Non-Beverage Alcohol Consumption In Izhevsk: 15 Years Later

Alcohol and Alcoholism, 2021, 56(4) 470–474 https://doi.org/10.1093/alcalc/agaa116 Advance Access Publication Date: 14 November 2020 Article Article Non-Beverage Alcohol Consumption In Izhevsk: 15 Years Later 1 and Downloaded from https://academic.oup.com/alcalc/article/56/4/470/5974942 by guest on 17 October 2022 Andrey Korotayev1 ,*, Daria Khaltourina2 , Alisa Shishkina Leonid Issaev1 1 National Research University Higher School of Economics, 20, Myasnitskaya, Moscow 101000, Russia , and Federal Research Institute for Health Organization and Informatics of Ministry of Health of the Russian Federation, Dobrolyubova St. 11, Moscow 127254, Russia 2 *Corresponding author: National Research University Higher School of Economics, 20, Myasnitskaya, Moscow 101000, Russia. Tel.: +7 917 517 8034; Fax: +7 (495) 628-79-31; E-mail: [email protected] Received 14 July 2020; Revised 29 September 2020; Editorial Decision 3 October 2020; Accepted 3 October 2020 Abstract Aims: Non-beverage alcohol was a major cause of preventable mortality of working-age males in Izhevsk (Russia) in 2003–2004. The Russian government has since taken measures to reduce availability of non-beverage alcohol. Yet, some types of non-beverage alcohol still remain available for consumers. The aim of this study was to assess the availability and sources of non-beverage alcohol in Udmurtia. Methods: A survey of adults on the streets of Izhevsk and its environs was performed on workdays to assess non-beverage drinking patterns in 2018. The questionnaire included questions about socio-demographic status and alcohol use, including non-beverage alcohol consumption and drinking patterns. Results: One hundred and sixty-eight people were questioned, of whom, 28% reported consuming non-beverage alcohol. Non-beverage alcohol consumers were more likely to be single, unemployed or retired, younger or older than 19–29 years, have lower educational status and income, have hangovers and drink moonshine. Conclusion: Non-beverage alcohol consumption still took place at Izhevsk, a typical Russian city, in 2018, and its availability was still high. Untaxed and cheap medicinal non-beverage alcohol consumption seems to have become the major source of non-beverage alcohol consumption. Further regulation of non-beverage alcohol may be required in Russia. INTRODUCTION Alcohol mortality in the Russian Federation Earlier research suggested that the excessive mortality in Russia is strongly related to dangerous patterns of alcohol consumption (Leon et al., 1997; McKee et al., 2001; Nemtsov, 2002; Shkolnikov et al., 2004; Leon et al., 2007; Razvodovsky, 2012; Zaridze et al., 2014; Horvat et al., 2018). Very high mortality in Russia—and likely in other countries—seems to be largely caused by the high distilled alcohol consumption, which has a stronger impact on mortality than the low content alcohol beverages (Khaltourina and Korotayev, 2008; Khalturina and Korotaev, 2008; Razvodovsky, 2010; Treisman, 2010; Korotayev et al., 2018), as there is a suggestive link between the consumption of stronger alcoholic drinks and higher alcohol-related harm (Rehm and Hasan, 2020). Leon et al. (2007) identified another source of excessive alcoholrelated mortality in Russia: ethanol consumption in the form of 70–90% ethanol-containing liquids not intended for drinking (nonbeverage alcohol), including tinctures, sanitizers and perfumes. They conducted a population-based study of alcohol use and mortality in a typical Russian city (Izhevsk). The mortality odds ratio (OR) © The Author(s) 2020. Medical Council on Alcohol and Oxford University Press. All rights reserved. 470 Alcohol and Alcoholism, 2021, Vol. 56, No. 4 Russian legislation to curb non-beverage alcohol consumption Generally, alcohol policy changes in Russia since 2006 seem to have had positive effects on both drinking behavior and health outcomes (Neufeld and Rehm, 2013; Pridemore et al., 2014; Khaltourina and Korotayev, 2015; World Health Organization, 2019). Yet, curbing non-beverage alcohol consumption still remains a challenge. Russia adopted a set of amendments to its alcohol control legislation in early 2006, including effective denaturation and taxation of ethanol-containing products, followed by additional regulations and amendments (Khaltourina and Korotayev, 2015). Yet, some types of perfume, medical and veterinary products remain untaxed, creating an impetus for consumption. A decree by the chief medical doctor banned methanol in automobile care products in 