International Journal of Epidemiology

IJE Advance Access originally published online on September 4, 2008
International Journal of Epidemiology 2009 38(1):143-153; doi:10.1093/ije/dyn160

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Published by Oxford University Press on behalf of the International Epidemiological Association © The Author 2008; all rights reserved.

Alcohol poisoning is a main determinant of recent mortality trends in Russia: evidence from a detailed analysis of mortality statistics and autopsies

David Zaridze¹, Dimitri Maximovitch¹, Alexander Lazarev², Vladimir Igitov², Alex Boroda¹, Jillian Boreham³, Peter Boyle⁴, Richard Peto³ and Paolo Boffetta^4,*

¹Russian N.N. Blokhin Cancer Research Centre, Kashirskoye shosse 24, 115478 Moscow, Russia.
²Altai Branch of Russian N.N. Blokhin Cancer Research Centre, Barnaul, Russia.
³University of Oxford, CTSU, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford OX3 7LF, UK.
⁴International Agency for Research on Cancer, 150 Cours Albert Thomas, 69008 Lyon, France.

* Corresponding author. Lifestyle, Environment and Cancer Group, International Agency for Research on Cancer, 150 cours Albert Thomas, 69008 Lyon, France. E-mail: boffetta{at}iarc.fr

	Abstract

Top Abstract Introduction Materials and methods Results Discussion Supplementary Data Appendix Acknowledgements References

 
Background The changes in Russian mortality rates during the last two decades are unprecedented in a modern industrialized country. Although these fluctuations have attracted much interest, trends for major groups of causes of death have been analysed while trends in specific causes of death might shed light on the underlying determinants.

Methods We analysed trends in total and cause-specific mortality in Russia for 1991–2006. The records of 24 836 forensic autopsies carried out during the period 1990–2004 in the city of Barnaul were analysed with respect to blood alcohol level.

Results Diseases of the circulatory system (in the age group 35–69 years) and external causes (in the age group 15–34 years) were the main contributors to the fluctuations in Russian mortality rates observed in 1991–2006. The largest relative changes were for conditions directly related to alcohol intake. Among cardiovascular diseases, fluctuations were due to ‘other forms’ of acute and chronic ischaemia, and to atherosclerotic heart disease, while rates of myocardial infarction were low and relatively constant. In the autopsy series a very high proportion of decedents whose death was attributed to ‘other’ or ‘not classified’ cardiovascular diseases had lethal or potentially lethal concentrations of ethanol in blood.

Conclusions The increases in mortality in 1991–94 and in 1998–2003 coincided with economic and societal crisis, while decreases in 1994–98 and 2003–06 correlate with improvement in the economic situation. Excessive alcohol intake is a major cause of premature male Russian mortality, although many alcohol-related deaths are wrongly attributed to diseases of the circulatory system.

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Keywords alcohol intoxication, mortality, Russia, cardiovascular diseases, epidemiology

Accepted 14 July 2008

	Introduction

Top Abstract Introduction Materials and methods Results Discussion Supplementary Data Appendix Acknowledgements References

 
Mortality rates in Russian middle-aged men were among the highest in the world in the late 1980s.¹ In addition, sharp increases in mortality rates have occurred during 1991–94,² which was followed by a steep decline between 1994 and 1998, with a new increase emerging between 1998 and 2001.^{2,3 More recent data have not been published. It has been estimated that the increase in mortality during the period 1991–2001 has led to 2.5–3 million extra deaths in young and middle-aged Russians.3} Evidence has accumulated that alcohol consumption is the main determinant of Russian mortality patterns.^{2,4–7 Other proposed explanations include societal factors, linked to general economic and social uncertainty.8} However, these two hypotheses are complementary, as alcohol consumption patterns, most likely, correlate with societal factors.

Although the fluctuations in Russian mortality during the last two decades have attracted much interest, only trends for major groups of causes of death have been analysed. Here we examine in detail the disease-specific rates and trends for the period 1991–2006 and, in particular for the period 1998–2006. We also analysed the cause of death and the level of ethanol in blood in 24 836 decedents who underwent forensic autopsy.

