Alcohol and mortality in British men: explaining the U-shaped curve

Relationship of dietary intake to hospital admission for coronary heart and vascular disease: the NHANES II national probability study

After excluding 2,908 subjects (25% of the cohort) whose diets had changed, possibly as a consequence of disease discovery, in 8,679 individuals from the NHANES II national probability study, our specific aim was to determine which nutritional factors were significant independent contributors to overnight hospitalization with coronary heart and vascular disease (CHD). Covariance adjustments were made for multiple sociodemographic, educational, geographic factors, total cholesterol, high-density lipoprotein cholesterol (HDL-C), race, age, sex, and relative ponderosity (obesity). After these adjustments, linoleic acid (p = 0.049) and alcohol (p = 0.017) were independently inversely associated with CHD hospitalizations; cigarette smoking (p = 0.054) was positively associated. Relative risk for CHD hospitalization was 1.0 for linoleate 0-6 g/day, 0.72 for 6-11.59 g/day, and 0.49 for > or = 11.6 g/day, p < or = 0.01. Relative risk for CHD hospitalization was 1.0 for no coffee intake, 0.6 for regular coffee, 1.8 for regular coffee plus decaffeinated coffee, 2.6 for decaffeinated coffee, and 5.2 when decaffeinated coffee was drunk by virtue of physicians' advice, p < or = 0.001. Unlike our extensive exclusions (25% of the cohort) for diet change, we did not exclude any subjects on the basis of self-directed or physician-recommended changes in smoking habits of initiation of decaffeinated coffee use, following, or as a consequence of disease discovery. We speculate that the relationship of decaffeinated coffee to CHD reflects behavior change after CHD hospitalization. Dietary cholesterol (p = 0.038) was an independent positive predictor of serum total cholesterol.(ABSTRACT TRUNCATED AT 250 WORDS)

Regular light-to-moderate intake of alcohol and the risk of ischemic stroke. Is there a beneficial effect?

BACKGROUND AND PURPOSE

To evaluate the association between different patterns of alcohol consumption and the risk of ischemic stroke in young or middle-aged men.

METHODS

One hundred fifty-six patients and 153 control subjects were included in this case-control study. The pattern and the estimated average weekly intake of alcohol were assessed using a structured questionnaire. The pattern of drinking was defined as regular (daily or almost daily) or irregular (up to three times per week), and the weekly amount of consumption was defined as nondrinking, light-to-moderate drinking (up to 150 g/wk), moderate drinking (> 150 to 300 g/wk), and heavy drinking (> 300 g/wk). Multiple stepwise logistic regression models were used, and adjustments were carried out for potential confounders.

RESULTS

Heavy alcohol intake associated with an increased risk of stroke (odds ratio, 4.45; 95% confidence interval, 1.09 to 18.1), whereas the risk tended to be reduced in light-to-moderate drinkers (odds ratio, 0.54; 95% confidence interval, 0.28 to 1.05). Accounting for the pattern of alcohol intake in addition to the average weekly amount in grams, regular light-to-moderate drinking showed a significant inverse association with stroke (odds ratio, 0.12; 95% confidence interval, 0.02 to 0.65), and an irregular pattern of consumption attenuated this association. Based on the same multivariate analyses, other significant independent risk factors for stroke were arterial hypertension, coronary heart disease, and history of snoring, whereas the contributions of age, diabetes mellitus, smoking, and body mass index proved to be nonsignificant.

CONCLUSIONS

Light-to-moderate alcohol intake appears to have an inverse association with the risk of ischemic stroke. The beneficial effect appears to be most prominent if the consumption of alcohol is regular and evenly distributed throughout the week, whereas a sporadic or an occasional pattern of drinking seems to weaken the association. This study also supports the role of heavy drinking as an independent risk factor for ischemic stroke.

The risk of alcohol

We have reviewed 156 papers which provided sufficient information to relate individual alcohol consumption to risk for a variety of physical damage. Overall, there was evidence for a dose-response relationship between level of alcohol consumption and risk of harm for liver cirrhosis, cancers of the oropharynx, larynx, oesophagus, rectum (beer only), liver and breast, and blood pressure and stroke. An increased risk of cardiac arrhythmias, cardiomyopathy and sudden coronary death was associated with heavy drinking. There was evidence for a protective effect of alcohol consumption against risk of coronary heart disease, which could be achieved at consumption levels of less than 10 g alcohol a day. The mortality of non-drinkers was higher than that of moderate drinkers in some studies. Level of alcohol consumption and total mortality were dose-related when non-drinkers were excluded. The finding of a dose-relationship between alcohol and harm suggested causality. It was not possible to define individual risk for all harms at a given level of alcohol consumption because of variations in methodology, but some idea of the order of magnitude of the increased risk can be obtained from calculating trends of pooled log-odds ratios. At levels of alcohol consumption of more than 20-30 g a day, all individuals are likely to accumulate risk of harm. Current guidelines on upper limits of lower risk drinking in different countries (168-280 g of alcohol a week for men and 84-140 g a week for women) reflect levels at which the risk of total mortality is not greatly increased above one.

