The anti-alcohol campaign (1985-88), launched by Mikhail Gorbachev, was initially successful but ended with a failure. It was accompanied, along with a temporary decrease in the alcohol-related mortality (1), by numerous fatal cases because of the increased consumption of alcohol-containing surrogates and technical fluids. The quality of alcoholic beverages deteriorated during that period (14). After the campaign, the alcohol consumption increased again, with vodka forming a larger share in the total (15), having partly replaced wine (16). 
As mentioned in the preceding section, veiled propaganda of alcohol consumption was recognizable from 1970 to 1985 but took place also earlier (3); more details are in (2). Retrospectively, it becomes clear that the anti-alcohol campaign (1985-88) was used for the same purpose: its failure and the recoil-effect was predictable and occurred when it was needed. Massive alcohol consumption after the anti-alcohol campaign facilitated the economical reforms of early 1990s. It is known that alcohol abusers can experience shame and guilt and have a low self-esteem (17), therefore being easier to manipulate and to command. Workers did not oppose privatizations of state-owned enterprises partly due to their drunkenness, involvement in workplace theft and other illegal activities, e.g. use of equipment for private purposes, which was often tolerated by the management at that time. 
Similarly, the impact of earlier anti-alcohol measures was sometimes quite different from the proclaimed goals. In 1972, the sales of vodka and other spirits on Sundays, and between 7 p.m. and 11 a.m. on all other days, were prohibited. However, after 7 p.m. till the closing of shops at 8-10 p.m., and on Sundays, fortified wines with the alcohol concentration 17-19 % were sold. Some cheaper fortified wines were poor quality, being noticed to induce more severe intoxication and hangover than vodka. In practice, workers who finished work at around 5 p.m., considering that there were usually queues at the shops, started drinking vodka (often at the workplace) but continued with fortified wines or consumed the latter only. It was generally known that it were not advisable to drink fortified wine after vodka: it often brought about more severe intoxications, vomiting, sleeping down in public places etc. At the same time, 0.25l vodka bottles disappeared almost completely, replaced by 0.5l bottles. On the rare occasions when the 0.25l bottles were on sale, it induced a visibly positive emotional reaction. For aged alcoholics in particular, it was preferable to buy a 0.25l bottle of vodka after work and to go home: then he or she would wake up next morning in a better condition for the next workday. Instead, they often continued with poor quality fortified wines, which caused deeper intoxications, being associated with higher health-related and social risks. This was a foreseeable consequence of the anti-alcohol measures of 1972. 
During the Soviet time, even beyond the anti-alcohol campaigns, alcoholic beverages were not as easily available as in many other countries: number of bottle stores was limited, queues were usual. It was difficult to buy a bottle of beer in case of an occasional demand such as stress. After standing a queue, larger amounts of alcohol were usually purchased and consumed. Analogously, people rarely came to a beerhouse just for one drink: after standing a queue, people usually stayed there for hours. In the author�s opinion, technically complicated availability of alcohol is one of the factors contributing to deeper alcohol intoxications. 
After the anti-alcohol campaign (1985-88), the quality of alcoholic beverages deteriorated (14), but they have become easily available. However, recent governmental measures in Russia, limiting availability of alcohol, in particular, a prohibition of small (0.33l) beer cans, contribute even today to alcohol consumption in higher doses. The prohibition from the 1 January 2013 of beer selling between 23 p.m. and 8 a.m. (18) apparently results in purchasing by some people larger amounts in advance with subsequent consumption. Prohibition of beer sales at small kiosks (18) will probably have a similar effect in the places with no shops near at hand. There is an opinion that the latter measure would have no impact on the volume of beer sales (19). The superficial anti-alcohol measures of this kind and accompanying rhetoric are in fact distracting public attention from the problems, which the government does not tackle, among them the insufficient public health and social security systems (20, 21). 