	Materials and methods

Top Abstract Introduction Materials and methods Results Discussion Supplementary Data Appendix Acknowledgements References

 
The data were obtained from the State Statistics Committee and include numbers of deaths by cause, sex, 5-year age group and calendar year together with corresponding population denominators. The disease categories in classifications used in Russia before and after 1999 closely correspond to ICD-9⁹ and ICD-10¹⁰ codes and are comparable (Table A1).³

All death rates were standardized for age according to the World Standard population.¹¹ Population estimates for 1991–2001 were based on the 1989 census, while the population estimates for 2002–06 were computed on the basis of the 2002 census. In general rates based on the 2002 census are smaller than rates based on 1989 census (Table A2).

All consecutive records of 24 836 forensic autopsies carried out during 1990–2004 in Barnaul were retrieved from the local department of Forensic Medicine and data on cause of death and concentration of ethanol in blood were abstracted. Barnaul is a city with a population of about 600 000 and mortality rates and trends close to the Russian average.³ As a rule forensic autopsy is performed when criminal offence is suspected, or when deaths occur outside hospital and when the cause of death is unclear and cannot be determined by observation or external examination.

During 1991–2004 the autopsy rate in Barnaul was 39% for men and 24% for women. More than 80% of decedents from external causes and 36% of men and 20% of women, who died from vascular diseases underwent autopsy. The autopsy rate was high among young adults who died from vascular diseases. It was lower in middle-aged adults and low in old adults (Table A3).

	Results

Top Abstract Introduction Materials and methods Results Discussion Supplementary Data Appendix Acknowledgements References

 
Out of 1 148 561 male deaths recorded in 2006 in Russia 49% (558 231) were from diseases of the circulatory system, 19% (219 216) from external causes, 13% (152 828) from cancer. Of 1 018 142 women who died in 2006 in Russia 66% (673 952) died from diseases of the circulatory system, 13% (132 305) from cancer and 6%, (63 596) from external causes.

Mortality trends in young adults (age group 15–34 years)
The overall mortality rate in young men increased between 1998 and 2000 by 22%. While a decrease was observed during the period 2000–02, the rate started to increase again in 2003–05, followed by a small decrease in 2006. Among young women, an increase in mortality from all causes was still present in 2005 and the mortality rate was higher than in 1994 (Supplementary Table 1).

Overall, mortality trends in this age group were driven by external causes. In men the sharpest increase was observed for suicides. There were also substantial increases in mortality from poisoning by alcohol, transport accidents and homicides. These increases were followed by a steep decline. The increase in the death rates from circulatory diseases was mainly due to ‘other forms’ of acute and chronic ischaemia, as well as of atherosclerotic heart disease, while mortality from myocardial infarction slightly declined. A marked increase in death rates has occurred for pneumonia, tuberculosis, alcoholic liver disease and cirrhosis (Supplementary Table 1).

Mortality trends in middle-aged adults (35–69 years)
The overall mortality rate increased between 1998 and 2003 by 28% and 21% in men and women, respectively. In 2003 a small downturn in rates has began to appear. The main determinants of trends were diseases of the circulatory system (Supplementary Table 1, Figure 1). The increase and subsequent decrease in mortality from circulatory diseases was predominantly due to ‘other forms’ of acute and chronic ischaemia, atherosclerotic heart disease and cerebrovascular disease. Death rates from myocardial infarction remained relatively constant since 1998 (Supplementary Table 1, Figure 2).

View larger version (11K): [in this window] [in a new window] [Download PowerPoint slide]   Figure 1 Age-standardized mortality rates (per 100 000) from major causes of death—Russian men aged 35–69 years, 1990–2006

 

View larger version (12K): [in this window] [in a new window] [Download PowerPoint slide]   Figure 2 Age-standardized mortality rates (per 100 000) from selected cardiovascular diseases—Russian men aged 35–69 years, 1990–2006

 
The increase in mortality from external causes, which started in 1998, continued until 2002. After 2002 a small decline was observed for both sexes. The sharpest fluctuation occurred for poisoning from alcohol suicides, pneumonia, tuberculosis, alcoholic liver disease and liver cirrhosis (Supplementary Table 1).

Since the early 1990s a downturn has been observed in the trend for cancer mortality especially for lung and stomach cancer (Supplementary Table 1).

