In the following section I will describe the implications of my findings regarding the alcogenic environment and social capital for policy in the fSU.
8.5.1 The alcogenic environment
The fluctuations observed in alcohol consumption and associated mortality in fSU countries (4, 6, 8, 289), as well as the presence of abstainers in these countries (125), (especially in Georgia and Kyrgyzstan) (147), shows that hazardous alcohol consumption in this region is not inevitable and is likely to be influenced by state policy (5). The findings of this thesis indicate that alcohol advertisements and outlet density are associated with hazardous alcohol consumption. It is likely that alcohol price and availability would also have been found to be associated with consumption if more robust data were available, given evidence from other regions of the world supporting the role of tax and price increases (168, 290, 291), and reduced hours of alcohol sale (63, 74) in reducing consumption of alcohol. As discussed in Chapter 1, there is extensive evidence of the effectiveness of policies directed at each of the alcohol-related community characteristics analysed in this thesis (72). Specifically, a review of the literature (72) found that i) reducing outlet density can reduce violence, harm to others and drunk driving fatalities (71), ii) reducing alcohol advertising can delay youth initiation of drinking and lessen the amount of alcohol consumed by current drinkers (72, 73), iii)
reducing days and hours of alcohol sale can limit consumption and alcohol-related harm (63, 74) and iv) increasing minimum prices for alcohol or increasing taxation on alcohol can lower consumption (i.e. consumption is price elastic) (73, 75) and reduce acute and chronic alcohol-related harms (76, 292). There is also evidence that these policies are cost-effective (72). More evidence is needed at the country level in the fSU, but the findings of this thesis suggest that the state can play a role in reducing the prevalence of hazardous alcohol consumption in this region by addressing the marketing and accessibility of alcohol.
Despite the great mortality and morbidity burden caused by alcohol consumption in the region, as of 2011, only one of the nine countries included in this study (Kazakhstan) had policies addressing all of the issues studied in this thesis (advertising, outlet density, price and availability) (Table 1.1) (70). A stakeholder analysis conducted in 2007 on alcohol policy in Russia provides some clues as to the barriers to adopting comprehensive policies in
the region (293). Its findings suggested that organisations which might be expected to take action on alcohol policy, such as health-sector and education sector agencies, and oblast and municipal-level authorities, are disengaged from the issue, have a very limited view of their power to influence policy and low awareness of effective policy options. Moreover, those organisations that favour alcohol restrictions seem to be highly fragmented (293). The factors preventing countries in the fSU from adopting comprehensive policies are likely also similar to those identified in an earlier analysis of alcohol policy-making in Hungary, such as an absence of shared vision and ownership of policies, a lack of technical and policy-making capacity and corruption (5, 294). The alcohol retail and hospitality industries in these
countries are also likely to have a strong influence over policy. With respect to price specifically, it is also possible that governments are reluctant to increase prices on alcohol for fear of possible negative consequences such as increased smuggling or home production of alcohol (63). However, despite opposition among some groups, there is evidence of public support for alcohol price increases in the fSU (295), which may suggest public support for policies aimed at reducing alcohol generally.
In order to motivate governments and other organisations in the fSU that are unaware of the demographic consequences of alcohol or wary of revenue losses from reduced consumption, evidence of mortality attributable to alcohol, as well as of the direct costs to society due to treatment of alcohol-related disease and indirect costs from lost productivity, is needed. This evidence has been compiled for Russia (296-299), and is thought to have contributed to the Russian government’s decision to implement a range of measures, since 2006, to reduce alcohol consumption. An evaluation of these policies is in progress but initial evidence suggests that they have been effective (300).
8.5.2 Social capital
The findings of this thesis also point to social aspects of the community that might be addressed through policy or other programmatic interventions. In the quantitative analysis,
active civic engagement, and, specifically, active trade union membership, was associated with hazardous alcohol consumption. My qualitative research suggested that this association may be driven, in part, by social solidarity among co-workers in occupational subcultures where alcohol is normalized and used as a means of expressing this solidarity. The potential for social networks, and the norms transmitted by them, to have a negative impact on education and health behaviours such as smoking and weight management has been
described by others (199, 226, 301, 302). This does not preclude, of course, the potential for these social networks to have a positive influence on health behaviours. In the interviews conducted for my qualitative research, I learned that engagement in sport and family activities may 'protect' some railway workers from the prevailing norms of the co-worker social circle. I also learned that all formal social activities at UNR are planned by the trade union, but currently tend to consist mostly of birthday celebrations and occasional retreats to nearby recreational destinations. As such, the trade union may play a role in altering
occupational norms by organising workplace events that support community engagement through non-alcohol-related activities such as sports or other outings that include workers’
families. Evidence from other regions points to the positive effect of workplace interventions aimed at improving dietary habits (258), especially when family members were included (260).
Social isolation, both at the level of the individual and the community, was also associated with hazardous alcohol consumption in the fSU. Further qualitative evidence of the
mechanisms via which isolation and hazardous alcohol consumption are linked in this region is required. However, it is possible that, here too, interventions that promote community engagement in socially-isolated communities, through, for example, arts and cultural activities (303), may play a valuable role. The feasibility of measuring the impact of such interventions through a randomized controlled trial (RCT) has been shown (304). Evidence from a currently on-going randomized-controlled trial of community engagement
interventions to improve health behaviours and mental well-being in the UK will provide valuable lessons for intervention planning in other countries (304).