Alcohol on trial: the evidence.

1. Epidemiological Considerations of Alcohol Consumption

Prevalence Among Underage Youth

* Faden VB, Fay MP. Trends in drinking among Americans age 18 and younger: 1975-2002. Alcohol Clin Exp Res 2004;28:1388-1395.

Alcohol consumption among eighth, tenth, and twelfth graders has decreased substantially since the 1970s. Consumption rates are still high among these age groups, with 12.4% of 8th and 28.6% of 12th graders reporting drinking five or more drinks in a row in the past 2 weeks. Alcohol consumption rates have remained stable over the past decade.

* Grunbaum JA, Kann L, Kinchen SA, et al. Youth risk behavior surveillance-United States, 2001. J Sch Health 2002;72:313-328.

About 47% of American high school students had consumed alcohol within the 30 days preceding this survey-based study. Additionally, 30.7% had ridden with a driver who had been drinking. The Youth Risk Factor Behavior Surveillance System is a national school-based survey sponsored by the Centers for Disease Control and Prevention (CDC). The survey study is conducted by the CDC and state and local agencies. These results represent data collected from February to December of 2001.

Additional readings

* Foley Kl K, Altman D, Durant Rh R, et al. Adults' approval and adolescents' alcohol use. J Adolesc Health 2004;35:345-346.

Prevalence Among Adults

* Curry SJ, Ludman E, Grothaus L, et al. At-risk drinking among patients making routine primary care visits. Prev Med 2000;31:595-602.

Approximately 10% of patients seen for routine primary care were at risk of suffering negative consequences from alcohol consumption in this population-based health survey (n = 3439). In this multicenter study of 23 primary care practices, abstainers from alcohol tended to be older minorities of poorer health and lower socioeconomic status. Single males and users of other substances (eg, tobacco, marijuana, and cocaine) had an increased risk of suffering negative consequences from drinking alcohol. Binge drinkers were more likely to be tobacco and marijuana users, perceive their health as poor, and report the most negative consequences from alcohol consumption.

Prevalence Among Older Adults

* Moore AA, Hays RD, Greendale GA, et al. Drinking habits among older persons: findings from the NHANES I Epidemiological Followup Study (1982-1984). National Health and Nutrition Examination Survey. J Am Geriatr Soc 1999;47:412-416.

According to this population-based study of American adults, 79% of older adults reported current drinking. Of those currently drinking participants, 25% drank daily. When alcohol consumption was quantified, 16% of older men and 15% of older women were classified as heavy drinkers. The definition of heavy drinking was gender specific (>2 drinks daily for men; >1 drink daily for women). The following factors were associated with increased alcohol consumption: male gender, younger age, and greater income. This study was based on data from NHANES I. These data were obtained from 3448 adults, 65 years of age or older, living in the United States.

Additional readings

* Bacharach SB, Bamberger PA, Sonnenstuhl WJ, et al. Retirement, risky alcohol consumption and drinking problems among blue-collar workers. J Stud Alcohol 2004;65:537-545.

Mortality

* Dawson DA. Alcohol and mortality from external causes. J Stud Alcohol 2001;62:790-797.

Risk of death from external causes among drinkers increases with amount of alcohol consumed. At increased risk are 1) former drinkers, 2) those who drink less than once a month having five or more drinks per occasion, and 3) those who drink at least twice a week having more than a couple of drinks per occasion. Light and moderate drinkers do not have a reduced risk. Results are based on a prospective study of the relationship between alcohol consumption and risk of death from external causes using information from the 1988 National Health Interview Study and 1988-1995 National Death Index. Data included volume of intake and drinking patterns in 42,910 adults 18 years of age or older.

* Gaziano JM, Gaziano TA, Glynn RJ, et al. Light-to-moderate alcohol consumption and mortality in the Physicians' Health Study enrollment cohort. J Am Coll Cardiol 2000;35:96-105.

Alcohol consumption exhibited a U-shaped relationship to total mortality in this prospective study of 89,299 men. Compared with abstainers, those who drink 1-6 drinks per week or 1 drink per day have significantly lower mortality rates. The relative risks for total mortality are presented below (Table). The follow-up time was 5.5 years from baseline. Men in this study were between the ages of 40 and 85 years with no history of myocardial infarction, stroke, cancer, or liver disease.

* Hingson RW, Heeren T, Zakoes RC, et al. Magnitude of alcohol-related mortality and morbidity among U.S. college students ages 18-24. J Stud Alcohol 2002;63:126-144.

Of the 8 million students enrolled in college, at least 1400 students aged 18 to 24 died in 1998 from alcohol-related causes (unintentional injuries and motor vehicle accidents). Additionally, 2 million college students reported driving under the influence of alcohol and more than 3 million reported riding with an impaired driver. More than 500,000 students were unintentionally injured while drinking, and more than 600,000 were hit or assaulted by another student who was under the influence. Data for this study were obtained from several national databases and reports.

* Jensen MK, Andersen AT, Sorensen TI, et al. Alcoholic beverage preference and risk of becoming a heavy drinker. Epidemiology 2002;13:127-132.

Drinking beer instead of wine or spirits is more likely to lead to heavy or excessive drinking according to this longitudinal study of Dutch moderate drinkers. Men who prefer beer, compared with those who prefer wine, were at increased odds for becoming heavy drinkers (OR 1.16, 95% CI: 0.84-1.58) or excessive drinkers (OR 1.81, 95% CI: 0.85-3.82). Women preferring beer are also at increased risk for becoming heavy drinkers (OR 1.14, 95% CI: 0.87-1.50) or excessive drinkers (OR 1.50, 95% CI: 0.93-2.43). In this study, heavy drinking was defined as more than 21 drinks per week for men and more than 14 drinks per week for women. Excessive drinking was defined as more than 35 drinks per week for men and more than 21 drinks per week for women.

For Mortality secondary to specific conditions (e.g. alcohol and cardiovascular disease mortality), please refer to those disease subheadings.

Additional readings

1. Alcohol-attributable deaths and years of potential life lost--United States, 2001. MMWR Morb Mortal Wkly Rep 2004;53:866-870.

2. Bray I, Brennan P, Boffetta P. Projections of alcohol- and tobacco-related cancer mortality in central Europe. Int J Cancer 2000;87:122-128.

3. Fillmore KM, Kerr WC, Bostrom A. Changes in drinking status, serious illness, and mortality. J Stud Alcohol 2003;64:278-285.

4. Laatikainen T, Manninen L, Poikolainen K, et al. Increased mortality related to heavy alcohol intake pattern. J Epidemiol Community Health 2003;57:379-384.

5. Liao Y, McGee DL, Cao G, et al. Alcohol intake and mortality: findings from the National Health Interview Surveys (1988 and 1990). Am J Epidemiol 2000; 151:651-659.

6. Nolte E, Britton A, McKee M. Trends in mortality attributable to current alcohol consumption in East and West Germany. Soc Sci Med 2003;56:1385-1395.

7. Norstrom T. Per capita alcohol consumption and allcause mortality in Canada, 1950-98. Addiction 2004;99:1274-1278.

Socioeconomic Impact

* Foster Se, Vaughan RD, Foster WH, et al. Alcohol consumption and expenditures for underage and adult excessive drinking. JAMA 2003;289:989-995.

American consumers spent $116.2 billion on alcohol during 1999 according to this study based on several national databases. Of that total $116.2 billion, $34.4 billion was attributable to adult excessive drinking and $22.5 billion was accounted for by underage drinkers. The estimated total number of alcoholic beverages consumed by Americans was 4.21 per month, and underage drinkers consumed 19.7% of those beverages. It is estimated that 50% of youths aged 12 to 20 years and 52.8% of adults 21 years and older consume alcohol.

* Gallo WT, Bradley EH, Siegel M, et al. The impact of involuntary job loss on subsequent alcohol consumption by older workers: findings from the health and retirement survey. J Gerontol B Psychol Sci Soc Sci 2001;56:S3-S9.