Blood alcohol levels in forensic autopsies
We analysed records for 22 658 forensic autopsies of adults above 15 years old at death, performed in Barnaul during 1990–2004 and whose blood was tested for ethanol (Table 1). Among 5732 autopsied men in the aged 35–69 years who were reported to have died from circulatory diseases, 2781 (49%) had ethanol detected in their blood. In 14% blood concentration of ethanol was 4 g/l or more and 5 g/l or more in 7%. Among 1928 autopsied women of the same age, whose deaths were attributed to one of the circulatory diseases, 834 (43%) had ethanol detected in their blood; in 13% the concentration was 4 g/l or more and 5 g/l or more in 6%. These proportions were particularly high among those whose death was attributed to other forms of acute ischaemia, acute ischaemia, unspecified, atherosclerotic heart disease and sudden cardiac death. The proportion of autopsies with ethanol detected was low among those dying from myocardial infarction.

View this table: [in this window] [in a new window]   Table 1 Results of the analyses of 24 836 forensic autopsies performed in Barnaul, Russia during 1990–2004

 
Of 5880 autopsied men aged 35–69 years, whose blood was tested and who were reported to have died from external causes 76% had ethanol detected in their blood. In 25% of them ethanol concentration was 4.0 g/l or more and in 13% it was 5.0 g/l or more. Among the corresponding 1804 autopsied women tested for ethanol who died from external causes 65% had ethanol detected in their blood. In 24% the concentration was 4.0 g/l or more and in 12% it was 5.0 g/l or more. Eighty-one per cent of middle-aged men and women who died from alcohol poisoning had ethanol concentration of 4 g/l or more, and about 50% had 5 g/l or more.

A similar pattern was observed among young adults and in individuals aged 70 years or more, although results were less stable because of small numbers.

	Discussion

Top Abstract Introduction Materials and methods Results Discussion Supplementary Data Appendix Acknowledgements References

 
The contribution of major groups of causes of death to the increase in Russian mortality in 1998–2003 was similar to that observed in 1991–94, with diseases of the circulatory system and external causes explaining a large proportion of these trends.^{2,3 The trends were similar in all administrative regions of Russia. The mortality rates and trends in Siberia, where Barnaul is situated, are very close to average Russian rates.3} Increases in mortality rates coincided with economic crisis in Russia, while the decreases in 1994–98 and 2003–06 correlate with improvements in the economic situation.^12,13 There is strong evidence of a key role of alcohol consumption in explaining a large part of these trends. Recently, evidence has emerged that the trends may have been influenced by consumption of alcohol products not intended for consumption.^7,13

The trends in mortality for young adults are sensitive to the population estimates used. In 2002 the rates for women based on the 2002 census are 4–5% lower than the rates based on the 1989 census (Table A2). The population estimates before the 2002 census did not included migrants, while deaths among migrants were included in mortality figures, and it was suggested that mortality rates in large cities, are overestimated because of the presence of migrants in the numerator but not in the denominator.¹⁴

The most important advantage of our mortality time-trend study is that we examined trends in specific subcategories of ischaemic heart disease, while in all previous studies only trends in aggregated ischaemic heart diseases were studied.

We have shown that fluctuations in the death rates from vascular diseases were due to changes in mortality from ‘other forms’ of acute and chronic ischaemia, and atherosclerotic heart disease. Death rates from myocardial infarction did not follow the fluctuations observed for total mortality. Furthermore, in Russia the proportion of deaths from myocardial infarction among all deaths from cardiovascular disease is lower than in Western countries (men: 6% vs 20–35%; women: 4% vs 15–30%),¹⁵ while the proportion of deaths from other forms of acute or chronic ischaemia and atherosclerotic heart disease is higher. Such ‘other’ and ‘unspecified’ circulatory causes of death represent more than 50% of all deaths from circulatory diseases in Russia. These observations led us to conclude that the rates for the subcategories of ischaemic heart disease, other than myocardial infarction, are overestimated and that some of these deaths are probably caused by alcohol poisoning. This prompted our decision to carry out the autopsy study.

The results of the analysis of the forensic autopsies support the hypothesis that alcohol poisoning may play a more important role in mortality in Russia than that suggested by the analysis of death certificates. We have found lethal or potentially lethal blood concentrations of ethanol in an exceptionally high proportion of autopsies for those whose death was attributed to ‘other’ or ‘unspecified’ vascular diseases, suggesting that these deaths occurred from alcohol poisoning rather than from vascular disease.

