EUROPEAN JOURNAL OF PUBLIC HEALTH 2003; 13: Health behaviour in Estonia, Finland and Lithuania Standardized comparison

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1 EUROPEAN JOURNAL OF PUBLIC HEALTH 2003; 13: Health behaviour in Estonia, Finland and Lithuania Standardized comparison PEKKA PUSKA, VILLE HELASOJA, RITVA PRÄTTÄLÄ, ANU KASMEL, JURATE KLUMBIENE * Background: The Finbalt Health Monitor project collects standardized information on health and health-related behavioural activity and related trends in Finland and those Baltic countries that have major public health problems with noncommunicable diseases related to lifestyle and behavioural factors. The aims of this study were to compare patterns of and trends in selected health behaviours and their socioeconomic associations in Estonia, Finland and Lithuania in the period Methods: Standardized questionnaires were posted to nationally representative samples in 1994, 1996 and Response rates varied between 62% and 83%. The total number of respondents was 3808 in Estonia, 9608 in Finland and 5716 in Lithuania. Prevalence of smoking, consumption of strong alcoholic beverages, use of vegetable oil in food preparation and leisure-time physical exercise were analysed in this study. Results: No major changes in daily smoking, consumption of strong alcoholic beverages and leisure-time physical exercise emerged. However, the use of vegetable oil increased rapidly in Estonia and particularly in Lithuania (from 41% to 81%). In 1994 the prevalence of daily smoking was 53%, 28% and 44% among men and 24%, 18% and 6% among women in Estonia, Finland and Lithuania, respectively. In Lithuania the prevalence of smoking among women was notably low but increased (from 6% to 13%). The prevalence of strong alcoholic beverage consumption was similar in all countries. Leisure-time physical exercise was most common in Finland. The socioeconomic differences remained similar in all countries, unhealthy behaviours were typical among the less educated groups and men, especially in the age groups years. Conclusions: The sociodemographic pattern of risk-related lifestyles appears to be rather similar and stable in Estonia, Finland and Lithuania. However, from the view point of possible public health implications the rapid changes in the prevalences of some behaviours are notable. Keywords: Baltic, health behaviours, socioeconomic differences, trends The need for feasible, rapid and appropriate systems for monitoring indicators of public health and its determinants has become obvious in modern public health. Although there is progress in the treatment of noncommunicable diseases (NCDs) and health problems, the main public health potential lies in their prevention, which has a sound scientific basis with regard to wellestablished causal risk factors. Typical of these factors is that they relate closely to behaviours and lifestyles, and often concern several NCDs. In this situation the World Health Organization and many others have issued recommendations for action to prevent NCDs and promote health. 1 The new WHO strategy calls for specific focusing on behavioural risk factors (tobacco use, unhealthy diet, physical activity etc.) as practical targets for NCD prevention and health promotion. 1 The same resolution points out the need for strengthening the health information system and especially for monitoring the level of exposure to risk factors and their determinants in the population. There is considerable interest in the public health situation of the former Eastern Europe and particularly of the former Soviet Union area. Generally, public health there is much poorer than in Western Europe. 2,3 The reasons for this difference have been discussed in several papers. 4 Even if many uncertainties remain, the role of some lifestyle-related factors such as smoking and alcohol use is obvious. Although there is increasing information on risk factor levels and health behaviour patterns in the former Eastern Europe, very few studies have carefully standardized comparative data. In addition, the factors behind the trends have been much less analysed than those behind the cross-sectional differences. The Baltic countries are newly independent former Soviet republics that share many characteristics typical of Eastern Europe. 5,6 The public health situation in the Baltic countries is very similar to that in Finland during the 1960s. Finland traditionally had extremely high rates of cardiovascular disease (CVD), cancer and related NCDs but in the 1970s initiated active and com- * P. Puska 1, V. Helasoja 2, R. Prättälä 2, A. Kasmel 3, J. Klumbiene 4 1 Department of Noncommunicable Disease Prevention and Health Promotion, World Health Organization, Geneva, Switzerland 2 National Public Health Institute, Department of Epidemiology and Health Promotion, Helsinki, Finland 3 Estonian Centre for Health Promotion 4 Institute for Biomedical Research, Kaunas University of Medicine, Lithuania Correspondence: Pekka Puska, director, Department of Noncommunicable Disease Prevention and Health Promotion, World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland, tel , fax , puskap@who.ch 11