Uncontrolled job loss is linked to subsequent alcohol consumption among those who had been nondrinkers. Conversely, individuals with a history of alcohol consumption experienced no substantial change in alcohol intake subsequent to job loss. Individuals who began drinking after involuntary job loss did so twice as often as employed persons (OR = 2.01; 95% CI = 1.06-3.80). The data for this case-control study was obtained from the 1992 and 1994 Health and Retirement Survey. Daily alcohol intake and the period of time when alcohol consumption began were evaluated for 207 employees who lost their jobs between survey dates and 2,866 workers who maintained their employment status.

* Wiese JG, Shlipak MG, Browner WS. The alcohol hangover. Ann Intern Med 2000;132:897-902.

Hangover accounts for $148 billion each year in decreased occupational performance and absenteeism in the United States. This report is based on a review of studies dating from 1966 to 1999. Hangover is characterized by dehydration, hormonal alterations, dysregulated cytokine pathways, and augmented cardiac exertion with normal peripheral resistance. Counterbalance can be achieved via rehydration, prostaglandin inhibitors, and vitamin B6.

Additional readings

1. Picone GA, Sloan F, Trogdon JG. The effect of the tobacco settlement and smoking bans on alcohol consumption. Health Econ 2004;13:1063-1080.

2. Williams J, Liccardo Pacula R, Chaloupka FJ, et al. Alcohol and marijuana use among college students: economic complements or substitutes? Health Econ 2004;13:825-843.

Table.

                                  Relative risk for total
Alcohol consumption               mortality (95% CI) (a)

Rarely/never                      1.00 (referent)
1-3/month                         0.86 (0.75-0.99)
1/week                            0.74 (0.65-0.85)
2-4/week                          0.77 (0.68-0.87)
5-6/week                          0.78 (0.67-0.90)
1/day                             0.82 (0.74-0.92)
[greater than or equal to] 2/day  0.95 (0.79-1.14)

(a) Adjusted for age and other cardiovascular risk factors. P for trend
< 0.001.

2. Binge Drinking

Youth

* Nelson TF, Wechsler H. Alcohol and college athletes. Med Sci Sports Exerc 2001;33:43-47.

College athletes consume alcohol more frequently than nonathlete students and also binge drink more frequently. This discrepancy exists between athletes and nonathletes despite frequent exposure to alcohol prevention attempts and highly motivating factors to discourage alcohol consumption by athletes. These findings were reported in a study of randomly chosen college students from 4-year academic institutions in the United States. In this study, binge drinking was defined as five or more drinks at a time during a 2-week period for men; four or more for women. Students were classified as athletes if they were involved in 1 or more hours of intercollegiate sports each day. The authors concluded that binge drinking and drinking-related harms are common among college athletes.

* Wechsler H, Lee JE, Kuo M, et al. Trends in college binge drinking during a period of increased prevention efforts. Findings from four Harvard School of Public Health College Alcohol Study surveys: 1993-2001. J Am Coll Health 2002;50:203-217.

Approximately 44% of students attending 4-year colleges admit to binge drinking, and this percentage has varied little since 1993. This report is based on the 2001 Harvard School of Public Health College Alcohol Study survey, which evaluated drinking trends among college students from 1993 to 2001.

* Weitzman ER, Nelson TF, Wechsler H. Taking up binge drinking in college: the influences of person, social group, and environment. J Adolesc Health 2003;32:26-35.

College students are more likely to become binge drinkers if they are exposed to environments where alcohol is accessible, prevalent, and cheap. This report comes from a cross-sectional study using data from the 1999 Harvard School of Public Health College Alcohol Study (CAS). Additionally, binge drinkers were more likely to think the drinking age should be lower and were more likely to describe binge drinking in inflated terms (ie, report the minimum drinks to be classified as "binge drinking" as higher than the standard). The CAS is a 20-page questionnaire filled out by a random sample of full-time undergraduate students at participating universities and colleges.

Adults

* Denny CH, Serdula MK, Holtzman D, et al. Physician advice about smoking and drinking: are U.S. adults being informed? Am J Prev Med 2003; 24: 71-74.

The majority of binge drinkers (77%) were not advised to reduce alcohol consumption by their health care providers according to this cross-sectional study based on the 1997 Behavior Risk Factor Surveillance System (BRFSS). Among binge drinkers, health intervention by a provider was more likely to occur for men and for non-Hispanics. Approximately 2 million binge drinkers with a routine check up appointment in the 12 months preceding the survey were not counseled on alcohol use by their provider. By contrast, 70% of smokers were advised to quit smoking by their health care providers during the same period. The authors conclude that there are many missed counseling opportunities, and that physician education may be needed. The BRFSS is a continuous, random-digit telephone survey of US adults that is sponsored by the Centers for Disease Control and Prevention.

* Naimi TS, Brewer RD, Mokdad A, et al. Binge drinking among U.S. adults. JAMA 2003;289:70-75.

Binge drinking episodes have increased in the United States from 1.2 billion in 1993 to 1.5 billion in 2001 according to this longitudinal study based on the Behavior Risk Factor Surveillance System (BRFSS). Binge drinking episodes per person per year also increased 17.3% over the same period (P = 0.03). Binge drinking was most common in men (81% of binge-drinking episodes). Although binge drinking is common among young adults, 69% of episodes were reported by those aged 26 years and older. Binge drinkers were 14 times more likely to drive after drinking than non-binge drinkers. The BRFSS is a continuous, random-digit telephone survey of US adults that is sponsored by the Centers for Disease Control and Prevention. The BRFSS includes adults 18 years of age and older.

Additional reading

Weissenborn R, Duka T. Acute alcohol effects on cognitive function in social drinkers: their relationship to drinking habits. Psychopharmacology 2003;165:306-312.

Binge Drinking and Pregnancy

* Naimi TS, Lipscomb LE, Brewer RD, et al. Binge drinking in the preconception period and the risk of unintended pregnancy: implications for women and their children. Pediatrics 2003;111:1136-1141.

Preconception binge drinking was associated with unintended pregnancy according to this case-control study of 72,907 women. Once the data was adjusted for potential confounders, preconception binge drinking was associated with unintended pregnancy for white women (OR 1.63, 95% CI: 1.47-1.80) but not black women. Out of all study participants, 14% of the women reported binge drinking in the three months prior to conception. Women who binge drank prior to pregnancy were more likely to be white, to be unmarried, to be smokers, to be exposed to domestic violence, and to consume alcohol during pregnancy. This study was based on data from the Pregnancy Risk Assessment Monitoring System. The data was collected in 15 states from 1996 to 1999.

* Whitehead N, Lipscomb L. Patterns of alcohol use before and during pregnancy and the risk of small-for-gestational-age birth. Am J Epidemiol 2003;158:654-662.

Women who reported moderated to heavy alcohol consumption late in pregnancy were more likely to have a small-for-gestational age infant. In this prospective study based on the Pregnancy Risk Assessment Monitoring System (n = 50,461), women who reported binge drinking before pregnancy were less likely to have a small-for-gestational-age infant than nondrinkers. When women who reported moderate to heavy alcohol use (four or more drinks per week) were isolated, those who also binged were more likely to have a small-for-gestational-age infant. The Pregnancy Risk Assessment Monitoring System is a survey study of women who have recently given birth to a live infant. This study was based on data collected from 1996 to 1999.

Prevention of Binge Drinking

Refer to Treatment section.

Binge Drinking and Cardiovascular Disease

Refer to Damaging Effects of Alcohol in the Cardiovascular Disease section.

3. Driving While Impaired

* Asbridge M, Mann RE, Flam-Zalcman R, et al. The criminalization of impaired driving in Canada: assessing the deterrent impact of Canada's first per se law. J Stud Alcohol 2004;65:450-459.

Criminalization of drinking and driving corresponded with an 18% reduction in the number of drunk driving-related fatalities. Data from 1962 to 1996 was presented. The drunk driving law was introduced in 1969. The article also included information on the introduction of MADD (Mothers Against Drunk Driving), seat belt use, and other confounding variables.

