This mini-review is an updated summary of the recently published book and other publications [1,2]. The topic is particularly relevant for the former Soviet Union (SU) and some other countries. In the Russian Federation (RF), the problem has sometimes been exaggerated in order to shift responsibility for the comparatively low life expectancy, especially among men, onto citizens. Alcohol often appears in literature in the context of domestic violence. Without denying the importance of this topic, it should be noted that it is not difficult to denounce a drunken troublemaker. Perpetrators from the privileged milieu know how to avoid responsibility, accuse the victim of slander, and force her or him to remain silent. Drunkenness is a well-known criminogenic factor, but focusing on drunken troublemakers distracts attention from corruption and organized crime. The fight against drunk driving is necessary, but when drunk drivers are held primarily responsible for traffic injuries and the goal is declared to be zero blood alcohol content [3], insufficient attention is paid to the condition of roads, vehicles and other causes of accidents. Of note, alcohol-related violence and other misbehavior is common among young and working-age people [4]. Many older alcohol-dependent people know their maximum dose and do not violate public order.

Recent History

The anti-alcohol campaign (AAC), launched in 1985, was initially effective, but after 1987 the consumption started to increase, with fortified, dry and sparkling wines giving way to low-quality vodka [5]. Alcohol-related mortality declined during the AAC; but there was an increase in poisonings by technical fluids. Inexpensive perfumes and other ethanol-containing liquids were sold en masse, e.g. the window cleaner in Krasnoyarsk Krai in 1988 [6]. During the AAC, the quality of legally sold beverages declined. Mass drinking after the AAC facilitated the economic reforms. It is known that drunkards are prone to emotions of guilt and shame, have low self-esteem [7], so they are easier to control and to manipulate. Workers and intelligentsia did not interfere with the privatization of state enterprises due to drunkenness and participation in illegal activities: theft in the workplace, use of equipment for personal purposes, to which the administration often turned a blind eye before the economic reforms of the 1990s. After the abolition of the state monopoly on alcohol, the country was flooded with low-quality drinks made from imported or domestic alcohol from non-food raw materials: synthetic and hydrolytic. It was reported that in the 1990s, the turnover of such alcohol in the retail trade reached 60%, while the mortality rate from alcohol poisonings in RF was 65 times higher than the European average [8]. In the 1990s and early 2000s, ethanol was supplied in large quantities from Georgia and Ukraine. The author observed a line of tanker trucks on the Georgian Military Highway. This alcohol was used to produce vodka, beer and wine. North Ossetia was known as a source of low-quality alcohol throughout the country [9].

Drinks sold in shops and kiosks caused poisoning. The following quantities of fatal poisonings from alcohol-containing liquids were reported by year: 1998 - 21,800, 1999 - 24,100, 2000 - 27,200 [10]. Real figures were probably greater. In many lethal cases, the concentration of ethanol in blood was not high. In 2006, mass poisoning with liver damage and jaundice was presumably caused by the disinfectant Extrasept-1, sold in vodka bottles in different regions of RF. In addition to ethanol, the liquid contained diethyl phthalate (about 0.45 mg/ml) and polyhexamethylene guanidine hydrochloride (PHMG) - 0.344 mg/ml [11]. A total of 12,611 poisonings (including 1,189 fatal) were reported for the period August-November 2006 [12,13]. Histological examination described cholestatic hepatitis with inflammatory component [13]. However, PHMG does not have significant hepatotoxicity and is broadly used to disinfect swimming pools. The median lethal dose (LD50) of PHMG for rats and rabbits is 500-800 mg/kg [11,14]. Extrapolating to humans, this means that a 100 kg individual would have to ingest about 60 kg of Extrasept-1 to obtain the LD50 of PHMG. Moreover, the animals died with symptoms of damage to the nervous system, not the liver. As for diethyl phthalate, this substance is not highly toxic. The role of organochlorine compounds as the cause of poisoning was assumed [15]. It seems likely that the bottles with vodka labels contained admixtures of tetrachloromethane, dichloroethane or other solvents used in dry cleaning of clothes [9,16]. Even alcohol-dependent persons will not drink the named liquids because they have a characteristic smell. However, liquid from a labeled vodka bottle can be gulped without smelling it; such cases, ending up in death, are known. Low-quality, counterfeit vodka was sold in stores, kiosks and snack bars. Industrial alcohol was added to beer and wine. Consumers recognized the taste of non-beverage ethanol, which had long been stolen from factories and scientific institutions [17]. These facts were camouflaged by some authors, creating the impression that surrogates were deliberately purchased for drinking (from Russian): “The outbreak was caused by the use of antiseptics with chloride compounds due to a shortage of other non-potable alcohol” [15]. In fact, in 2006 there was not the “shortage of non-potable alcohol” but a temporary shortage of vodka in some places as a result of increased excise taxes and tightening of regulations with the closure of kiosks and many small shops [10]. The shortage was made up for by surrogates sold in vodka bottles [12].