Alcohol, hypertension and cardiovascular disease--implications for management

Regular alcohol consumption raises blood pressure and in drinking populations contributes significantly to the prevalence of hypertension. The effect of alcohol is additive to that of obesity. Reduction in alcohol intake leads to a lowering of blood pressure over 1-4 weeks. Acute alcohol ingestion in the evening may lower blood pressures overnight. Heavy weekend drinking may lead to a pressor effect for the succeeding 3 to 4 days. Certain personality types or heavy job strain increase susceptibility to pressor effects of alcohol. Alcohol consumption in the range of 1-3 standard drinks a day appears to have a protective effect against coronary disease and ischaemic stroke, which may be greater in those with a higher risk of vascular disease. At higher levels of consumption the risks of haemorrhagic stroke, cardiomyopathy and hypertension deaths predominate. Moderation of alcohol consumption to no more than two standard drinks a day can be an effective means of improving blood pressure control reducing drug requirements in treated hypertensives, and avoiding drugs in mild hypertensives. Moderating alcohol and reducing excess weight have additive effects in reducing overall cardiovascular risk.

Alcohol and stroke. A case-control study of drinking habits past and present

BACKGROUND AND PURPOSE

Previous studies have reported a U-shaped relation between alcohol consumption and stroke. Those studies have been criticized for failing to distinguish between lifelong abstainers from alcohol and those who have given up drinking.

METHODS

We examined current and previous drinking habits of 364 cases of acute stroke and 364 community-based control subjects matched for age, sex, and family practitioner.

RESULTS

Stroke patients were more likely to have been lifelong abstainers from alcohol than were the control subjects. The odds ratio (OR) or lifelong abstainers versus those who had ever drunk regularly was 2.36 (95% confidence interval [CI], 1.67 to 3.37). No relation was found between stroke and current nondrinkers. Current male heavy drinkers also had an increased risk of stroke (OR, 2.88; 95% CI, 1.08 to 2.31).

CONCLUSIONS

Lifelong abstention from alcohol is associated with an increased risk of stroke. Moderate alcohol consumption may protect against cerebrovascular disease.

Alcohol consumption and the risk of acute myocardial infarction in women

STUDY OBJECTIVE

To investigate the relationship between alcohol consumption and the risk of acute myocardial infarction in women.

DESIGN

This was a hospital based, case-control study carried out between 1983 and 1990. Main outcome measures were average daily number of drinks of various alcoholic beverages consumed and corresponding multivariate relative risk estimates and 95% confidence intervals (CI).

SETTING

A network including major teaching and general hospitals in northern Italy.

SUBJECTS

Cases were 298 women with acute myocardial infarction but no history of ischaemic heart disease and controls 685 women admitted to hospital for acute conditions, unrelated to alcohol consumption or to known or suspected risk factors for ischaemic heart disease.

MEASUREMENTS AND MAIN RESULTS

Compared with non-drinkers, the estimated relative risks (RR) were 0.7 (95% CI 0.5, 1.0) for one drink or less per day, 0.8 (95% CI 0.6, 1.2) for more than one to two drinks per day, 1.4 (95% CI 0.8, 2.3) for more than two to three, and 2.6 (95% CI 1.5, 4.6) for more than three drinks per day. These estimates were consistent across strata of selected covariates, including age, education, and smoking. Allowance for major identified risk factors for myocardial infarction did not materially modify the risk estimate for light drinkers (RR 0.7, 95% CI 0.5, 1.1), but reduced the RR in heavy drinkers to 1.8 (95% CI 0.9, 3.5).

CONCLUSIONS

This study indicates that women who do not drink alcohol have a risk of myocardial infarction that is higher than that of light drinkers, although the protection of light drinking was not significant. Among drinkers, however, there was a significant direct trend in risk with dose. The raised risks in heavy drinkers may reflect a real association or result from other unfavourable characteristics or habits associated with high alcohol consumption.

The conflict between public health goals and the temperance mentality

OBJECTIVES

The prevailing view today is that alcohol consumption is unambiguously a social and public health problem. This paper presents evidence to balance this view.

METHODS

Evidence of beneficial effects of alcohol against coronary artery disease is examined, together with cultural reasons for resistance in the United States to the implications of this evidence.

RESULTS

Alcohol use reduces the risk of coronary artery disease--the major cause of heart disease, America's leading killer--even for those at risk for such disease. Moreover, recent research indicates that alcohol continues to reduce risk at the higher levels of drinking measured in general populations. However, with consumption of more than two drinks daily, these gains are increasingly offset by greater mortality from other causes.

CONCLUSIONS

Educators, public health commentators, and medical investigators are uneasy about findings of healthful effects of drinking. A cultural preoccupation with alcoholism and the negative effects of drinking works against frank scientific discussions in the United States of the advantages for the cardiovascular system of alcohol consumption. This set has deep roots in American history but is inconsistent with public health goals.

Moderate drinking and coronary heart disease mortality: evidence from NHANES I and the NHANES I Follow-up

Data from the National Health and Nutrition Examination Survey, conducted from 1971 through 1974, and the National Health and Nutrition Examination Survey Follow-up, conducted from 1982 through 1984, were used to test for a beneficial effect of moderate alcohol consumption on coronary heart disease mortality among White men and women. Evidence of such an effect was found for White men; accelerated time-to-failure models showed 3% to 4% longer life spans for moderate drinkers than for nondrinkers or light drinkers.