* Gruenewald PJ, Johnson FW, Millar A, et al. Drinking and driving; explaining beverage-specific risks. J Stud Alcohol 2000;61:515-523.

Individuals who drink alcoholic beverages often are more likely to drink away from home and are also more likely to drink and drive. Although particular beverages are not directly associated with drinking and driving, beer drinkers are most likely to drink and drive; and they are young, male, heavier drinkers who regularly go to bars and restaurants. Frequent consumers prefer beer and spirits to wine. Results are based on a telephone survey of 5,231 drinkers in six US communities.

* Johnson FW, Gruenewald PJ, Treno AJ. Age-related differences in risks of drinking and driving in gender and ethnic groups. Alcohol Clin Exp Res 1998;22:2013-2022.

Young people, regardless of gender or ethnicity, are more likely than adults or older adults to drive while intoxicated. This conclusion is based on data from 4,395 individuals 12 to 80 years of age in 20 urban areas of the United States. Of those included in the study, about 26% had consumed more than one alcoholic beverage and driven during the previous month. Measurements included drinking frequency, average drinking quantity, and number of drinks per occasion. The study sample was ethnically diverse with both males and females represented.

Youth

* Begg DJ, Stephenson S, Alsop J, et al. Impact of graduated driver licensing restrictions on crashes involving young drivers in New Zealand. Inj Prev 2001;7:292-296.

Graduated driver licensing (GDL) reduces the number of serious automobile crashes involving young drivers. This study of hospital records and police crash reports for 1980-1995 compared car wrecks of young drivers licensed before the graduated driver licensing system with those holding restricted graduated licenses and with those holding full graduated licenses. Total number of subjects was 4,505. Compared to drivers in the period before GDL, drivers with restricted driver's licenses had fewer crashes at night (P = 0.003), fewer crashes involving passengers of all ages (P = 0.018), and fewer alcohol-related crashes (P = 0.034). Vehicle crashes with young casualties did not decrease (P = 0.980). Fewer night accidents occurred among drivers with full graduated licenses (P = 0.042), but other statistics were similar to drivers before GDL.

* Greening L, Stoppelbein L. Young drivers' health attitudes and intentions to drink and drive. J Adolesc Health 2000;27:94-101.

Educating teenagers about potential danger does not deter them from drinking and driving. Answers to a questionnaire of 304 college drivers 17 to 20 years of age revealed that those who report intentions to drink and drive are those who perceive it rewarding. The questionnaire assessed personal rewards, risk vulnerability/severity, and alternatives to drinking and driving in the context of the Protection Motivation Theory (PMT) health attitude model. Perceived personal costs and low self-confidence for ability to implement alternative responses contributed to intentions to drink and drive. The PMT accurately predicts teens' intentions involving drinking and driving.

Also refer to the following reference in the Mortality section:

* Hingson RW, Heeren T, Zakoes RC, et al. Magnitude of alcohol-related mortality and morbidity among U.S. college students ages 18-24. J Study Alcohol 2002;63:126-144.

Older Adults

* Cook LJ, Knight S, Olson LM, et al: Motor vehicle crash characteristics and medical outcomes among older drivers in Utah, 1992-1995. Ann Emerg Med 2000;35:613-615.

Although older drivers are less likely to have automobile accidents due to alcohol, drugs, or high speed, they have more wrecks involving left-hand turns and higher overall rates of vehicle mortality and hospitalization. Among drivers wearing seat belts, those 70 years of age or older are 7 times more likely than younger drivers to be killed or hospitalized following automobile accidents (OR, 6.9; 95% CI, 5.4-8.9). When compared with all drivers 30-39 years of age, those [greater than or equal to]70 years of age are three-and-a-half times more likely to die or to be hospitalized after vehicle crashes (OR, 3.5; P < 0.001). The odds of having an accident involving a right-hand turn are similar for both age groups, but older drivers are twice as likely to wreck when turning left (OR, 2.3; 95% CI, 2.2-2.5). When compared with drivers between the ages of 30 and 39 years, the odds ratio for drivers >69 years of age to be involved in vehicle crashes involving drugs or alcohol is 0.1 (95% CI, 0.1-0.2) and in crashes involving high speed is 0.6 (95% CI, 0.6-0.7). These are the results of a study of 1992-1995 motor vehicle crashes and hospital discharge records in Utah. Analyzed data included 14,466 crashes involving drivers >69 years of age and 68,706 crashes involving drivers 30-39 years of age.

Additional readings

1. Abdel-Aty MA, Abdelwahab HT. Exploring the relationship between alcohol and the driver characteristics in motor vehicle accidents. Accid Anal Prev 2000;32:473-482.

2. Arnedt JT, Wilde GJ, Munt PW, et al. Simulated driving performance following prolonged wakefulness and alcohol consumption: separate and combined contributions to impairment. J Sleep Res;9:233-241.

3. Sauvola A, Miettunen J, Jarvelin MR, et al. An examination between single-parent family background and drunk driving in adulthood: findings from the Northern Finland 1966 Birth Cohort. Alcohol Clin Exp Res 2001;25:206-209.

4. Alcohol and Its Effects on Organ Systems

The Cardiovascular System: Beneficial Effects of Alcohol

Congestive heart failure

* Abramson JL, Williams SA, Krumholz HM, et al. Moderate alcohol consumption and risk of heart failure among older persons. JAMA 2001;285:1971-1977.

Alcohol consumption by older adults reduced the risk of heart failure in this prospective study. An analysis of 2,235 older adults (mean age 73.7 years) showed that consuming 21 to 70 ounces of alcohol carried a risk ratio of 0.53 (95% CI, 0.32-0.88; P = 0.02) compared to abstainers. Consumption of 1 to 20 ounces of alcohol in the month prior to baseline reduced the risk of heart failure (RR, 0.79; 95% CI, 0.60-1.02) compared to abstainers, after adjustment for age, sex, race, education, angina, history of myocardial infarction and diabetes, myocardial infarction during follow-up, hypertension, pulse pressure, body mass index, and current smoking. At baseline, none of the participants had heart failure. The maximum follow-up period was 14 years.

* Walsh CR, Larson MG, Evans JC, et al. Alcohol consumption and risk for congestive heart failure in the Framingham Heart Study. Ann Intern Med 2002;136:181-191.

Drinking alcoholic beverages does not increase a person's risk for congestive heart failure. In the community-based, prospective observational Framingham Heart Study, the risk was not higher even in those participants considered to be "heavy drinkers," ie, 15 or more drinks per week in men and 8 or more drinks per week in women. In fact, moderate alcohol consumption may protect against congestive heart failure. After adjustment for multiple confounders, results indicated that men who consumed less than 1 alcoholic drink per week had a greater risk for congestive heart failure than did those at all other levels of alcohol consumption.

For Mortality and Congestive Heart Failure, please refer to the following reference in the Cardiovascular System Mortality section:

* Faris RF, Henein MY, Coates AJ. Influence of gender and reported alcohol intake mortality in nonischemic dilated cardiomyopathy. Heart Dis 2003;5:89-94.

Additional reading

1. Piano MR. Alcoholic cardiomyopathy: incidence, clinical characteristics, and pathophysiology. Chest 2002;121:1638-1650.

Coronary artery disease

* Ajani UA, Gaziano JM, Lotufo PA, et al. Alcohol consumption and risk of coronary heart disease by diabetes status. Circulation 2000;102:500-505.

Light to moderate alcohol consumption is associated with similar reductions in the risk of coronary heart disease in diabetic and nondiabetic men. These conclusions are based on a prospective study of 87,938 US physicians (2,790 of whom had diabetes mellitus) followed up for a mean of 5.5 years.

* Augustin LS, Gallus S, Tavani A, et al. Alcohol consumption and acute myocardial infarction: a benefit of alcohol consumed with meals? Epidemiol 2004;15:767-769.

