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ALCOHOL
ISM CLINICAL
AND EXPERIMFNI
A I RESEARCII
January 2000
Background:This study examined the effects of alcohol consumption and DSM-IV alcohol dependence
on the risk of mortality.
Methods: Data from the 1988 National Health Interview Survey Alcohol Supplement were matched to
the National Death Index for the years 1988 to 1995 (baseline n = 37,682 U.S. adults age 2 2 5 linked to
3,586 deaths). All mortality analyses were based on proportional hazards models that adjusted for age, sex,
raceiethnicity, marital status, education, income, labor force status, body mass index, smoking status, and
poor health indicators at baseline.
Results: When dependence was not considered and all past-year abstainers were used as the reference
group, both light and moderate drinkers exhibited a reduced risk of mortality, with hazards ratios of 0.76
(0.68-0.84) and 0.84 (0.74-0.96). Heavy drinkers had about the same risk of dying as did past-year
abstainers, and very heavy drinkers had an increased risk that was not significant (OR = 1.17, CI =
0.93-1.47). When lifetime abstainers were used as the reference category, the protective effect of moderate
drinking fell short of significance, and there were nearly significant increased risks among former drinkers
and vety heavy drinkers. When dependence was considered, light and moderate drinkers without dependencc had a reduced mortality risk regardless of reference group, and there was no significant effect among
heavy or very heavy drinkers without dependence. Among dependent drinkers, there was no protective
effect of light or moderate drinking, and very heavy drinkers had a significantly increased risk (OR = 1.56
relative to past-year abstainers and 1.65 relative to lifetime abstainers).
Conclusions: Because alcohol dependence nullifies the protective effect of light and moderate drinking,
it is important to understand its role as an independent risk factor for mortality. Differences between
dependent and nondependent drinkers who drank comparable amounts suggest that this risk may result
from longer and heavier drinking histories before baseline, more severe health problems at baseline, more
heavy episodic drinking, and, possibly, differences in beverage preference.
Key Words: Mortality, Consumption, Dependence, Alcoholism.
73
neck cancers, both alcoholism and a history of alcoholrelated systemic conditions were positively associated with
the risk of dying (Deleyiannis et al., 1996), and a study of
patients receiving inpatient treatment for alcohol problems
found that they were almost 10 times as likely to have died
over a 10 year follow up period as were matched community controls (Finney and Moos, 1991). In a rare study using
a representative population sample of Norwegian military
conscripts followed for 40 years, Rossow and Amundsen
(1 997) found that alcohol abusers had an excess mortality
risk of 3.3 compared to nonabusers.
No study to date has evaluated the independent effects
of both alcohol dependence and volume of ethanol intake
as predictors of all-cause mortality. Thus, the existing literature does not indicate the extent to which the increase in
mortality risk among heavy drinkers is based on the experience of dependent drinkers- drinkers whose risk of dying
may be affected by deleterious drinking patterns and comorbid mental and physical conditions that augment the
simple effects of their volume of consumption. This paper
represents an attempt to bridge these two branches of
mortality research. In this study I examined deaths over a
7.5 year follow-up period among a representative sample of
U.S. adults interviewed in 1988 as part of the US. National
Health Interview Survey, using both volume of ethanol
intake and alcohol dependence as predictors of the risk of
dying. Additionally, I controlled for a variety of preexisting
conditions that might bias estimates of the association between alcohol consumption and mortality; evaluated the
effects of using lifetime as opposed to baseline abstainers as
the reference group for the mortality estimates; examined
the effects of prior intake level among former drinkers; and
incorporated data on -episodic heavy drinking to obtain
better estimates of volume of intake than can be derived
solely from questions on usual frequency and quantity of
intake. Finally, I examined factors beyond volume of consumption that may account for any residual difference in
mortality risk between dependent and nondependent
drinkers. These include length of drinking history, consumption during period of heaviest drinking, episodic
heavy drinking, beverage preference, and degree of health
impairment at baseline.
METHODS
Sample
For this analysis, data from the 1988 National Health Interview Survey
(NHIS) were linked with death records for the period 1988 to 1995 (the
most recent year available) to examine the associations between alcohol
consumption and mortality risk. The 1988 NHIS was based on a nationally
representative sample of the household population residing in the contiguous United States. Within each sample household, a randomly chosen
adult 18 years of age or over was selected to respond a variety of supplemental questionnaires that were attached to the basic 1988 NHIS. These
included one supplement devoted to alcohol and another that obtained
smoking history. A total of 43,763 adults 18 years of age and over responded to both of these supplemental surveys, 86% of those who were
eligible.