According to the author�s observations, the pattern of alcohol consumption in Russia has been changing since approximately the year 2000, with the average amounts of consumed alcohol tending to decrease. The decrease was mentioned in some publications (22, 23); but for an inside observer this tendency seems to be more pronounced, especially in the large cities such as Moscow. During the Soviet time and the 1990s, many inebriated individuals could be seen in public places: drinking, sleeping, making noise, etc. In contrast with the past, there are almost no heavily drunk people in the streets today; even the marginalized are rarely seen drunk in public. 
During the last 1-2 decades, the pattern of alcohol consumption has been changing primarily in large cities: less heavy binge drinking of vodka, partly replaced by the moderate consumption of beer (16). A similar tendency is also generally noticed in smaller towns and rural areas, favored by the ongoing immigration from the regions with less widespread alcohol consumption, such as Middle Asia and the Caucasus, or explained by the fact that local alcoholics have �died out� with fewer successors. Other reasons for these changes have been discussed previously: the more responsible way of life under the conditions of the market economy, intimidation and crime against alcoholics and people with alcohol-related dementia, aimed at appropriation of their apartments, houses and other property (24-26). 
A discussion of the changing pattern of alcohol consumption in Russia would be incomplete without an overview of social transformations during the two last decades, including the dissolution of the social strata containing the majority of alcohol consumers in urban areas � working class and intelligentsia. Their carefree lifestyle, often accompanied by alcohol consumption, was largely lost after the economic reforms of the early 1990s: many factories and scientific institutions were closed or restructured; and personnel faced unemployment in conditions of an underdeveloped social security system with by far insufficient unemployment benefits. Many people, in order to preserve a current or to find a new job, had to discontinue or reduce their alcohol consumption. In addition, the ongoing replacement of ethnic Russian workers by immigrants from less drinking regions has further contributed to the per capita decrease in alcohol consumption by workers. 
It was discussed above that certain governmental measures, supposedly aimed at reduction of mass alcohol abuse, have in fact contributed to deeper intoxications and increased mortality due to the widespread consumption of toxic alcohol-containing fluids. After the anti-alcohol campaign (1985-88), average life expectancy at birth decreased sharply, especially in men: by 1993 it had slumped to about 59 years (15), today being estimated to be 64 years (20). According to a widespread opinion, many Russian alcohol abusers do not live long enough to die of liver cirrhosis or its complications. Among the most frequent causes of death of alcoholics are bronchopulmonary diseases including chronic bronchitis, bronchopneumonia, pleural empyema, and tuberculosis (28-31). This is partly caused by the cold climate coupled with the limited availability of warm public houses for the people with low incomes, so that they often drink and loiter outdoors and can fall asleep in a cold place. Smoking is also likely to be a contributing factor.   
Another cause of the relatively high mortality has been the poor quality of alcoholic beverages, in particular, consumption of counterfeit products and surrogates sold also in legally operating shops (14). During the anti-alcohol campaign, many poisonings were caused by alcohol-containing technical fluids. The quality of legally sold alcoholic beverages deteriorated during that period; and after the campaign, poor-quality alcoholic beverages were produced and sold en masse (32). Numerous cases of death after the ingestion of moderate amounts (33), with a relatively low blood alcohol level (32) were reported, obviously caused by the substances other than ethanol contained in the consumed products. 