Alcohol consumption ([greater than or equal to]3 drinks per day) with meals may protect against acute myocardial infarction (OR, 0.50; 95% CI, 0.30-0.82). Alcohol consumption outside of meals did not offer the same effect ([greater than or equal to]3 drinks per day: OR, 0.98; 95% CI, 0.49-1.96). These findings held when analyzing only wine drinkers. These findings are based on a case-control study (cases = 507, controls = 478) conducted in Milan, Italy.

* Brenner H, Rothenbacher D, Bode G, et al. Coronary heart disease risk reduction in a predominantly beer-drinking population. Epidemiol 2001;12:380-382.

Beer drinking is associated with a reduced risk of coronary heart disease. This conclusion is based on a case control study that included 312 patients with clinically stable, angiographically confirmed coronary heart disease, and 479 healthy controls. The odds ratio for coronary heart disease was 0.55 (95% CI, 0.37-0.83) for drinkers compared with non-drinkers. This inverse relationship persisted after controlling for possibly confounding variables, suggesting that the protective effect of alcoholic drinks is partly due to the effects of ethanol on lipids and hemostatic factors.

* Denke MA. Nutritional and health benefits of beer. Am J Med Sci 2000;320:320-326.

The moderate use of any type of alcoholic beverage is beneficial in reducing cardiovascular disease. The key is defining moderate use of alcohol: 1 drink per day for women and 2 for men. Physicians, however, have been reluctant to encourage moderate alcohol consumption for fear of alcohol abuse. As far as the nutritional benefit, beer has more of the B vitamins and more protein than wine. Although both beer and wine contain antioxidants, there are differences in the type of antioxidant, and there is no evidence to support the consumption of beer over wine or vice-versa.

* Mukamal KJ, Rimm EB. Alcohol's effects on the risk for coronary heart disease. Alcohol Res Health 2001;25:255-261.

Moderate drinking may promote molecular changes that reduce the risk of heart disease, but at the same time may induce other changes that promote heart disease. Genetics may also affect the relationship between heart disease and alcohol consumption. These were the conclusions from a Harvard Medical School review and metaanalysis of 42 studies.

* Rimm E. Alcohol and cardiovascular disease. Curr Atheroscler Rep 2000;2:529-535.

A review of 70 epidemiologic studies suggests a causal correlation between alcohol intake and reduced risk of coronary heart disease in healthy men and women. The beneficial effects of alcohol are partly due to its effects on serum lipids and clotting factors. There is as yet insufficient evidence to recommend that abstainers consume alcohol.

Additional readings

1. De Gaetano G, Cerletti C. Wine and cardiovascular disease. Nutr Metab Cadiovasc Dis 2001;11:47-50.

2. de Lorimier AA. Alcohol, wine, and health. Am J Surg 2000;180:357-361.

3. Janszky I, Mukamal KJ, Orth-Gomer K, et al. Alcohol consumption and coronary atherosclerosis progression--the Stockholm Female Coronary Risk Angiographic Study. Atherosclerosis 2004;176:311-319.

4. Sierksma A, Sarkola T, Eriksson CJ, et al. Effect of moderate alcohol consumption on plasma dehydroepiandrosterone sulfate, testosterone, and estradiol levels in middle-aged men and postmenopausal women: a diet-controlled intervention study. Alcohol Clin Exp Res 2004;28:780-785.

5. Wakabayashi I, Kobaba-Wakabayashi R. Effects of age on the relationship between drinking and atherosclerotic risk factors. Gerontology 2002;48:151-156.

Hypertension

* Thadhani R, Camargo CA Jr, Stampfer MJ, et al. Prospective study of moderate alcohol consumption and risk of hypertension in young women. Arch Intern Med 2002;162:569-574.

There is a U- or J-shaped association between alcohol consumption and risk of hypertension in young women. Relative risk by alcohol consumption level is presented in Table 1. This prospective study included 70,891 women between the ages of 25 and 42, and the follow up time was 8 years.

Additional reading

1. Stranges S, Wu T, Dorn JM, et al. Relationship of alcohol drinking pattern to risk of hypertension. A population-based study. Hypertension 2004;44:813-819.

Lipids

* van der Gaag MS, van Tol A, Vermunt SH, et al. Alcohol consumption stimulates early steps in reverse cholesterol transport. J Lipid Res 2001;42:2077-2083.

Alcohol consumption increases high-density lipoprotein (HDL) cholesterol levels by stimulating the cellular cholesterol efflux and its esterification in plasma. These effects are observed regardless of the type of alcoholic drink consumed: red wine, beer, or gin. These conclusions are based on a 3-week prospective study of 11 healthy middle-aged men.

* van Tol A, Hendriks HF. Moderate alcohol consumption: effects on lipids and cardiovascular disease risk. Curr Opin Lipidol 2001;12:19-23.

Epidemiologic studies suggest a causal inverse relationship between alcohol consumption and the risk of coronary heart disease, ischemic stroke, and possibly type 2 diabetes mellitus. Possible mechanisms include stimulation of HDL-mediated processes, reverse cholesterol transport, and anti-oxidative effects.

Additional reading

Lemos-Santos MG, Valente JG, Goncalves-Silva RM, et al. Waist circumference and waist-to-hip ratio as predictors of serum concentration of lipids in Brazilian men. Nutrition 2004;20:857-862.

Mortality

* Faris RF, Henein MY, Coates AJ. Influence of gender and reported alcohol intake mortality in nonischemic dilated cardiomyopathy. Heart Dis 2003;5:89-94.

Alcohol consumption increases mortality in females with nonischemic dilated cardiomyopathy and decreases mortality in males with the same condition (hazards ratios for death were 7.3 and 0.44, respectively). This gender relationship was consistent when adjusting for quantity of alcohol consumed. The data for this study were obtained from 396 consecutive patients with nonischemic dilated cardiomyopathy (mean age 53 years, 74% men). Of these patients, at a mean follow-up of 42 months, 83 patients had died and 15 underwent transplantation.

* Theobald H, Bygren LO, Carstensen J, et al. A moderate intake of wine is associated with reduced total mortality and reduced mortality from cardiovascular disease. J Stud Alcohol 2000;61:652-656.

Moderate consumption of wine reduces mortality. This conclusion is based on a study of 1,828 individuals between the ages of 18 and 65 years. Intake of wine once or more a week, compared with less than once a week or abstaining, was associated with a relative risk ratio of 0.58 for total mortality (95% CI, 0.40-0.84) and 0.49 for mortality from cardiovascular disease (95% CI, 0.27-0.90). The relative risk for ex-drinkers compared with lifelong abstainers and those who consume more than 50 grams of alcohol per week is 2.64 (95% CI, 1.56-4.49). Wine, beer, and distilled spirits consumption was assessed in all subjects and mortality recorded after 22 years.

* Wannamethee SG, Shaper AG. Taking up regular drinking in middle age: effect on major coronary heart disease events and mortality. Heart 2002;87:32-36.

The beneficial effects of alcohol consumption on heart-related illness may be offset by an increased risk of noncardiovascular and total mortality. New middle-aged regular drinkers have a lower risk for major coronary heart disease events than do stable occasional drinkers (RR, 0.70; 95% CI, 0.48-1.03; P = 0.07), but relative risk of noncardiovascular mortality is 1.40 (95% CI, 0.99-1.97; P = 0.06). These are the results of a prospective study that included 7,735 British men 40 to 59 years of age screened in 1978-1980, and follow-up data on changes in alcohol intake from 7,157 men 45 to 64 years of age 5 years later.

Also see the following reference in the Mortality section:

* Gaziano JM, Gaziano TA, Glynn RJ, et al. Light-to-moderate alcohol consumption and mortality in the Physicians' Health Study enrollment cohort. J Am Coll Cardiol 2000;35:96-105.

Additional reading

1. Renaud SC, Gueguen R, Conard P, et al. Moderate wine drinkers have lower hypertension-related mortality: a prospective cohort study in French men. Am J Clin Nutr 2004;80:621-625.