2 EUROPEAN JOURNAL OF PUBLIC HEALTH VOL NO prehensive work to prevent major NCDs by intervention to change risk-related lifestyles in the population. 7,8 In these projects a simple system to monitor target behaviours was developed. In 1978 the National Public Health Institute (KTL) of Finland launched a similar system for national monitoring of health behaviour among the Finnish adult population. 9 After the political change in Eastern Europe during the early 1990s, contacts between public health experts of Finland and the Baltic countries increased rapidly. In Estonia the first national health behaviour survey was carried out in 1990 as Finnish Estonian collaboration, and related to a joint smoking-cessation TV programme. Thereafter, the surveys have been carried out every second year in Estonia. Within this framework, Lithuania initiated its own health behaviour monitoring system in 1994 and Latvia in Since then all the Baltic countries have carried out the surveys every second year, following the common Finbalt Health Monitor protocol and procedures. 10 Here we present the first trend results of the Finbalt project through examples from the four main areas of health behaviour: smoking, alcohol consumption, food habits and physical activity. The aims of this study were: To compare the patterns of health behaviours among men and women in Estonia, Finland and Lithuania over the period To assess the stability of sociodemographic differences of health behaviours among men and women in Estonia, Finland and Lithuania in 1994, 1996 and METHODS Data from cross-sectional, nationally representative population surveys of 1994, 1996 and 1998 from all three countries were used. The data were gathered by similar posted questionnaires that included questions on health status and on the use of health services, smoking, nutrition, use of alcohol, physical activity and traffic safety. The questionnaires were posted in all countries in April May and one or two follow-up reminders were sent. Response rates in 1994 were 83%, 70%, 64%, in 1996 they were 77%, 72%, 69% and in 1998 these rates were 68%, 70%, 62% in Estonia, Finland and Lithuania, respectively. Despite the common protocol of the project, the selection of questions with exactly the same formulation in every year and in every country was limited due to differences in local situations and the need to add questions of local relevance. For the present study, data on one key indicator from each of the four areas of health behaviour were chosen. The variable describing smoking prevalences was smoking index based on several questions. 11 This index was dichotomized as follows: i) Daily smokers and ii) Others. Frequency of strong alcoholic beverage consumption was assessed with the following question: How often do you usually have strong spirits? 1) daily; 2) 2 3 times a week; 3) once a week; 4) 2 3 times a month; 5) a few times a year; or 6) never. It was dichotomized as follows: i) Frequent consumption (men once per week or more, women 2 3 times per month or more) and ii) Others. Vegetable oil used in food preparation was assessed with the following question: What kind of fat do you mostly use for food preparation at home? (please circle only one alternative) 1) vegetable oil; 2) margarine; 3) butter or product with mainly butter; 4) lard or other animal fat; or 5) no fat at all. There were some local items in each of the participating countries, but in all cases the variable could be dichotomized as follows: i) Vegetable oil and ii) Others. Frequency of leisure-time physical exercise was assessed with the following question: How often do you do physical exercise at leisure lasting at least 30 min making you at least mildly short of breath or perspire? 1) daily; 2) 4 6 times a week; 3) 2 3 times a week; 4) once a week; 5) 2 3 times a month; 6) a few times a year or less; or 7) I cannot exercise because of an illness or disability. It was categorized as follows: i) Frequent exercise (2 3 times a week or more) or ii) Others. Gender, age, education and place of were the variables characterizing the population groups. The classification of these variables and basic characteristics of the material are presented in table 1. Education was measured as the total years of education from the questionnaire and was categorized into the following three groups: i) low = 9 years or less; ii) medium = years and iii) high = 13 years or more. The classifications chosen fit reasonably well into the educational systems of all three countries and yielded groups large enough for analysis. There were no marked changes in these demographic characteristics during the study period. National datasets from Estonia, Finland and Lithuania were analysed separately with SPSS. Patterns of health behaviours were compared by fitting logistic regression models to dichotomous variables. 12 All the models were fit separately in each country to males and females, and the main effects were included in their temporal order. The overall effect was added first followed by age, education and finally urbanization. Models comprising the overall effect and each main effect only were also evaluated. To assess the continuity/discontinuity of the individual level relationships over time, the interactions of year with age, education and urbanization were included separately in the adjusted main effect model. The first category of each factor was the reference category. The statistical significance (p<0.001) of the terms was assessed with the scaled deviance and change with the degrees of freedom ( SD and DF). Results of the adjusted main effect models are presented in odds-ratios and 95% confidence intervals in tables 3 6. RESULTS Prevalence and trends Among men, smoking was more common in 1994 in Estonia and Lithuania than in Finland. In 1994 smoking was less common in Lithuanian women than in Estonian or Finnish women. Prevalence of smoking decreased in Estonian men during the period , but in Lithuania it increased among men and especially among women (table 2).