Deaths due to the toxic effects of acute over-ingestion of alcohol usually involve blood ethanol concentrations of 0.35% and higher. However, a non-tolerant individual may die from a blood ethanol level as low as 0.20–0.30%.¹⁶ According to Russian classification ethanol concentration in blood ranging from 3 to 5 g/l causes heavy alcohol intoxication, coma and is potentially lethal. An ethanol concentration of 5 g/l or more is absolutely lethal.¹⁷ However it is not realistic to firmly establish a criterion for lethal concentration of ethanol in blood (and hence death definitely due to alcohol poisoning). A conservative criterion, which we propose, is 4 g/l or more, although for some people lesser concentrations would be lethal. This provides a reasonable trade-off, which will allow avoiding extreme over- and underestimation of death caused by alcohol poisoning.

The rate of forensic autopsies in Barnaul was quite high at the time of our study. Nevertheless, the results of our autopsy study, though impressive in terms of numbers, could not be extrapolated to Russia as a whole. However our observations could help in the design and interpretation of future epidemiological studies. We have pointed out, that the results of blood testing, showing potentially lethal or lethal concentrations of ethanol, do not result in a re-classification of the cause of death.

Similar results are reported in a smaller study from Kursk.¹⁸ The results of a recent autopsy study which has shown that none of 89 deaths from cardiovascular diseases had alcohol levels above 4 g/l, may be explained by a very small sample size.¹⁹

It was hypothesized, that an increase in alcohol consumption in Russia caused the increase in mortality from diseases of the circulatory system.^{2,4–7,19 A cohort study from Moscow which reported an increase in the risk of death from vascular diseases associated with alcohol consumption, was based on official death certificates, which we have described as potentially erroneous.20} The author of another study from Novosibirsk analysed the association of alcohol consumption with mortality from aggregated ischaemic heart diseases, but not from subcategories of this ‘broad’ group of cause, such as myocardial infarction, other forms of acute and chronic ischaemia, atherosclerotic heart disease.²¹

The decline in mortality from cancer, especially from lung cancer, could also be partly explained by the under-diagnosis and under-reporting of deaths from this cause. An additional explanation of this observation in men is the gradual decline in the levels of tar in Russian cigarettes, which started in the late 1980s. It has been suggested that the decline in lung cancer followed a path determined by changes in rates of smoking in the post-war period, and is expected to begin to rise again in the first decade of the 21st century.²² However we now see that the decrease in mortality from lung cancer has continued in 2005 and 2006.

In our autopsy series the proportion of autopsies with lethal blood concentrations of ethanol was very high among those whose deaths were attributed to an external cause. Questions arise as to the actual cause of death in theses cases. For example, where the cause was attributed to freezing, did the person die from alcohol poisoning and was subsequently found in a frozen state, or did they freeze to death in a state of heavy alcohol intoxication? Similarly, was the person killed by alcohol and subsequently found in a fire, or were they burned to death in an intoxicated state? Either way, many deaths from external causes would probably not have occurred if the persons concerned had not been drunk.

Our analysis of cause-specific patterns and trends in Russian mortality has suggested that a substantial proportion of deaths from ‘vaguely’ defined causes coded as diseases of the circulatory system were in fact due to poisoning by alcohol. In addition, alcohol poisoning, is most probably an actual cause of death for an appreciable proportion of deaths from external causes. Thus, alcohol plays a far more important role in Russian mortality than can be judged from the mortality statistics alone.

	Supplementary Data

Top Abstract Introduction Materials and methods Results Discussion Supplementary Data Appendix Acknowledgements References

 
Supplementary data are available at IJE online.