The Cardiovascular System: Damaging Effects of Alcohol

* Frost L, Vestergaard P. Alcohol and risk of atrial fibrillation or flutter: a cohort study. Arch Intern Med 2004;164:1993-1998.

Alcohol consumption was associated with an increased risk of atrial fibrillation in men (P for trend = 0.04) but not in women (P for trend = 0.69). These findings are based on the Danish Diet, Cancer, and Health Study (n = 47,949). Atrial fibrillation was developed in 556 participants (men 374, women 182). Mean alcohol consumption over the course of the study was 28.2 [+ or -] 25 grams for men and 13.9 [+ or -] 15 grams for women. The average follow-up time was 5.7 years.

* Marques-Vidal P, Arveiler D, Evans A, et al. Different alcohol drinking and blood pressure relationships in France and Northern Ireland: The PRIME Study. Hypertension 2001;38:1361-1366.

In Northern Ireland, where 66% of total alcohol consumption occurs on Fridays and Saturdays, blood pressures are higher on Mondays and decrease until Thursdays. Alcohol consumption in France only slightly increases during weekends, and blood pressures there remain constant. Nondrinkers from France and Northern Ireland show no variances in blood pressure levels. These are results from the Prospective Epidemiological Study of Myocardial Infarction, which included 6,523 male subjects in France and Northern Ireland who drank at least once a week.

* Murray RP, Connett JE, Tyas SL, et al. Alcohol volume, drinking pattern, and cardiovascular disease morbidity and mortality: is there a U-shaped function? Am J Epidemiol 2002;155:242-248.

Although it has no effect on the risk for other cardiovascular disease, binge drinking increases the risk of coronary heart disease in both men and women, and increases the risk of hypertension in men. This longitudinal, population-based study yielded a hazard ratio of 2.26 (95% CI, 1.22-4.20) for increased risk of coronary heart disease among men, and 1.10 (95% CI, 1.02-118) for women. Risk of hypertension was 1.57 (95% CI, 1.04-2.35) in men. Subjects between the ages of 18 and 64 years were interviewed in Winnipeg, Manitoba, Canada, and data obtained from 1,154 patients in 1990-1991 were linked to health care utilization and mortality records, with analyses performed for an 8-year follow-up period. Binge drinking was defined as consumption of 8 or more drinks at one sitting.

* Spies CD, Sander M, Stangl K, et al. Effects of alcohol on the heart. Curr Opin Crit Care 2001;7:337-343.

Consuming more than 90 to 100 g of alcohol per day damages the heart and can increase the risk of sudden cardiac death and cardiac arrhythmias, especially in coronary heart disease patients. In this review article, the authors report that cardiac complications after surgery are three to four times more frequent in heavy drinkers than in occasional or nondrinkers. Patients with heart failure due to cardiomyopathy will profit from intervention, but those who continue to drink alcohol or smoke tobacco products significantly increase their risk for hospitalization. To avoid adverse effects in the course of routine care, physicians should include the level of alcohol consumption in patients' records.

The Digestive System

Esophageal cancer and gastrointestinal cancer

* Engel LS, Chow WH, Vaughan TL, et al. Population attributable risks of esophageal and gastric cancers. J Natl Cancer Inst 2003;95:1404-1413.

The relationship of alcohol consumption to gastric cancer varies by type of gastric cancer according to this casecontrol study of 1,838 individuals (1,143 cases, 695 controls). Four types of gastric cancer were examined: esophageal adenocarcinoma (n = 293), gastric cardia adenocarcinoma (n = 261), esophageal squamous cell carcinoma (n = 221), and noncardiac gastric adenocarcinoma (n = 368). The population-attributable risks were calculated for risk factors known to be linked to gastric cancer. Alcohol consumption accounted for 72.4% (95% CI, 53.3-85.8%) of esophageal squamous cell carcinomas. Other risk factors analyzed included: smoking status, history of gastric ulcers, body mass index, H pylori infection, low fruit and vegetable intake, and history gastroesophageal reflux.

Additional readings

1. Dal Maso L, La Vecchia C, Polesel J, et al. Alcohol drinking outside meals and cancers of the upper aerodigestive tract. Int J Cancer 2002;102:435-437.

2. Morita M, Araki K, Sacki H, et al. Risk factors for multicentric occurrence of carcinoma in the upper aerodigestive tract-analysis with a serial histologic evaluation of the whole resected-esophagus including carcinoma. J Surg Oncol 2003;83:216-221.

3. Sasazuki S, Sasaki S, Tsugane S. Cigarette smoking, alcohol consumption and subsequent gastric cancer by subsite and histologic type. Int J Cancer 2002;101:560-566.

4. Znaor A, Brennan P, Gajalakshmi V, et al. Independent and combined effects of tobacco smoking, chewing, and alcohol drinking on the risk of oral, pharyngeal, and esophageal cancers in Indian men. Int J Cancer 2003;105:681-686.

Gastritis

* Brenner H, Rothenbacher D, Bode G, et al. Inverse graded relation between alcohol consumption and active infection with Helicobacter pylori. Am J Epidemiol 1999;149:571-576.

Alcohol consumption, particularly wine consumption, is associated with reduced risk of active infection with H pylori according to this cross-sectional study of German health insurance employees (n = 425). There was a significant inverse relationship between alcohol consumption and H pylori infection (P = 0.017) after controlling for confounding variables. Individuals consuming more than 75 g of alcohol per week had an infection odds ratio of 0.31 (95% CI, 0.12-0.81). The authors reported a stronger relationship between wine and H pylori infection. Alcohol consumption was assessed via questionnaire and active H pylori infection was evaluated using the 13C-urea breath test.

* Murray LJ, Lane AJ, Harvey IM, et al. Inverse relationship between alcohol consumption and active Helicobacter pylori infection: the Bristol Helicobacter project. Am J Gastroenterol 2002;97:2750-2755.

Moderate alcohol consumption (7 grams per week) is protective against H pylori infection. This cross-sectional population-based study (n = 10,537) measured H pylori infection using 13C-urea breath testing. Individuals consuming 3 to 6 units of wine per week had a lower risk of H pylori infection than those drinking no wine (OR, 0.89; 95% CI, 0.80-0.99) after controlling for age, sex, ethnic status, childhood and adult social class, smoking, coffee consumption, and intake of alcoholic beverages other than wine. Increased wine consumption was also associated with reduced risk of infection (OR, 0.83; 95% CI, 0.64-1.07). Intake of 3 to 6 units of beer was associated with a similar reduction in the risk of infection when compared to no beer intake (OR, 0.83; 95% CI, 0.75-0.91). Increased intake of beer was not associated with further reduction in risk. Coffee consumption and tobacco use were not associated with H pylori infection.

Additional reading

1. Brenner H, Berg G, Lappus N, et al. Alcohol consumption and Helicobacter pylori infection: results from the German National Health and Nutrition Survey. Epidemiology 1999;10:214-218.

Gastrointestinal bleeding

* Hsu PI, Lai KH, Tseng HH, et al. Risk factors for presentation with bleeding in patients with Helicobacter pylori-related peptic ulcer diseases. J Clin Gastroenterol. 2000;30:386-391.

Alcohol consumption was not related to risk of gastric bleeding according to this study of patients with H pylori-related ulcer diseases (n = 119). In a multivariate analysis, alcohol consumption, age, sex, smoking, the histologic grade of gastritis, location and number of ulcers, and the cytotoxin-associated gene (CagA) status of H pylori strain were not related to risk of bleeding. Use of NSAIDs (OR, 5:4; P = 0.0156), ulcer size of 1 cm or more (OR, 4:2; P = 0.0033), and low bacterial density (OR, 4:1; P = 0.0030) were independent factors associated with the risk of bleeding. Bleeding occurred in 39 of the patients.

* Kaufman DW, Kelly JP, Wiholm BE, et al. The risk of acute major upper gastrointestinal bleeding among users of aspirin and ibuprofen at various levels of alcohol consumption. Am J Gastroenterol 1999;94:3189-3196.

