Estimating the causal effect of alcohol consumption on well-being for a cross-section of 9 former Soviet Union countries
Introduction
Alcohol is major contributor to the global burden of disease; accounting for about 3.8% of all global deaths and 4.6% of global disability-adjusted life-years (Rehm et al., 2009). In addition to its adverse health effects, alcohol has serious economic consequences. Of the estimated 1% of gross national product in high and middle income countries attributable to alcohol related harm, the largest shares were due to productivity loss, costs of law enforcement and other indirect costs (Rehm et al., 2009).
The costs, both human and economic, associated with alcohol are far greater in the former Soviet Union (fSU), where the long tradition of hazardous drinking has been exacerbated in recent years by the large-scale production of cheap, easily available sources of alcohol in a population that has faced massive social and economic dislocation. It is now clear that alcohol is the main proximal cause of the large fluctuations in life expectancy that have characterised this region in the past two decades (Leon et al., 1997; Shkolnikov, McKee, & Leon, 2001) and research using individual-level data has found that approximately 40% of deaths of working age men in a typical Russian city could, conservatively, be attributed to hazardous alcohol consumption (Leon, Shkolnikov, & McKee, 2009; Tomkins et al., 2012). In Ukraine it was estimated that alcohol was responsible for 24% of male deaths and 6% of female deaths in 2004 at all ages (Krasovsky, 2009).
Beyond its association with premature mortality, there is an extensive literature on its detrimental effects on psychological well-being and mental health; alcohol dependent adults face an increased likelihood of major depression, phobias, anxiety and personality disorders among others (Cargiulo, 2007). These problems are common even among moderate drinkers, who are more likely to develop psychosocial problems than organ damage (Thakker, 1998). In contrast, some research reports better physical health among light and moderate consumers, although the association is less consistent for mental health (Green, Perrin, & Polen, 2004). Lang et al. (Lang, Wallace, Huppert, & Melzer, 2007) reported better cognition and subjective well-being and fewer depressive symptoms for moderate drinkers when compared to those who never had a drink, while Leigh reported beneficial effects on outcomes of stress, mood elevation and relaxation (Leigh & Stacy, 1991).
However, establishing causal pathways between alcohol consumption and well-being is not straightforward. Issues of reverse causality – e.g. individuals with low well-being (i.e. ill-being) self-medicate or are more prone to increased alcohol consumption – can bias estimates and thus lead to misguided policy recommendations. This endogeneity problem is rarely acknowledged or accounted for in the literature, so that existing studies of associations between alcohol and mental well-being must be viewed with caution. Such problems have recently been discussed in a study of the link between major depression and alcohol consumption in New Zealand, which used structural equation modelling in a birth cohort to argue that associations between alcohol and well-being were best explained by a causal model where problems with alcohol increased the risk of depression (Fergusson, Boden, & Horwood, 2009).
The aim of this paper is to examine the influence of alcohol use on psychological wellbeing while addressing the endogenous relationship between alcohol consumption and individual mental well-being using an instrumental variable (IV) approach. We utilise a unique dataset with information on individuals from 9 fSU countries, as well as information on their neighbourhood characteristics. The latter provides the opportunity to identify and use variables exogenous to the individual to estimate a causal effect of alcohol on the respondents' reported well-being.
Section snippets
Data source
For the analysis we use data collected in 2010/11 for the Health in Times of Transition (HITT) study (http://www.hitt-cis.net/) which was a follow-up to the 2001 Living Conditions, Lifestyles and Health (LLH) study. Standardised information on socio-economic, demographic, health and lifestyle characteristics was collected using cross-sectional surveys of 18,000 individuals (aged 18+) in 9 fSU countries (Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia, and
Results
Table 1 presents summary statistics for the well-being indicators, alcohol consumption, instrument and covariates for the restricted estimation sample (N = 2124). On average, individuals report about 5.9 and 6.5 out of 7 as satisfaction with life and happiness, respectively, while on average (across individuals and countries) individuals report consuming about 2 cl of alcohol on a regular drinking session, with a high standard deviation of 5.3. About 80% of the sample has a 24-h alcohol sales
Discussion
This study presents the first attempt to estimate causal links between alcohol consumption and mental well-being using an instrumental variable approach for a large sample of individuals in the fSU. We instrument alcohol consumption through the availability of 24-h alcohol outlets in the neighbourhood of the individuals. The instrument performs well, with past theoretical/empirical evidence and statistical testing supporting its validity. In brief, we find that alcohol consumption increases
Conclusions
This study has shown that alcohol consumption among individuals of the fSU has detrimental effects on mental well-being and that ignoring the reverse causality between the two significantly underestimates the size of those effects. Future research should examine this association using more robust panel data and larger sample sizes.
Acknowledgements
We are grateful to all members of the Health in Times of Transition Project (HITT) study teams who participated in the co-ordination and organization of data collection for this paper.
The HITT Project was funded by the European Union's 7th Framework Program; project HEALTH-F2-2009-223344. The European Commission cannot accept any responsibility for any information provided or views expressed.
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