2007. This measure was replicated in the EU in 2018 (European Commission Regulation 2018/589 of 18 April 2018). However, Neufeld et al. (2016) reported violations of this decree in a Siberian city Novosibirsk and warned about possible methanol poisonings. And a mass methanol poisoning took place in another Siberian city, Irkutsk, in 2016. That event involved pseudo-perfumes contaminated with methanol stolen from a facility for illegal methanol-containing automobile care liquid production. The latter event stimulated the Russian government to take additional measures against non-beverage alcohol consumption. The President and Prime Minister of the Russian Federation both ordered the government to take additional measures to improve control of ethanol-containing liquids. As a result, the chief sanitary doctor issued a decree introducing a minimum retail price for ethanolcontaining liquids (with the exception of medicines) in late 2016, which was later reinforced by Decree No. 1505 on 10 December 2018. In this decree, the minimum price for liquids containing ethanol was set to the same level as the Russian Ministry of Finance’s minimum price for vodka. The regulation did not affect normal perfumes but made cheap pseudo-perfume alcohol surrogates illegal. Spirituous food flavor enhancers, which were imported in huge quantities from Kazakhstan and looked just like vodka—but were not taxed—were banned in Russia in 2017. And the Russian Ministry of Health issued a decree that required smaller bottles for some—but not all—alcoholcontaining medicinal liquids in late 2016. These measures were followed by a major decrease in mortality among working-age males, implying that a small group of consumers of non-beverage alcohol has had a major impact on mortality. Male life expectancy at birth increased by more than 1 year from 2016 to 2017. These regulatory changes positively affected Udmurtia as well, resulting in a decrease in alcohol poisoning rate from 114 to 48 per 100·000 during this period (Kirzhanova et al., 2019). The burden of alcohol abuse in Udmurtia seems to be, on average, higher than in Russia overall. For instance, the incidence of alcoholic psychosis in the Udmurt Republic in 2018 was 47·6 per 100·000, higher than the average in Russia of 32·9 per 100·000. Mortality from accidental alcohol poisoning in 2018 was 15·4 per 100·000, more than twice the Russian average of 7·5 per 100·000 (Rosstat, 2019). Registered alcohol retail sales were 11·7 L of ethanol per person older than 15 y.o. per year in Udmurtia and 7·2 L in Russia. METHODS A survey of adults was conducted on the streets of several locations in Udmurtia, including Izhevsk (its capital) and its environs, to assess changes in the patterns of non-beverage alcohol consumption in 2018. The other cities were Sarapul, Balezino and Glazov; surveys were also conducted in smaller urban settlements (Malaya Purga, Yakshur-Bodya). Individuals were approached on streets and in public places as well as in the places of the most probable purchase and use of non-beverage drinks: near pharmacies, bus and rail stations, Downloaded from https://academic.oup.com/alcalc/article/56/4/470/5974942 by guest on 17 October 2022 for non-beverage alcohol-consuming men, compared with those who either abstained or were non-problematic beverage drinkers, was 7·0 (5·5–9·0) after adjustment for education level and smoking status. This extremely high impact on mortality could be explained by a combination of low socio-economic status and a high level of alcohol dependence among non-beverage alcohol consumers as well as the extremely high ethanol content and low prices of such products. Non-beverage alcohol products are called alcohol surrogates, or just surrogates, in Russia. They are distinct from home-brewed liquor and other illegal sources of ethanol, as they are legally manufactured and sold in conventional retail outlets, including pharmacies, and until recently, in small shops and street kiosks. Chemical analysis of these surrogates has not identified toxic admixtures in most samples of non-beverage alcohol (McKee et al., 2005; Solodun et al., 2011). Yet, some types of non-beverage alcohols may be more toxic than those containing ethanol alone (e.g. formic spirit, which contains formic acid as well as ethanol) (Gil et al., 2018c). Therefore, the main toxicological risk factor of non-beverage alcoholic surrogates in Russia is the very high ethanol content. Analyses (McKee et al., 2005; Gil et al., 2018c) have not identified traces of plant extracts in most ‘tinctures’ or