3 Health behaviour in Estonia, Finland, Lithuania In 1994 there were no major differences between the countries in the prevalence of frequent strong alcoholic beverage consumption. There were also no changes during the period , except a slight increase among Finnish men (table 2). In 1994 the use of vegetable oil in food preparation was more common in Estonia than in Lithuania or Finland. During the period the use of vegetable oil Table 1 Characteristics of respondents Estonia Finland Lithuania Total n=3808 n=9608 n=5716 % % % Gender Low (0 9 years) Medium (10 12 years) High ( 13 years) Cities Towns Villages Table 2 Prevalences of the selected health behaviours in the period , % and 95% CI increased in all countries. The increase was substantial in Estonia and particularly in Lithuania (table 2). In 1994 frequent leisure-time physical exercise was most common in Finland, and there was practically no difference between Estonia and Lithuania. There were no changes during except the slight increase among Estonian and Lithuanian women (table 2). Similar trends to those in table 2 were observed after adjusting for age, education and urbanization (tables 3 6). The main effect of year was statistically significant (p<0.001) in smoking among Lithuanian women and in the use of vegetable oil in all the countries among men and women. Sociodemographic differences In all countries smoking was more prevalent in the younger age-groups (p<0.001). The prevalence was lower among the better-educated (p<0.001 in Finland and Lithuania). The only exception was that among Lithuanian women smoking was most prevalent in the medium education group. The differences between urban and rural areas were small and inconsistent in all countries. Only in Finland was smoking less prevalent in the countryside, especially among women (p<0.001; table 2). In Estonia and Lithuania year-old men drank strong alcoholic beverages more often than the other men did. In Finland the oldest men drank the most (p<0.001). In Estonian and Lithuanian women consumption was lowest in the oldest age group (p<0.001). The differences between educational groups were small. Only in Finnish men and Lithuanian women was high consumption more prevalent in the highest educational group. The Total n=1655 n=4578 n= % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) Daily smoking (48 57) 28 (26 31) 44 (40 47) 24 (21 27) 18 (16 20) 6 (5 8) (46 54) 29 (27 31) 48 (45 52) 22 (19 25) 18 (16 20) 10 (8 11) (38 46) 31 (29 33) 51 (48 55) 20 (17 23) 20 (18 22) 13 (11 15) Frequent strong alcoholic beverage consumption (29 38) 23 (21 25) 32 (28 35) 35 (32 39) 28 (25 30) 27 (24 29) (32 40) 27 (25 29) 29 (26 32) 35 (32 38) 32 (29 34) 29 (26 32) (27 35) 29 (26 31) 27 (24 30) 30 (26 33) 29 (27 31) 31 (28 33) Use of vegetable oil in cooking (56 65) 31 (28 33) 31 (28 34) 68 (65 72) 35 (33 37) 48 (45 51) (67 74) 34 (32 37) 54 (51 57) 78 (75 81) 39 (36 41) 69 (66 71) (74 81) 39 (37 41) 74 (70 77) 86 (84 89) 43 (40 45) 87 (84 89) Frequent leisure-time physical exercise (27 35) 60 (57 62) 31 (28 35) 25 (21 28) 61 (59 63) 25 (23 28) (32 39) 59 (57 62) 35 (32 38) 29 (26 32) 64 (62 66) 34 (31 36) (28 35) 59 (57 62) 35 (32 38) 32 (28 35) 62 (60 65) 30 (27 32) 13

4 EUROPEAN JOURNAL OF PUBLIC HEALTH VOL NO. 1 differences according to the place of were small and inconsistent among men in all countries. Among women consumption was more prevalent in urban areas (p<0.001 in Lithuanian women). In Estonian and Lithuanian men the use of vegetable oil in food preparation was less prevalent among the older (p<0.001), but in Finland the pattern was reversed. In Estonian women there were no differences, but in Lithuania (p<0.001) and Finland (p<0.001) patterns were similar to those in men; older Lithuanian women used vegetable oil less frequently in contrast to older Finnish women who used oil most frequently. In all countries the use of vegetable oil was more prevalent among the better-educated men and women (p<0.001, except the Estonian women). In Lithuania and Finland use was more prevalent in urban areas (p<0.001). Table 3 Prevalence of daily smoking by background variables, OR-values a and 95% CI ( ) 1.04 ( ) 1.23 ( ) 0.89 ( ) 1.02 ( ) 1.52 ( ) ( ) 1.20 ( ) 