74
Linkage with death records was performed by the National Center for
Health Statistics, based on identifiers collected at the time of the NHIS
interview, such as the respondents social security number (SSN), date of
birth, and so forth. These identifiers were combined in various ways to
produce 12 alternative criteria for selecting a possible match with a death
record, for example, (1) SSN plus first name both match, (2) SSN plus last
name both match, (3) month and year of birth and first and last names all
match, and so forth. All cases that met even 1of the 12 criteria for a match
were assigned to one of five classes, ordered by the certainty of the match.
In the first class, where there were matches on SSN, first, middle, and last
names, sex, state of birth, and month and year of birth (i.e., on all
matching data), every match was considered to be a true match, that is, an
actual death. In the fifth class, where the SSN was known but did not
match, all matches were considered to be false matches. In the intervening
three classes, a score was devised to represent the probability of a true
match. This score was a weighted function of the 12 matching criteria, with
positive weights used for criteria that were met and negative weights for
criteria that were not met. A cutoff level was then selected within each
class to maximize the proportion of records correctly classified and minimize the number of records incorrectly classified. Using two large national population surveys where longitudinal follow-up provided an indcpendent ascertainment of vital status (i.e., of whether the respondent was
dead or alive at the end of the follow-up period), this matching procedure
yielded accurate matches for 94% of female respondents and 97% of male
respondents (National Center for Health Statistics, 1997).
When the NHIS sample was matched with death records for 1988 to
1995, approximately one third of all potential matches fell below the
required cutoff and were treated as nondeaths. Cases with insufficient
linkage data were removed from the sample, leaving a total of 42,910 cases
with linked alcohol, smoking, and mortality data. These cases were reweighted to match the original 1988 NHIS poststratification estimates of
the adult population by age, sex, and race (Massey et al., 1989).
This analysis was restricted to the 37,682 cases where the respondents
were 25 years of age or older at baseline. Younger respondents, many of
whom were below the legal drinking age when originally interviewed, were
excluded from the analysis to minimize the possibility that baseline drinking habits would differ substantially from those over the follow-up period
and to facilitate comparisons with other surveys of adult samples. The
total number of deaths among the analytical sample was 3,586, or 9.5% of
all cases. This corresponds to a weighted mortality estimate of 8.3%, with
the differential reflecting the oversampling of Blacks, whose mortality
rates were higher than those of non-Blacks.
Measures
The 1988 NHIS collected detailed information on alcohol intake from
individuals who were classified as past-year drinkers. These were individuals who in screening reported having had at least 12 alcohol drinks in the
year preceding interview. Other categories of drinkers defined by the
screening questions were lifetime abstainers (drank less than 12 drinks in
their lives), lifetime infrequent drinkers (drank 12 or more drinks in their
lives but never drank 12 or more drinks in any one year), and former
drinkers (drank 12 or more drinks in at least 1 year, but not the year
preceding interview). In this analysis, lifetime abstainers were assumed to
have consumed no drinks in the year preceding interview. Lifetime infrequent drinkers and former drinkers were asked how many drinks they had
consumed in the preceding year (range = 0-11). This number was converted to an average daily ethanol intake by assuming a standard drink size
of 0.54 oz of ethanol (the mean drink size reported by this sample) and
dividing by 365.
Past-year drinkers were asked how often they usually drank (no time
reference period specified, recorded in exact number of days per week,
month, or year) and how many drinks they usually consumed on those
days. They also were asked whether they had consumed any alcohol in the
2 weeks preceding the interview and the date of their last drink. For a 2
week reference period (either the 2 weeks preceding interview or the most
recent 2 weeks in which a drink was consumed), they were asked number
DAWSON
of drinking days, usual quantity of drinks per drinking day, and usual drink
size in separate series of questions for beer, wine, and liquor. Based on
these data, usual volume of intake was ascertained in one of three ways:
(1) For individuals who provided detailed 2 week data and whose lasr
drink occurred during the 2 wceks immediately preceding the interview
(80.8% of all past-year drinkers), annual volume of ethanol intake was
calculated as the product of annualized frequency (26 times the 2 week
frequency) times quantity of drinks per drinking day times drink size in
ounces times an ethanol conversion factor of 0.045 for beer, 0.121 for
wine, and 0.409 for liquor (DISCUS, 1985; Kling, 1989; Modern Brewery
Age, 19Y2; Turner, 1990; Williams et al., 1993). These volumes were
summed across beverage type and divided by 365 to yield average daily
ethanol intake. Because interviewing was conducted continuously
throughout the year, the estimation of annual intake from a 2 week
reference period should not entail any seasonal bias.