In 2013, 65-70 thousand cases of fatal intoxication were reported in RF, of which 50-60 % were poisonings with alcoholic beverages and surrogates [18]. In 2016, 74 fatal poisonings were reported in Irkutsk. According to published information, the cause was the methanol-containing bath concentrate “Boyaryshnik” with an alcohol content of “no more than 93%” (250 ml bottles) [19]. It remains unclear why 250 ml of spirit must be added to the bath. The cost of concentrated solutions per unit of dissolved substance is relatively high. There are suspicions that the poisoning was caused by hawthorn (boyaryshnik in Russian) tincture containing 70% of medicinal ethanol, a pharmaceutical product often used for drinking purposes [20]. The misinformation could have been intended to conceal the fact that methanol was used instead of medical alcohol.

The exaggeration of the issue of “non-commercial” alcohol shifts the responsibility for poisonings onto consumers alleged to intentionally drink toxic surrogates [21]. The concept of unaccounted or non-commercial alcohol is not applicable to RF without the comment that ethanol from non-food raw materials, redirected from industry or imported, was used to produce legally sold drinks [16,17,22-24]. Without opening the bottle, the consumer cannot distinguish the authentic beverage from the counterfeit. In the 1990s, signs of counterfeit vodka included crooked labels and loose caps. Today, bottles of genuine and counterfeit products are indistinguishable by sight [25]. After the aforementioned mass poisonings, there was a tendency for quality to improve; however, vodka and beer sometimes smell of industrial alcohol now as before. The use of technical ethanol for beverage production can be interpreted as concealment of information about facts that pose a health risk. Citizens have the right to expect that government agencies will ensure quality control. Modern methods such as chromatography and spectrometry should be used to control the quality of drinks and detect impurities. In particular, the following should be applied more widely by supervising authorities: gas chromatography with flame ionization detection (GC-FID), using a column separating admixtures and gas chromatography - mass spectrometry (GC-MS) [26-28]. Spectrophotometry using chromotropic acid has been proposed by the Organization of Vine and Wine (OIV) as a low-cost alternative for methanol analysis in wines and spirits. Recent studies have improved this method [29]. Toxicity and quality control of alcoholic beverages is a perspective topic of the future research.

The decrease in the frequency of heavy binge drinking is visible to the naked eye. Compared to the 20th century, heavy intoxication is less common today, even among marginalized individuals. In this regard, it is necessary to mention the Siberian bichi. In populated areas and temporary shelters in the taiga forest live homeless citizens without documents, called bichi; they worked in the sapping industry and other jobs [6]. Society's attitude towards them has not always been humane. The state should take care of them, as well as homeless citizens in general, provide them with hostels; they need help in obtaining documents and housing. Quality control of alcoholic products is also necessary, including seizure of surrogates and counterfeits containing industrial alcohol sold under the guise of vodka and other drinks.

The Anti-Alcohol Policy

Some authors exaggerate the effectiveness of governmental anti-alcohol measures. The policies’ impact on public health is sometimes discussed as if vodka were the main factor determining mortality (from Russian): “The relatively high mortality rate in Russia is associated with the consumption of strong alcoholic beverages, mainly vodka” [30]; “Alcohol is the most important factor of male mortality in industrialized countries; and the strength of the alcoholic beverages consumed is of great importance” [31]. In this way, other factors are ignored: the availability and quality of medical care, toxicity of the drinks on sale, crimes against alcoholics and people with alcohol-related dementia. The following quotes are also worth noting: “The positive effect of the alcohol taxation measures appears to be significant. However, the effectiveness of measures to limit the availability of ethyl alcohol and surrogates with very high alcohol content was significantly higher” and further: “These measures significantly reduced the availability of alcohol” [30]. In fact, vodka, beer and other drinks have remained affordable since the AAC: sales in supermarkets, no queues, the ratio of the average income to vodka price higher and selling time longer than prior to the AAC [1]. The monograph [32] discusses the “crisis of medicine”, denying its significant impact on mortality. However, the arguments are unconvincing, for example, the stable level of mortality from strokes, despite the growth of morbidity. The tendency to overdiagnose cardio- and cerebrovascular diseases postmortem in unclear cases is known. The frequency of unfounded diagnoses is inversely proportional to the quality of diagnosis and the healthcare in general [33]. The decline in infant and maternal mortality since 1999, cited by the authors as evidence of improved quality of health care [32], may reflect priorities in governmental policy, but has no relation to drunkenness and alcoholism.