	Appendix

Top Abstract Introduction Materials and methods Results Discussion Supplementary Data Appendix Acknowledgements References

 

Table A1 Correspondence between Russian and international classifications of diseases

Cause Russian classification 1988–98 ICD-9 Russian classification 1999–2004 ICD-10 Infectious and parasitic diseases 1–44 001–139 1–19, 22–55 A00–A32, A35–A99, B00–B99 Tuberculosis 9–13 010–018 9–15 A15–A19 Cancer 45–66 140–208 56–88 C00–C97 Lip, oral cavity and pharynx 45 140–149 56 C00–C14 Oesophagus 46 150 57 C15 Stomach 47 151 58 C16 Colon 49 153 60 C18 Rectum 50 154 61 C19–C21 Larynx 52 161 65 C32 Trachea, bronchus and lung 53 162 66 C33, C34 Breast 57 174 72 C50 Cervix 58 180 73 C53 Prostate 61 185 77 C61 Urinary tract 63 188, 189.0 79–81 C64–C68 Leukaemia 65 204–208 87 C91–C95 Diseases of the blood and blood–forming organs 71, 72 280–289 90–92 D50–D89 Endocrine, nutritional and metabolic diseases 68–70 240–279 93–96 E00–E90 Diabetes mellitus 68 250 93 E10–E14 Mental and behaviour disorders 73–77 290–319 97–103 F01–F99 Due to use of alcohol 73, 75 291, 303 97, 98 F10 Diseases of the nervous system and sense organs 78–83 320–389 104–111 G00–G98 Diseases of the circulatory system 84–102 390–459 115–147 I00–I99 Rheumatic heart disease 84, 85 390–398 115, 116 I00–I02, I05–I09 Hypertensive disease 86– 89 40–405 117–120 I10–I13, I15 Miocardial infarction 90, 91 410 121, 123 I21–I23 Atherosclerotic heart disease 92, 93 414.0 125 125.0–125.1 Other forms of acute and chronic ischaemia 94, 95 411–413, 414.1, 414.8, 414.9 127, 129 I20, I24, I25.2–125.9 Ischaemic heart disease 90–95 410–414 121–129 I20–I25 Cerebrovascular disease 98, 99 430–438 133–141 I60–I69 Diseases of the respiratory system 20, 103–114 034, 460–519 148–164 J00–J99 Acute respiratory infections 103 460–466 148, 155 J00–J01, J02.8–9, J20–J22 Pneumonia 105–107 480–483, 485,486 151–153, 154 J12–J16, J18 Chronic lower respiratory diseases 108–110 490–496 156–160 J40–J47 Lung diseases due to external agents 111 500–508 161 J60–J70 Suppurative and necrotic conditions of lower respiratory tract 112 510, 513 163 J85, J86 Diseases of the digestive system 115–127 520–579 165–179 K00–K93 Alcohol liver diseases 122 571.0–571.3 173 K70 Non-alcoholic fibrosis and cirrhosis of liver 123 571.5–571.6 174 K74 Gastric and duodenal ulcer 115, 116 531–533 165–167 K25–K27 Gastritis and duodenitis 117 535 168 K29 Deseases of appendix 118 540–543 169 K35–K38 Hernia 119 550–553 170 K40–K46 Non-infective enteritis and colitis 120 555–558 171 K50–K52 Intestinal obstruction 121 560 172 K56 Cholelithiasis and cholecystisis 124 574, 575.0 176, 177 K80, K81 Diseases of pancreas 126 577 178 K85, K86 Diseases of the urinary system 128–132 580–599 185–191 N00–N39 Urolithiasis 131 592, 594 190 N20–N23 Pregnancy, childbirth and the puerperium 135–141 630–676 21, 194–205 A34, O00–O99 Perinatal conditions 151–157 764–779 206–216 P05–P96 Congenital anomalies 145–150 740–759 217–225 Q00–Q99 Symptom, senility, ill–defined and unknown cause 158, 159 780–799 226–228 R00–R99 All external causes 160–175 E800–E999 239–255 V01–Y89 Transport accidents 160, 161, 162 E800–E807, E810–E848 239, 240, 241 V01–V99 Accidental poisoning by alcohol 163 E860 247 X45 Other accidental poisoning 164 E850–E858, E861–E869 248 X40–X44, X46–X49 Accidental falls 166 E880–E888 242 W00–W19 Accidents caused by fire 167 E890–E899 246 X00–X09 Accidental drowing 168 E910 243 W65–W74 Suicides 173 E950–E959 249 X60–X84 Homicides 174 E960–E969 250 X85–V09 Injury of undetermined intent 175 E980–E989 251 Y10–Y34

