Arthur L. Klatsky

Alcohol and mortality

OBJECTIVE To study the relation between alcohol intake and mortality in a large ambulatory population with attention to causes of death and differences related to age, sex, race, and baseline risk. DESIGN Prospective cohort study. SETTING Prepaid comprehensive health care program facilities in Oakland and San Francisco, California. PARTICIPANTS Adults (n = 128,934) who supplied data at health evaluations between 1978 and 1985. MEASUREMENTS Demographic data and health history were supplied using questionnaires. Death was ascertained by an automated linkage system and was individually validated. Relative risk for death at various levels of drinking was calculated by Cox proportional hazards models using lifelong nondrinkers as the reference and controlling for eight covariables. RESULTS Heavier drinkers were at greater risk for death from noncardiovascular causes (relative risk at greater than or equal to 6 drinks per day compared with no alcohol = 1.6, 95% Cl, 1.3 to 2.0) especially cirrhosis, unnatural death, and tobacco-related cancers. This alcohol-associated risk was higher in women (relative risk for death from all causes at greater than or equal to 6 drinks per day = 2.2; Cl, 1.4 to 3.8) and younger persons (for persons less than 50 years of age, relative risk for death from all causes at greater than or equal to 6 drinks per day = 1.9; Cl, 1.3 to 2.9). Lighter drinkers were at lower risk for death from cardiovascular disease, especially coronary heart disease (relative risk at 1 to 2 drinks per day = 0.7; Cl, 0.6 to 0.9), independent of baseline risk, with the greatest reduction of risk in older persons. Lighter drinkers over 60 years of age also had a slightly lower risk for noncardiovascular death, but this finding was not independent of baseline coronary heart disease risk. CONCLUSIONS Women and younger persons appear more susceptible to the increased mortality risk of heavy drinking. The reduced cardiovascular risk of lighter drinkers is more pronounced in older persons. Lower coronary disease prevalence may reduce the noncardiovascular mortality risk of lighter drinkers.

The Leukocyte Count as a Predictor of Myocardial Infarction

Abstract The multiphasic-examination findings of 464 persons in whom a first myocardial infarction later developed were compared with those of two control groups, one matched for age, sex and race (ordinary controls), and the other matched in addition for standard coronary risk factors (risk controls). The total leukocyte count, measured, on the average, 16.8 months before the myocardial infarction, was strikingly related to development of infarction. The mean leukocyte count in cases was significantly higher (p<0.001) than in either control group. Ascending from lowest to highest quartile in the cases and ordinary controls the increase in risk of myocardial infarction associated with the leukocyte count was similar to that found for cholesterol and blood pressure. Cigarette smoking, which was strongly related to the leukocyte count, may account for about two thirds of the relation of the count to infarction. The leukocyte count may prove valuable in the routine assessment of risk of myocardial infarction...

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

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

Alcohol and Mortality: A Ten-Year Kaiser-Permanente Experience

We studied 10-year mortality in relation to baseline alcohol use habits among four groups of 2015 persons, well matched for age, sex, race, and cigarette smoking. Persons reporting daily use of two drinks or fewer fared best; the heaviest drinkers (six or more drinks) had a doubled mortality rate, and users of three to five drinks had a mortality rate, and users of three to five drinks had a mortality rate approximately 50% higher. The nondrinkers had a mortality rate similar to that of users of three to five drinks per day. Cancer, cirrhosis, accidents, and nonmalignant respiratory conditions contributed significantly to the excess mortality of the heavier drinkers; coronary disease mortality was significantly higher among nondrinkers. Smoking intensity was a possible factor in the increased mortality of heavier drinkers, but the data were also compatible with the hypothesis that smoking and drinking are synergistic in the production of certain cancers and nonmalignant chronic respiratory illness. Other traits associated with alcohol use or abstinence are possible contributors to the excess mortality of both heavy drinkers and nondrinkers.

The relationships between alcoholic beverage use and other traits to blood pressure: a new Kaiser Permanente study.

In a new study controlled for many factors, we reconfirmed the relationship of higher blood pressure to alcohol use. This relationship was slightly stronger in men, whites, and persons 55 years of age or older. A slight increase in blood pressure appeared in men who drank one to two drinks daily, and a continuous increase occurred at all higher drinking levels among white men who had constant drinking habits. Among women, an increase occurred only at three or more drinks daily. The data suggest complete regression, beginning within days, of alcohol-associated hypertension upon abstinence. Blood pressure showed minor differences with beverage preference: those who preferred liquor had higher adjusted mean blood pressure than those preferring wine or beer. The results of this study contribute to the likelihood that the alcohol-blood pressure association is causal. Smoking, coffee use, and tea use showed no association with higher blood pressure. Systolic pressure showed a positive relationship to total serum calcium and an inverse relationship to serum potassium, but diastolic pressure showed little relationship to these blood constituents; the explanations include a possible direct effect on regulation of blood pressure.

