Abstract
Background
Evidence suggests that people who abstain from alcohol have a higher mortality rate than those who drink low to moderate amounts. However, little is known about factors that might be causal for this finding. The objective was to analyze former alcohol or drug use disorders, risky drinking, tobacco smoking, and fair to poor health among persons who reported abstinence from alcohol drinking in the last 12 months before baseline in relation to total, cardiovascular, and cancer mortality 20 years later.
Methods and findings
A sample of residents aged 18 to 64 years had been drawn at random among the general population in northern Germany and a standardized interview conducted in the years 1996 to 1997. The baseline assessment included 4,093 persons (70.2% of those who had been eligible). Vital status and death certificate data were retrieved in the years 2017 and 2018.
We found that among the alcohol-abstinent study participants at baseline (447), there were 405 (90.60%) former alcohol consumers. Of the abstainers, 322 (72.04%) had met one or more criteria for former alcohol or drug dependence or abuse, alcohol risky drinking, or had tried to cut down or to stop drinking, were daily smokers, or self-rated their health as fair to poor. Among the abstainers with one or more of these risk factors, 114 (35.40%) had an alcohol use disorder or risky alcohol consumption in their history. Another 161 (50.00%) did not have such an alcohol-related risk but were daily smokers. The 322 alcohol-abstinent study participants with one or more of the risk factors had a shorter time to death than those with low to moderate alcohol consumption. The Cox proportional hazard ratio (HR) was 2.44 (95% confidence interval (CI), 1.68 to 3.56) for persons who had one or more criteria for an alcohol or drug use disorder fulfilled in their history and after adjustment for age and sex. The 125 alcohol-abstinent persons without these risk factors (27.96% of the abstainers) did not show a statistically significant difference from low to moderate alcohol consumers in total, cardiovascular, and cancer mortality. Those who had stayed alcohol abstinent throughout their life before (42; 9.40% of the alcohol-abstinent study participants at baseline) had an HR 1.64 (CI 0.72 to 3.77) compared to low to moderate alcohol consumers after adjustment for age, sex, and tobacco smoking. Main limitations of this study include its reliance on self-reported data at baseline and the fact that only tobacco smoking was analyzed as a risky behavior alongside alcohol consumption.
Conclusions
The majority of the alcohol abstainers at baseline were former alcohol consumers and had risk factors that increased the likelihood of early death. Former alcohol use disorders, risky alcohol drinking, ever having smoked tobacco daily, and fair to poor health were associated with early death among alcohol abstainers. Those without an obvious history of these risk factors had a life expectancy similar to that of low to moderate alcohol consumers. The findings speak against recommendations to drink alcohol for health reasons.
Author summary
Why was this study done?
- According to evidence, alcohol abstinence seems to be associated with a lower life expectancy than low to moderate alcohol consumption.
- Individuals who abstain from alcohol might include those who have risk factors that can be reasons for the shorter life expectancy compared to low to moderate alcohol consumers.
What did the researchers do and find?
- A random adult general population sample had been drawn and the study participants been inquired about their consumption of or abstinence from alcohol in a first contact.
- Twenty years later, proportions of deceased and time to death were determined and compared between former alcohol abstainers and low to moderate alcohol consumers among the 4,028 study participants.
- The findings show that 91% of the alcohol abstainers at first contact had consumed alcohol in life before and 72% had a history of one or more criteria of a former alcohol or drug use disorder, former risky alcohol consumption, efforts to cut down or to stop drinking, daily tobacco smoking, or fair to poor health.
- In terms of mortality rate, no statistically significant difference was apparent between alcohol abstinent persons without these risk factors and who had self-rated their health as good to excellent and persons who consumed low to moderate amounts of alcohol.
What do these findings mean?
- Former alcohol use disorders, risky consumption, efforts to cut down on drinking, ever daily tobacco smoking, and fair to poor health may predict early death among alcohol abstainers.
- Healthy alcohol abstainers who have no alcohol- or tobacco-related risk factors may not have a higher mortality than low to moderate alcohol consumers.
- The findings speak against recommendations to drink alcohol for health reasons.
Citation: John U, Rumpf H-J, Hanke M, Meyer C (2021) Alcohol abstinence and mortality in a general population sample of adults in Germany: A cohort study. PLoS Med 18(11):
e1003819.
https://doi.org/10.1371/journal.pmed.1003819
Academic Editor: Charlotte Hanlon, Addis Ababa University / King’s College London, ETHIOPIA
Received: February 10, 2021; Accepted: September 17, 2021; Published: November 2, 2021
Copyright: © 2021 John et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its Supporting Information files.