1.37 ( ) 0.83 ( ) 1.17 ( ) 1.97 ( ) ( ) 0.84 ( ) 0.96 ( ) 0.94 ( ) 0.79 ( ) 0.66 ( ) ( ) 0.50 ( ) 0.51 ( ) 0.30 ( ) 0.32 ( ) 0.17 ( ) Medium 0.77 ( ) 0.80 ( ) 0.97 ( ) 0.84 ( ) 0.78 ( ) 2.39 ( ) High 0.57 ( ) 0.43 ( ) 0.56 ( ) 0.62 ( ) 0.38 ( ) 1.29 ( ) Towns 0.85 ( ) 1.04 ( ) 1.11 ( ) 0.76 ( ) 1.01 ( ) 0.73 ( ) Villages 0.98 ( ) 0.82 ( ) 1.17 ( ) 0.89 ( ) 0.64 ( ) 0.76 ( ) a: Adjusted for all other terms of the model. Table 4 Prevalence of frequent strong alcohol consumption a by background variables, OR-values b and 95% CI ( ) 1.20 ( ) 0.89 ( ) 0.99 ( ) 1.21 ( ) 1.12 ( ) ( ) 1.28 ( ) 0.80 ( ) 0.79 ( ) 1.08 ( ) 1.16 ( ) ( ) 1.59 ( ) 1.42 ( ) 0.84 ( ) 1.02 ( ) 0.62 ( ) ( ) 2.13 ( ) 1.02 ( ) 0.47 ( ) 0.90 ( ) 0.35 ( ) Medium 0.79 ( ) 1.06 ( ) 0.96 ( ) 1.25 ( ) 1.07 ( ) 1.32 ( ) High 0.80 ( ) 1.23 ( ) 0.83 ( ) 1.11 ( ) 1.09 ( ) 1.39 ( ) Towns 0.86 ( ) 0.82 ( ) 0.94 ( ) 0.90 ( ) 0.87 ( ) 0.66 ( ) Villages 0.82 ( ) 0.90 ( ) 1.10 ( ) 0.76 ( ) 0.79 ( ) 0.66 ( ) 14 a: men 1 week, women 2 3 times a month or more. b: Adjusted for all other terms of the model.

5 Health behaviour in Estonia, Finland, Lithuania Among men the lowest prevalence of physical exercise was in the middle age group in all countries (p<0.001 in Finland and Lithuania). In contrast to Estonia and Lithuania, the highest prevalence in Finland was in the oldest age group. Among women the prevalence was also highest in the oldest age group (p<0.001), but in Estonia the difference was not statistically significant. There were no statistically significant differences between the educational groups or between urban and rural areas. The only exception was that among Lithuanian women prevalence was highest in the countryside. The socioeconomic differences of all four health behaviours remained similar in the period in all countries, since none of the interactions of year and age, education or place of was statistically significant. Table 5 Prevalence of use of vegetable oil in cooking by background variables, OR-values a and 95% CI ( ) 1.16 ( ) 2.83 ( ) 1.58 ( ) 1.15 ( ) 2.56 ( ) ( ) 1.38 ( ) 6.90 ( ) 2.69 ( ) 1.33 ( ) 7.47 ( ) ( ) 1.10 ( ) 0.74 ( ) 0.79 ( ) 0.91 ( ) 0.89 ( ) ( ) 1.36 ( ) 0.52 ( ) 0.86 ( ) 1.21 ( ) 0.63 ( ) Medium 1.68 ( ) 1.55 ( ) 1.35 ( ) 1.40 ( ) 1.28 ( ) 1.69 ( ) High 1.87 ( ) 2.60 ( ) 1.37 ( ) 1.71 ( ) 2.14 ( ) 1.86 ( ) Towns 1.17 ( ) 0.73 ( ) 0.66 ( ) 0.98 ( ) 0.59 ( ) 0.60 ( ) Villages 0.90 ( ) 0.67 ( ) 0.36 ( ) 0.88 ( ) 0.58 ( ) 0.22 ( ) a: Adjusted for all other terms of the model. Table 6 Prevalence of frequent leisure-time physical exercise a by background variables, OR-values b and 95% CI ( ) 0.96 ( ) 1.17 ( ) 1.21 ( ) 1.16 ( ) 1.55 ( ) ( ) 0.95 ( ) 1.15 ( ) 1.45 ( ) 1.06 ( ) 1.29 ( ) ( ) 0.92 ( ) 0.67 ( ) 0.68 ( ) 1.03 ( ) 1.08 ( ) ( ) 1.52 ( ) 0.85 ( ) 1.10 ( ) 1.30 ( ) 1.63 ( ) Medium 0.68 ( ) 1.02 ( ) 1.15 ( ) 1.22 ( ) 0.91 ( ) 0.96 ( ) High 0.78 ( ) 1.18 ( ) 1.31 ( ) 1.09 ( ) 0.97 ( ) 1.22 ( ) Towns 0.76 ( ) 1.02 ( ) 0.87 ( ) 0.92 ( ) 1.05 ( ) 0.99 ( ) Villages 0.84 ( ) 0.97 ( ) 1.21 ( ) 1.17 ( ) 1.13 ( ) 1.34 ( ) a: 2 3 times a week or more. b: Adjusted for all other terms of the model. 15

6 EUROPEAN JOURNAL OF PUBLIC HEALTH VOL NO DISCUSSION Standardized comparative information on health determinants in the former Eastern Europe is limited, but that on trends is even scarcer. To our knowledge this is the first study comparing patterns of health behaviours in Estonia, Finland and Lithuania. Moreover, the present study also assesses trends from 1994 to The Finbalt surveys have been carried out following a commonly agreed protocol and use of a common core questionnaire. The data have been centrally analysed at KTL in Finland. Close collaboration between the teams has occurred throughout the work. 10 Despite these efforts, some differences in methods may have emerged. The response rates were reasonably high for this type of population survey. Furthermore, the rates were rather similar in the three surveys in Finland and Lithuania. In Estonia the decrease in response rate may have influenced the results. However, according to data quality analysis of the 1998 survey, the direction of possible error was similar in all the countries studied. Late response was only weakly related to age, education or place of. The total proportion of missing information from the respondents was below 10%, and in all countries the older and lesseducated respondents had more missing information on their questionnaires. 