Coffee, tea, and mortality

Except for conflicting evidence about coffee and risk of coronary disease, coffee and tea are not linked to major causes of death. Because of widespread use of both beverages and limitations of prior studies, concern persists. Using Cox models (ten covariates) we studied relations in 128,934 persons to 4501 subsequent deaths. Except for slightly increased risk from acute myocardial infarction among heavier (> or = 4 cups/d) coffee users (relative risk versus nondrinkers = 1.4, 95% confidence interval = 1.0 to 1.9, P = 0.07), there was no increased risk of mortality for all deaths (relative risk per cup of coffee per day = 0.99, 95% confidence interval = 0.97 to 1.01; relative risk per cup of tea per day = 0.98, 95% confidence interval = 0.96 to 1.00) or major causes in adjusted analyses. Coffee was related to lower risk of liver cirrhosis death (relative risk per cup of coffee per day = 0.77, 95% confidence interval = 0.67 to 0.89). Use of both beverages was related to a lower risk of suicide, progressively lower at higher coffee intake (relative risk per cup of coffee per day = 0.87, 95% confidence interval = 0.77 to 0.98). We conclude that coffee and tea have no overall relation to mortality risk. If coffee increases coronary risk, this is balanced by an unexplained lower risk of other conditions, notably cirrhosis and suicide.

Lung function and risk of myocardial infarction and sudden cardiac death.

In a serach for risk factors for myocardial infarction and sudden cardiac death, the mean total vital capacity as measured at multiphasic health checkups was lower in persons who later had a first myocardial infarction than in risk-factor-matched controls (3.17 vs. 3.29 liters, 395 pairs, P less than 0.05) and non-risk-factor-matched controls (3.16 vs. 3.41 liters, 401 pairs, P less than 0.001). Findings were little affected by age and height adjustment and were similar for sudden cardiac death. The first-second vital capacity was also inversely related to later development of these conditions, but the ratio of that measurement to total vital capacity was not. Heavy smoking, productive cough, exertional dyspnea and cardiac enlargement were associated with diminished total capacity. However, exclusion of subjects with these findings did not reduce the predictive value of total vital capacity. Diminished vital capacity deserves continued attention as a possible coronary risk factor. Its relation to subsequent coronary events is not well explained.

Alcoholic beverage choice and risk of coronary artery disease mortality : do red wine drinkers fare best ?

Abstract Several population studies have described a lower coronary artery disease (CAD) mortality risk in alcohol drinkers (vs abstainers). 1–3 Those studies showed no consensus that any specific beverage type (wine, liquor or beer) is likely to be more protective than are the others. 3 The importance of allowing for other traits and habits related to wine, liquor or beer use when studying beverage choice is now clear. 4 Recent media attention (e.g., “60 Minutes,” CBS Television Network, 7:00 p.m. , November 17, 1991) concerning the “French paradox” (lower CAD incidence in France than in the United States) has focused on the possible benefits of red wine in particular. Isolated reports suggest a possible role of tannins 5 or phenolic compounds 6 in red wine. In this report, we present data from a large prospective population study that are pertinent to the possible role of preference for wine, liquor or beer in CAD mortality risk.

Alcohol consumption, smoking, and other risk factors and prostate cancer in a large health plan cohort in California (United States).

Alcohol consumption and cigarette smoking have been suggested as possible causes of prostate cancer. We therefore examined this relation in a cohort of 43,432 men who were members of a prepaid health plan in northern California (United States) and who had received a health examination in the period from 1979 through 1985. Detailed information on demographic variables, alcohol consumption, smoking habits, medical complaints and conditions, occupation, and surgery (including vasectomy) was assessed. Symptoms of prostatism and a history of sexually transmitted diseases were abstracted from the medical records of all prostate cancer patients and of a matched subsample of randomly selected control-subjects. Alcohol consumption was associated with no elevated prostate cancer risk for the 238 men in our study in whom prostate cancer developed, but smoking one or more packs of cigarettes per day was associated with an adjusted relative risk (RR) of 1.9 (95 percent confidence interval [CI]=1.2–3.1). Prostate cancer risk for Black men was 2.2 (CI=1.6–3.1) when compared with that for White men, and education level was associated positively in an increasing trend (P<0.02) up to an RR of 1.4 (CI=0.9–2.1) among men with postgraduate education. Symptoms of prostate hypertrophy were not associated with elevated risk of prostate cancer if they occurred two or more years before the diagnosis. The finding that smoking increased the risk of prostate cancer confirms the observations of others but needs cautious interpretation because we were unable to adjust for the potential confounding effect of dietary and hormonal factors.

Alcohol use and subsequent cerebrovascular disease hospitalizations.

We studied the relations between reported alcohol use and the incidence of hospitalization for several types of cerebrovascular disease. Daily consumption of three or more drinks, but not lighter drinking, was related to higher hospitalization rates for hemorrhagic cerebrovascular disease, especially intracerebral hemorrhage. Age, blood pressure, and black race were other independent predictors of hemorrhagic events; higher blood pressure appeared to be a partial mediator of the relation between alcohol use and hemorrhagic events. Alcohol use was associated with lower hospitalization rates for occlusive cerebrovascular disease; an inverse relation was present in both sexes, whites and blacks, and for extracranial and intracerebral occlusive lesions. Other predictors of hospitalization for occlusive disease included age, blood pressure, smoking, blood glucose and total cholesterol concentrations, and baseline disease. Our data suggest that heavier drinking increases the risk of hemorrhagic cerebrovascular events, but that alcohol use may lessen the risk of occlusive lesions.