The risk of upper gastrointestinal bleeding (UGIB) is increased among individuals that are consuming alcohol and using nonprescription nonsteroidal antiinflammatory drugs (NSAIDS). The relative risk of UGIB was directly related to alcohol consumption. Those individuals consuming 21 or more drinks per week had a risk of 2.8 when compared to those consuming less than 1 drink per week. For regular aspirin use at dosages greater than 325 mg, the relative risk among current drinkers was 7.0. For those regularly using aspirin at dosages less than 325, the relative risk among current drinkers was 2.8, and for occasional aspirin users, the risk was 2.4. All of these values were reported to be statistically significant. The authors reported that relative risk of UGIB with ibuprofen use did not vary across alcohol consumption levels. For regular use of ibuprofen (all doses combined), the relative risk among all drinkers was 2.7. Occasional ibuprofen use was not related to UGIB.

Liver disease

* Abosh D, Rosser B, Kaita K, et al. Outcomes following liver transplantation for patients with alcohol- versus nonalcohol-induced liver disease. Can J Gastroenterol 2000;14:851-855.

Liver transplant patients who are alcoholics face more postoperative problems than do nonalcoholic transplant recipients. Although organ rejection is less common in alcoholics, overall posttransplantation outcomes are negatively affected by alcoholism. Table 2 shows the results of a study of 10 alcoholics and 48 nonalcoholics who attended a liver transplantation follow-up clinic for an average of 41 months.

* Becker U, Gronbaek M, Johansen D, et al. Lower risk for alcohol-induced cirrhosis in wine drinkers. Hepatology 2002;35:868-875.

Heavy alcohol consumption increases risk for cirrhosis, but wine drinkers have lower risk than those who drink beer or spirits. Relative risk increases as consumption increases. Having more than five drinks per day results in a relative risk of 14 to 20 for developing cirrhosis of the liver, compared with abstainers and light drinkers. If 51% or more of total alcoholic intake is wine, the relative risk for developing cirrhosis is 0.3 (95% CI, 0.2-0.5). If 16 to 30% of total alcoholic intake is wine, the relative risk is 0.4 (95% CI, 0.3-0.6). These are the results of three prospective studies in Copenhagen involving 30,630 subjects who provided data on weekly alcohol consumption, sex, age, body mass index, smoking habits, and education.

Additional readings

1. Dakeishi M, Iwata T, Ishii N, et al. Effects of alcohol consumption on hepatocellular injury in Japanese men. Tohoku J Exp Med 2004;202:31-39.

2. Yuan JM, Govindarajan S, Arakawa K, et al. Synergism of alcohol, diabetes, and viral hepatitis on the risk of hepatocellular carcinoma in blacks and whites in the U.S. Cancer 2004;101:1009-1017.

Nutrition and diet

* Kesse E, Clavel-Chapelon F, Slimani N, et al. Do eating habits differ according to alcohol consumption? Results of a study of French cohort of the European Prospective Investigation into Cancer and Nutrition (E3N-EPIC). Am J Clin Nutr 2001;74:322-327.

The consumption of alcohol can lead to changes in eating habits according to a study on a French cohort of women born between 1925 and 1950. The researchers reported that increased alcohol intake is linked to a greater consumption of foods containing cholesterol, fatty acids, retinol, iron, vitamin E, and energy in the form of proteins and lipids, as well as animal products, cheese, potatoes, oil, bread, and breakfast cereals. Conversely, increased alcohol consumption is linked to a decreased ingestion of vegetables, beta-carotene, and foods that provide energy through carbohydrates. Nutrition information from this study was obtained from 73,000 dietary questionnaires.

Nutrition and diet and older adults

Refer to Older Adults section

Additional general readings

1. Flechtner-Mors M, Biesalski HK, Jenkinson CP, et al. Effects of moderate consumption of white wine on weight loss in overweight and obese subjects. Int J Obes Retal Metab Disord 2004;28:1420-1426.

2. Klein BE, Klein R, Knudtson MD. Life-style correlates of tooth loss in an adult Midwestern population. J Public Health Dent 2004;64:145-150.

The Endocrine System

Insulin-dependent diabetes mellitus

* Toeller M, Buyken AE, Heitkamp G, et al. Nutrient intakes as predictors of body weight in European people with type 1 diabetes. Int J Obes 2001;25:1815-1822.

Moderate alcohol consumption (up to 20 g/day) was significantly predictive ([beta] = 1.211; P = 0.013) of increased waist circumference in men with type 1 diabetes according to this cross-sectional study of European diabetics. In women, no alcohol consumption significantly predicted a lower body mass index ([beta] = -0.567; P = 0.02). A total of 1,458 males and 1,410 females from the EURODIAB IDDM Complications Study were included in this analysis.

* Turner BC, Jenkins E, Kerr D, et al. The effect of evening alcohol consumption on next-morning glucose control in type 1 diabetes. Diabetes Care 2001;24:1888-1893.

Individuals with type 1 diabetes may experience hypoglycemia within hours of an after-dinner drink. This is the conclusion reached from a study of six type 1 diabetic men 19 to 51 years of age hospitalized from 5 PM until noon the following day on two occasions. Drinking dry white wine (0.75 g/kg alcohol) from 9 PM to 10:30 PM resulted in reduced fasting and postprandial blood glucose levels (postprandial peak 8.9 [1.7] vs 15 [1.5] mmol/l, P < 0.01). About 12 hours after wine consumption, five subjects required treatment for hypoglycemia (nadir 1.9-2.9 mmol/L). Reduced nocturnal growth hormone secretion occurred between midnight and 4 AM.

Insulin sensitivity

* Zilkens RR, Burke V, Watts G, et al. The effect of alcohol intake on insulin sensitivity in men: a randomized controlled trial. Diabetes Care 2003;26:608-612.

Reduction in moderate to heavy drinking from 7.2 to 0.8 drinks per day did not change insulin sensitivity in this study of 16 healthy men. After a 4 week period of replacing regular alcohol intake with 0.9% alcohol beer, there was no change in insulin sensitivity index, fasting insulin, glucose, or homeostasis model assessment (HOMA) score. The mean age of the participants was 51 years. The HOMA score is a surrogate measure of insulin sensitivity.

Effect of alcohol on individuals with noninsulin-dependent diabetes mellitus

* Diem P, Deplazes M, Fajfr R, et al. Effects of alcohol consumption on mortality in patients with type 2 diabetes mellitus. Diabetologia 2003;46:1581-1585.

Moderate alcohol consumption (60-30 g/day) was associated with increased all-cause mortality in Swiss individuals with type 2 diabetes (n = 287). For all-cause mortality, the relative risk was 0.36 (95% CI, 0.09-0.99; P < 0.05) for alcohol consumption of 16 to 30 g/day of alcohol compared to abstaining. There was also a U-shaped relationship between alcohol consumption and death from cardiovascular disease. Relative risk data is presented in Table 3. The participants in this study were part of the World Health Organization Multinational Study of Vascular Disease in Diabetes cohort. The mean follow up time for this study was 12.6 years.

* Solomon CG, Hu FB, Stampfer MJ, et al. Moderate alcohol consumption and risk of coronary heart disease among women with type 2 diabetes mellitus. Circulation 2000;102:494-499.

Alcohol consumption reduced the risk of coronary heart disease in women with diabetes according to this analysis of 39,092 person-years of follow-up. For women consuming five or more grams per day, the relative risk of coronary heart disease was reduced (RR, 0.48; 95% CI, 0.32-0.72) when compared to abstainers. The risk was also reduced for women consuming between 0.1 and 4.9 grams per day (RR, 0.74; 95% CI, 0.56-0.98). This study was based on the Nurses' Health Study cohort. After a 14-year follow-up period, there were 295 events of coronary heart disease.

* Tanasescu M, Hu FB, Willett WC, et al. Alcohol consumption and risk of coronary heart disease among men with type 2 diabetes mellitus. J Am Coll Cardiol 2001;38:1836-1842.