9 Obviously, four years is a relatively short time period to assess changes in national lifestyles. However, these years were of particular interest in the Baltic countries, due to the political and economic situation. A considerable economic recession also occurred in Finland during the mid-1990s with recovery of the economy in Of the risk-related behaviours studied, smoking among men and leisure-time physical activity among both sexes showed the greatest difference between Finland and the Baltic countries. Among women, smoking was less common, especially in Lithuania, where a clear increasing trend was, however, observed. A decrease in smoking among men in Estonia was a positive finding and can contribute to the improvement in public health. Assessment of alcohol consumption is especially problematic in this type of survey, because alcoholics are less likely to respond. Furthermore, the questions give only a limited picture of the patterns of drinking. Despite this, no major differences were observed between countries or years. The increase in alcohol consumption in Finland, associated with the more liberal alcohol policy, can also be seen in the consumption statistics. Comparable information on levels, trends and sociodemographic differences in alcohol consumption in Estonia and Lithuania is limited. The common feature at a very general level appears to be low consumption among women and older people. 13 It is very likely, however, that problems with underreporting are present in these countries. 14,15 The Finbalt surveys cannot provide information on the nutritional status of the populations. However, some dietary patterns can be observed. Since CVD is by far the greatest killer, the type of fat consumed is of obvious interest. All three countries have a long tradition of dairy fat use and low use of vegetable oil. This fact is obviously an important background for the generally high CVD rates in these countries. The increase in vegetable oil use from 1994 to 1998 in all three countries was the most consistent trend observed in this study and relates both to national health education efforts (especially in Finland) and to improved availability (especially in the Baltic countries). The rapid change from the subsidized food market during the Soviet era to the current market economy greatly reduced the availability of dairy fat, increased their relative prices and brought to the market a wide variety of vegetable oilbased fatty products. This major change in the pattern of fat consumption may have contributed to a positive change in mortality from CVD. An analysis of public health changes in Poland revealed similar findings there and indicated that this was the most obvious contributor to the decline in CVD mortality observed at the same time. 16 Leisure-time physical activity was clearly more common in Finland than in Estonia or in Lithuania and concerned both sexes. This finding relates to the active physical activity health promotion that has occurred in Finland. On the other hand, this indicator does not concern low level physical activity at leisure or work-related physical activity that has declined especially rapidly in Finland with the advent of advanced technology. The relationships found between health behaviours and the socioeconomic background variables used were somewhat mixed. As far as age and sex are concerned, year-old men are clearly a specific high-risk group with little physical activity, common alcohol consumption and smoking. The effect of place of was inconsistent. Among women there was a tendency for alcohol consumption (especially in Lithuania) and smoking (especially in Finland) to be more common in urban areas. For vegetable oil use the trend was reversed: a more favourable situation was observed in urban areas. Concerning educational level, it is well known that upper educational groups generally enjoy better health. In the present study smoking and low vegetable oil use were indeed more common among lower-educated people. For alcohol consumption and leisure-time physical activity this was not found. As discussed previously, information on non-participants might change the picture as other studies have found relation between leisure-time sedentarity and education level in the Baltic countries. 