pleasant scent in the ‘aftershaves’, making them pseudo-perfumes. Gil et al. (2009) showed that cheap alcohol surrogates, including tinctures and fake perfumes, were readily available throughout the country in 2007. This was the case despite federal regulations introduced to reduce the availability and consumption of non-beverage alcohols in 2006, which may have had some effect on certain classes of non-medicinal products (Khaltourina and Korotayev, 2015). Notably, a survey in a district of Moscow Oblast in 2010 showed that 3·5% of respondents consumed non-beverage alcohol, while 12% knew someone who consumed it (Kholdin et al., 2014). And Razvodovsky (2013) found that 11·8% of alcoholics admitted to a narcological clinic in Grodno, Belarus, in 2012, reported having consumed non-beverage alcohol, including medications and industrial spirits (Razvodosky, 2013). Gil et al. (2018b) point to the high availability of specific sorts of medicinal and perfumery non-beverage alcohols in 2015–2017. They purchased more than 2000 samples of non-beverage alcohols, 81.5% of which were represented by medicinal tinctures and antiseptics (personal communication with Artyom Gil), which were very cheap and could be obtained in pharmacies. Other sources of alcohol, mainly perfumery and cosmetics, could be purchased in shops, kiosks, from individual persons and other types of retail outlets. This research recorded the disappearance of a group of formerly consumed brands of perfumery and cosmetic spirituous liquids from the market in 2017, which likely stemmed from the regulatory changes (Gil et al., 2018b). Another study by Gil et al. (2018a), conducted during the same period, found a high rate of nonbeverage alcohol consumption in narcology patients in the city of Kazan, Russia. The most commonly consumed non-beverage alcohols were perfumery alcohols, medicinal tinctures and technical/medicinal ethanol. 471 472 RESULTS We surveyed 210 eligible respondents and collected responses from 168 people. Of these, 81% were male and 19% female, aged 15– 70+ years. Thirty-six percent of respondents were married. Note that not all respondents answered all questions of our survey. The non-response rate was 20%. This was higher for young female interviewers (students), which may reflect gender-specific aspects of stigmatization of heavy drinking. Nearly a quarter (22%) of the respondents were from the metropolitan city of Udmurtia, Izhevsk, while 78% were from its environs. Some 8% of respondents reported higher education, 3% had unfinished higher education and 37% had completed secondary education, while 50% were graduates of technical schools and 2% had primary education; 12% were unemployed, significantly higher than the average rate of unemployment in Udmurtia (4.8%) (Rosstat, 2020). About a 10th (11%) were abstainers, although underreporting due to stigma around alcoholism is highly likely; the smell of alcohol could be detected in some cases. Others reported drinking alcohol, including beer (70%), wine (52%), spirits (77%), alcopops (16%) and moonshine (38%). More than a quarter (28%) of respondents admitted consuming non-beverage alcohol (surrogates), which points to a continuing problem of non-beverage alcohol drinking in Udmurtia. Many respondents (28%) indicated that they drink alcohol in the morning (see Table S1), while about the same number (29%) reported drinking spirits in large quantities without snacks. At the same time, 18% admitted ‘drinking too much’ at least once a month and 13% reported doing so several times a month. Approximately, 10% reported having a hangover at least once a month (Table S2). Fig. 1. Empty non-beverage alcohol containers near trash bins. The town of Balezino, Udmurtia, Russia. September 2, 2018. Among non-beverage alcohol drinkers, 13% reported drinking surrogates almost every day; 13% did so 3–4 times a week, 7% 1–2 times a week, 24% 1–3 times a month and 24% several times a year (Table S3). Most non-beverage drinkers (69%) reported being heavy drinkers before switching to surrogates, and most reported chaindrinking episodes (zapoy). The availability of purchase places of alcohol substitutes is also important: for example, 35·6% of respondents indicated that it takes 5–10 min to get to the nearest place to purchase them. Non-beverage drinking correlated negatively with the level of education, being employed (including self-employed) or married (Table S4). Secondary professional or higher education seems to be protective against non-beverage alcohol drinking (Table S5). The rate of non-beverage