Men with type 2 diabetes mellitus may lower their risk of developing coronary heart disease by moderate alcohol consumption. These findings are based on the Health Professionals' Follow-up Study, which included 2,419 males with a diagnosis of diabetes at [greater than or equal to]30 years of age. Relative risk data is presented in Table 4.

* Wakabayashi I, Kobaba-Wakabayashi R, Masuda H. Relation of drinking alcohol to atherosclerotic risk in type 2 diabetes. Diabetes Care 2002;25:1223-1228.

Light drinking (<210 g/week) has protective effects on atherosclerosis in individuals with type 2 diabetes. There was lesser atherosclerotic progression in persons consuming light levels of alcohol when compared to nondrinkers and heavy drinkers (>210 g/week). Heavy drinkers had significantly increased systolic blood pressure, HDL cholesterol, and triglyceride levels when compared to light and nondrinkers. There was no significant difference in any of these parameters in light and nondrinkers. Mean BMI, glycosylated hemoglobin, uric acid, and fibrinogen were not different between the three groups. This cross-sectional analysis included 194 individuals with type 2 diabetes grouped by alcohol consumption level. Degree of atherosclerotic progression was assessed via aortic pulse wave velocity.

Risk of non-insulin-dependent diabetes mellitus

Editors' Note: The bulk of the research seems to support the notion that moderate alcohol consumption protects against developing non-insulin-dependent diabetes mellitus. For the sake of brevity, only a few studies of high quality are presented in this review. Many additional studies are referenced in the additional reading section for your review if this is an area of great interest.

* Ajani UA, Hennekens CH, Spelsberg A, et al. Alcohol consumption and risk of type 2 diabetes mellitus among US male physicians. Arch Intern Med 2000;160:1025-1030.

Low to moderate alcohol consumption may reduce men's risk of developing type 2 diabetes mellitus according to this prospective cohort study of 20,951 physicians 40 to 84 years of age. Relative risk data is presented in Table 5. Average follow-up period was 12.1 years, and the results reflect adjustment for age, smoking, physical activity, and body mass index. Hypertension, cholesterol, and family history of myocardial infarction and diabetes did not influence the results.

* Conigrave KM, Hu BF, Camargo CA Jr, et al. A prospective study of drinking patterns in relation to risk of type 2 diabetes among men. Diabetes 2001;50:2390-2395.

Frequent alcohol consumption substantially reduces the risk of type 2 diabetes mellitus in men, regardless of the choice of beverage. Risk is reduced by 7% (95% CI: 3-10%) for each additional day of alcohol consumption when compared to infrequent drinkers, and drinking at least five days a week appears to be the most beneficial. Those who drink 15 to 29 g alcohol per day reduce their risk of developing diabetes by 36% (RR, 0.64; 95% CI, 0.53-0.77) compared to abstainers, and the relative risk is 0.60 (95% CI, 0.50-0.73) when compared to light drinkers. Relative risk is 0.48 (95% CI, 0.27-0.86) for less than one drink per day. These are the results of a 12-year prospective study of 46,892 men. Data were collected from biennial questionnaires of US health professionals.

Additional readings

1. Carlsson S, Hammar N, Efendic S, et al. Alcohol consumption, type 2 diabetes mellitus and impaired glucose tolerance in middle-aged Swedish men. Diabet Med 2000;17:776-781.

2. Carlsson S, Hammar N, Grill V, et al. Alcohol consumption and the incidence of type 2 diabetes: a 20-year follow-up of the Finnish twin cohort study. Diabetes Care 2003;26:2785-2790.

3. de Vegt F, Dekker JM, Groeneveld WJ, et al. Moderate alcohol consumption is associated with lower risk for incident diabetes and mortality: the Hoorn Study. Diabetes Res Clin Pract 2002;57:53-60.

4. Kao WH, Puddey IB, Boland LL, et al. Alcohol consumption and the risk of type 2 diabetes mellitus: atherosclerosis risk in communities study. Am J Epidemiol 2001;154:748-757.

5. Lu W, Jablonski KA, Resnick HE, et al. Alcohol intake and glycemia in American Indians: the strong heart study. Metabolism 2003;52:129-135.

6. Wannamethee SG, Shaper AG, Perry IJ, et al. Alcohol consumption and the incidence of type II diabetes. J Epidemiol Community Health 2002;56:542-548.

7. Wannamethee SG, Camargo CA Jr, Manson JE, et al. Alcohol drinking patterns and risk of type 2 diabetes mellitus among younger women. Arch Intern Med 2003;163:1329-1336.

8. Wei M, Gibbons LW, Mitchell TL, et al. Alcohol intake and incidence of type 2 diabetes in men. Diabetes Care 2000;23:18-22.

Pancreatic cancer

* Michaud DS, Giovannucci E, Wilett WC, et al. Coffee and alcohol consumption and the risk of pancreatic cancer in two prospective United States cohorts. Cancer Epidemiol Biomarkers Prev 2001;10:429-437.

Alcohol consumption is not related to risk of pancreatic cancer according to this prospective study of 136,593 individuals (47,794 men, 88,799 women). After 1,907,222 person-years of follow up, 288 cases of pancreatic cancer were reported. Relative risk data from this study are presented in Table 6. There was no significant relationship between alcohol consumption and risk of pancreatic cancer (P = 0.94). This study was obtained from two large cohort studies, the Health Professionals Follow-Up Study and the Nurses' Health Study. The results from these two studies were pooled to determine overall relative risk for pancreatic cancer.

* Villeneuve PJ, Johnson KC, Hanley AJ, et al. Alcohol, tobacco, and coffee consumption and the risk of pancreatic cancer: results from the Canadian Enhanced Surveillance System case-control project. Eur J Cancer Prev 2000;9:49-58.

Alcohol consumption was not significantly related to risk of pancreatic cancer in this case-control study. Cigarette smoking was related to risk of pancreatic cancer in men and women. This study included 583 cases of histologically confirmed pancreatic cancer and 4,814 controls.

Additional readings

1. Lin Y, Tamakoshi A, Kawamura T, et al. Risk of pancreatic cancer in relation to alcohol drinking, coffee consumption and medical history: findings from the Japan collaborative cohort study for evaluation of cancer risk. Int J Cancer 2002;10:742-746.

2. Zheng W, McLaughlin JK, Gridley G, et al. A cohort of smoking, alcohol consumption, and dietary factors for pancreatic cancer (United States). Cancer Causes Control 1993;4:477-482.

Thyroid function

* Knudsen N, Bulow I, Laurberg P, et al. Alcohol consumption is associated with reduced prevalence of goitre and solitary thyroid nodules. Clin Endocrinol (Oxf) 2001;55:41-46.

Moderate to high alcohol consumption decreases the risk for thyroid enlargement and solitary nodules in the thyroid. As wine or beer consumption increases, the prevalence for these thyroid abnormalities decreases. In a cross-sectional study of 4,649 Danish subjects 18 to 65 years of age, the odds ratio for thyroid enlargement in high alcohol consumers was 0.44 (95% CI, 0.22-0.88) and 0.74 (95% CI, 0.57-0.96) in moderate consumers compared to nondrinkers. The odds ratio for a solitary nodule was 0.41 (95% CI, 0.12-1.37) in high alcohol consumers and 0.64 (95% CI, 0.42-0.96) in moderate consumers. High alcohol consumers had an average thyroid volume of 10.9 mL, compared to 13.5 mL in nondrinkers. Thyroid abnormality prevalence did not vary between abstainers and low alcohol groups. Low alcohol consumption was defined as less than 7 drinks/week, moderate as 8-28 drinks/week for women and 8-42 drinks/week for men, and high as 28-42 drinks/week.

The Immune System

Editor's Note: The effect of alcohol on the immune system is not well documented. Moderate alcohol intake may produce some benefits, including protection against immune cell damage via antioxidants. The two study summaries included present conflicting results. Differences may be attributable to measurement of immune function (eg, biomarkers versus rate of infection) and the state of the participants (healthy versus postsurgery).

