heart disease mortality are overshadowed by the negative effects with regard to both injuries and cardiovascular disease (Jackson and Klotsky, 1996).

As pointed out by Shkolnikov and Nemtsov, the anti-alcohol campaign undertaken by the Gorbachev government in the 1980s revealed the important role of alcohol abuse in cardiovascular and injury mortality in Russia. During the campaign, over the period 1984-1987, life expectancy increased for males by 3.2 years and for females by 1.3 years. This is an impressive gain that has taken at least a decade in other developed countries. The impact was most pronounced in the reduction of mortality due to injuries, poisoning, and some cardiovascular disease among adult males. Changes in mortality due to respiratory and digestive diseases were also noted, but were less sensitive to the effects of the campaign. No major change occurred in rates of death due to neoplasm during the period.

The results presented in this volume are consistent with current knowledge on the association between alcohol and mortality. Alcohol abuse is very likely one of the main reasons for the high percentage of people worldwide with arterial hypertension, according to the MONICA studies. Russia has some of the highest proportions of individuals with high blood pressure—40 percent for males and 30 percent for females (Williams and Martin, 1994). Hypertension is a leading cause of ischemic heart disease and hemorrhagic stroke (Poulter and Sever, 1992), the two most common cardiovascular diseases in the NIS. Alcohol consumption has a "J"-shaped relationship with ischemic heart disease; that is, abstainers and heavy drinkers have a greater risk of ischemic heart disease than moderate drinkers. But even in moderate amounts, alcohol consumption has been found to be associated with hemorrhagic stroke. The association has been found with both binge drinking and recent alcohol intoxication; although this finding has been best studied among Finnish young adults, the results have been found elsewhere (Camargo, 1989). Shkolnikov and Nemtsov point out that alcohol is the only risk factor among the three considered in this volume to show a correlation with cardiovascular mortality trends. Furthermore, alcohol and tobacco are the risk factors that differ most between men and women. This volume presents structured arguments suggesting that a large part of the increased mortality in the NIS is probably due to alcohol.

The anti-alcohol campaign was motivated largely by productivity losses due to alcohol abuse. Studies based in the United States also reveal that alcohol abuse is generally responsible for large productivity losses to society (Sindelar. 1994). Such losses—including greater absenteeism, reduced on-the-job performance, and increased work-related accidents and injuries—represent by far the largest component of the costs of alcohol abuse. Indirect costs associated with alcohol-related morbidity and mortality are also quite large, relative to the direct costs associated with treatment and support for alcohol abusers.

Policy instruments for reducing alcohol-related costs have been evaluated in the United States. It is clear that no one policy dominates others in effectiveness, and that the combined effects of multiple policies have still not eliminated this



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