Drinking and mortality. The Albany Study

Alcohol use, other traits, and risk of unnatural death: a prospective study

This study prospectively explores relations of usual alcohol intake in a Northern California population of 128,934 persons to risk of subsequent unnatural death. Of 385 such deaths during the 8-year study period, 88 were due to motor vehicle accidents (MVAs), 106 to suicide, 52 to homicide, and 139 to miscellaneous other unnatural causes. Comparisons of ex-drinkers and 5 levels of current drinkers to lifelong abstainers were studied by Cox proportional hazards models with 9 covariates. In adjusted analyses, persons reporting intake of 6 or more drinks daily were at greatly increased risk of death from suicide (6 times) and homicide (7 times), and at moderately increased risk of death from MVAs (2 times). Lighter and ex-drinkers were not at significantly increased risk for all unnatural deaths or any of its subsets. Among persons reporting 6 or more drinks/day, women and persons below 50 years of age were at especially high risk, but Blacks and Whites were at similar risk. Persons who usually drank liquor or wine were at greater risk for MVAs than those who usually drank beer; beverage choice was unrelated to the other causes of death. Among other covariates, men and not married persons were at higher risk and college graduates at lower risk, for each cause of death. The only major racial difference was a lower risk of suicide for Blacks (versus Whites). These data provide considerable detail about usual alcohol use and risk of unnatural death. They point to special need for preventive efforts among younger persons and women, with particular attention to suicide and homicide.

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-related mortality in Spain

Alcohol-related mortality and years of potential life lost in Spain in 1986 have been studied according to the official statistics with regard to the population mortality in our country. 6.1% of the deaths in Spain in 1986 were related to alcohol consumption, mainly caused by malignant neoplasm (26.0%), digestive diseases (23.6%), and unintentional injuries (21.1%). Mean potential years of life lost for alcohol-related deaths until 65 was 7.3. Unintentional injuries were responsible for the greater part (61.2%) of alcohol-related years of potential life lost. The present study shows the high mortality rate associated with alcohol consumption in our country, as well as its importance in premature death.

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.

Health risk behaviors of Hispanics in the United States: findings from HHANES, 1982-84

With data from the Hispanic Health and Nutrition Examination Survey (HHANES), we examined several health risk behaviors (cigarette smoking, alcohol use, dietary practices, and recency of health screening) of Mexican American, Cuban American, and Puerto Rican adults (ages 20-74). For each sample, a greater percentage of men than women smoked cigarettes and used alcohol. Heavy smoking (20+ cigarettes per day) was most prevalent for Cuban American males, and heavy drinking (1.00+ oz ethanol per day) was most prevalent for Mexican American and Puerto Rican men. Acculturation correlated positively with alcohol use (particularly for females) and negatively with dietary balance (for Mexican American men and women). The Puerto Ricans' diet was less balanced than that of the other two groups. For each sample, more men than women had not had a routine physical or dental examination within the past five years; the recency of screening was lowest for Mexican American men. Screening (including Pap smear for the women) was lower for those who smoked cigarettes and for those with poor dietary practices, indicating that many Hispanics at special risk of disease underutilize preventive health services, increasing the likelihood of diagnosis at a later stage of illness.

Interaction of alcohol and stress at the cardiovascular level

Research on the interaction of alcohol and stress on the cardiovascular system published since 1981 is reviewed. Important variables that can modify the interaction of alcohol and stress are also discussed. Consistent findings have come from studies on stress-induced tachycardia which has been shown to be decreased by alcohol ingestion. Evidence from clinical, cohort, case-control, epidemiological research indicates that long-term ingestion of alcohol is associated with lower risk of coronary heart disease. Less clear is the association of the risk of hypertension and alcohol ingestion. Primarily in women, there might be a threshold low level of alcohol consumption which is not associated with the development of hypertension. With some stressors, alcohol may depress the stressor-induced elevation of plasma catecholamines. Mechanisms believed to mediate the described alcohol-stress interaction are discussed. Existing evidence support the following mechanisms: mediation via changes in plasma lipoproteins in the case of coronary heart disease and changes in plasma calcium levels for the blood pressure effects.

Alcohol and mortality: a review of prospective studies

Non-drinkers and heavy drinkers tend to have higher total and cardiovascular mortality rates than light or moderate drinkers. The finding is not disputed; it is the interpretation of this U-shaped curve that is controversial, and in particular the belief that light and moderate drinking protects against coronary heart disease. The British Regional Heart Study of middle-aged British men has shown that 70% of non-drinkers are ex-drinkers. Those ex-drinkers have high rates of doctor-diagnosed illnesses including heart disease, hypertension, diabetes and bronchitis as well as high prevalence rates of measured hypertension, obesity, current smoking and regular medical treatment. Over a five-year period men who were diagnosed as having heart disease, had multiple diagnoses or were put on regular medication had an increased likelihood of becoming non-drinkers or occasional drinkers. The study suggests a downward drift from heavy and moderate drinking towards non-drinking under the influence of accumulating ill health. The data strongly suggest that the observed alcohol-mortality relationships in prospective studies are produced by symptoms and disease present at the time of screening, and by the prior movement of men with such disorders into non-drinking or occasional drinking categories. The concept of a protective effect on mortality which ignores the dynamic relationship between ill health and drinking behaviour is likely to be ill-founded. A review of the major prospective studies reveals an inadequate exploration of the nature of non-drinkers, who are clearly unsuitable for use as a baseline in studies of the effects of alcohol on health.

