Alcohol and mortality: the Honolulu Heart Study

Sex-specific association between alcohol consumption and liver cirrhosis: An updated systematic review and meta-analysis

Different studies have shown that females develop liver diseases at lower levels of alcohol consumption than males. Our aim was to quantify the dose-response relationship between alcohol consumption and the risk of liver cirrhosis by sex and identify the differences between females and males. A systematic review was conducted using PubMed/Medline and Embase to identify longitudinal and case-control studies that analyzed the relationship between the level of alcohol use and liver cirrhosis (LC) incidence, and mortality (ICD-8 and ICD-9 codes 571 and ICD-10 codes K70, K73, K74). Pooled relative risks (RR) were calculated by random effects models. Restricted cubic splines were used to model the dose-response relationship. A total of 24 studies were included in the analysis. There were collectively 2,112,476 females and 924,853 males, and a total of 4,301 and 4,231 cases of LC for females and males, respectively. We identified a non-linear dose-response relationship. Females showed a higher risk for LC compared to males with the same amount of alcohol consumed daily. For instance, drinking 40 g/day showed RRs of 9.35 (95% CI 7.64-11.45) in females and 2.82 (95% CI 2.53-3.14) in males, while drinking 80 g/day presented RRs of 23.32 (95% CI 18.24-29.82) in females and 7.93 (95% CI 7.12-8.83) in males. Additional analyses showed that a higher risk for females was found for morbidity and for mortality. Understanding the influence of sex on the association of alcohol consumption and the risk of LC is needed to develop recommendations and clinical guidelines for prevention and treatment.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022299680, identifier CRD42022299680.

Harmful Impact of Tobacco Smoking and Alcohol Consumption on the Atrial Myocardium

Tobacco smoking and alcohol consumption are widespread exposures that are legal and socially accepted in many societies. Both have been widely recognized as important risk factors for diseases in all vital organ systems including cardiovascular diseases, and with clinical manifestations that are associated with atrial dysfunction, so-called atrial cardiomyopathy, especially atrial fibrillation and stroke. The pathogenesis of atrial cardiomyopathy, atrial fibrillation, and stroke in context with smoking and alcohol consumption is complex and multifactorial, involving pathophysiological mechanisms, environmental, and societal aspects. This narrative review summarizes the current literature regarding alterations in the atrial myocardium that is associated with smoking and alcohol.

Alcohol Policy Scores and Alcohol-Attributable Homicide Rates in 150 Countries

INTRODUCTION

More comprehensive state-level alcohol policy environments are associated with lower alcohol-attributable homicide rates in the U.S., but few studies have explored this internationally. This study tests whether 3 national-level alcohol policy scores are associated with alcohol-attributable homicide rates.

METHODS

Data were from the 2016 WHO Global Survey on Alcohol and Health and the 2017 Global Burden of Disease Study (N=150 countries). In 2020, the authors calculated domain-specific alcohol policy scores for physical availability, marketing, and pricing policies. Higher scores represented more comprehensive/restrictive alcohol policy environments. Negative binomial regressions with Benjamini-Simes-Hochberg multiple testing correction measured the associations between policies and alcohol-attributable homicide rates. Authors stratified countries by World Bank income group to determine whether the associations differed among low- and middle-income countries.

RESULTS

A 10% increase in the alcohol policy score for pricing was associated with an 18% lower alcohol-attributable homicide rate among all the countries (incidence rate ratio=0.82, adjusted p-value or q<0.001) and with a 14% (incidence rate ratio=0.86, q=0.01) decrease among 107 low- and middle-income countries. More controls on days and times of retail sales (incidence rate ratio=0.96, q=0.01) and affordability of alcohol (incidence rate ratio=0.95, q=0.04) as well as adjusting excise taxes for inflation (incidence rate ratio=0.96, q<0.01) were associated with a 4%-5% lower alcohol-attributable homicide rate in the full sample.

CONCLUSIONS

Countries with policies that reduce alcohol's affordability or days/hours of sales tend to have fewer alcohol-attributable homicides, regardless of their income level. Alcohol-attributable homicide rates are highest in low- and middle-income countries; policies that raise alcohol-relative prices may hold promise for curbing these harms.

Alcohol and All-Cause Mortality: A Pooled Analysis

Reviewing 59 studies of the risk curve for alcohol consumption level and all-cause mortality, a general J-shaped curve is confirmed, particularly in cohorts with experience starting at middle age (rather than in youth or old age). The divergence in most studies that are exceptions to this rule can be plausibly explained. A pooled analysis of studies with cohorts age 45 and above at entry shows the most beneficial effect for women in a drinking category with a midpoint of one drink every second day, and for men in the drinking category with a midpoint of one and a half drinks per day though most of the benefit can be obtained by men, too, in the category with a midpoint of one-half drink per day. For men under 45, there was an almost linear increase in mortality risk with increasing consumption; data are lacking for a similar analysis for women. Directions are suggested for development in future studies, including the use of data on patterns of drinking.

Alcohol as a risk factor for liver cirrhosis: a systematic review and meta-analysis

INTRODUCTION AND AIMS

Alcohol is an established risk factor for liver cirrhosis. It remains unclear, however, whether this relationship follows a continuous dose-response pattern or has a threshold. Also, the influences of sex and end-point (i.e. mortality vs. morbidity) on the association are not known. To address these questions and to provide a quantitative assessment of the association between alcohol intake and risk of liver cirrhosis, we conducted a systematic review and meta-analysis of cohort and case-control studies.

DESIGN AND METHODS

Studies were identified by a literature search of Ovid MEDLINE, EMBASE, Web of Science, CINAHL, PsychINFO, ETOH and Google Scholar from January 1980 to January 2008 and by searching the references of retrieved articles. Studies were included if quantifiable information on risk and related confidence intervals with respect to at least three different levels of average alcohol intake were reported. Both categorical and continuous meta-analytic techniques were used to model the dose-response relationship.

RESULTS

Seventeen studies met the inclusion criteria. We found some indications for threshold effects. Alcohol consumption had a significantly larger impact on mortality of liver cirrhosis compared with morbidity. Also, the same amount of average consumption was related to a higher risk of liver cirrhosis in women than in men.

DISCUSSION AND CONCLUSIONS

Overall, end-point was an important source of heterogeneity among study results. This result has important implications not only for studies in which the burden of disease attributable to alcohol consumption is estimated, but also for prevention.

Association of alcohol consumption with selected cardiovascular disease outcomes: a systematic review and meta-analysis

OBJECTIVE

To conduct a comprehensive systematic review and meta-analysis of studies assessing the effect of alcohol consumption on multiple cardiovascular outcomes.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

A search of Medline (1950 through September 2009) and Embase (1980 through September 2009) supplemented by manual searches of bibliographies and conference proceedings. Inclusion criteria Prospective cohort studies on the association between alcohol consumption and overall mortality from cardiovascular disease, incidence of and mortality from coronary heart disease, and incidence of and mortality from stroke. Studies reviewed Of 4235 studies reviewed for eligibility, quality, and data extraction, 84 were included in the final analysis.