The relation of alcohol consumption to cardiovascular risk factors and stroke. The west Birmingham stroke project

The disputed relation between recent alcohol consumption and stroke was examined in a community case control study. One hundred and twenty five incident first time stroke patients and 198 controls, aged 35 to 74 years, were recruited over two years from a general practice population. The age and sex adjusted relative risks for stroke by recent weekly "drinks" of alcohol were; 0-1.0 (reference), 1 to 14-0.57, 15 to 29-0.63, and > 29-0.99. Among the controls it was noted that non-drinkers were more likely than light/moderate drinkers (1 to 29 drinks per week) to have the following characteristics; history of obesity (p < 0.001), not a recent walker (p < 0.05), and no vigorous exercise in early adulthood (p < 0.01). The apparent association of light and moderate alcohol consumption with decreased stroke risk disappeared when these variables were included in the multiple risk factor adjusted analysis; 0-1.0, 1 to 14-0.88, 15 to 29-1.11, and > 29-1.23. The pattern for proved cerebral infarction (n = 81) was similar. The results of this study do not support the idea that recent heavy alcohol consumption is an important cause of either overall stroke or cerebral infarction. The association of non-drinking with a history of overweight and inactivity may explain the apparent protective effect of lighter alcohol consumption on the risks of both stroke and coronary heart disease.

Nutritional and non-nutritional factors for 'healthy' longevity

The far-reaching effects of the ageing of populations is being increasingly appreciated. Lengthening longevity, associated with decreasing family size, evokes rising charges, socioeconomically, and on health services. Information on these and other parameters is presented for developed and developing populations. Examples are given, with lessons to be learned, of long-living segments of populations, past and present. The roles of diet, physical activity, and smoking and alcohol consumption also of attitudes, are discussed. It is concluded that if the middle-aged and elderly could be persuaded to follow long-term practices associated with good public health, then morbidity could be compressed, and disability-free years extended. However, this goal could only be achieved with a high level of motivation.

Diet and incident ischaemic heart disease: the Caerphilly Study

The Caerphilly Prospective Ischaemic Heart Disease (IHD) Study is based on a sample of 2512 men aged 45-59 years when first seen. Nutrient intakes, estimated using a self-administered semi-quantitative food frequency questionnaire, are available for 2423 men (96%). Amongst these, 148 major IHD events occurred during the first 5 years of follow-up. Associations were examined between these events and baseline diet. Incident IHD (new events) was negatively associated with total energy intake: men who went on to experience an IHD event had consumed 560 kJ (134 kcal)/d (6%) less at baseline than men who experienced no event (P = 0.01). The relative odds of an IHD event was 1.5 among men in the lowest fifth of energy intake, compared with 1.3, 1.2, 0.9 and 1.0 respectively for the other four fifths (P < 0.05). The difference in energy intake was reflected in lower intakes of every nutrient examined. When expressed as a percentage of total energy, mean intakes of men who experienced an IHD event were virtually identical to those of men who did not. There was some evidence suggesting a positive association between total fat intake and IHD risk, but the trend was not consistent and not statistically significant. There was no association for animal fat. Alcohol consumption was negatively associated with subsequent IHD, but only in men who already had evidence of IHD at baseline (P < 0.05). Dietary fibre, particularly from fruit and vegetables, was 7% lower in men who had an incident IHD event (P < 0.05), but the difference was not independent of total energy. There was a trend of increasing IHD risk with decreasing vitamin C intake, the relative odds of an IHD event being 1.6 among men in the lowest one-fifth of the vitamin C distribution, but this was not statistically significant.

Alcohol consumption, Lewis phenotypes, and risk of ischaemic heart disease

We have previously found an increased risk of ischaemic heart disease (IHD) in men with the Lewis phenotype Le(a-b-) and suggested that the Lewis blood group has a close genetic relation with insulin resistance. We have investigated whether any conventional risk factors explain the increased risk in Le(a-b-) men. 3383 men aged 53-75 years were examined in 1985-86, and morbidity and mortality during the next 4 years were recorded. At baseline, we excluded 343 men with a history of myocardial infarction, angina pectoris, intermittent claudication, or stroke. The potential risk factors examined were alcohol consumption, physical activity, tobacco smoking, serum cotinine, serum lipids, body-mass index, blood pressure, prevalence of hypertension and non-insulin-dependent diabetes mellitus, and social class. In 280 (9.6%) men with Le(a-b-), alcohol was the only risk factor significantly associated with risk of IHD. There was a significantly inverse dose-effect relation between alcohol consumption and risk; trend tests, with adjustment for age, were significant for fatal IHD (p = 0.02), all IHD (p = 0.03), and all causes of death (p = 0.02). In 2649 (90.4%) men with other phenotypes, there was a limited negative association with alcohol consumption. In Le(a-b-) men, a group genetically at high risk of IHD, alcohol consumption seems to be especially protective. We suggest that alcohol consumption may modify insulin resistance in Le(a-b-) men.

Alcohol and sudden cardiac death

OBJECTIVE

To assess the relation between alcohol intake and sudden cardiac death--ie, death within one hour of the onset of symptoms.

DESIGN

Prospective study of a cohort of men followed up for eight years.

SETTING

General practices in 24 towns in England, Wales, and Scotland.

SUBJECTS

7735 men aged 40-59 at screening who were selected at random from one general practice in each of 24 towns.

MAIN OUTCOME MEASURE

All deaths from ischaemic heart disease with particular reference to those that were sudden (death within one hour of the onset of symptoms).

