Alcohol and premature mortality: a causal and preventive factor

In most developed countries, heavy alcohol consumption is second only to cigarette smoking as the leading avoidable cause of all premature deaths and all cancer deaths. Heavy alcohol consumption also contributes to premature death from traffic accidents, cirrhosis, violent crime, suicide, and industrial accidents. Alcoholism leads to acute toxicities, as well as chronic psychoses and a wide range of morbid conditions that make alcohol abuse a leading cause of admission to chronic care facilities. In addition, heavy drinkers are among those at highest risk of dying from cardiovascular disease. Against this backdrop of clear harm, however, there is some evidence that consumption of small-tomoderate amounts of alcohol may confer protection against the development of coronary heart disease. Many epidemiological studies of primary and, more recently, secondary prevention have shown a J-shaped association between amount of alcohol consumed and total mortality. The benefits of lightto-moderate alcohol consumption appear to be mediated largely by a decrease in coronary mortality. This is most likely due to the antiatherogenic effects of alcohol-related increases in high density lipoprotein cholesterol (HDL-C) but other mechanisms, including antithrombotic effects, have also been postulated. Basic research has provided plausible mechanisms for benefits of small-to-moderate alcohol consumption. Furthermore, epidemiological studies — both case-control and, more recently, large prospective cohort studies — have consistently shown benefits on cardiovascular mortality among individuals who selfselect to consume small-to-moderate amounts of alcohol. The fact that many different investigations using very different design strategies tend to reach a similar conclusion adds to the credibility that small amounts of alcohol, rather than other characteristics of the individuals who self-select to consume alcohol, decrease risks of coronary heart disease. At the same time, basic research and epidemiological studies have also demonstrated that alcohol consumption, even in small amounts, can have some deleterious