RESULTS

The pooled adjusted relative risks for alcohol drinkers relative to non-drinkers in random effects models for the outcomes of interest were 0.75 (95% confidence interval 0.70 to 0.80) for cardiovascular disease mortality (21 studies), 0.71 (0.66 to 0.77) for incident coronary heart disease (29 studies), 0.75 (0.68 to 0.81) for coronary heart disease mortality (31 studies), 0.98 (0.91 to 1.06) for incident stroke (17 studies), and 1.06 (0.91 to 1.23) for stroke mortality (10 studies). Dose-response analysis revealed that the lowest risk of coronary heart disease mortality occurred with 1-2 drinks a day, but for stroke mortality it occurred with ≤1 drink per day. Secondary analysis of mortality from all causes showed lower risk for drinkers compared with non-drinkers (relative risk 0.87 (0.83 to 0.92)).

CONCLUSIONS

Light to moderate alcohol consumption is associated with a reduced risk of multiple cardiovascular outcomes.

Alcohol, cardiovascular diseases and all causes of death: a review of the epidemiological evidence

This paper reviews the epidemiological evidence on the association of alcohol consumption with the major cardiovascular diseases (hypertension, stroke and coronary heart disease), and all causes of death. The focus is on light and moderate consumption and several important methodological issues are apparent with the epidemiological evidence on alcohol and mortality. The epidemiological data justify the following recommendations on alcohol consumption. The evidence does not support the unqualified claim that light and moderate drinking confers overall health benefits. However, in persons over 35 years of age, there is no consistent evidence that daily consumption of up to 2-3 drinks in men or up to 1-2 drinks in women increases the risk of dying. Non-drinkers should not be encouraged to change their drinking status. The consumption of more than 2-3 drinks per day in men and more than 1-2 drinks per day in women should be actively discouraged. Further research on the effects of light and moderate alcohol consumption on cardiovascular disease and all causes of death are required, particularly in young people, women and the elderly.

What supports the role of alcohol as a risk factor for stroke?

For more than 30 years, clinical observations to link alcohol abuse and stroke have accumulated in several countries. Studies of general populations have indicated that the risk for stroke increases with increasing alcohol consumption. Studies of young victims of stroke where the classical risk factors of stroke are uncommon, have demonstrated that even occasional heavy drinking carries an increased risk for stroke. In particular, the increased occurrence of strokes during weekends, the very time of heavy alcohol consumption in non-alcoholics, supports this notion. Alcoholics seem to get their strokes at an earlier age than non-alcoholics. Paradoxically, the published evidence has implicated drinking in both ischemic and hemorrhagic strokes, which suggests that there may be more than one mechanism by which alcohol can increase the risk. Strokes seem to be precipitated during the alcohol intoxication itself rather than the following withdrawal syndrome, but the contributing mechanisms, except for bleedings caused by external violence, are unknown. Alcohol can produce fluctuations in platelet reactivity and untoward interactions with certain drugs, but it remains to be demonstrated that such effects are temporally related to the onset of ischemic and hemorrhagic strokes.

Alcoholic intemperance, coronary heart disease and mortality in middle-aged Swedish men

High alcohol consumption is one of the major risk indicators for premature death in middle-aged men. An indicator of alcohol abuse--registration with the social authorities for alcoholic problems--was used to evaluate the role of alcohol in relation to general and cause-specific mortality in a general population sample. Altogether 1,116 men (11%) out of a total population of 10,004 men were registered for alcoholic problems. Total mortality during 11.8 years' follow-up was 10.4% among the non-registered men, compared to 20.5% among men with occasional convictions for drunkenness and 29.6% among heavy abusers. Fatal cancer as a whole was not independently associated with alcohol abuse, but oropharyngeal and oesophageal cancers together were seven times more common in the alcohol-registered groups. Total coronary heart disease (CHD) was significantly and independently associated with alcohol abuse, but nearly all the excess CHD mortality among the alcohol-registered men could be attributed to sudden coronary death. Cases with definite recent myocardial infarction were not more common in the alcoholic population. A combined effect of coronary arteriosclerosis and heart muscle damage secondary to alcohol abuse is suggested. Other causes of death strongly associated with registration for alcohol abuse include pulmonary embolism, pneumonia and peptic ulcer, as well as death from liver cirrhosis and alcoholism. Of the excess mortality among alcohol-registered subjects, 20.1% could be attributed to CHD, 18.1% to violent death, 13.6% to alcoholism without another diagnosis and 11.1% to liver cirrhosis.

Epidemiology of myelodysplastic syndromes

Myelodysplastic syndromes (MDS) are one of the most common hematological conditions among the elderly. Differences in disease classification and diagnosis have made population-based studies an arduous endeavor. A variety of risk factors have been linked with increased risk (smoking and exposure to solvents and agrochemicals) or decreased risk of MDS (wine drinking), but the majority of cases remain unexplained. One area that has not been explored is the influence of diet in MDS development. Much still needs to be learned about what causes MDS and the genetic factors that increase susceptibility. Multi-institutional studies with a molecular-epidemiologic approach are necessary to develop a MDS risk predictive model.

Drinking pattern and mortality in Danish nurses

BACKGROUND/OBJECTIVE

Moderate alcohol consumption has beneficial effects on survival. Sex differences, however, have been suggested implying less beneficial effect among women. We examined the impact of alcohol consumed on weekdays and at weekends, respectively, on risk of death among women.

SUBJECTS AND METHODS

At baseline in 1993, a total of 17 772 female members of the Danish Nurse Association completed questionnaires on alcohol intake and other lifestyle factors. The influence of alcohol intake on risk of death was analyzed using Cox proportional hazard model.

RESULTS

Alcohol intake of 1-3 drinks per week was associated with the lowest risk of death. Intake above six drinks per weekend (Friday through Sunday) increased risk of death from all causes by 3% for each additional drink consumed per weekend (corresponding to an increased risk by 9% per drink per weekend day). Consumption of one or more drinks per weekday (Monday, Tuesday, Wednesday or Thursday) increased risk by 4% for each additional drink consumed per day.

CONCLUSIONS

The results indicated an increasing risk of death for intake above six drinks per weekend and of one or more drinks per weekday.