Recent anti-alcohol measures were superficial compared to those of the Soviet era. Taking inflation into account, vodka prices fluctuated moderately [1]. The availability of alcohol did not really decrease. As in the Soviet times, some restrictions encouraged the consumption of higher doses: the disappearance of beer in 0.33 l cans, absence of vodka in 150-200 ml bottles. Inside observers recollect that the cessation of vodka sales in 250 ml bottles after the anti-alcohol measures of 1972 led to the consolidation of the stereotype of “half a liter for three”, which appeared after the ban of selling by the glass in stores and canteens in 1960. For many elderly alcohol-dependent people, even 250 ml is too much; they would prefer to buy after work a 150-200 ml of vodka plus 1-2 bottles of beer and go home. Instead, between 1972 and 1985, they consumed half a liter for three persons, then sometimes added fortified wine (vodka was sold until 7 p.m.). Consumption in high doses was contributed by queues, after standing in which more alcohol was purchased and consumed. In fact, in 1985, many elderly people and veterans were forced to stand in hours-long lines and/or to drink surrogates. Certainly, it is better not to drink at all, but this does not justify selling counterfeit beverages in regularly labeled bottles, deceit of alcohol-dependent citizens, deprivation of quality healthcare, of apartments and houses [1].

The author agrees to the opinion that “the anti-alcohol measures implemented in Belarus and Russia simply coincided with fluctuations in alcohol-related mortality which originated in the past” [34] due to social factors. Apparently, the main reason for the decline in alcohol consumption is a responsible lifestyle in a market economy. This primarily concerns workers and the intelligentsia. As a result of the economic reforms of the 1990s, confidence in the future has largely been lost. Enterprises and scientific institutions closed or reduced their staff. At the same time, property crime has increased, leaving many alcoholics and people with dementia homeless. Finally, the immigration from less drinking regions has contributed to a decrease in alcohol consumption.

Alcohol-Related Morbidity and Mortality

“There is no doubt that alcohol is an important cause of mortality in Eastern Europe and globally... It remains uncertain, however, whether the high long-term mortality rates of middle aged and older persons in Russia are caused predominantly by alcohol and what is the contribution of other factors” [35]. Those “other factors” are evident for inside observers: deterioration of the healthcare after 1990, toxicity of some drinks on sale, increase in violent crime [3]. Related factors have been mooted as being responsible for the fluctuations in life expectancy and mortality since 1990: stress associated with the transition to capitalism, quality and availability of food, smoking levels, insufficient social care [36]. In addition, heavy binge drinking after the failure of AAC has been discussed as a cause of increased mortality. Without denying the harm from this style of alcohol consumption, it should be stressed that the frequency of binge drinking has been decreasing since the early 2000s [37]. Over the period 2003-2017, a consistent positive life expectancy trend emerged that was statistically independent of alcohol poisoning [38].

In the period 2016-2019, the age-standardized mortality rate from diseases of the circulatory system, including ischemic heart disease (IHD), per 100 thousand people in RF was 262 (IHD - 135), in Germany 132 (74), Italy 93 (53), Great Britain 91 (48), France 77 (31) [39]. The reasons for the relatively high cardiovascular mortality in RF and of its further increase after 1990 are obvious for pathologists. Cardiovascular diseases (CVD) are sometimes diagnosed postmortem without sufficient grounds, both at autopsy and among those who died at home and were not subjected to postmortem examination. If the cause of death is unclear, one of the standard diagnoses is “IHD with heart failure” and other similar formulations [33]. It is not surprising that an increase in registered mortality from CVD coincided with the quality decline of postmortem diagnostics and the healthcare in general during the 1990s and early 2000s [40].