alcohol drinking was highest among unemployed (53%) and retired (39%) respondents and was lowest among self-employed (12·5%) and employed people (18%) (Table S6). Non-beverage alcohol consumption was lower among 19to 29-year-olds (10%) than among those aged 15–18 (24%), which can be explained by the low incomes of adolescents. A third (33%) of the respondents aged 30–60 reported consuming surrogates. Non-beverage alcohol consumption was strongly correlated with having hangovers (ρ = 0·52, P < 0·0001), drinking in the morning (ρ = 0·48, P < 0·0001) and moonshine consumption (ρ = 0·54, P < 0·0001). Data on self-reported income level shows that almost two-thirds (62%) of those who use non-beverage alcohol belong to the lowest income group, who can only afford to buy food; only 22% of those who do not drink alcohol surrogates belong to this income group (Table S7). Trash bin and dump analysis was performed in 10 places (2 per location). Spontaneous dumps showed the abundance of recently consumed non-beverage alcohol bottles. They were least prominent in high-tech, industrialized Glazov and most prominent in semi-rural and depressed Balezino. The survey and analysis of trash bins identified the most popular brands of alcohol surrogates. Among these were registered medical drugs, including antiseptics, such as ‘ethanol’ and ‘aceptolin’ as well as medicinal tinctures with hawthorn, red pepper, etc. Among the most notable producers were ‘Gippokrat’, ‘Tul’skaya farmatsevticheskaya fabrika’ (Tula pharmaceutical factory) and ‘RFK’ (Russian pharmaceutical company) (Figs 1 and 2: online only). Downloaded from https://academic.oup.com/alcalc/article/56/4/470/5974942 by guest on 17 October 2022 garages, etc. Surveys were primarily conducted in the afternoon and early evening to increase the chance of approaching non-beverage alcohol drinkers, as they could be sleeping or managing a hangover in the morning. We interviewed people who looked like alcohol consumers using a questionnaire adopted from Leon et al. (2007). The structured questionnaire included questions on the respondent’s place of residence, sex, age, marital status, level of education and financial condition as well as self-reported frequency and amount of consumption of normal alcoholic beverages and non-beverage alcohol consumption and drinking patterns. The sample consisted of 168 respondents. Verbal consent was obtained before each interview commenced and participants were assured that their data would be treated confidentially. In the course of the field research, we also examined and photographed places of accumulation of non-beverage alcohol waste— garbage bins, illegal dumps and locations near garages and forest belts. We also recorded the prices of non-beverage alcohol. The authors managed to carry out overt observation and controlled purchase of non-beverage alcohol in Sarapul. We asked local residents where to buy alcohol and they showed us a house near the distillery, the owner of which illegally sold alcohol in plastic bottles. For estimation of associations and correlations, we used Spearman’s Rho with the associated significance tests; in pair tables, we applied phi coefficients with Fisher’s exact test. Where the sizes of compared groups were small and the use of statistical tests and correlation coefficients was not possible, associations were assessed based on the percentage distribution of estimated parameters. Alcohol and Alcoholism, 2021, Vol. 56, No. 4 Alcohol and Alcoholism, 2021, Vol. 56, No. 4 DISCUSSION This survey shows that non-beverage alcohol consumption persists in Udmurtia. These findings are in agreement with those of Gil et al. (2018a), who found that unemployment, irregular paid work, not being married or being separated were associated with consumption of non-beverage alcohols. The high share of episodic non-beverage alcohol drinkers in our study may indicate either underreporting or normalization of nonbeverage alcohol consumption among those who typically consume normal alcohol drinks. The introduction of a minimum price for ethanol-containing liquids significantly reduced the consumption of concentrated nonbeverage alcohol, probably leading to a major decline in the mortality of the affected groups. Unfortunately, this regulation did not cover ethanol-containing medicines. As a result, surrogate consumers largely switched from the formerly predominant fake perfumes to ethanol-containing medicines (antiseptics and tinctures) purchased in pharmacies. Ethanol-containing liquids are regulated at the national level in