Alcohol Consumption and Abnormalities of Brain Structure and Vasculature

Research on how alcohol consumption influences the structure and blood supply of the brain has generally focused on two primary areas of interest: the atrophic effect of heavy drinking on brain structure and the effects of moderate and heavy drinking on the risk of stroke. Heavy alcohol consumption results in atrophy of gray and white matter, particularly in the frontal lobes, cerebellum, and limbic structures. Heavy drinking also raises the risk of ischemic and hemorrhagic stroke, while light drinking is associated with a lower risk of ischemic stroke. Recently, the author and his colleagues studied alcohol consumption and prevalence of subclinical abnormalities detected by magnetic resonance imaging of the brain among 3376 older adults enrolled in the Cardiovascular Health Study. They found that alcohol consumption was positively associated with measures of brain atrophy and inversely associated with subclinical infarcts in a dose-dependent manner. Alcohol consumption and white matter lesions had a U-shaped relationship, with the lowest prevalence among those who consumed 1-6 drinks per week. Further research is needed to determine how these associations interact to influence overall brain function.

Factors influencing the relation between alcohol and cardiovascular disease

PURPOSE OF REVIEW

Light-to-moderate alcohol intake is known to have cardioprotective properties in some subsets of the population. This review focuses on factors that modify the relation between alcohol and cardiovascular disease.

RECENT FINDINGS

Several large American studies have shown that the J-shaped relation is influenced by age and coronary heart disease risk-factor status since only middle-aged and elderly and those already at risk of developing coronary heart disease seem protected by drinking alcohol. It has also been suggested that only those who have a steady - in contrast to a binge - intake of alcohol have benefits with regard to cardiovascular disease. Prospective studies from the UK, Sweden and Denmark have further suggested that wine drinkers have a lower mortality than beer and spirits drinkers.

SUMMARY

The J-shaped relation between alcohol intake and cardiovascular disease seems to be influenced by age, gender, drinking pattern and type of alcohol.

Impact of alcohol drinking on total cancer risk: data from a large-scale population-based cohort study in Japan

We conducted a cohort study of alcohol consumption and total cancer incidence and mortality in 73,281 subjects (35,007 men and 38,274 women) aged 40-59 years old at baseline over a 10-year follow-up period. During 1990-2001, a total of 3403 cases of newly diagnosed cancer and 1208 cancer deaths were identified. In men, the lowest risk of developing cancer was observed among occasional drinkers, and a linear positive association with increased ethanol intake was noted (hazard ratio 1.18 for 1-149 g per week, 1.17 for 150-299 g per week, 1.43 for 300-449 g per week, 1.61 for > or = 450 g per week, P for trend < 0.001). The positive relation was similar for cancer incidence and mortality, but was more striking among current smokers and alcohol-related cancers. Relatively few women were regular drinkers. Our results suggest that increased ethanol intake linearly elevates the risk of cancer, and that nearly 13% of cancers among males in this study were due to heavy drinking (> or = 300 g per week of ethanol), to which smoking substantially contributed. The simultaneous reduction of smoking is therefore important for reducing the effect of alcohol on cancer risk.

Influence of alcohol consumption on restenosis rate after percutaneous transluminal coronary angioplasty and stent implantation

OBJECTIVE

To disclose possible influences of alcoholic beverages on restenosis rate in men with coronary artery disease treated with percutaneous transluminal coronary angioplasty (PTCA) and stent implantation.

DESIGN

Retrospective cohort study.

PATIENTS

225 consecutive male patients underwent PTCA and stent implantation. All patients had a control angiography and were contacted for a questionnaire regarding their drinking habits.

MAIN OUTCOME MEASURES

Mean late loss of luminal diameter, rate of coronary restenosis of 50% or more within the stented segment, and rate of repeat angioplasty.

RESULTS

53 patients (with 80 stents) consumed < 50 g of alcohol a week and 172 (with 266 stents) consumed more (50-700 g a week). Baseline characteristics were similar in both groups except for a higher prevalence of reduced cardiac function and multivessel disease and a lower high density lipoprotein cholesterol concentration among patients who consumed little or no alcohol. Patients who consumed > or = 50 g alcohol a week had a lower mean late loss of the luminal diameter (1.1 (0.79) mm v 1.45 (0.82) mm, p = 0.002), a lower rate of coronary restenosis within the stented segment (33.7% v 48.8%, p = 0.001), and a lower rate of repeat angioplasty (23.3% v 42.5%, p = 0.002). In multivariate analysis, only alcohol consumption and diabetes were independent and significant discriminators for late loss of luminal diameter (p = 0.005 and p = 0.01, respectively), restenosis (odds ratio 0.54 and 2.08, respectively), and repeat angioplasty (odds ratio 0.39 and 2.18, respectively).

CONCLUSION

Alcohol intake is associated with reduced restenosis after PTCA and stent implantation.

Epidemiologic evidence for the cardioprotective effects associated with consumption of alcoholic beverages

The impact of alcohol intake on mortality from all causes has been described in a large number of prospective population studies from many countries. Most have shown a J-shaped relation between alcohol intake and subsequent mortality, indicating that there are both beneficial and harmful effects of ethanol on health. The risk of death from ischemic heart disease is seen to be significantly increased, and highest among abstainers, but not significantly increased among heavy drinkers. Some studies have found plausible mechanisms for the beneficial effect of light to moderate drinking. Subjects with a moderate alcohol intake have a higher level of high density lipoprotein than abstainers. Further, moderate drinkers are seen to have a lower low density lipoprotein. Also, alcohol has a beneficial effect on platelet aggregation, and thrombin level in blood is higher among drinkers than among non-drinkers. In the other end of the range of intake, the ascending leg of the U-shaped curve has been explained by the increased risk of cirrhosis, pancreatitis, and development oropharynx, oesophagus, and breast cancer. In exploring the French paradox, it has been suggested that wine may have beneficial effects additional to that of ethanol. Recently, several prospective population studies have supported this idea. It is, however, also likely that the apparent additional beneficial effect of wine on health in addition to the effect of ethanol itself is a consequence of confounding.

Alcohol Consumption and Mortality in Japan: The Miyagi Cohort Study

BACKGROUND: We examined the association between alcohol consumption and all-cause mortality in Japanese men and women.

METHODS: From June through August 1990, a total of 39,076 subjects (20,660 men and 18,416 women) in 14 municipalities of Miyagi Prefecture in rural northern Japan (40-64 years of age) completed a self-administered questionnaire that included information about alcohol consumption and various health habits. During 11 years of follow-up, we identified 1,879 deaths (1,335 men and 544 women). We used Cox proportional-hazards regression to estimate relative risk (RR) of all-cause mortality according to categories of alcohol consumption and to adjust for age, education, marital status, past histories of chronic diseases, body mass index, smoking, walking and dietary variables.