RESULTS

During the follow up period of eight years there were 217 deaths from ischaemic heart disease of which 117 (54%) were classified as sudden. Although heavy drinkers (more than six drinks daily) did not show a high incidence rate of fatal heart attack, they showed the highest incidence rate of sudden cardiac death. This was seen in both manual and non-manual workers and was most clearly seen in older (50-59) men. Death from ischaemic heart disease was more likely to be sudden in heavy drinkers than in other drinking groups; this phenomenon was seen irrespective of the presence or degree of pre-existing ischaemic heart disease. The positive association between heavy drinking and the incidence of sudden death was most apparent in men without pre-existing ischaemic heart disease, with heavy drinkers showing an increase of > 60% compared with occasional or light drinkers. After adjustment for age, social class, and smoking, heavy drinkers free of pre-existing ischaemic heart disease had a marginally significantly higher incidence rates of sudden death than other drinkers combined (relative risk 2.00, 95% confidence interval 0.98 to 4.8). Additional adjustment for systolic blood pressure reduced the risk to 1.7.

CONCLUSIONS

This study suggests that heavy drinking is associated with an increased risk of sudden death. Studies that do not take pre-existing ischaemic heart disease into account are likely to underestimate the adverse effects of heavy drinking on the incidence of sudden death because the effects are not as evident in men with pre-existing ischaemic heart disease.

Determinants of plasma fibrinogen: relation to body weight, waist-to-hip ratio, smoking, alcohol, age, and sex. Results from the second MONICA Augsburg survey 1989-1990

In the second World Health Organization MONItoring Trends and Determinants in CArdiovascular Disease (MONICA) Augsburg survey in 1989-1990 (n = 4,940), the association between nephelometric plasma fibrinogen level and lifestyle-related potential determinants was assessed in 4,434 subjects aged 25-74 years (89.8% of participants). Irrespective of pregnancy and the use of oral contraceptives, crude fibrinogen values were consistently higher in women than in men of all ages (age-standardized difference, 12.2 mg/dl; 95% confidence interval, 7.0-17.4 mg/dl). Fibrinogen concentrations were positively correlated (p less than or equal to 0.0001) with age, body mass index, and waist-to-hip ratio in both sexes and with cigarette smoking in men and were negatively correlated with alcohol consumption in both sexes. In multiple linear regression analyses using categorized determinants as independent variables, a strongly J-shaped relation for body mass index in women and a linear association for waist-to-hip ratio in men were revealed. Smoking had a dose-dependent effect on fibrinogen concentration in men but a lesser effect in women. For alcohol consumption a U-shaped association was found, particularly in men. The curvilinear relations were confirmed in multiple polynomial regression models using continuous determinant variables. The potential epidemiological impact of a determinant was assessed by calculating differences in adjusted fibrinogen concentrations associated with the 10th and 90th percentile values of the determinant distributions actually observed among the study participants. This impact on the population fibrinogen level was most pronounced for age in both sexes, followed by body mass index, cigarette smoking, and alcohol consumption in women and by smoking, waist-to-hip ratio, and alcohol consumption in men.(ABSTRACT TRUNCATED AT 250 WORDS)

Lipoproteins and blood pressure as biological pathways for effect of moderate alcohol consumption on coronary heart disease

BACKGROUND

Several epidemiological studies have shown light-to-moderate alcohol consumption to have a net protective effect on the incidence of coronary heart disease (CHD).

METHODS AND RESULTS

Major components of this effect, both positive and negative, may be explored using models that include both alcohol and variables expected to mediate the observed alcohol effect. Such modeling in a cohort of men of Japanese descent followed in the Honolulu Heart Program indicates that about half of the observed protection against CHD afforded by moderate alcohol consumption is mediated by an increase in high density lipoprotein cholesterol. An additional 18% of this protection is attributable to a decrease in low density lipoprotein cholesterol, but it is counterbalanced by a 17% increase in risk due to increased systolic blood pressure. The explanation for the residual 50% benefit attributable to alcohol is unknown but may include interference with thrombosis. The results in this population replicate those in the Lipid Research Clinics cohort studied earlier with the same analytic technique.

CONCLUSIONS

The consistency of these findings across populations, along with the demonstration of reasonable biological pathways for this effect of alcohol, provides strong support for the hypothesis that light-to-moderate alcohol intake is protective against heart disease in men.

The effects of alcohol use on rebleeding and mortality in patients with alcoholic cirrhosis following variceal haemorrhage

The effect of continued alcohol intake on prognosis in alcoholic cirrhotics who have already bled from varices is controversial. To investigate the effect of alcohol intake on prognosis we studied 189 consecutive alcoholic cirrhotics admitted, for the first time, to the Royal Free Hospital with variceal bleeding. Sixty-six died within 30 days of admission and 23 were excluded from the study for other reasons. Of the 100 remaining 15 remained 'probably abstinent' over long-term follow-up, 29 drank occasionally and 56 continued to misuse/abuse alcohol. The percentage survival probability at 2 years was 66% in the probable abstainers, 68% in the occasional drinkers and 63% in the alcohol abuse/misuse group. There were no significant differences in either mortality or rebleeding rates between the three groups. A rebleeding index (designed to take account of the number of rebleeds per patient and the total length of follow-up) also failed to show any significant difference between the three groups. The Cox proportional hazard model was used to study the effect of the following factors on rebleeding and mortality; age, sex, alcohol use, Pugh's score, acute treatment received for initial variceal bleed and long-term treatment received for prevention of recurrent variceal haemorrhage. Pugh's score was significantly related to risk of death during follow-up (p = 0.0122), but none of the other factors was significantly related to risk of rebleeding or mortality. Using conventional methods to determine alcohol use we were unable to demonstrate significant effects of alcohol intake on rebleeding or mortality in alcoholic cirrhotics who had bled from oesophageal varices.

