Substance Use & Misuse, 44:1821–1832 Copyright © 2009 Informa Healthcare USA, Inc. ISSN: 1082-6084 (print); 1532-2491 (online) DOI: 10.3109/10826080802490717 Original Article Drinking Alcohol Surrogates Among Clients of an Alcohol-Misuser Treatment Clinic in Novosibirsk, Russia NATALIA BOBROVA,1 ROBERT WEST,1 DARYA MALUTINA,2 EVGENIA KOSHKINA,3 RAVIL TERKULOV,4 AND MARTIN BOBAK1 1Department of Epidemiology and Public Health, University College London, London, UK 2National Research Center on Addictions, Ministry of Health and Social Development of the Russian Federation, Moscow, Russia 3State Regional Narcological Dispensary, Novosibirsk, Russia 4Novosibirsk State Technical University, Novosibirsk, Russia For personal use only. A pilot study was conducted in the Russian city Novosibirsk during 2006–2007 with 40 participants sampled from clients admitted to health services for drinking-related problems to explore surrogates for alcoholic beverage drinking using semistructured interviews. Types of surrogates consumed and reasons for their consumption were inves- tigated. Results revealed that the most prevalent reported surrogate used was industrial spirit. The main reasons for drinking surrogates were the high affordability and physical availability of surrogates combined with the need to relieve severe withdrawal symp- toms. The study limitations are described, and suggestions for future research are made. Keywords alcohol; surrogate alcohol; drinking patterns; Russia; hazardous drinking Subst Use Misuse Downloaded from informahealthcare.com by University College London Introduction The mortality crisis in Russia during the period of political, economic, and social transition has been repeatedly linked with high levels of alcohol intake. According to the World Health Organization, alcohol-based beverages was a prime risk factor for disability-adjusted life years lost in 2002 in Russia (The World Health Report, 2002). It has been estimated that Address correspondence to Natalia Bobrova, Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London WC1E 6BT, UK. E-mail: [email protected]. This study was supported by the Wellcome Trust. We are grateful to Prof. Nemtsov from the Moscow Institute of Psychiatry and Dr. Karpets from alcohol treatment service for providing their expertise in the preparation stage of the study. We thank the staff at the alcohol treatment facility in Novosibirsk for their great support and to all study participants for their contribution. 1821 1822 Bobrova et al. around 40,000 people die every year from alcohol poisoning compared with just several hundreds in the United States (Nemtsov, 2001). A recently published case–control study suggested that as much as 43% of all deaths among young Russian men might be attributable to the consumption of drinking substances that are not intended to be drunk (or alcoholic beverage surrogates) and the prevalence of surrogate drinking among controls in this case– control study was 8% (Leon et al., 2007). Surrogates include substances such as industrial spirits, antifreeze, cologne, aftershave, lotions, and medicines with a high percentage of ethanol. Most of these substances have twice the concentration of alcohol as traditional vodka. One of the major concerns about these substances is that, besides having high levels of ethanol, they could also contain toxic substances that could severely damage the liver and could be lethal. Poisoning by alcoholic beverage surrogates has received much attention recently, when a wave of hospitalizations and deaths swept through 22 Russian regions. In just several months of 2006 (July–December), around 11,000 cases of alcohol poisoning due to such substances came to hospitals (Nemtsov, 2007). The government called this situation an unprecedented epidemic. One explanation for the epidemic of alcohol poisonings suggested by the media and government officials is the introduction of a number of new government policies governing licensing and labeling, designed to protect the quality of the legal alcohol- based products. The law, effective since July 2006, had several consequences. Alcohol sales declined as alcohol producers waited for new labels; cheap vodka disappeared from the shelves of the stores; and vodka prices increased substantially. All these changes could have contributed to the increased consumption of surrogates. However, there is an alternative interpretation, suggesting that the attention to the mass alcohol surrogate poisoning in the state media in 2006 was largely driven by the government’s desire to monopolize the vodka market. It has been argued that the number of alcohol-related poisonings in 2005 was considerably higher than in 2006, and surrogate consumption was always a part of Russian