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Alcohol and coronary heart disease reduction among British doctors: confounding or causality? In the absence of experimental evidence, the interpretation of observed associations may be difficult unless they are exceptionally strong. There is no simple rule for distinguishing between associations of moderate strength that are partly or wholly causal and those that are entirely due to confounding between the factor under study and some other factor that is actually a cause of the disease. All importantly relevant evidence has to be taken into account, including the biological plausibility of causality. Several epidemiological studies have found an inverse association between the consumption of alcohol and coronary heart disease, and many authors have concluded that the most plausible explanation is that alcohol can be somewhat protective. Some, however , remain unconvinced. Shaper' 11 , for example, believes that the inverse association may well arise just because the non-drinking group is 'particularly predisposed to ill-health in all forms, and for several reasons, most particularly predisposed to coronary heart disease'. One widely discussed possibility is that the non-drinking group includes a substantial proportion of ex-drinkers who have given up alcohol because they already had heart disease, but the inverse relationship holds even after ex-drinkers have been excluded' 2 " 41 and it also holds among men and women with no self-reported history of coronary heart disease in the past' 3 ' 5 " 81. The other possible non-causal explanation for the observed inverse association involves confounding , lifelong abstainers being at relatively high risk because of some personal characteristics that affect the risk of the disease (other than the effects of their abstinence, or their past history of coronary disease). In our 1978-91 prospective study of mortality in relation to the consumption of alcohol in British doctors' 6 ' we, like many others, found that moderate alcohol consumption was associated with a reduction in mortality from vascular disease (Fig. 1) and concluded that the apparently protective effect was likely to be partly or wholly real. Shaper' 91 , however, has t I 0 21 42 63 Units (U.K.) of alcohol per week in 1978 questionnaire Figure 1 Trend in mortality from vascular disease (is-chaemic heart disease and stroke and residual vascular; ICD 9th revision 401-459) with consumption of alcohol (U.K. units per week) in British doctors 1978-1991. Floating absolute risk and 95% confidence interval, standardized for exact age and smoking. proposed that the lower …