RESULTS: Among men, the risk for all-cause mortality was significantly higher in past drinkers than never-drinkers (multivariate RR, 1.86; 95% confidence interval [CI], 1.50-2.29). There was a dose-response association between alcohol consumption and the risk of all-cause mortality among current drinking men: multivariate RRs in reference to never-drinkers (95% CI) were 1.10 (0.90-1.33), 1.17 (0.96-1.42), 1.16 (0.96-1.40), and 1.62 (1.32-1.99) in current drinkers who consumed less than 22.8 g, 22.8-45.5 g, 45.6-68.3 g, and 68.4 g or more alcohol per day, respectively (P for trend<0.001). Similar association was observed among women (P for trend=0.005).

CONCLUSIONS: The results indicated that alcohol consumption tended to be associated with linear increase in risk of all-cause mortality among Japanese men and women, and the association was remarkable for younger men.

Occupational exposure to electromagnetic fields and acute leukaemia: analysis of a case-control study

AIMS

To investigate whether the risk of acute leukaemia among adults is associated with occupational exposure to electromagnetic fields.

METHODS

Probable occupational exposure to electromagnetic fields at higher than typical residential levels was investigated among 764 patients diagnosed with acute leukaemia during 1991-96 and 1510 sex and age matched controls. A job exposure matrix was applied to the self reported employment histories to determine whether or not a subject was exposed to electromagnetic fields. Risks were assessed using conditional logistic regression for a matched analysis.

RESULTS

Study subjects considered probably ever exposed to electromagnetic fields at work were not at increased risk of acute leukaemia compared to those considered never exposed. Generally, no associations were observed on stratification by sex, leukaemia subtype, number of years since exposure stopped, or occupation; there was no evidence of a dose-response effect using increasing number of years exposed. However, relative to women considered never exposed, a significant excess of acute lymphoblastic leukaemia was observed among women probably exposed to electromagnetic fields at work that remained increased irrespective of time prior to diagnosis or job ever held.

CONCLUSION

This large population based case-control study found little evidence to support an association between occupational exposure to electromagnetic fields and acute leukaemia. While an excess of acute lymphoblastic leukaemia among women was observed, it is unlikely that occupational exposure to electromagnetic fields was responsible, given that increased risks remained during periods when exposure above background levels was improbable.

Alcohol consumption and risk of stroke: a meta-analysis

CONTEXT

Observational studies suggest that heavy alcohol consumption may increase the risk of stroke while moderate consumption may decrease the risk.

OBJECTIVE

To examine the association between alcohol consumption and relative risk of stroke.

DATA SOURCES

Studies published in English-language journals were retrieved by searching MEDLINE (1966-April 2002) using Medical Subject Headings alcohol drinking, ethanol, cerebrovascular accident, cerebrovascular disorders, and intracranial embolism and thrombosis and the key word stroke; Dissertation Abstracts Online using the keywords stroke and alcohol; and bibliographies of retrieved articles.

STUDY SELECTION

From 122 relevant retrieved reports, 35 observational studies (cohort or case control) in which total stroke, ischemic stroke, or hemorrhagic (intracerebral or total) stroke was an end point; the relative risk or relative odds and their variance (or data to calculate them) of stroke associated with alcohol consumption were reported; alcohol consumption was quantified; and abstainers served as the reference group.

DATA EXTRACTION

Information on study design, participant characteristics, level of alcohol consumption, stroke outcome, control for potential confounding factors, and risk estimates was abstracted independently by 3 investigators using a standardized protocol.

DATA SYNTHESIS

A random-effects model and meta-regression analysis were used to pool data from individual studies. Compared with abstainers, consumption of more than 60 g of alcohol per day was associated with an increased relative risk of total stroke, 1.64 (95% confidence interval [CI], 1.39-1.93); ischemic stroke, 1.69 (95% CI, 1.34-2.15); and hemorrhagic stroke, 2.18 (95% CI, 1.48-3.20), while consumption of less than 12 g/d was associated with a reduced relative risk of total stroke, 0.83 (95%, CI, 0.75-0.91) and ischemic stroke, 0.80 (95% CI, 0.67-0.96), and consumption of 12 to 24 g/d was associated with a reduced relative risk of ischemic stroke, 0.72 (95%, CI, 0.57-0.91). The meta-regression analysis revealed a significant nonlinear relationship between alcohol consumption and total and ischemic stroke and a linear relationship between alcohol consumption and hemorrhagic stroke.

CONCLUSIONS

These results indicate that heavy alcohol consumption increases the relative risk of stroke while light or moderate alcohol consumption may be protective against total and ischemic stroke.

Lower risk for alcohol-induced cirrhosis in wine drinkers

Although there is a well-known relationship between total alcohol intake and future risk for cirrhosis, other factors such as the type of alcohol consumed are sparsely studied. The aim of this study was to assess the effects of wine compared with other types of alcoholic beverages on risk for alcohol-induced cirrhosis. In 3 prospective studies, 30,630 participants from the Copenhagen area were followed-up for a total observation time of 417,325 person-years. Information on weekly intake of beer, wine, and spirits, and sex, age, body mass index, smoking habits, and education was obtained from questionnaires. The primary outcome measures were first admission or death, with alcohol-induced cirrhosis obtained from death certificates and from the National Hospital Discharge Register. Data were analyzed by means of multiplicative Poisson regression models. We confirmed the increasing risk for cirrhosis with increasing alcohol intake. Individuals who drank more than 5 drinks per day had a relative risk of 14 to 20 for developing cirrhosis compared with non- or light drinkers. However, compared with individuals who drank no wine (relative risk set at 1.0), individuals drinking 16% to 30% wine of their total intake had a relative risk of 0.4 (95% confidence limits, 0.3-0.6) and those drinking 51% or more of wine had a relative risk of 0.3 (95% confidence limits, 0.2-0.5) for developing cirrhosis. In conclusion, the results suggest that a high intake of all 3 types of alcohol conveys an increased risk for cirrhosis, but wine drinkers are at a lower risk than beer and spirits drinkers.