U-shaped dose-response curves: their occurrence and implications for risk assessment

A class of curvilinear dose-response relationships in toxicological and epidemiological studies may be roughly described by "U-shaped" curves. Such curves reflect an apparent reversal or inversion in the effect of an otherwise toxic agent at a low or intermediate region of the dose continuum. Several examples of U-shaped dose-response functions are presented to illustrate the variety of agents and end points that can follow this form. Such findings are not thought to represent a unitary phenomenon, but may be explained through numerous possible principles or mechanisms, some of which are illustrated and discussed in general terms. U-shaped dose-response curves raise important issues for toxicological and environmental health risk assessments, particularly in the identification of no-observed-effect levels and in the evaluation of multiple outcomes and the tradeoffs between potential risks and benefits of a given agent. It is especially important to avoid focusing exclusively on an apparent improvement in one end point and failing to consider other, possibly deleterious effects of the same agent.

[The association between alcohol consumption and health services utilization]

The association between alcohol consumption patterns and the use of health services was examined in a cross-sectional survey of the general population of the Region of Madrid. Logistic regression analysis was used to determine the odds of moderate drinkers, excessive drinkers and non-drinkers to utilize health care services. Our findings indicate that moderate drinkers have a lower probability of utilizing health care services as compared to non-drinkers. Specifically, moderate drinkers showed a lower probability of utilizing both hospital (OR = 0.65 CI = 0.48-0.89) and ambulatory care (OR = 0.79 CI = 0.66-0.95) services. Furthermore, the frequency of use of ambulatory (OR = 0.79 CI = 0.64-0.95) and emergency care services (OR = 0.38 CI = 0.21-0.69) was also lower for moderate drinkers. Excessive drinkers also showed a tendency to use emergency care services less frequently (OR = 0.43 CI = 0.19-0.93). Both moderate and excessive drinking were also significantly associated with a shorter length of stay as compared to non-drinkers. The odds ratios are 0.41 (CI = 0.21-0.79) and 0.29 (CI = 0.19-0.39) respectively. Possible explanations of this "protective" effect of alcohol consumption, especially of moderate drinking, are discussed in relation to the diagnostic entities motivating the use of health care services.

Moderate alcohol consumption and stroke. The epidemiologic evidence

An extensive search of the English-language literature identified 62 epidemiologic studies that examined the relation between moderate alcohol consumption and risk of stroke. Moderate drinking (less than 60 g ethanol/day) and ischemic stroke have a complex association that might be explained by interaction with race; a J-shaped association has been found in predominantly white populations, while little (if any) association has been found among Japanese. By contrast, moderate drinking increases risk of both intracerebral and subarachnoid hemorrhage in diverse populations. There is insufficient epidemiologic evidence to conclude whether recent alcohol use affects risk of either ischemic or hemorrhagic stroke. These distinctive associations help explain contradictory reports on the relation between moderate alcohol consumption and risk of "stroke." The high prevalence of alcohol use throughout the world suggests opportunities for primary prevention and the importance of continued research in this area.

Determinants of cardiovascular diseases in the elderly

The roles of age, gender, diet, plasma lipoproteins, blood pressure, smoking, physical activity, alcohol consumption and psychosocial factors as determinants of cardiovascular diseases have been studied mainly in the middle aged but little in the elderly. The risk factor status of glucose intolerance, body weight, and the physical and chemical environment has been less firmly established. This review examines the published evidence, emphasising the potential of extending the prevention of cardiovascular diseases beyond 60.

Alcohol consumption and mortality in aging or aged Finnish men

The association between alcohol consumption and 10-year mortality by death cause was studied in 1112 men aged 55-74 years and living either in eastern or south-western Finland. After adjustment for age, blood pressure, smoking, serum cholesterol, and other variables, the relative odds ratio of 10-year total mortality associated with consuming 1-273 g of absolute alcohol per month was 0.9 (95% confidence interval of 0.6-1.2) and with consuming more than 273 g per month due to violence was small, 15, but relative odds of violent death associated with consuming 1-273 and 274 or more grams of alcohol per month were 3.4 and 16.2, respectively (95% confidence intervals of 0.4-31.9 and 1.9-141.2).

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

In a prospective study of 7735 middle-aged 7 British men, 504 of whom died in a follow-up period of 7.5 years, there was a U-shaped relationship between alcohol intake and total mortality and an inverse relationship with cardiovascular mortality, even after adjustment for age, cigarette smoking, and social class. These mortality patterns were seen in all smoking categories (with ex-smoking non-drinkers having the highest mortality) and were observed in manual but not in non-manual workers. The alcohol-mortality relationships (total and cardiovascular) were present only in men with cardiovascular or cardiovascular-related doctor-diagnosed illnesses at initial examination. The data suggest that the observed alcohol-mortality relationships are produced by pre-existing disease and by the movement of men with such disease into non-drinking or occasional-drinking categories. The concept of a "protective" effect of drinking on mortality, ignoring the dynamic relationship between ill-health and drinking behaviour, is likely to be ill founded.

Associations between alcoholic beverage consumption and hospitalization, 1983 National Health Interview Survey

Data collected in the Alcohol Supplement and core 1983 National Health Interview Survey were used to examine associations between alcoholic beverage consumption and hospitalization. Hospitalizations in acute care facilities (excluding hospitalizations for delivery) in the past 12 months, were treated as dichotomous (any vs none) and examined in relation to alcohol consumption in a logistic regression model adjusting for age, race, income, and smoking. Findings are based on 17,600 individuals meeting inclusion criteria. The adjusted odds ratio of having one or more hospitalization for current drinkers relative to life-long abstainers in females was 0.67 (95 per cent confidence interval 0.57-0.79) and in males was 0.74 (0.57-0.96). U-shaped relationships between level of current alcohol intake and odds of hospitalization were found. While some causes of hospitalization are clearly increased among drinkers, the overall acute care hospitalization experience of moderate drinkers appears to be favorable.