Russia; individual regions have virtually no authority over these (unlike regular alcoholic beverages). Therefore, it is not surprising that personal communications from many regions confirm that Udmurtia’s situation is largely the same as that of Russia in general— with some minor exceptions, like republics with a predominantly Muslim population. Another exception is Chuvashia, where the regional government initiated voluntary agreements with pharmacies to cease sales of tinctures and antiseptics, the major types of medical non-beverage alcohol (Vladimir Dubov (personal communication)). Thus, it seems likely that to reduce mortality further, Russia must eliminate this major source of untaxed and very concentrated nonbeverage alcohol. The strong correlation between non-beverage alcohol and moonshine consumption implies that the elimination of surrogates will lead to a transition to moonshine, which seems to be a less hazardous option. This study has a number of limitations. The survey was conducted in only one region of the Russian Federation on a non-representative sample of respondents. This makes it difficult to generalize findings to the rest of Russia and judge the prevalence of non-beverage alcohol use in Udmurtia. Further, the sample size was too small to allow the use multivariate analysis. All associations (correlations) were univariate unadjusted, and the use of correlation analysis with an estimation of statistical significance of association was not possible in every case. Among the advantages of this study is the employment of a variety of approaches for assessing the consumption of non-beverage alcohol, such as the use of a questionnaire, observation, trash bin survey and controlled purchase of surrogate alcohol. Another advantage is that this study was conducted in the Russian region in which two previous major international epidemiological studies were carried out—the Izhevsk Family Studies I and II (Shkolnikov et al., 2004; Leon et al., 2007)—which provided insights into the use of nonbeverage alcohol in Udmurtia. The present study was conducted not only in Izhevsk but also in other cities and settlements of Udmurtia, providing a higher geographical coverage of the region. The situation in Russia may have policy implication for other countries affected by non-beverage alcohol consumption. Nonbeverage alcohol should be considered a neglected global health problem affecting vulnerable groups. The European Commission Regulation 2018/589 limited methanol content in windscreen washing fluids and in denatured alcohol in 2018 to avoid poisonings among consumers of unrecorded alcohol. Ogilvie (2018) reports nonbeverage alcohol use in the USA, and Ezard et al. (2018) covered this issue on Australia. This problem may currently be underrepresented in the medical research literature. Access to non-beverage alcohol should be restricted globally to protect vulnerable people from the consequences of its use. CONCLUSION Non-beverage alcohol consumption still took place in Izhevsk in 2018, and its availability remained high. The introduction of minimum prices for ethanol-containing products other than medicines successfully decreased the non-beverage alcohol consumption in Russia. Untaxed and cheap medicines that contain alcohol seem to have become the major source of non-beverage alcohol consumption, indicating further regulation may be required. This issue should become a part of global alcohol control agenda and not be neglected as a minor issue due to the stigmatization of alcohol abuse and dependence. SUPPLEMENTARY MATERIAL Supplementary material is available at Alcohol and Alcoholism online. ACKNOWLEDGEMENTS We would like to express our gratitude to Luidmila Saburova, Artyom Gil and Vladimir Dubov. FUNDING This research has been supported by the National Research University Higher School of Economics Field Research Program “Discovering Russia Again”. CONFLICT OF INTEREST STATEMENT None declared. Downloaded from https://academic.oup.com/alcalc/article/56/4/470/5974942 by guest on 17 October 2022 Fig. 2. Coupon for medicinal drug ethanol produced by PLC Gippokrat with 95% ethanol content. 473 474 REFERENCES Nemtsov AV (2002) Alcohol-related human losses in Russia in the 1980s and 1990s. Addiction 1413–25. Neufeld M, Lachenmeier D, Hausler T, et al. (2016) Surrogate alcohol containing methanol, social deprivation and public health in Novosibirsk, Russia. Int J Drug Policy 37:107–10. http://dx.10.1016/j.drugpo.2016.08.001 (10 April 2020, date last accessed). 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