Letter to the editor in regard to Gil, Polikina, Koroleva, McKee, Tomkins, and Leon (2009): "Availability and characteristics of nonbeverage alcohols in 17 Russian cities in 2007". Unrecorded alcohol in Russia: is there more to it than just ethanol?

T HE RECENT ARTICLE of Gil and colleagues (2009) is the first systematic investigation into the availability of nonbeverage or surrogate alcohols in a range of Russian cities. According to WHO nomenclature, surrogate alcohols constitute a subgroup of ‘‘unrecorded alcohol,’’ defined as alcohol products not officially intended for human consumption (for details see the Global Information System on Alcohol and Health on http://www.who.int/globalatlas/default. asp; see also Lachenmeier et al., 2009). Examples for surrogate alcohol include cosmetics such as mouthwash or perfumes, denatured alcohol, automobile products such as alcohol-based antifreeze, or medicinal compounds such as rubbing alcohol (Lachenmeier et al., 2007). It is remarkable that even with the exclusion of homedistilled spirits (samogon), previously described as representing the majority of unrecorded alcohol in Russia (Popova et al., 2007), Gil and colleagues (2009) identified 271 surrogate alcohol products, available in 17 Russian cities. From those, medicinal tinctures, purchased almost exclusively from pharmacies, were the most common product identified (most common: Hawthorn tincture), followed by eau-de-colognes (most common: Troynoy brand). Many of the types of surrogate alcohols sold had been reported to be consumed by cases or controls in an earlier study of the same authors, the Izhevsk study (Leon et al., 2007). The authors concluded that plausible nonbeverage candidates for human consumption have a particular profile characterized by a high ethanol concentration combined with low unit cost ratio. In accordance with the authors’ previous findings, the high mortality associated with drinking nonbeverage alcohols in Russia was attributed to the toxic effects of high levels of ethanol per se (Gil et al., 2009; Leon et al., 2007). This is consistent with a number of previous studies on unrecorded alcohol, which generally contained higher alcoholic strengths than legal alcohol (Huckenbeck et al., 2003; Lachenmeier et al., 2009; Lang et al., 2006; McKee et al., 2005; Nuzhnyi, 2004; Savchuk et al., 2006). Overall, given recent results from a large autopsy study, it seems certainly possible, that most of the overmortality can be explained by ethanol alone (Zaridze et al., 2009; see also Rehm and Gmel, 2007). The authors seem to dismiss the possibility of other constituents of the unrecorded alcohol additionally contributing to the high mortality. For example, the citations of previous research on the chemical composition of surrogate alcohol show that these products had been measured with zero or very low levels of methanol and higher alcohols (Lang et al., 2006; McKee et al., 2005; Pärna et al., 2007). In general, we agree with this assessment, referring to our own research of surrogate alcohol from Lithuania, which confirms the absence of methanol and higher alcohols because such products are manufactured with so-called neutral alcohol (Lachenmeier et al., 2009). However, Gil and colleagues (2009) seem to ignore other compounds that may be contained in medicinal products or cosmetic products used as surrogate alcohol. The Hawthorn tincture is interesting in this regard, as hawthorn (Crataegus spp.) extract may have pharmacological properties [e.g., in some countries hawthorn is approved as a prescription medicine to treat chronic heart failure and clinical trials have shown a significant beneficial effect (Pittler et al., 2008)]. There is currently a lack of data on the safety of hawthorn preparations and adverse effects may include dizziness ⁄ vertigo or gastrointestinal complaints (Daniele et al., 2006). From Chemisches und Veterinäruntersuchungsamt (CVUA) (DWL), Karlsruhe, Germany; and Centre for Addiction and Mental Health (CAMH) (FK, JR), Toronto, Ontario, Canada. Copyright 2009 by the Research Society on Alcoholism.