Table A2 Mortality rates in Russia in 2002 computed using two different population estimates based on the censuses carried out in 1989 and 2002

Census 1989 Census 2002 Difference %a Census 1989 Census 2002 Difference % Men 15–34 years Women 15–34 years All causes 442 434 1.84 125 120 4.17 Infectious and parasitic diseases 20.5 20.3 0.99 5.88 5.67 3.70 Tuberculosis 17.5 17.3 1.16 4.40 4.24 3.77 Cancer 11.7 11.5 1.74 11.5 11.0 4.55 Diseases of the circulatory system 37.1 36.8 0.82 11.7 11.2 4.46 Myocardial infarction 1.38 1.37 0.73 0.22 0.21 4.76 Atherosclerotic heart disease 1.47 1.47 0.00 0.39 0.37 5.41 Other forms of acute and chronic ischaemia 9.25 9.18 0.76 2.06 1.98 4.04 Cerebrovascular diseases 5.04 4.98 1.20 2.39 2.30 3.91 Diseases of the respiratory system 11.5 11.3 1.77 4.39 4.23 3.78 Pneumonia 9.18 9.08 1.10 3.35 3.23 3.72 Chronic lower respiratory diseases 0.87 0.86 1.16 0.38 0.37 2.70 Diseases of the digestive system 13.2 13.0 1.54 5.09 4.89 4.09 Alcohol liver disease 2.26 2.24 0.89 1.02 0.98 4.08 Non-alcoholic fibrosis and cirrhosis of liver 3.89 3.86 0.78 1.74 1.67 4.19 External causes 309 303 1.98 68.5 66.0 3.79 Transport accidents 55.3 54.0 2.41 16.2 15.6 3.85 Accidental poisoning by alcohol 18.2 18.1 0.55 4.01 3.86 3.89 Other accidental poisoning 19.5 19.1 2.09 5.07 4.88 3.89 Suicides 70.0 68.5 2.19 10.0 9.67 3.41 Homicides 48.3 47.4 1.90 13.4 12.9 3.88 Men 35–69 years Women 35–69 years All causes 2673 2663 0.38 905 896 1.00 Infectious and parasitic diseases 78.4 78.5 –0.13 12.1 12.0 0.83 Tuberculosis 72.9 73.1 –0.27 8.97 8.92 0.56 Cancer 378 375 0.80 184 183 0.55 Stomach cancer 55.6 55.2 0.72 20.8 20.6 0.97 Colorectal cancer 31.6 31.4 0.64 22.6 22.4 0.89 Lung cancer 121 120 0.83 10.9 10.8 0.93 Breast cancer – – – 40.0 39.6 1.01 Cervical cancer – – – 10.7 10.6 0.94 Prostate cancer 12.0 11.9 0.84 – – – Diseases of the circulatory system 1183 1176 0.60 434 429 1.17 Myocardial infarction 85.0 84.4 0.71 23.8 23.5 1.28 Atherosclerotic heart disease 207 205 0.98 70.4 69.6 1.15 Other forms of acute and chronic ischaemia 355 353 0.57 92.0 91.0 1.10 Cerebrovascular diseases 308 305 0.98 158 156 1.28 Diseases of the respiratory system 164 164 0 29.9 29.6 1.01 Pneumonia 87.9 87.7 0.23 16.7 16.5 1.21 Chronic lower respiratory diseases 62.1 61.6 0.81 10.5 10.4 0.96 Diseases of the digestive system 117 117 0.00 52.6 52.1 0.96 Alcohol liver disease 17.5 17.5 0.00 8.18 8.09 1.11 Non-alcoholic fibrosis and cirrhosis of liver 44.0 43.8 0.46 24.4 24.1 1.24 External causes 588 589 –0.17 127 126 0.79 Transport accidents 52.5 52.6 –0.19 14.5 14.5 0.00 Accidental poisoning by alcohol 97.3 97.4 –0.10 26.9 26.6 1.13 Other accidental poisoning 32.2 32.3 –0.31 6.83 6.77 0.89 Suicides 91.7 91.9 –0.22 13.1 13.1 0.00 Homicides 69.7 70.0 –0.43 17.8 17.6 1.14

^a100% (rate by census 1989 – rate by census 2002)/rate by census 2002.