(2) For the 1.5% of past-year drinkers who had missing data for the 2
week reference period but did provide usual frequency and quantity of
drinks (no time reference period specified), average daily ethanol intake
was estimated as the product of this annualized frequency and quantity
(assuming 0.54 oz of ethanol per drink), divided by 365.
(3) For the 17.7% of past-year drinkers who provided detailed 2 week
data but whose most recent drink was not consumed during the 2 weeks
immediately preceding the interview, multiplying the 2 week consumption
levels times 26 would have overestimated of annual frequency of drinking.
Moreover, the date of last drink was missing for more than two thirds of
these individuals. After comparing the results of various ways to estimate
annual intake volume for these drinkers, I decided to multiply their 2 week
consumption times 13 to obtain annual frequency, which was multiplied,
as in (I), by number of drinks, drink size, and the appropriate ethanol
conversion factor and then summed across beverages. In essence, these
individuals were assumed to drink half as frequently as those whose last
drink had been consumed in the 2 weeks preceding the interview. This
resulted in a volume of at least 13 drinks in the past year, which ensured
that they met the threshold of >12 drinks required to be defined as a
past-year drinker. When this approach was compared to the alternative of
constructing an estimate based on usual frequency and quantity of drinking, as in method 2, the cases were evenly divided in terms of which
approach yielded the highest volume estimate. The median value of the
ratio of the estimates yielded by these two approaches was 1.01.
Past-year drinkers also were asked the past-year frequencies of consuming 2 5 and 2 9 drinks on a single day (with the difference between the
two representing the frequency of drinking 5-8 drinks). If one of these two
frequencies was missing, it was imputed on the basis of the other nonmissing frequency. If both were missing, they were imputed on the basis of
average daily ethanol intake. Consumption on these heavy drinking days
was incorporated into an adjusted estimate of average daily ethanol intake
by replacing the unadjusted average daily intake with an intake of 3.24 oz
(6 standard drinks) on days of consuming 5 to 8 drinks and an intake of
6.48 oz (12 standard drinks) on days of consuming 2 9 drinks and then
recalculating the daily average. (If this reduced average daily intake, the
original value was retained.) This adjusted average daily ethanol intake
formed the basis for the categories of past-year consumption that were
used in this analysis:
Both current and former drinkers were asked frequency of drinking and
usual quantity of drinks consumed during their period of heaviest drinking. Again assuming a standard drink size of 0.54 oz ethanol, these
variables were multiplied together to estimate average daily ethanol intake
during the period of heaviest consumption. This intake was categorized by
using the same categories and definitions as listed previously for past-year
consumption, to describe the drinking categories of former drinkers.
Alcohol dependence was classified in accordance with the DSM-IV
criteria (American Psychiatric Association, 1994) and was measured using
a set of 17 symptom item indicators taken from a larger list of 41
alcohol-related problems. (Although the list of indicators was designed
before the publication of the DSM-IV criteria, it contained items that
were sufficient to generate DSM-IV diagnoses.) To be classified with
alcohol dependence, an individual had to meet three or more of the seven
75
Table 1. Number and Characteristicsof Adults Age 25 and Older, By Drinking Status at Baseline
Number of
cases at
baseline
Total
Past-year abstainers
Lifetime abstainers
Lifetime infrequent drinkers
Former drinkersa
Light/moderateb
Heavyhery heavyb
Past-year drinkers
Lightd
Moderated
Heavy*
Very heavyd
37,682
19,102
7,148
4,579
7,375
4,999
1,335
18,580
9,557
6,422
1,402
1,086
Distribution
of cases at
baseline
100.0 (0.0)
49.5 (0.4)
17.8 (0.3)
11.8 (0.2)
19.9 (0.3)
15.5 (0.2)
4.4 (0.1)
50.5 (0.4)
26.0 (0.3)
17.6 (0.3)
3.9 (0.1)
3.0 (0.1)
% With
alcohol
% Dying
dependence in
in follow-
year preceding
baseline
interval
4.6 (0.1)
0.0 (0.0)
0.0 (0.0)
0.0 (0.0)
0.0 (0.0)
0.0 (0.0)
0.0 (0.0)
9.1 (0.3)
2.4 (0.2)
10.2 (0.4)
24.4 (1.4)
42.4 (1.6)
8.3 (0.2)
11.3 (0.2)
11.5 (0.4)
9.4 (0.5)
12.2 (0.4)
10.7 (0.5)
13.5 (1.0)
5.5 (0.2)
4.8 (0.2)
5.3 (0.3)
6.3 (0.7)
10.0 (1.O)
UP
~~
Including those with unknown volume of consumption during year preceding baseline interview.