Life-style and serum lipids and lipoproteins

In reviewing the trends and influences of life-style in this country on health and disease in the latter half of 20th century, we focused our attention on 4 major habits of smoking, drinking, exercise and diets, and collected data on the Japanese to conduct a meta-analysis of their relationship with serum lipids and lipoproteins, which are the metabolic risk factors most closely related to atherosclerosis. 1) The percentage of smokers was 54.0% in adult males and 14.5% in adult females in 1999. In the data of 7,256 subjects (mean age 47 years) in 16 papers, smoking increased triglycerides by 13 mg/dl (0.15 mmol/L) or in 559 non-drinkers with a mean age of 49 years in 3 papers by 18 mg/dl (0.20 mmol/L), and decreased HDL-cholesterol by 3.5 mg/dl (0.09 mmol/L) with every 20 cigarettes smoked according to the regression equation. 2) As for drinking, the annual ethanol consumption per adult was 8.5L in 1996. The effects of alcohol on serum lipids were analyzed in 27,035 males (mean age 47 years) in 24 studies. Drinking elevated triglycerides by a mean of 10 mg/dl (0.11 mmol/L), and also HDL-cholesterol by 2.5 mg/dl (0.06 mmol/L) per 23 g of alcohol intake (corresponding to 1 go of sake or 1 large bottle of beer). 3) Concerning exercise habit, 25% of males and 21% of females (mean age 47 years) regularly performed exercise such as jogging, swimming, aerobics, and tennis. However, walking was regarded as an easy exercise to be practiced by subjects of all ages. The effects of walking on serum lipids were studied in a total of 46,074 subjects (mean age 47 years) in 8 populations. Triglycerides were significantly lower by 10 mg/dl (0.11 mol/L), and HDL-cholesterol higher by 3 mg/dl (0.08 mmol/L) in those who walked 6,000 or more steps/day than in those who walked less than 2,000 steps/day. The effects of harder exercise like jogging or swimming were analyzed in 2,242 subjects in 14 papers (mean age 44 years). Triglycerides decreased by 10 mg/dl (0.11 mmol/L), and HDL-cholesterol elevated by 5 mg/dl (0.13 mmol/L) with an increase in the exercise intensity by one level of about 300 kcal. In exercise therapy, triglycerides were decreased by a mean of 20 mg/dl (0.23 mmol/L), and HDL cholesterol increased by a mean of 10 mg/dl (0.26 mmol/L) by exercise at a mean heart rate of about 135 bpm, which is equivalent to 50% VO2max for 30 minutes x 3 times/week. 4) In nutritional trends, the mean energy intake in 52 postwar years averaged 2,116+/-84 kcal with no marked changes according to nutritional surveys. However, the percentage of fat in total energy intake was lowest at 7% in 1946, increased thereafter until it exceeded 20% in 1973, and surpassed 25% in 1988. The mean total cholesterol level of the Japanese increased by 28 mg/dl (0.72 mmol/L) in the past 30 years and reached 204 mg/dl (5.28 mmol/L) in a survey in 1990. 5) Concerning dietary habits, total cholesterol was lower by a mean of 13 mg/dl (0.34 mmol/L), triglycerides lower by 40 mg/dl (0.45 mmol/L), and HDL-cholesterol higher by 5 mg/dl (0.13 mmol/L) in the group who ate 7 or more Japanese-style meals in the 9 meals during 3 days than in the group who ate 3 or less Japanese-style meals in the 9 meals. When serum lipids were compared among individuals living in cities (8 groups; 3,613 subjects; mean age 51 years), agricultural villages (13 groups; 5,364 subjects; mean age 51 years), and fishing villages (9 groups; 1,071 subjects; mean age 52 years). Total cholesterol was lower by a mean of 10 mg/dl (0.26 mmol/L) in fishing villages than in cities, and triglycerides lower by a mean of 15 mg/dl (0.17 mmol/L) in fishing villages than in cities and agricultural villages. HDL-cholesterol was 5 mg/dl (0.13 mmol/L) higher in agricultural villages and 3 mg/dl (0.08 mmol/L) higher in fishing villages than in cities. 6) The effects of dietary therapy or guidance were evaluated in 585 subjects (mean age, 53 years) in 12 papers. Total cholesterol was reduced by 20 mg/dl (0.52 mmol/L), triglycerides by a mean of 40 mg/dl (0.45 mmol/L), and HDL-cholesterol was increased by 5 mg/dl (0.13 mmol/L) by restriction of fat intake or restriction of the intake of saturated fat and dietary cholesterol. The results of these meta-analyses are considered to indicate the extent to which abnormalities of serum lipids are caused by a distorted life-style and the extent to which they are improved by correction of the life-style and exercise or dietary therapy. Correction of the life-style as a non-drug therapy may clearly improve hyperlipidemias or hypo-HDL-cholesterolemia so that this approach should be aggressively employed as part of the prevention and treatment for hyperlipidemias.

Factors influencing the relation between alcohol and mortality--with focus on wine

The impact of alcohol intake on mortality has been described in a large number of prospective population studies from many countries. Most have shown a J-shaped relation between alcohol intake and subsequent mortality, indicating that there are both beneficial and harmful effects of ethanol on health. In exploring the French paradox, it has been suggested that wine may have beneficial effects additional to that of ethanol. Recently, several prospective population studies have supported this idea. However, it is also likely that the apparent additional beneficial effect of wine on health is confounding.

High prevalence of hyperhomocysteinemia in chronic alcoholism: the importance of the thermolabile form of the enzyme methylenetetrahydrofolate reductase (MTHFR)

Alcoholism is related to malnutrition and low levels of several vitamins that take part in the metabolism of homocysteine. The objective of the study was to analyze the prevalence of hyperhomocysteinemia in patients with heavy alcohol intake and the factors on which it depends. Included in the study were 103 hospitalized heavy drinkers (i.e., patients with an intake of alcohol greater than 80 g per day). Serum homocysteine, folate, and vitamin B(12) levels, plasma vitamin B(6) levels, and CT677 polymorphisms of methylenetetrahydrofolate reductase (MTHFR) were determined. We also recorded the intensity of alcoholism, the status of nutrition, and the existence of liver cirrhosis. Determination of biochemical data was repeated after 15 days of withdrawal. Serum homocysteine levels were found to be significantly elevated, whereas serum folate and plasma B(6) levels were significantly decreased. Serum homocysteine levels were significantly higher in those heavy drinkers who showed the TT polymorphism of MTHFR, with a prevalence of hyperhomocysteinemia of 84.2% in the homozygote TT, 54.3% in the heterozygote CT, and 31.6% in the normal CC genotype. Serum homocysteine inversely correlated with serum folate, serum B(12), and plasma B(6) levels. We did not find any relation between serum homocysteine and intensity of alcoholism, nutritional status, or liver cirrhosis. Serum folate levels were significantly decreased in heavy drinkers, mainly depending on irregular feeding and malnutrition. After 15 days of withdrawal, serum homocysteine levels significantly decreased, whereas folate, B(12), and B(6) levels significantly increased. The conclusion is that heavy drinkers show a high prevalence of hyperhomocysteinemia related to low levels of folate, B(6), and B(12) and to the TT polymorphism of MTHFR.

A longitudinal study of drinking and cognitive performance in elderly Japanese American men: the Honolulu-Asia Aging Study

OBJECTIVES

This study prospectively describes the relationships between alcohol intake and subsequent cognitive performance among participants in the Honolulu Heart Program (HHP).

METHODS

Alcohol intake was assessed at Exam III of the HHP, and cognitive performance was measured approximately 18 years later with the Cognitive Abilities Screening Instrument (CASI). Complete information was available for 3556 participants, aged 71 to 93 years at follow-up.