Alcohol and hypertension

The relationship between regular alcohol consumption and blood pressure elevation is now firmly established. Outstanding issues which will be discussed relate to the nature of the dose response curve, interactions between alcohol and other dietary and behavioural factors, mechanisms involved and the question of any protective influence of alcohol on atherosclerotic and ischaemic cardiovascular disease associated with hypertension. Alcohol is an important contributory to the prevalence of hypertension, and resistance to drug therapy in drinking communities. Heavy drinking and binge drinking increases the risk of stroke.

Association between baseline risk factors, cigarette smoking, and CHD mortality after 10.5 years. MRFIT Research Group

METHODS

The association between baseline risk factors and death from coronary heart disease (CHD) after 10.5 years was investigated for cigarette smokers and nonsmokers who entered the Multiple Risk Factor Intervention Trial (MRFIT).

RESULTS

Rates per thousand person-years of CHD mortality were higher for smokers than for nonsmokers at every level of baseline risk factors examined. There were significant associations between CHD mortality and plasma low-density lipoprotein and high-density lipoprotein cholesterol for smokers and nonsmokers. The inverse association between CHD mortality and high-density lipoprotein cholesterol was significantly stronger among nonsmokers compared with that among smokers and was attributable to a very strong association for former smokers. An inverse relationship between CHD and body mass index was evident for smokers and nonsmokers. Rates of CHD death rose sharply when levels of fasting glucose exceeded 140 mg/dl, and there was a significant association between CHD mortality and blood sugar levels for nonsmokers but not for smokers. For both smokers and nonsmokers, an inverse univariate association between alcohol consumption and CHD mortality was evident. This association, however, did not persist after adjustment for plasma high-density lipoprotein cholesterol.

CONCLUSION

Intervention on blood pressure and blood lipids is particularly important among cigarette smokers because of their increased risk of CHD death. The different associations between high-density lipoprotein cholesterol, fasting serum glucose, and CHD mortality for smokers and nonsmokers requires further investigation.

Prospective study of alcohol consumption and risk of coronary disease in men

Although an inverse association between alcohol consumption and risk of coronary artery disease has been consistently found in several types of studies, some have argued that the association is due at least partly to the inclusion in the non-drinking reference group of men who abstain because of pre-existing disease. The association between self-reported alcohol intake and coronary disease was studied prospectively among 51,529 male health professionals. In 1986 the participants completed questionnaires about food and alcohol intake and medical history, heart disease risk factors, and dietary changes in the previous 10 years. Follow-up questionnaires in 1988 sought information about newly diagnosed coronary disease. 350 confirmed cases of coronary disease occurred. After adjustment for coronary risk factors, including dietary intake of cholesterol, fat, and dietary fibre, increasing alcohol intake was inversely related to coronary disease incidence (p for trend less than 0.001). Exclusion of 10,302 current non-drinkers or 16,342 men with disorders potentially related to coronary disease (eg, hypertension, diabetes, and gout) which might have led men to reduce their alcohol intake, did not substantially affect the relative risks. These findings support the hypothesis that the inverse relation between alcohol consumption and risk of coronary disease is causal.

Alcohol consumption and risk of coronary heart disease

OBJECTIVE

To investigate the hypothesis that the apparent protective effect of habitual alcohol consumption on coronary heart disease is due to drinkers at high risk of coronary heart disease becoming non-drinkers.

DESIGN

Case-control population based study. Data were obtained from interviews with patients with non-fatal myocardial infarction and their controls and with the next of kin of those who had died of coronary heart disease and their controls.

SETTING

Auckland, New Zealand.

SUBJECTS

Two groups of cases were studied. The first comprised 227 men and 72 women with non-fatal myocardial infarction identified from a population based surveillance programme for coronary heart disease; controls were 525 men and 341 women randomly selected from the same population group and matched for age and sex. The second group comprised 128 men and 30 women who had died of coronary heart disease and had been identified from the surveillance programme; controls were a sample of the previous control group and comprised 330 men and 214 women matched for age and sex. All participants were aged 25-64 years and without diagnosed coronary heart disease.

MAIN OUTCOME MEASURES

Regular alcohol consumption; high density lipoprotein cholesterol and low density lipoprotein concentrations.

RESULTS

Men with myocardial infarction and men who had died of coronary heart disease were more likely to have been never drinkers (had never drunk more than once a month) than controls (18% v 12% and 23% v 13% respectively). After possible confounding factors had been controlled for, people in all categories of drinking (up to more than 56 drinks per week) had at least a 40% reduction in risk of fatal and non-fatal coronary heart disease compared with never drinkers. Former drinkers also had a lower risk of non-fatal myocardial infarction than never drinkers (relative risks 0.41 and 0.10 in men and women respectively) but a similar risk of death from coronary heart disease. The reduction in risk was consistently greater in women than in men in all drinking categories but there was no clear dose-response effect in either sex.

CONCLUSIONS

The results support the hypothesis that light and moderate alcohol consumption reduces the risk of coronary heart disease. This protective effect in this population was not due to the misclassification of former drinkers with a high risk of coronary heart disease as non-drinkers.