Furthermore, a relatively high mortality rate from cardiovascular diseases in Russia has been reported (34, 35). A cause of the high registered cardiovascular mortality in the former SU is evident for anatomic pathologists. Since the Soviet time, autopsy has remained obligatory for all patients dying in hospitals; but the attitude towards post-mortem examinations has become less rigorous. Autopsies were often performed incompletely (36). Two examples: in the late 1990s, a young pathologist, who has recently become professor, performed an autopsy in a central clinical hospital in Moscow and wrote as a post mortem diagnosis �cancer of oral mucosa� without looking into the oral cavity, on the basis of a preceding cytological report mentioning �atypical cells� in a smear from the oral cavity. Another example from the same institution: aplastic anemia was diagnosed post mortem referring to clinical data in an elderly patient with red bone marrow in the femoral diaphysis without its histological examination and iron stain. Both diagnoses were approved by a professor and head of pathology services. If a cause of death is not entirely clear, it is usual to write on a death certificate: �Ischemic heart disease with cardiac insufficiency� or a similar formulation. A tendency to overdiagnose cardiovascular diseases also exists for people dying at home and not undergoing autopsy. This is likely to be one of the causes of the considerable increase in registered cardiovascular mortality, especially among men (37). It can be indirectly confirmed by the following statement: �Increases and decreases in mortality [have been] related to cardiovascular diseases (CVD), particularly to �other forms of acute and chronic ischemia� and �atherosclerotic heart disease�, but not to myocardial infarction, the proportion of which in Russian CVD-related mortality is extremely low.� (38) The explanation for this discrepancy is evident: the diagnosis of myocardial infarction is usually based on clear clinical and/or pathological criteria, while entities such as �acute and chronic ischemia� or �atherosclerotic heart disease� can be used post mortem without strong evidence; more details are in (21). 
The following typical statement should be commented upon: �Numerous epidemiological studies led to the consensus that vodka binge drinking is a key reason for these observed changes,� i.e. for premature mortality (34). It is difficult to generalize without reliable statistics, but heavy binge drinking is visibly in decline in today�s Russia, especially in large cities such as Moscow (14). The role of alcohol as a cause of premature death cannot be denied, but this role was obviously more significant during the 1990s, when alcohol consumption increased as a recoil effect after the anti-alcohol campaign. The causative role of alcohol in Russian mortality rates was obviously exaggerated in some publications, e.g. (39), where �the enormous scale of alcohol-related mortality� was reiterated without mentioning the insufficient availability and quality of health care as another cause of premature death. There is a tendency in the Russian literature to exaggerate the topic alcohol abuse and its causative relationship with mortality especially from cardiovascular diseases (28, 29, 32, 39, 40). In this way, responsibility for the higher mortality due to the shortages of the health care system is shifted onto the patients themselves: they supposedly suffered from self-inflicted diseases in consequence of excessive alcohol consumption. In fact, statements such as �Alcohol accounts for most of the large fluctuations in Russian mortality, and alcohol and tobacco account for the large difference in adult mortality between Russia and Western Europe.� (41) tend to disguise another cause of the difference: insufficient availability and quality of health care.
For example, it was stated on the basis of a large autopsy study that all studied 654 deceased hard drinkers were diagnosed post mortem with cardiomyopathy; while in the majority of the patients classified as chronic alcoholics (172 cases) the cardiomyopathy was graded as pronounced (29). According to (28), clinically significant cardiomyopathy was diagnosed in about 50% of habitual alcohol consumers. Accordingly, cardiomyopathy has been used to explain for sudden death among alcohol consumers (29), while the real cause could have been undiagnosed diseases, poisonings or others (38). The tendency to exaggerate the cause-effect relationship between alcohol and the cardiovascular morbidity/mortality is relatively new in the Russian-language literature. An earlier epidemiological study reported that rates of cardiovascular diseases including hypertension were not significantly higher among excessively drinking men compared to the general male population (30); a lesser prevalence of atherosclerosis in alcoholics older than 40 years compared to the controls was reported in (31). 
Finally, it should be mentioned that evaluating results of surveys (42-44), it should be taken into account that surveys and questionnaires have been largely discredited in Russia by means of obtrusive solicitations to partake in different surveys, often asking for private information: in the streets, per telephone, and previously also by agents coming to private homes. Answers to the questionnaires can be biased, especially with regard to such a delicate topic as alcohol use and misuse.
Conclusion
Societies should care for vulnerable members, including aged citizens suffering of alcoholism and alcohol-related dementia (45). This is feasible today in view of the economical growth in Russia. Furthermore, apart from excessive alcohol consumption, the following causes of the relatively low life expectancy in Russia, not clearly perceptible from the literature, should be pointed out: insufficient quality and availability of the health care, particularly for middle-aged and elderly men, including those prone to the alcohol consumption; low quality and toxicity of some alcoholic beverages, acknowledging that there have been improvements over approximately the last decade. 
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