RESULTS

In multivariate analyses, the relationship between drinking and later cognitive performance appeared nonlinear, as nondrinkers and heavy drinkers (more than 60 ounces of alcohol per month) had the lowest CASI scores and the highest risks of poor and intermediate CASI outcomes. Compared with nondrinkers, the risk of a poor CASI score was lowered by 22% to 40% among men who consumed 1-60 ounces of alcohol per month.

CONCLUSIONS

We report a positive association between moderate alcohol intake among middle-aged men and subsequent cognitive performance in later life. However, it is possible that the health risks associated with drinking outweight any potential benefits for many elderly persons.

Health-associated changes in drinking: a period prevalence study of the Atherosclerosis Risk In Communities (ARIC) cohort (1987-1995)

BACKGROUND

Several investigators have suggested that drinking cessation occurs because of poor health which may bias studies on the benefit or risk of alcohol consumption.

METHODS

Drinking status, level of alcohol consumption, and two measures of health (perceived health and physician diagnosed chronic disease status) were determined from exams 1 (1987-1989) and 3 (1993-1995) on 12,562 African- and European-American participants, who were aged 45-64 years at exam 1 in the ARIC Study. For those in good health at exam 1, logistic regression analyses were used to model the association between health decline and drinking change at exam 3.

RESULTS

Among the total population, drinking cessation was significantly more common among those who reported poor health at exam 3, and nondrinkers were unlikely to begin drinking regardless of exam 3 health. Using different measures of health status resulted in associations whose strength and significance varied with ethnicity and, in some cases, by gender.

CONCLUSION

While the current data do not prove that the health decline occurred prior to drinking cessation, our findings support the hypothesis that poor health results in drinking changes which could potentially bias studies of alcohol's benefit and risk even when lifetime abstainers are used as the reference group.

The health effects of moderate alcohol intake in humans: an epidemiologic review

A large body of scientific evidence associates the moderate intake of alcohol with reduced mortality among middle-aged and older people in industrialized societies. This association is due largely to a reduced risk of death from coronary heart disease, which appears to outweigh any possible adverse effects of moderate drinking. The regular consumption of small amounts of alcohol is more healthful than the sporadic consumption of larger amounts. No beneficial effect of moderate drinking on mortality has been demonstrated in young adults (premenopausal women and men who have not reached their forties). It is theoretically possible that moderate drinking in young adulthood might reduce the risk of later heart disease; however, this has not been clearly demonstrated. For some individuals (e.g., those who cannot keep their drinking moderate, pregnant women, and those who are taking medications that may interact adversely with alcoholic beverages), the risks of alcohol consumption, even in moderation, outweigh any potential benefits. Because even small amounts of alcohol can impair judgment and coordination, no one should drink alcoholic beverages, even in moderation, before driving a motor vehicle or performing other activities that involve attention and skill.

Tobacco and the risk of acute leukaemia in adults

Self-reported smoking histories were collected during face-to-face interviews with 807 patients with acute leukaemia and 1593 age- and sex-matched controls. Individuals who had smoked regularly at some time during their lives were more likely to develop acute leukaemia than those who had never smoked (odds ratio (OR) = 1.2, 95% confidence interval (CI) 1.0-1.4). The association was strongest for current smokers, defined here as smoking 2 years before diagnosis (OR = 1.4, 95% CI 1.1-1.7). With respect to the numbers of years smoked, risk estimates were raised in all groups except those who had smoked for fewer than 10 years. Similarly, the odds ratio decreased as the number of years 'stopped smoking' increased, falling to one amongst those who had given up smoking for more than 10 years. No significant linear trends were found, however, with either the numbers of years smoked or the numbers of years stopped smoking, and no significant differences were found between AML and ALL.

Screening for alcohol problems in primary care

Alcohol problems are common among patients seen in primary care settings, yet they are often missed by physicians. This article offers a model for alcohol screening designed to facilitate early identification of alcohol problems. This approach emphasizes the heterogeneity of alcohol problems and looks at alcohol use along a spectrum, with different risks depending on where in the spectrum a patient falls. The authors provide practical suggestions on integrating alcohol screening and early intervention into routine care.

Health care spending as determinants of health outcomes

This paper revisits the relationship between health care spending and health outcomes. While previous researchers found it difficult to establish such a relationship based on international comparisons, the results based on rather homogenous province-specific Canadian data show that lower health care spending is associated with a statistically significant increase in infant mortality and a decrease in life expectancy in Canada. This relationship is independent of various economic, socio-demographic, nutritional and lifestyle factors, as well as provincial specificity or time trend. It is based on annual data collected from the ten Canadian provinces over 15 years.

Wine, beer and spirits and the risk of myocardial infarction: a systematic review

BACKGROUND

Alcohol has beneficial and harmful effects on health at the same time. Wine may be more beneficial for the heart than other types of alcoholic beverages.

OBJECTIVES

1. To assess the current status of knowledge regarding the relationship between death and alcohol consumption. 2. To assess the relationship between myocardial infarction (MI) and consumption of different types of alcoholic beverages, both low doses (1-4 drinks a day), and high doses (> 4 drinks a day).

METHODS

Meta-analysis of major cohort and case-control studies. For the assessment of death and alcohol consumption eight cohort studies were used; for the assessment of MI and different types of alcoholic beverages, 12 cohort and two case-control studies were used.

RESULTS AND CONCLUSIONS

1. Small doses of alcohol (1-4 drinks a day) are associated with a slightly reduced risk of mortality and coronary heart disease (CHD). 2. Small doses (1-4 drinks a day) of wine, beer, and spirits are equally beneficial. 3. Apart from a direct beneficial effect of low doses of alcohol on mortality and CHD, some psychological factors may contribute to its beneficial effect. 4. High doses of alcohol (> or = 5 drinks a day) are not associated with a reduced risk of death and CHD. 5. Apart from a direct effect of alcohol, confounding factors, particularly those of a psychological nature, may very well again contribute to the loss of benefits.