A prospective study of the effects of cigarette smoking and alcohol abuse on mortality

OBJECTIVE

To compare the relative risks of alcohol abuse and cigarette smoking.

DESIGN

Cohort studies utilizing a 12-to-16-year follow-up of 47-to-52-year old men.

PARTICIPANTS AND SETTING

237 Caucasian college sophomores (COLLEGE sample) and 366 socially disadvantaged junior high school students (CORE-CITY sample) selected in 1940-43 for relative mental health and for interdisciplinary study.

MAIN RESULTS

The presence of many risk factors for death, including alcohol abuse and smoking, had been assessed prior to age 47 (CORE-CITY sample) and age 52 (COLLEGE sample). Over the next 12 years (CORE-CITY sample) and the next 16 years (COLLEGE sample), the men's mortality was monitored. Heavy use of cigarettes and alcohol abuse were highly correlated. When the effect of alcohol abuse was controlled, heavy smoking was associated with elevated mortality risks in both samples, although this was not statistically significant in the CORE-CITY sample. When smoking was controlled, the odds ratios for mortality from alcohol abuse were substantial in both samples.

CONCLUSIONS

These results and a literature review suggest that insufficient alcohol abuse histories may lead clinicians to underestimate the mortality risk of alcohol abuse.

Alcohol and psychiatric illness: longitudinal study of psychiatric admissions in a cohort of Swedish conscripts

The association between level of alcohol consumption and admission for psychiatric care during a 15-year follow-up was studied in a cohort of 49,464 Swedish conscripts. The relative risk for psychiatric admission among high consumers of alcohol (more than 250 g alcohol per week) was 5.3 (95% confidence interval 4.7-6.0) compared with moderate consumers (1-100 g alcohol per week). After control for social background variables in a multivariate model, the odds ratio was 1.8 (1.5-2.1). Abstainers had the same rate of admission as moderate consumers. The association with alcohol was positive in all diagnostic categories studied. Neurotic depression was found to be a risk factor for admission for alcoholism, indicating that a causal association between alcohol and neurotic depression may go in both directions.

Risk factors for stroke in middle aged British men

OBJECTIVE

To determine the risk factors for stroke in a cohort representative of middle aged British men.

DESIGN

Prospective study of a cohort of men followed up for eight years.

SETTING

General practices in 24 towns in England, Wales, and Scotland (the British regional heart study).

SUBJECTS

7735 men aged 40-59 at screening, selected at random from one general practice in each town.

MAIN OUTCOME MEASURE

Fatal and non-fatal strokes.

RESULTS

110 of the men had at least one stroke; there were four times as many non-fatal as fatal strokes. The relative risk of stroke was 12.1 in men who had high blood pressure (systolic blood pressure greater than or equal to 160 mm Hg) and were current smokers compared with normotensive, non-smoking men. Diastolic blood pressure yielded no additional information, and former cigarette smokers had the same risk as men who had never smoked. Heavy alcohol intake was associated with a relative risk of stroke of 3.8 in men without previously diagnosed cardiovascular disease. Men with pre-existing ischaemic heart disease had an increased risk of stroke, but only when left ventricular hypertrophy on electrocardiography was also present.

CONCLUSIONS

Systolic blood pressure, cigarette smoking, and left ventricular hypertrophy on electrocardiography in men with pre-existing ischaemic heart disease were found to be the major risk factors for stroke in middle aged British men. Heavy alcohol intake seemed to increase the risk of stroke in men without previously diagnosed cardiovascular disease. A large proportion of strokes should be preventable by controlling blood pressure and stopping smoking.

Lipid and apolipoprotein levels in an Australian community

Serum levels of total and high density lipoprotein (HDL) cholesterol and apolipoproteins A1 and B were measured in over 600 men and women aged 30-69 years who were selected at random from an Australian community. Total cholesterol and apolipoprotein A1 and B levels increased with age, with this effect being most pronounced for total cholesterol and apolipoprotein B in women. Body mass index and waist-to-hip ratio were positively correlated with apolipoprotein B and total cholesterol levels, and negatively correlated with apolipoprotein A1 and HDL cholesterol levels. All lipid and apolipoprotein A1 levels increased with the quantity of alcohol consumed. After adjusting for age, body mass index and smoking, the association with alcohol was strongest for apolipoprotein A1 and HDL cholesterol levels in men (P = 0.0001), and for apolipoprotein A1 levels in women (P = 0.01). Levels of apolipoprotein A1 and HDL cholesterol were lower, and of apolipoprotein B and total cholesterol were higher, in current cigarette smokers than non-smokers, with significant associations for apolipoprotein B (P = 0.004) and HDL cholesterol levels (P = 0.04) in men. In general, the associations between apolipoprotein A1 levels and the other variables were weaker than those for HDL cholesterol levels, whereas the associations with apolipoprotein B levels were stronger than those for total cholesterol levels (except for alcohol consumption). Thus, obesity, alcohol consumption and cigarette smoking should be considered when interpreting apolipoprotein levels.