Funding: UJ received a grant from the German Federal Ministry of Education and Research (https://www.bmbf.de/en/index.html; grant number: 01 EB 9406) and the German Research Foundation (www.dfg.de; grant number: JO 150/11-1). CM received a grant from the German Research Foundation (www.dfg.de; grant number: ME 3180/4-1). HJR received a grant from the German Research Foundation (www.dfg.de; grant number: RU 1570/3-1). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Abbreviations:
AUDIT-C,
Alcohol Use Disorder Identification Test-Consumption; CI,
confidence interval; HR,
hazard ratio; OR,
odds ratio
Introduction
Growing evidence speaks against the J-shaped curve according to which not only heavy drinkers but also alcohol abstainers have a higher total, cardiovascular, and cancer mortality than low to moderate drinkers [1–4]. According to the Global Burden of Disease study, moderate alcohol consumption was not protective against mortality from alcohol-related disorders [5]. Meta-analysis data revealed that persons who had abstained from alcohol their entire life before had no higher risk of all-cause or coronary heart disease mortality than low to moderate drinkers (<25 grams alcohol per day) [4,6]. It has been concluded that it is safest not to drink alcohol [5]. Second, for cancer of the female breast, even low drinking amounts (<7.5 grams pure alcohol per drinking day) were associated with higher risk of death compared to abstainers [7]. No evidence for a low-risk threshold of alcohol for breast cancer has been found [8].
Concern has been raised over potential causes of increased mortality risk among study participants who affirmed not to drink alcohol [4,9,10]. After limiting abstainers to those who indicated that they have been abstinent their entire life before, no increased mortality risk was found compared to low-volume alcohol consumers [4]. However, to choose lifetime abstainers as a comparison group might not be sufficient in the search for evidence on potential causes of higher mortality rates among alcohol abstainers. Both lifelong abstainers and former drinkers may include subpopulations with a variety of risk factors that may contribute to death. These are insufficiently known. They include former alcohol or drug use disorders, particularly dependence or abuse, risky alcohol drinking, tobacco smoking, and fair to poor health in general. Among alcohol-abstinent subgroups in the general population, individuals exist who have stopped drinking due to an alcohol or drug use disorder. However, little is known about how large this group is. There is a lack of studies about alcohol drinking or tobacco smoking histories of subgroups among those in the general adult population who indicated that they currently live abstinently from alcohol. Current alcohol abstainers include former drinkers and lifetime abstainers. However, lifetime abstainers have been revealed by cohort data to be a small minority. Only 1.7% did not have consumed any alcohol throughout their life until age 50 or higher in a cohort followed for more than 30 years [11]. Tobacco smoking has a high mortality risk itself but may also add to combined effects of alcohol and tobacco on mortality risk [12]. Particularly high risks of death have been revealed by data from use of alcohol and tobacco [13,14]. Combined effects of former alcohol consumption and tobacco smoking on disease and death may be supramultiplicative [12]. Cohort study data revealed that after controlling for smoking status, alcohol abstainers did not have higher total or cardiovascular mortality rates than low to moderate alcohol consumers [4,6]. Smokers did not seem to have any mortality benefit if they consumed low to moderate amounts of alcohol [15]. Further health conditions have been investigated by the assessment of self-rated health, which turned out to be associated with mortality. Increased risks of people who disclosed fair or poor health in their own view have been shown for total [16], cardiovascular [16,17], and cancer mortality [16], in contrast to those with good, very good, or excellent health.
The purpose of the present paper was to analyze risk factors for early death among adult respondents who indicated that they had abstained from alcohol during the last 12 months prior to an interview at baseline. The risk factors included former alcohol or drug dependence or abuse, alcohol risky drinking, having tried to cut down or to stop drinking, tobacco smoking, and self-rated fair to poor health. Twenty years later, a mortality follow-up was conducted.
Methods
Sample
In a northern German region, a random adult population sample aged 18 to 64 years was drawn in 1995 using the registration office data in which every resident has to be enlisted by law. The area had been chosen by sociostructural criteria. It comprised the city of Lübeck and 46 surrounding municipalities. This study area covered a total of 193,452 residents at age 18 to 64 [18]. Among the 5,829 individuals eligible for the baseline study, 4,093 (70.2%) interviews had been completed July 1996 to March 1997, and 4,075 were analyzed [18].
A mortality follow-up was conducted from April 2017 to April 2018. The median number of years from the baseline interview to the ascertainment of vital status was 20.6 years [19]. Vital status was ascertained for the 4,075 baseline study participants. Vital statistics data were retrieved from the residents’ registration files at the place of the last residence. In a first step, data of the residents’ registration office that had been responsible at the time of the baseline interview were retrieved. Second, when address changes had been documented, we received data of the registration offices in the single communities. The last place of residence was provided and the information whether the individual was alive or at which date deceased. Residents’ registration offices in the respective federal states of Germany and in single places of residence in other nations were contacted. Among the 4,075 study participants with complete baseline data, for 47 persons, vital statistics data could…
Alcohol abstinence and mortality in a general population sample of adults in Germany: A