Inhibition of advanced glycation endproduct formation by acetaldehyde: role in the cardioprotective effect of ethanol

Epidemiological studies suggest that there is a beneficial effect of moderate ethanol consumption on the incidence of cardiovascular disease. Ethanol is metabolized to acetaldehyde, a two-carbon carbonyl compound that can react with nucleophiles to form covalent addition products. We have identified a biochemical modification produced by the reaction of acetaldehyde with protein-bound Amadori products. Amadori products typically arise from the nonenzymatic addition of reducing sugars (such as glucose) to protein amino groups and are the precursors to irreversibly bound, crosslinking moieties called advanced glycation endproducts, or AGEs. AGEs accumulate over time on plasma lipoproteins and vascular wall components and play an important role in the development of diabetes- and age-related cardiovascular disease. The attachment of acetaldehyde to a model Amadori product produces a chemically stabilized complex that cannot rearrange and progress to AGE formation. We tested the role of this reaction in preventing AGE formation in vivo by administering ethanol to diabetic rats, which normally exhibit increased AGE formation and high circulating levels of the hemoglobin Amadori product, HbA1c, and the hemoglobin AGE product, Hb-AGE. In this model study, diabetic rats fed an ethanol diet for 4 weeks showed a 52% decrease in Hb-AGE when compared with diabetic controls (P < 0.001). Circulating levels of HbA1c were unaffected by ethanol, pointing to the specificity of the acetaldehyde reaction for the post-Amadori, advanced glycation process. These data suggest a possible mechanism for the so-called "French paradox," (the cardioprotection conferred by moderate ethanol ingestion) and may offer new strategies for inhibiting advanced glycation.

Alcohol and all-cause mortality: an overview

The relationship between alcohol consumption and all-cause mortality is J-shaped in most industrialized countries. The J-shape is the result of the combination of adverse and beneficial effects of alcohol consumption. Adverse effects include several types of cancer (oropharyngeal, oesophageal, liver, laryngeal and breast cancer), other diseases of the aerodigestive tract, diseases of the heart (alcoholic cardiomyopathy, haemorrhagic stroke, arrhythmia, hypertension), addiction-related mental disorders, and accidents and injuries. Beneficial effects are for ischaemic heart disease and ischaemic stroke. The exact shape of the all-cause mortality curve in a given region depends upon the proportion of the population consuming alcohol at different levels, especially heavy consumption, and on the prevalence of the disorders named above. Thus regions with a relatively low prevalence of ischaemic cardiovascular disease show almost no benefits of consumption, and an all-cause mortality curve which is almost exponential. Females experience a minimum mortality risk at a level of alcohol intake which is lower than that associated with the minimum risk for men. Similarly, an upturn in mortality risk occurs at lower intake levels for women than for men. At present, there is no satisfactory explanation for the observation that the shape of the mortality curve varies with the consumption level of the cohort under study. Heavier-drinking cohorts tend to display their minimum risk at relatively higher levels of alcohol intake than cohorts with lower alcohol consumption.

Fatal poisoning with alcohol and drugs in the Greater Amman County

A study of fatal poisoning due to alcohol and drugs was carried out, to examine the mortality resulting from alcohol and drugs in the Greater Amman County, Jordan. A retrospective review of all autopsy records and certified deaths issued by the Department of Forensic Medicine at Jordan University Hospital in the greater Amman county was undertaken. During the 18 years (1978-1996) 6109 postmortem cases were performed in our department. A total of 60 cases were identified and analyzed according to age, race, sex, manner of death of the victims along with blood alcohol concentration, the drug detected at autopsies, the scene circumstances, and the geographic location of the accident and death.

Type of alcoholic beverage and risk of myocardial infarction

We examined the relation of alcoholic beverage type and risk of myocardial infarction (MI) in a case-control study among 340 cases of MI and an equal number of age-, sex-, and community-matched controls. Alcohol consumption was estimated using a food frequency questionnaire, with alcohol drinkers defined as those consuming > or = 1/2 drink/day on average of any alcoholic beverage. Beer, wine, and liquor drinkers had at least half of their consumption from 1 beverage type. Fasting venous blood samples were obtained and analyzed for lipid profiles. Compared with nondrinkers, after adjustment for age and sex, reductions in risk of MI were similar for regular drinkers of any type of alcoholic beverage (relative risk [RR] 0.54; 95% confidence interval [CI] 0.37 to 0.79; p = 0.001), beer (RR 0.55; 95% CI 0.31 to 0.97; p <0.05), wine (RR 0.48; 95% CI 0.27 to 0.87; p <0.05), and liquor (RR 0.59; 95% CI 0.38 to 0.91; p <0.05) drinkers. Comparable benefits remained apparent even after multivariate adjustment for a wide range of nonlipid coronary risk factors. High-density lipoprotein (HDL) levels were significantly higher in all 4 beverage categories when compared with levels in nondrinkers, and as expected, adjustment for total HDL, a major direct effect of alcohol, substantially attenuated the protective effect in all 4 beverage categories. Relative risks were 0.94 for any beverage, 1.09 for beer, 0.97 for wine, and 0.83 for liquor after further adjustment. This strongly suggests that the protective effect of each beverage type is, in large part, mediated by increased HDL. These data indicate that regular consumption of small to moderate amounts of alcoholic beverages, regardless of the type, reduces the risk of MI, and further suggest that there is benefit, in large part, from increases in HDL levels.

Alcohol and lipids

Alcoholic fatty liver and hyperlipemia result from the interaction of ethanol and its oxidation products with hepatic lipid metabolism. An early target of ethanol toxicity is mitochondrial fatty acid oxidation. Acetaldehyde and reactive oxygen species have been incriminated in the pathogenesis of the mitochondrial injury. Microsomal changes offset deleterious accumulation of fatty acids, leading to enhanced formation of triacylglycerols, which are partly secreted into the plasma and partly accumulate in the liver. However, this compensatory mechanism fades with progression of the liver injury, whereas the production of toxic metabolites increases, exacerbating the lesions and promoting fibrogenesis. The early presence of these changes confers to the fatty liver a worse prognosis than previously thought. Alcoholic hyperlipemia results primarily from increased hepatic secretion of very-low-density lipoprotein and secondarily from impairment in the removal of triacylglycerol-rich lipoproteins from the plasma. Hyperlipemia tends to disappear because of enhanced lipolytic activity and aggravation of the liver injury. With moderate alcohol consumption, the increase in high-density lipoprotein becomes the predominant feature. Its mechanism is multifactorial (increased hepatic secretion and increased extrahepatic formation as well as decreased removal) and explains part of the enhanced cholesterol transport from tissues to bile. These changes contribute to, but do not fully account for, the effects on atherosclerosis and/or coronary heart disease attributed to moderate drinking.