Based on intake level during year preceding baseline interview.
DSM-IV criteria for dependence: ( I ) tolerance: (2) withdrawal (including
relief or avoidance of withdrawal); (3) persistent desire or unsuccessful
attempts to cut down on or stop drinking; (4) much time spent drinking,
obtaining alcohol, or recovering from its effects; ( 5 ) reduction or cessation
of important activities in favor of drinking; (6) impaired control over
drinking; and (7) continued use despite physical or psychological problems
caused by drinking. Criteria not associated with duration qualifiers were
considered to be satisfied if an individual reported one or more positive
symptoms of the criterion during the past year. Criteria with duration
qualifiers were considered to be satisfied if a person reported two or more
symptoms during the past year or one symptom that occurred at least two
times during the past year. To be consistent with the syndromal definition
of the withdrawal criterion, two or more positive symptoms were required
in addition to satisfaction of the duration qualifier.
I constructed a dichotomous measure of poor health at baseline to
control for the potentially confounding effect of health-related selectivity
into the categories of lifetime abstainers and former drinkers. The latter
was coded positively if the respondent reported any of six preexisting
major health problems (heart disease, arteriosclerosis, hypertension, diabetes, liver disease, or cancer), major limitations of activity, or selfperceived fair or poor health status. The health problems were ascertained
by the question, Tell me whether or not you have ever had any of the
following conditions and did not stipulate whether the condition was
diagnosed by a doctor. Individuals were coded as having a major limitation
of activity if they were unable to perform their main activity (e.g., work,
housework, school attendance) because of an impairment or health problem. The response options for the question on health status (Would you
say your health in general is . . .) were excellent, very good, good, fair, or
poor.
Analysis
The 1988 NHIS used a complex, multistage sampling design (Massey et
al., 1989) that featured selection of primary sampling units with probability
proportional to size and oversampling of the Black population. To account
for these design features in estimating confidence intervals for the hazards
ratios and descriptive statistics, I generated all of the results presented in
this paper using SUDAAN software (Shah et al., 1997), which uses
Taylor-series linearization techniques to adjust variance estimates for
complex sample design characteristics.
Mortality hazard rate ratios (HRRs) were derived from multivariate
proportional hazards models assuming discrete time intervals. Intervals
were measured in months between the date of interview (estimated from
the processing quarter and week) and either the date of death (taken from
the death certificate) or December 1995, the end of the linkage period and
RESULTS
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76
Table 2. Adjusteda Mortality Hazard Rate Ratios (HRRs) for Adults Age 25 and
Older by Drinking Status at Baseline
Table 3. Adjusted Mortality Hazard Rate Ratios (HRRs) for Adults Age 25 and
Older By Drinking Status and DSM-IV Alcohol Dependence at Baseline
Model 1
Model 2
Model 1
Model 2
HRR 95% CI
HRR 95% CI
HRR 95% CI
HRR 95% CI
1.OO (Reference)
1.OO (Reference)
a Adjusted for age, sex, racekthnicity, marital status, education, income, labor
force participation, body mass index, and smoking status.
Based on intake during period of heaviest drinking.
Based on intake during year preceding baseline interview.
1.OO (Reference)
1.OO (Reference)
0.93 (0.82 -1.06)
77
Table 4. Characteristics of Past-Year Drinkers Age 25 and Older, by Drinking Status and DSM-IV Alcohol Dependence at Baseline: Standardized for Age and Sex
Light drinkers
Dependent
Heavy drinkers
Nondependent
Dependent
Moderate drinkers
Nondependent
Dependent Nondependent
Dependent Nondependent
0.10 (<0.01)
50.0 (0.7)
1.9 (<0.1)
0.5 (<0.1)
0.1 ( i O . 1 )
40.9 (0.5)
29.5 (0.5)
29.6 (0.5)
0.67 (0.02)
145.2 (5.9)
3.7 (0.2)
10.9 (0.9)
3.0 (0.5)
54.8 (3.7)
13.9 (1.7)
31.2 (3.3)
0.59 (<0.01)
182.1 (2.0)
2.5 (<0.1)
5.1 (0.2)
0.8 (<0.1)
46.8 (0.7)
23.2 (0.6)