Effect of Liv.52, a herbal preparation, on absorption and metabolism of ethanol in humans

In 8 social drinkers, the effect of a single dose of Liv.52 or placebo on ethanol absorption has been studied after ingestion of 30 ml whisky in 5 min. The t1/2 absorption with Liv.52 was 3.62 min, significantly less than after placebo, 6.29 min. The peak concentration after Liv.52 (49.9 mg.100 ml-1) was significantly higher than with placebo (40.5 mg.100 ml-1). Whisky 120 ml consumed by regular alcohol users in 1 h, before and following 15 days of Liv.52 treatment produced significantly higher ethanol levels at 2, 3 and 4 h and significantly lower acetaldehyde levels at 3 and 4 h after Liv.52 treatment. Liv.52 enhanced the rate of absorption of ethanol and rapidly reduced acetaldehyde levels, which may explain its hepatoprotective effect on ethanol-induced liver damage.

Enhancing the utility of quantity-frequency measures of alcohol consumption with assessments of problem drinking in a population study. A methodologic note

Although quantity-frequency measures of alcohol consumption have been successfully used in epidemiologic studies of alcohol use, other measures may enhance detection of alcohol-disease associations. We examined two measures of alcohol consumption (quantity-frequency and an item eliciting history of heavy drinking) in a population-based longitudinal study of community-dwelling elderly men (baseline n = 1155). The primary utility of the quantity-frequency measure was in separating those who never drink, current drinkers, and former drinkers. The health and functional status of former drinkers was typically poorest. When persons who had consumed alcohol in the month prior to interview were stratified by quartile of total amount of alcohol, there were few systematic differences among the strata. The screening question on heavy drinking, however, was successful in detecting persons who were at markedly increased risk of morbidity and mortality. Thus although quantity-frequency measures are analytically appealing, other measures in some circumstances may serve a supplementary role in detecting persons at risk for adverse outcomes and for understanding the effects of alcohol consumption.

Risk of cardiovascular mortality in alcohol drinkers, ex-drinkers and nondrinkers

Lower cardiovascular mortality rates in lighter drinkers (versus abstainers or heavier drinkers) in population studies have been substantially due to lower coronary artery disease (CAD) mortality. Controversy about this U-shaped curve focuses on whether alcohol protects against CAD or, because of other traits, whether abstainers are at increased risk. Inclusion of ex-drinkers among abstainers in some studies has led to speculation that this might be the trait increasing the risk of abstainers. This new prospective study among 123,840 persons with 1,002 cardiovascular (600 CAD) deaths showed that ex-drinkers had higher cardiovascular and CAD mortality risks than lifelong abstainers in unadjusted analyses, but not in analyses adjusted for age, gender, race, body mass index, marital status and education. Use of alcohol was associated with higher risk of mortality from hypertension, hemorrhagic stroke and cardiomyopathy, but with lower risk from CAD, occlusive stroke and nonspecific cardiovascular syndromes. Subsets free of baseline cardiovascular or CAD risk had U-shaped alcohol-CAD curves similar to subsets with baseline risk. Among ex-drinkers, maximal past intake and reasons for quitting (medical versus non-medical) were unrelated to cardiovascular or CAD mortality. These data show that: (1) alcohol has disparate relations to cardiovascular conditions; (2) higher cardiovascular mortality rates among ex-drinkers are due to confounding traits related to past alcohol use; and (3) the U-shaped alcohol-CAD relation is not due to selective abstinence by persons at higher risk. The findings indirectly support a protective effect of lighter drinking against CAD.

Is alcohol a carcinogenic risk?

Consumption of alcoholic beverages has been implicated as a risk factor for the development of various cancers including oesophageal, oral, pharyngeal, laryngeal, liver and breast cancers. This article is a commentary on an earlier paper entitled 'Alcohol: a carcinogenic risk?' which challenges some of the evidence relating alcoholic beverage consumption to risk for these cancers. In the course of commenting on this paper, evidence is reviewed which shows a relationship between these cancers and consumption of alcoholic beverages, which is often found to be dose-related.

Apolipoprotein distribution in plasma HDL subfractions in alcohol consumers

Alcohol intake is known to increase plasma HDL subfractions and apo A levels. Few data are available, however, with regard to precise apoprotein composition of plasma lipoproteins in alcohol consumers. The aim of the present study was to examine the lipid and apoprotein distribution in plasma lipoproteins of subjects with different levels of alcohol intake. Thirty-six male regular drinkers were classified as social (n = 10, average daily consumption greater than or equal to 5 and less than or equal to 20 g), moderate (n = 11, average daily consumption greater than 20 g and less than 70 g) and heavy drinkers (n = 15, average daily consumption greater than or equal to 70 g). Reference data were obtained from 11 subjects, all lifelong abstainers. Lipoproteins were fractioned by sequential ultracentrifugation and apolipoprotein distribution in VLDL, HDL-2 and HDL-3 was determined by isoelectrofocusing in polyacrylamide-urea gel. HDL-2 cholesterol was significantly higher in heavy drinkers (P less than 0.005). A parallel trend for HDL-3 cholesterol was observed. In alcohol consumers HDL-2 particles were enriched in apos C, in particular apo C-II (P 0.005), displacing apo A-I. These data suggest that apolipoprotein distribution in the HDL-2 subfraction is influenced by alcohol intake even at the lowest level.

How much alcohol is in a 'standard drink'? An analysis of 125 studies

A group of researchers have undertaken a review of 125 international, published, epidemiological studies that relate various physical harms to different levels of alcohol consumption. For this review it was necessary to be able to compare the data from the different studies directly. The different measures of alcohol quoted in the studies were converted to the standard measure of grammes of alcohol. The present paper discusses the problems involved in doing this, and gives details of the conversion methods used.