The fact of overdiagnosis is confirmed by an increase in the registered mortality from CVD, but not from myocardial infarction (MI), the share of which in the Russian mortality is small [41]. The reason is clear for pathologists and other medics: the diagnosis of MI is usually based on specific clinical or morphologic criteria, while IHD with heart failure is used postmortem without sufficient evidence. The overdiagnosis of CVD has been observed together with “the absence of any significant differences in mortality rates from neoplasms, including those associated with alcohol, in the period 1984-1994” [42], since tumors are rarely diagnosed without evidence. Remarkably, deaths from lung cancer (the diagnosis requires an X-ray or autopsy) in men fell by 17% between 1998 and 2007, while deaths from breast cancer, which rarely goes undetected, increased [39]. “Changes in Russian mortality over the past few decades are unprecedented for industrialized countries in peacetime” [43]. Indeed, mortality fell rapidly with the onset of the AAC, and then increased significantly. The fluctuations were so sharp that the possibility of an artifact was discussed [42]. The above seems to be indicative of unreliable and possibly manipulated statistics, which was known to occur in the former SU [44]. The decline in mortality after 1985 was probably overstated to highlight the success of AAC, which was offset by an overestimation of rates after 1990. Some writers have exaggerated the causal relationship between alcohol and CVD, seeking to portray increased mortality as a result of alcohol abuse, e.g. [45], commented in [1,2]. The “outstanding puzzle” that “the risk of dying from IHD (excluding MI) is associated with heavy alcohol consumption” [46] has analogous explanations. It can be reasonably assumed that official statistics is unreliable now as before.

The comparatively high mortality rate from strokes [47] together with low mortality from myocardial infarction has a similar explanation: unlike myocardium, the macroscopic picture of cerebral infarction is easy to imitate artificially by destroying brain tissue at autopsy in case of impossibility (lack of toxicological tests) or unwillingness to look for the true cause of death. The unreliability of stroke diagnosis is indirectly confirmed by the report that in 2002, “the death rate from stroke among Russian men aged 45-54 was approximately 10 times higher than in Germany, France and Italy” [47]. The article [47] contains a reference to international statistics from 2004, according to which the registered stroke mortality in RF, without taking into account gender and age, was 4-8 times higher than in many developed countries [48].

Alcoholic cardiomyopathy has been diagnosed more frequently in RF than in other countries, sometimes without sufficient grounds. It was estimated that the registered mortality from alcoholic cardiomyopathy in RF is ≤100 times higher than in the USA, Finland and France [8]. The diagnosis of cardiomyopathy has been widely used postmortem in alcohol consumers [45], while the true cause of death sometimes remained unknown. Clinically significant cardiomyopathy usually develops after long-term abuse, especially in genetically predisposed individuals. There is an opinion that moderate alcohol consumption is not associated with the risk of CVD, and some epidemiological studies show that the risk is reduced among moderate consumers. However, the cardioprotective effect of low doses has not been confirmed by a number of studies; references are in [1].

There is some controversy in the literature about the risks of moderate alcohol consumption. The results of studies may be influenced by industry. It is beyond the scope of this review. Theoretically, a protective effect is not excluded due to the thousands-year adaptation of some peoples to alcohol and by-products of natural fermentation. Even if the cardioprotective effect of moderate doses exists, in advanced age it is largely neutralized by the toxic impact of ethanol on the liver, nervous system, skeletal muscles and immunity. It is important to emphasize that new methods of ethanol manufacturing (synthesis from ethylene, or cellulose hydrolysis with subsequent fermentation) are accompanied by new by-products, to which there is no adaptation. In animal experiments, ethanol obtained both synthetically and by hydrolysis turned out to be more toxic than that from food raw materials [22]. Experiments may overestimate the toxicity of beverages produced using traditional technologies, since animals lack adaptation.

Worthy of mention is the concept by Yury Razvodovsky, who assessed the level of alcohol consumption based on the incidence of alcoholic psychoses [49]. It should be noted that the frequency of psychosis depends not only on the quantity, but also on the quality of the drinks consumed (i.e. composition of admixtures), as well as on the consumption style. Alcoholic psychosis often develops against the background of severe binge drinking. Symptoms of psychosis are usually detected during or shortly after a binge as part of withdrawal syndrome [50,51]. Like other complications, psychosis-like conditions can be caused not only by ethanol, but also by other substances contained in low-quality drinks and surrogates. For example, methanol and carbon tetrachloride can cause hallucinations [52-54]. It is known that the quality of consumed alcohol has changed significantly in RF over the past decades.