Table A3 Forensic autopsy rate among deceased from vascular diseases by age in Barnaul in 1990–2004, men and women (15+ years)

15–34 35–69 70+ Total No. of deaths No. of autopsies Percentage of autopsies No. of deaths No. of autopsies Percentage of autopsies No. of deaths No. of autopsies Percentage of autopsies No. of deaths No. of autopsies Percentage of autopsies Men 1990 9 4 44.4 638 204 32.0 121 5 4.1 768 213 27.7 1991 16 8 50.0 695 228 32.8 129 11 8.5 840 247 29.4 1992 14 7 50.0 743 220 29.6 124 8 6.5 881 235 26.7 1993 20 17 85.0 953 392 41.1 172 14 8.1 1145 423 36.9 1994 32 26 81.3 1151 493 42.8 176 17 9.7 1359 536 39.4 1995 43 35 81.4 1031 453 43.9 206 18 8.7 1280 506 39.5 1996 33 27 81.8 995 379 38.1 242 26 10.7 1270 432 34.0 1997 33 26 78.8 868 368 42.4 248 26 10.5 1149 420 36.6 1998 17 15 88.2 731 275 37.6 250 29 11.6 998 319 32.0 1999 24 18 75.0 802 374 46.6 282 43 15.2 1108 435 39.3 2000 34 12 35.3 1058 371 35.1 355 37 10.4 1447 420 29.0 2001 36 17 47.2 1148 383 33.4 387 53 13.7 1571 453 28.8 2002 29 8 27.6 1264 584 46.2 390 53 13.6 1683 645 38.3 2003 26 11 42.3 1300 684 52.6 297 60 20.2 1623 755 46.5 2004 21 12 57.1 945 506 53.5 238 51 21.4 1204 569 47.3 Total 387 243 62.8 14 322 5914 41.3 3617 451 12.5 18 326 6608 36.1 Women 1990 3 2 66.7 405 64 15.8 235 15 6.4 643 81 12.6 1991 8 3 37.5 413 65 15.7 196 8 4.1 617 76 12.3 1992 6 2 33.3 446 65 14.6 221 7 3.2 673 74 11.0 1993 12 10 83.3 569 142 25.0 257 11 4.3 838 163 19.5 1994 5 2 40.0 691 180 26.0 294 24 8.2 990 206 20.8 1995 7 4 57.1 642 165 25.7 311 30 9.6 960 199 20.7 1996 10 7 70.0 615 171 27.8 340 36 10.6 965 214 22.2 1997 16 8 50.0 493 116 23.5 353 40 11.3 862 164 19.0 1998 6 5 83.3 431 108 25.1 368 38 10.3 805 151 18.8 1999 7 6 85.7 413 103 24.9 344 36 10.5 764 145 19.0 2000 4 1 25.0 526 117 22.2 414 29 7.0 944 147 15.6 2001 9 5 55.6 535 117 21.9 454 33 7.3 998 155 15.5 2002 12 4 33.3 592 202 34.1 406 50 12.3 1010 256 25.3 2003 3 0 0.0 575 221 38.4 376 57 15.2 954 278 29.1 2004 6 3 50.0 429 176 41.0 251 31 12.4 686 210 30.6 Total 114 62 54.4 7775 2012 25.9 4820 445 9.2 12 709 2519 19.8

	Acknowledgements

Top Abstract Introduction Materials and methods Results Discussion Supplementary Data Appendix Acknowledgements References

 
This study ‘Dramatic fall in life expectancy in Russia in the 1990.’ was funded by EC Grant Number ICA2-CT-2001-10002.

Conflicts of interest: None declared.

KEY MESSAGES Diseases of circulatory system and external causes are the main contributors of the increases in mortality observed among Russian men since 1991. Among cardiovascular diseases, fluctuations were due to ‘other forms’ of acute and chronic ischaemia, and to atherosclerotic heart disease, while rates of myocardial infarction were low and relatively constant. In a large autopsy series a very high proportion of decedents whose death was attributed to ‘other’ or ‘not classified’ cardiovascular diseases had lethal or potentially lethal concentrations of ethanol in blood. Excessive alcohol intake is a major cause of male Russian mortality, although many deaths from this cause are wrongly attributed to diseases of circulatory system.

 

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