Hospital admissions for somatic care among young men: the role of alcohol

The association between level of alcohol consumption and hospital admission for somatic care during a 15-year follow-up was studied in a cohort of 8226 Swedish conscripts. The relative risk for admission among high consumers of alcohol (more than 250 g alcohol per week) was 1.5 (95% confidence interval 1.2-1.8) compared with moderate consumers (1-100 g alcohol per week). After control for social background variables in a multivariate model the odds ratio was 1.2 (0.9-1.6). High consumers had a higher rate of recurring admissions; the number of admissions per capita increased from 1.8 among abstainers to 2.4 among high consumers. The association with alcohol was positive in all diagnostic categories studied. Earlier reports of a U-shaped curve for hospital admission was not confirmed; abstainers had the same rate of admission as moderate consumers.

Aspirin and dipyridamole and their limitations in the therapy of coronary artery disease

We have reviewed some of the voluminous literature on the effects of aspirin combined with dipyridamole on coronary thrombosis. There is clear evidence that aspirin is partially effective in preventing platelet aggregation and subsequent thrombosis in experimental constricted and damaged coronary arteries of dogs. Clinical studies show a clear reduction in myocardial infarction in male human subjects who are given aspirin as therapy for unstable angina, or as prophylaxis in asymptomatic individuals. In many studies aspirin and dipyridamole have been combined and are effective. We have not found dipyridamole to be effective in the dog with coronary artery constriction and find no substantial evidence that it is effective in preventing myocardial infarction in man. Until definitive studies show that combining dipyridamole with aspirin is more effective than aspirin alone, we do not recommend its use for prevention of coronary thrombosis.

Alcohol consumption, serum lipids and severity of angiographically determined coronary artery disease

The relation of alcohol consumption to serum lipids and the severity of coronary atherosclerosis was examined in 212 men undergoing coronary angiography. The severity of coronary atherosclerosis was assessed in terms of the presence of greater than or equal to 75% diameter stenosis and the Gensini severity score. Alcohol consumption was divided into 4 categories: none (0 ml alcohol/week), light (1 to 100 ml alcohol/week), moderate (101 to 300 ml alcohol/week) and heavy (greater than or equal to 301 ml alcohol/week). Alcohol consumption was positively related to high-density lipoprotein cholesterol and inversely related to total cholesterol, but was not associated with triglyceride. After adjustment for these serum lipids as well as for cigarette smoking and systemic hypertension, the risk of coronary stenosis was significantly decreased in the moderate drinkers. A decreased risk among moderate drinkers also was noted in terms of Gensini's severity score. These findings suggest that moderate alcohol consumption may protect against severe coronary atherosclerosis.

Statistical control in research on alcohol and tobacco: an example from research on alcohol and mortality

Many of the major studies of deaths related to alcohol use report evidence for a U-shaped relationship between mortality and consumption, with abstainers having higher mortality than moderate drinkers. Some have suggested that this indicates a protective effect of moderate drinking; others have argued that pre-existing health problems and demographic and lifestyle differences explain the finding. In this report, we present evidence that the U-shaped function is largely an artefact of inadequate controls for smoking and drinking intake and history. Never smoking abstainers die at about the same rate as never smoking moderate drinkers. We stress the importance of using precise measures of drug use history and drug use status and make the point that, given the strong interaction between smoking and drinking, controlling for smoking may produce misleading results.

Alcohol abuse and brain infarction

Recent findings on the relation between alcohol abuse and ischaemic brain infarction are reviewed. Much of the association has hitherto been explained by the effects of confounding factors such as smoking. Alcohol increases blood pressure in both hypertensive and normotensive subjects and alcohol induced hypertension enhances the risk of both hemorrhagic and ischaemic strokes. Analysis of case histories shows that alcohol abuse has precipitated cerebral embolism in conjunction with cardiac diseases including alcoholic cardiomyopathy and paradoxical embolism due to deep vein thrombosis via atrial septal defect. Among young adults, falling when intoxicated with alcohol has caused traumatic dissection of the carotid artery and consequent brain infarction. Alcohol may predispose individuals to cerebral embolism, thrombosis and ischaemia via its effects on the coagulation cascade, platelet count and function and contractility of the cerebral vessels. Further studies are needed to prove that these mechanisms are significant and to identify any other mechanisms which may mediate the risk associated with alcohol abuse. On the basis of current data, alcohol should be considered as an independent risk factor for ischaemic cerebral infarction in young adults.

Plasma fibrinogen and coronary risk factors: the Scottish Heart Health Study

Plasma fibrinogen was measured in a sample of 8824 men and women aged 40-59 years participating in the Scottish Heart Health Study, and related to cardiovascular risk factors. Women had higher fibrinogen levels than men. In both sexes, multivariate analysis showed that fibrinogen was positively associated with age, smoking, total cholesterol and body mass index and negatively associated with alcohol consumption. Among women, early menopause and systolic blood pressure were also associated with fibrinogen levels. Univariate analyses showed weak positive associations with fish consumption for both sexes although only male white fish consumption entered the final model. Women with a history of contraceptive pill usage had significantly lower fibrinogen levels. The relationship between fibrinogen and physical activity was complex, and could largely be explained by smoking. These findings support the hypothesis that raised fibrinogen is one mechanism by which several major risk factors may promote coronary heart disease. However, known risk factors explained, at most, 10% of the total variance in fibrinogen levels among the general population.