Alcohol and mortality: a review of prospective studies

Summary Non‐drinkers and heavy drinkers tend to have higher total and cardiovascular mortality rates than light or moderate drinkers. The finding is not disputed; it is the interpretation of this U‐shaped curve that is controversial, and in particular the belief that light and moderate drinking protects against coronary heart disease. The British Regional Heart Study of middle‐aged British men has shown that 70% of non‐drinkers are ex‐drinkers. Those ex‐drinkers have high rates of doctor‐diagnosed illnesses including heart disease, hypertension, diabetes and bronchitis as well as high prevalence rates of measured hypertension, obesity, current smoking and regular medical treatment. Over a five‐year period men who were diagnosed as having heart disease, had multiple diagnoses or were put on regular medication had an increased likelihood of becoming non‐drinkers or occasional drinkers. The study suggests a downward drift from heavy and moderate drinking towards non‐drinking under the influence of accumulating ill health. The data strongly suggest that the observed alcohol‐mortality relationships in prospective studies are produced by symptoms and disease present at the time of screening, and by the prior movement of men with such disorders into non‐drinking or occasional drinking categories. The concept of a protective effect on mortality which ignores the dynamic relationship between ill health and drinking behaviour is likely to be ill‐founded. A review of the major prospective studies reveals an inadequate exploration of the nature of non‐drinkers, who are clearly unsuitable for use as a baseline in studies of the effects of alcohol on health.