30.0 (0.6)
1.64 (0.01)
1.69 (0.05)
268.9 (4.6)
227.7 (8.7)
4.3 (0.2)
3.5 (0.1)
25.5 (1.2)
38.5 (2.8)
5.5 (0.6)
8.3 (0.8)
46.8 (1.7)
56.0 (3.0)
16.1 (4.6)
18.8 (1.5)
27.9 (4.6)
34.3 (1.6)
3.82 (0.12)
4.60 (0.25)
292.6 (6.7)
298.5 (5.9)
5.0 (0.2)
6.7 (0.5)
128.7 (11.1) 86.1 (6.4)
28.0 (2.8)
70.4 (10.9)
52.0 (2.6)
56.1 (3.4)
9.1 (3.5)
10.6 (1.8)
37.4 (2.5)
34.8 (4.3)
3.10 (0.50)
1.88 (0.07)
290.4 (4.8)
292.1 (6.7)
7.3 (1.0)
5.0 (0.3)
19.4 (0.2)
18.9 (0.3)
4.70 (0.40)
2.86 (0.1 1)
330.3 (5.2)
318.6 (5.8)
6.1 (0.2)
9.8 (0.7)
19.0 (0.4)
17.3 (0.4)
~~
0.13
64.3
3.5
1.8
0.4
51.1
9.2
39.7
(<0.01)
(6.4)
(0.3)
(0.2)
(0.1)
(3.1)
(1.6)
(2.9)
1.68 (0.19)
171.2 (8.9)
5.6 (0.4)
18.9 (0.2)
6.9
11.9
3.7
8.9
31.7
(1.3)
(2.6)
(1.5)
(2.2)
(3.3)
0.64 (0.02)
113.4 (1.4)
3.1 ((0.1)
20.3 (0.1)
4.1
6.9
2.0
3.7
29.0
(0.2)
(0.3)
(0.2)
(0.2)
(0.5)
1.95(0.15)
1.15(0.03)
236.1 (10.6) 220.3 (2.1)
5.6 (0.3)
3.8 (0.1)
18.4 (0.2)
19.6 (0.1)
8.7
9.5
3.2
6.7
36.3
(2.3)
(1.6)
(1.0)
(1.7)
(4.0)
4.1
7.0
1.5
2.8
28.2
(0.3)
(0.4)
(0.2)
(0.2)
(0.6)
18.2
16.1
13.8
10.2
40.8
(10.2)
(1.3)
(1.5)
(4.6)
(3.6)
2.8
6.4
1.0
2.5
32.5
(0.3)
(1.3)
(0.3)
(0.5)
(1.8)
11.4
18.1
13.9
6.5
56.2
(3.5)
(4.1)
(3.2)
(1.3)
(2.3)
4.8
8.9
2.7
4.3
34.7
(0.8)
(1.8)
(0.8)
(1.0)
(3.2)
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78
19
studies that have found a protective effect of light or moderate wine consumption (a finding that is by no means
consistent across studies; see White, 1996), this suggests
that beverage preference might be another factor associated with dependence being a positive risk factor for mortality.
The ranges of ethanol intake at which this study found
protective and risky effects with respect to all-cause
mortality were in line with those reported in other studies. For example, both the meta-analysis by Holman et al.
(1996) and the large-scale American Cancer Society prospective study (Thun et al., 1997) found that the increase
in mortality risk did not begin until an average of four or
more drinks per day were consumed, the same level at
which this study found the first significant and nearsignificant increased risks. However, in both the studies
by Thun et al. and Holman et al., this finding was restricted to specific subpopulations, individuals age 30 to
59 with low cardiovascular risk in the former case and
men in the latter case.
Holman et al. found a lower threshold for increased
risk among women (with a significantly increased risk at
intake levels of more than drinks per day) that was not
supported in this study. Although I did not a priori
stratify the sample by age and sex, I tested for and failed
to detect any significant interaction between sex and the
volume of intake consumption levels. (The only nearsignificant interaction with sex suggested a less strongly
protective effect of light drinking among male compared
to female drinkers, and no impact on the risk at the
heavy drinking level of approximately two to four drinks
per day that distinguished men and women in the study
by Holman et al.) Additional research is needed to clarify whether the risky volume thresholds do indeed differ
for men and women. Gender differentials in the selectivity of drinking and in sensitivity to reporting baseline
health conditions need to be examined. It is also important to adjust volume measures for atypical heavy drinking, as was done in this study, and to test for the significance of any differences in threshold rather than
assuming that a stratified analysis is justified.
These findings may not be generalizable to populations other than that used for analysis, which consisted of
U.S. adults 25 years of age and over. All-cause mortality
curves reflect the curves for the most common causes of
death, which vary substantially by age and among cultures with different diets and social practices. For the
study sample, coronary heart disease was the primary
cause of death, and its J-shaped association with alcohol
consumption has been widely documented. Populations
where mortality is predominantly associated with infectious diseases or external causes such as accidents and
suicide-and these populations include U.S. adolescents
and young adults as well as the populations of many
developing countries-cannot be assumed to experience
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