In conclusion of the section, the downward trend in alcohol consumption and alcohol-related mortality in RF should be pointed out. According to estimates by the World Health Organization (WHO) and some Russian authors, the alcohol consumption in RF reached its maximum around 2001, then fluctuated with a downward trend until 2010, after which the decline has continued [55-58]. Reportedly, the period from 2003 to 2017 saw the prevalence of alcohol dependence in patients registered in state-run treatment services fall by 38%, the prevalence of harmful use of alcohol drop by 54%, and the prevalence of alcoholic psychosis reduce by 64%.[36]. From 2005 to 2016, the consumption in terms of pure ethanol decreased from 18.7 to 11.7 liters per person per year [58]. Over the period 2010-2019, mortality in RF due to the toxic effects of alcohol decreased by about half. In the Siberian Federal District, this indicator decreased by 3.3 times over the period 2011-2020; the most significant decrease (more than 6 times) was noted in the Altai and Krasnoyarsk provinces as well as in the Republic of Tyva [55,56]. Today, in the fourth year of the Ukraine war (2025), alcohol consumption seems be increasing again, but there are no reliable data to confirm this impression.

The focus on alcohol distracts from other causes of relatively high mortality in RF. In this regard, it is necessary to pay more attention to citizens with alcohol use disorder, their protection from fraud and violence, from disdainful attitude in employment centers and medical institutions, from mobbing in the workplace and at home. It is known that older people are sometimes harassed to quit their jobs or change the place of residence. Even moderate alcohol consumption can serve as a pretext. The topic of elder abuse is scarcely covered in Russian literature [59,60]; it does not concern only drinkers, although alcohol abuse occurs among both perpetrators and victims. On the one hand, alcohol-dependent individuals have less real possibilities to protect their rights; on the other hand, maltreatment can cause stress and depression in the victim, predisposing to alcohol consumption. Elder abuse can take many forms and often goes unrecognized. Victims of abuse may have low self-esteem, blame themselves for what is happening, and do not want to “betray” their relatives. Bringing the death of an elderly person closer may be a strategy implemented consciously or subconsciously. This strategy includes involvement in binge drinking, failure to provide assistance, manipulation in the direction of social risks and auto-aggression [59]. People with alcohol use disorder and alcohol-related dementia are known to have been victims of property-related crimes, which resulted in an increase in homelessness. The mechanism by which people lost their homes included fraud, threats and violence.

The attitude in free governmental polyclinics, especially towards middle-aged and elderly men, is sometimes dismissive. Real or supposed alcohol abuse can serve as a pretext for this. For that reason, along with high prices of some drugs and marketing of placebos under the guise of evidence-based medicine [61], chronic diseases sometimes remain untreated. Mention should also be made of the employment service, where a dismissive attitude towards the unemployed was noticed. Nursing home personnel are not always friendly to residents. Some commercial nursing homes leave a permission to drink beer to the discretion of paying relatives, which is a violation of the elderly person's rights. It is known that alcohol consumption is contraindicated in a number of diseases and is incompatible with some medications. This necessitates qualified advice, not prohibitions. Maltreatment of supposed alcohol abusers in healthcare institutions with violations of medical ethics has been discussed previously [1,2].

Of great importance is the strengthening of measures to prevent alcohol addiction, in particular, effective anti-alcohol propaganda aimed primarily at young people [62,63]. This approach is used today: the media often present people with alcohol addiction in a pitiful light. Apparently, this has contributed to the fact that young people today drink less than in the 1980s and that heavy binge drinking is in decline. This approach has a drawback: criminals including migrants sometimes subdivide citizens at their own discretion into “krutye” (cool or tough) and the socially vulnerable. Many aged alcohol consumers find themselves in this latter category.

The labor productivity is rising, but unemployment remains; there are not enough prestigious jobs for everyone. Older drinkers can be considered voluntary outsiders, giving up their social positions to more energetic fellow citizens. Following the example of some countries, they could be given a possibility to spend time in pubs and then go home, provided that public order is maintained. The right solution would be to bring back inexpensive pubs of the Soviet era, with one difference: there should be enough seats. It is unhealthy for aged people to stand on their feet for a long time. The same applies to workers after their shift. In accordance with the principles of medical and general ethics, it is necessary to provide public assistance for those suffering from alcoholism and alcohol-related dementia. The homeless need help to obtain documents, housing and social assistance. Unfortunately, it is difficult not to agree with Denis Avtonomov that our fellow citizens with alcohol use disorder can be “rejected, despised, hated and persecuted legally and without any sense of guilt” [64].

Declaration

No conflict of interest.

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