[Wine and heart]

Many epidemiological studies have shown that moderate alcohol intake, from 10 to 30 g of ethanol a day, decreases cardiovascular mortality from atherosclerotic ischaemic heart disease and ischaemic stroke as compared to non-drinkers. This beneficial effect outweighs the risks of alcohol consumption in subgroups of people with a higher risk of atherosclerosis: the elderly, people with coronary risk factors and patients with previous coronary events. It has not been demonstrated that alcohol intake, even in moderate amounts, is beneficial for the general population, in particular, men under the age of 40 and women under 50, because it raises mortality due to other causes, especially injury, cirrhosis of the liver and some types of cancer, thereby outweighing the benefits for coronary artery disease. Thus, alcohol consumption should not be recommended as a prophylaxis for the general population. Guidelines on alcohol drinking habits--whether to continue, to start, to modify or to stop--must be given on an individual basis, taking into account the relative risks and benefits for each patient. The benefits of moderate alcohol consumption on the cardiovascular system seem to be exerted fundamentally through its effects on plasma lipoproteins, principally by raising high density lipoprotein (HDL) cholesterol and to a lesser degree, by decreasing low density lipoprotein (LDL) cholesterol. It appears to exert additional beneficial effects on the heart by decreasing platelet aggregability and by bringing about changes in the clotting-fibrinolysis system. Although there has been some debate about the relative superiority of different types of alcoholic beverages (wine, beer or hard liquor), and to a greater extent, about different types of wine, there is no current evidence of any kind of beneficial effect from other components of the beverage besides ethanol. Thus, it does not seem appropriate to recommend any particular type of alcoholic drink, except for sociocultural reasons. The added benefits from some components of different types of wine with a high antioxidant activity on plasma lipoproteins remain only an interesting hypothesis. Meanwhile, encouraging a healthy diet, flavonoid rich and with a predominance of natural ingredients (fruit, legumes, cereals and seeds), in the general population should stop the current tendency of Southern European countries from abandoning the Mediterranean diet. Because of the multifactorial nature of coronary heart disease, it is necessary to remember that atherosclerotic risk reduction is achieved by behavior modification of multiple risk factors present in individual patients and in the general population. Therefore, guidelines regarding alcohol intake should always be linked to pertinent recommendations about other atherosclerotic risk factors.

Independent and combined action of hepatitis C virus infection and alcohol consumption on the risk of symptomatic liver cirrhosis

Although alcohol intake and hepatitis C virus (HCV) infection are the major determinants of liver cirrhosis (LC) in Western countries, the joint effect of these two factors on LC risk has not yet been adequately studied. We used data from two hospital-based case-control studies performed in Italy. Cases were 285 cirrhotic patients admitted for the first time to district hospitals for liver decompensation. Controls were 417 patients admitted during the same period, and in the same hospitals as the cases, for acute diseases unrelated to alcohol. Alcohol consumption was expressed as lifetime daily alcohol intake (LDAI). Serum HCV antibodies (anti-HCV) were detected using a second-generation test and recombinant immunoblotting assay. We found a dose-effect relationship between LDAI and the risk of LC in both anti-HCV-negative and -positive subjects. Considering the extreme LDAI categories (LDAI = 0 g, lifetime teetotalers, and LDAI = 175 g), the LC odds ratios increased from 1.0 (reference category) to 15.0 (95% CI, 7.1-31.7) and from 9.2 (95% CI, 2.0-43.2) to 147.2 (95% CI, 42.1-514.3) in anti-HCV-negative and -positive patients respectively. The interaction between LDAI and HCV showed an additive structure for LDAI < 50 g/day and a multiplicative structure for consumption > 125 g/day. Alcohol intake and HCV infection are independent risk factors for symptomatic liver cirrhosis, each being sufficient to induce the disease. In subjects with high alcohol intake, the coexistence of HCV infection multiplies the alcohol-associated risk of cirrhosis. In subjects with low alcohol intake, other factors could be involved.

Alcohol consumption and mortality among middle-aged and elderly U.S. adults

BACKGROUND

Alcohol consumption has both adverse and beneficial effects on survival. We examined the balance of these in a large prospective study of mortality among U.S. adults.

METHODS

Of 490,000 men and women (mean age, 56 years; range, 30 to 104) who reported their alcohol and tobacco use in 1982, 46,000 died during nine years of follow-up. We compared cause-specific and rates of death from all causes across categories of base-line alcohol consumption, adjusting for other risk factors, and related drinking and smoking habits to the cumulative probability of dying between the ages of 35 and 69 years.

RESULTS

Causes of death associated with drinking were cirrhosis and alcoholism; cancers of the mouth, esophagus, pharynx, larynx, and liver combined; breast cancer in women; and injuries and other external causes in men. The mortality from breast cancer was 30 percent higher among women reporting at least one drink daily than among nondrinkers (relative risk, 1.3; 95 percent confidence interval, 1.1 to 1.6). The rates of death from all cardiovascular diseases were 30 to 40 percent lower among men (relative risk, 0.7; 95 percent confidence interval, 0.7 to 0.8) and women (relative risk, 0.6; 95 percent confidence interval, 0.6 to 0.7) reporting at least one drink daily than among nondrinkers, with little relation to the level of consumption. The overall death rates were lowest among men and women reporting about one drink daily. Mortality from all causes increased with heavier drinking, particularly among adults under age 60 with lower risk of cardiovascular disease. Alcohol consumption was associated with a small reduction in the overall risk of death in middle age (ages 35 to 69), whereas smoking approximately doubled this risk.

CONCLUSIONS

In this middle-aged and elderly population, moderate alcohol consumption slightly reduced overall mortality. The benefit depended in part on age and background cardiovascular risk and was far smaller than the large increase in risk produced by tobacco.

Health and gender differences between middle and senior managers in the Canadian Public Service

Most studies of the relationship between socioeconomic status (SES) and health have concentrated on disparities between the richest and poorest men; few studies have examined such relationships for women due to difficulties in measuring SES for women. For the present study, data collected from Canadian Public Service middle and senior managers provided an opportunity to examine associations between SES and health within the upper end of the SES spectrum for both genders, since women managers can be assumed to have a relatively high SES. Demographic, health and lifestyle characteristics are compared for middle and senior managers for each gender separately to determine whether women experience the health benefits associated with higher SES that have been previously observed for men. The results support the hypothesis that achieving a higher SES through work is a more stressful process for women than for men and that women's upward mobility is restricted compared to that of men. Despite these findings, there is little evidence that women's health has been adversely affected. Compared to male managers, fewer female managers smoke or drink and fewer have high body mass index, high blood pressure or high cholesterol levels. Female managers are also more likely to report being in good health.

Alcohol, hypertension and the cardiovascular system: a critical appraisal

Cross-sectional and longitudinal population studies have provided a considerable corpus of evidence for an inverse association between light to moderate alcohol intake and both coronary artery disease and stroke. The formulation of balanced public health advice on the basis of such studies, however, needs to take into account the full spectrum of the effects of alcohol on the cardiovascular system, particularly its equally well documented effect to increase level of blood pressure and prevalence of hypertension. In this review, the broader implications of the association of alcohol with hypertension are discussed, principally in the context of the effect of higher levels of alcohol consumption to increase ischaemic and haemorrhagic stroke, left ventricular hypertrophy, congestive cardiomyopathy, cardiac arrhythmia and sudden cardiac death.