drinking culture (Butaev, Zuzaev, Arslanov, and Plusnin, 2006). Whatever drew attention For personal use only. to the subject of surrogate alcohol, from a public health perspective one message remains important: surrogate drinking exists, and it causes substantial damage to human health and incurs costs to society. There appears to have been only one previous study that looked at surrogate drink- ing in Russia (Tomkins et al., 2007), and although several epidemiological studies have examined alcohol consumption and, less often, some aspects of drinking patterns in Rus- sia, few of them were designed to investigate in detail drinking behaviors, and especially hazardous drinking. There is almost no research on surrogate drinking patterns, types, reasons, and correlates. Understanding why people choose to drink such substances, and Subst Use Misuse Downloaded from informahealthcare.com by University College London in which environments, is essential to address this worrisome trend in drinking behavior. The present study aims to shed light on a relatively new and unstudied area, to provide useful information that can be used for public health interventions and policy development, and to contribute to the field of alcohol consumption research in general. The study ex- plores types of surrogates consumed, reasons behind surrogate consumption, and patterns of consumption in Novosibirsk. Methods Design and Study Setting Given the lack of data on the issue of surrogate alcohol use and misuse, we used a qualita- tive method to explore this largely unstudied area in Novosibirsk. Novosibirsk is the third Alcohol Surrogates Misuse 1823 largest city in Russia (population about 1.5 million), after Moscow and Saint Petersburg, and the industrial and administrative centre of Siberia. In terms of demographic and so- cioeconomic indicators, Novosibirsk is a typical Russian city. The study was conducted in a state-run inpatient alcohol and drug user treatment facility in Novosibirsk. The study site was recommended by the head doctor of alcohol and drug user treatment services in Novosibirsk. The incidence of alcoholism and alcohol psychosis in Novosibirsk region in 2006 was 102.0 per 100,000 or 2,703 persons in absolute numbers (the number in Russian Federation was 135.1 per 100,000). Subjects Semistructured qualitative interviews were conducted with 40 participants of alcohol mis- user treatment in-patient services in Novosibirsk between 2006 and 2007. All individuals in treatment at the time, with six consecutive visits, were approached by the first author of this article. The study aims were explained, and individuals were asked whether they would like to participate in the study. There were between 4 and 10 patients in the alcohol user treatment facility present at each visit. Three patients were admitted repeatedly to the service during the study time period, but were approached only once. One patient reported not feeling well and refused to participate in the study. All participants signed a consent form. No personal information was recorded during the study. The study was approved by UCL Ethics Committee and the Russian National Research Institute on Addictions. Data Collection All interviews were conducted by the first author in Russian. Interviews were conducted face to face in a private room, and lasted from 30 to 90 minutes. All interviews were tape recorded and transcribed verbatim. Participants’ history of alcohol consumption, including surrogate consumption, drinking practices, patterns, and history of treatment were explored. For personal use only. A topic guide was used to ensure that themes of interest were covered across all interviews. To understand the types of nonbeverage alcohol that exist and are consumed in Novosi- birsk, we first interviewed alcohol-misuser treatment providers and researchers who work in the area of alcohol in Russia and conducted pilot interviews with consumers of sur- rogates. It was found in our pilot interviews that it is better to ask concrete questions about a particular nonbeverage alcohol as, for example, diluted industrial spirit is often not perceived as being a nonbeverage alcohol because it is sold for drinking. Moreover, the question “Have you ever consumed surrogates?” was interpreted variously by participants. Most persons understood surrogates as being poor-quality products that could be bought Subst Use Misuse Downloaded from informahealthcare.com by University College London in legal outlets. When participants were asked whether they consumed surrogate alcohol, most answered, “What do you mean? Of course, now everything is surrogate: wine, mineral water, vodka.” In the main study, therefore, we asked about specific substances that were cited most often