17 Overall, the similarity of sociodemographic patterning indicated that there were no clear-cut international gaps in the health behaviours studied. It is also interesting to note that no major changes in this pattern were observed in any of the countries. This indicates the relative stability of the socioeconomic backgrounds of the risk-related lifestyles. The feasibility of this study and of the national monitoring system, including postal surveys, was also good in the Baltic countries, despite the presence of many economic constraints. It should be noted that Latvia

7 Health behaviour in Estonia, Finland, Lithuania joined the Finbalt Health Monitor in 1998, and in 2000 the surveys were again carried out in all the Baltic countries and Finland. In addition to research use, the establishment of this system has proven to be most valuable for a wide range of public health needs in the participating countries. REFERENCES 1 World Health Organisation Executive Board Session 105th. Global strategy for the prevention and control of non-communicable diseases: Report by the Director-General. Geneva: World Health Organisation, Report No.: EB 105/42. 2 Bobak M, Pikhart H, Rose R, Hertzman C, Marmot M. Socioeconomic factors, material inequalities, and perceived control in self-rated health: cross-sectional data from seven post-communist countries. Soc Sci Med 2000;51: Cavelaars AEJM, Kunst AE, Geurts JJM, Helmert U, Lahelma E. Differences in self-reported morbidity by income level in six European countries. In: Cavelaars AEJM. Cross-national comparisons of socio-economic differences in health indicators [dissertation]. Erasmus University of Rotterdam, Siegrist J. Place, social exchange and health: proposed sociological framework. Soc Sci Med 2000;51: Pudule I, Grinberga D, Kadziauskiene K, et al. Patterns of smoking in the Baltic Republics. J Epidemiol Community Health 1999;53: Pomerleau J, Pudule I, Grinberga D, et al. Patterns of body weight in the Baltic Republics. Public Health Nutr 2000;3: Puska P, Tuomilehto J, Nissinen A, Vartiainen E. The North Karelia Project: 20 year results and experiences. Helsinki: National Public Health Institute, Puska P, Vartiainen E, Tuomilehto J, Salomaa V, Nissinen A. Changes in premature deaths in Finland: successful long-term prevention of cardiovascular diseases. Bull World Health Organisation 1998;76: Helakorpi S, Uutela A, Prättälä R, Puska P. Health behaviour and health among Finnish adult population, Spring (Publications of the National Public Health Institute B8/2000.) Helsinki: National Public Health Institute, Prättälä R, Helasoja V, the Finbalt Group. Finbalt Health Monitor: Feasibility of a collaborative cystem for monitoring health behaviour in Finland and the Baltic countries. (Publications of the National Public Health Institute B21/1999.) Helsinki: National Public Health Institute, Helakorpi S, Uutela A, Prättälä R, Puska P. Health behaviour among Finnish adult population, Spring (Publications of the National Public Health Institute B12/1998.) Helsinki: National Public Health Institute, SPSS inc. SPSS Reference Guide. USA: SPSS inc., McKee M, Pomerleau J, Robertson A, et al. Alcohol consumption in the Baltic Republics. J Epidemiol Community Health 2000;54: Simpura J, Tigerstedt C, Hanhinen S, et al. Alcohol misuse as a health and social issue in the Baltic Sea region: a summary of findings from the Baltica Study. Alcohol Alcohol 1999;34: Harkin M, Anderson P, Goos C. Smoking, drinking and drug taking in the European Region. Copenhagen: WHO Regional Office for Europe, Zatonski WA, McMichael AJ, Powles JW. Ecological study of reasons for sharp decline in mortality from ischaemic heart disease in Poland since BMJ 1998;316: Pomerleau J, McKee M, Robertson A, Vaasc S, Kadziauskiene K, Abaravicius A, Bartkeviciute R, Pudule I, Grinberga D. Physical inactivity in the Baltic countries. Prev Med 2000;31(6)Dec: Received 23 March 2001, accepted 29 January