* Watzl B, Bub A, Pretzer G, et al. Daily moderate amounts of red wine or alcohol have no effect on the immune system of healthy men. Eur J Clin Nutr 2004;58:40-45.

Daily intake of red wine does not negatively impact immune function according to this longitudinal study of 24 healthy males. After daily consumption of 500 mL of alcohol (red wine or diluted ethanol) for 2 weeks, immune system parameters were unaffected. The authors concluded that daily intake of alcohol for cardiovascular disease risk reduction does not impair immune function. In this study, the following immune-related parameters were measured: phagocytic activity of neutrophils and monocytes, production of tumor necrosis factor-alpha (TNF-[alpha]), interleukin-2 and -4, transforming growth factor-beta, TNF-[alpha] mRNA, lymphocyte proliferation, lytic activity of natural killer cells, and percentage of apoptotic lymphocytes.

* Delgado-Rodriguez M, Mariscal-Ortiz M, Gomez-Ortega A, et al. Alcohol consumption and the risk of nosocomial infection in general surgery. Br J Surg 2003;90:1287-1293.

Male surgical patients who reported a high intake of alcohol (greater than 108 grams per day) had an increased risk of post-operative nosocomial infections (OR, 2.51; 95% CI, 1.06-5.96). Alcohol consumption greater than 72 grams per day was associated with an increased risk of lower respiratory tract infection (OR, 5.22; 95% CI, 1.04-26.2). This data was obtained from a longitudinal study of 1,505 consecutive general surgery patients.

The Nervous System

Central nervous system and cognitive function

* DeCarli C, Miller BL, Swan GE, et al. Cerebrovascular and brain morphologic correlates of mild cognitive impairment in the National Heart, Lung, and Blood Institute twin study. Arch Neurol 2001;58:643-647.

This study reported a significant, positive correlation between alcohol consumption and cognitive performance. Alcohol consumption offered a protective effect against mild cognitive impairment (MCI) for individuals with previous cerebrovascular accident (RR, 0.93; 95% CI, 0.88-0.99; P < 0.05). Subjects with MCI reported fewer consumed alcoholic drinks per day than those without MCI (3.7 vs 7.0). In this longitudinal study of 514 pairs of male twins born between 1917 and 1927, cognitive function was assessed using the California Verbal Learning Test. MCI was defined as a score of 4 or less on that test.

* Ding J, Eigenbrodt ML, Mosley TH Jr, et al. Alcohol intake and cerebral abnormalities on magnetic resonance imaging in a community-based population of middle-aged adults: the Atherosclerosis Risk in Communities (ARIC) study. Stroke 2004;35:16-21.

Alcohol intake was associated with brain atrophy in this prospective study of 1,909 middle-aged adults in the southeastern United States. For every additional alcoholic beverage per week, there was an increase in ventricular size (P = 0.03) and an increase in sulcal size (P = 0.02), even after adjusting for age, sex, body mass index, smoking, income, sports index, and diabetes. These findings were significant for all age and race groups. Additionally, alcohol was not protective against cerebral infarction. MRI scans were used to assess presence of cerebral infarction, extent of white matter lesions, ventricle size, and sulcal size. The scans were obtained during 1993 and 1994 as part of the Atherosclerosis Risk in Communities study.

* Mukamal KJ, Longstreth WT Jr, Mittleman MA, et al. Alcohol consumption and subclinical findings on magnetic resonance imaging of the brain in older adults: the cardiovascular health study. Stroke 2001;32:1939-1946.

There was a U-shaped relationship between alcohol consumption and white brain matter abnormalities in this cross-sectional study of 3,376 adults aged 65 and older. Based on this study, individuals reporting between 1 and 7 drinks per week had an odds ratio of 0.68 when compared to nondrinkers, and heavy drinkers had an odds ratio of 0.95 (P = 0.01 for trend). In addition, when compared to abstainers, heavy drinking was related to lower occurrence of infarcts (OR, 0.59; P = 0.004), larger ventricle size (OR, 1.32; P = 0.006) and sulcal size (OR, 1.53; P = 0.007). This study was based on the Cardiovascular Health Study cohort, which included 3,660 adults 65 years of age or older. For this study, 284 original cohort members were excluded due to confirmed cerebrovascular disease. MRI data was collected from 1992 to 1994. White matter grade, infarcts, ventricle size, and sulcal size were assessed by blinded neuroradiologists.

Additional reading

1. Bond GE, Burr R, McCurry SM, et al. Alcohol, gender, and cognitive performance: a longitudinal study comparing older Japanese and non-Hispanic white Americans. J Aging Health 2004;16:615-640.

2. Cervilla JA, Prince M, Joels S, et al. Long-term predictors of cognitive outcome in a cohort of older people with hypertension. Br J Psychiatry. 2000;177:66-71.

3. Gururaj G. The effect of alcohol on incidence, pattern, severity and outcome from traumatic brain injury. J Indian Med Assoc 2004;102:157-160, 163.

4. Zhang Y, Heeren T, Curtis Ellison R. Education Modifies the Effect of Alcohol on Memory Impairment: The Third National Health and Nutrition Examination Survey. Neuroepidemiology 2004;24:63-69.

5. Zuccala G, Onder G, Pedone C, et al. Dose-related impact of alcohol consumption on cognitive function in advanced age: results of a multicenter survey. Alcohol Clin Exp Res 2001;25:1743-1748.

Dementia

* Mukamal KJ, Kuller LH, Fitzpatrick AL, et al. Prospective study of alcohol consumption and risk of dementia in older adults. JAMA 2003;19:1405-1413.

Individuals consuming one to six drinks weekly had a lower risk of dementia than abstaining individuals. Those consuming 14 or more drinks a week were more at risk than abstainers. Relative risk information is presented in Table 7. These conclusions are based on a case-control analysis of data from a prospective study (cases = 373, controls = 373). Participants underwent cognitive testing and MRI of the brain between 1992 and 1994 and were followed until 1999.

* Ruitenberg A, van Swieten JC, Witteman JC, et al. Alcohol consumption and risk of dementia: the Rotterdam Study. Lancet 2002;359:281-286.

Light-to-moderate alcohol consumption (one to three drinks per day) is associated with a decreased risk of dementia (Alzheimer disease, vascular dementia, etc.) in individuals aged 55 years or older. These are the conclusions of a prospective study of 7,983 individuals who showed no previous signs of dementia. Results are based on an average follow-up period of 6 years, during which time 197 individuals developed some form of dementia, Alzheimer disease being the most common form. Each case was adjusted for age, gender, systolic blood pressure, level of education, cigarette use, and body-mass index, to determine the risk level of developing dementia associated with individuals who regularly consumed alcohol as opposed to those who did not.

Additional reading

1. Bennett HP, Corbett AJ, Gaden S, et al. Subcortical vascular disease and functional decline: a 6-year predictor study. J Am Geriatr Soc 2002;50:1969-1977.

2. den Heijer T, Vermeer SE, van Dijk EJ, et al. Alcohol intake in relation to brain magnetic resonance imaging findings in older persons without dementia. Am J Clin Nutr 2004;80:992-997.

3. Fujishima M, Kiyohara Y. Incidence and risk factors of dementia in a defined elderly Japanese population: the Hisayama study. Ann N Y Acad Sci 2002;977:1-8.

4. Huang W, Qiu C, Winblad B, et al. Alcohol consumption and incidence of dementia in a community sample aged 75 years and older. J Clin Epidemiol 2002;55:959-964.

5. Leibovici D, Ritchie K, Ledesert B, et al. The effects of wine and tobacco consumption on cognitive performance in the elderly: a longitudinal study of relative risk. Int J Epidemiol 1999;28:77-81.

6. Truelsen T, Thudium D, Gronbaek M. Amount and type of alcohol and risk of dementia: the Copenhagen City Heart Study. Neurology 2002;59:1313-1319.

Eye disease: age-related macular degeneration

* Ajani UA, Christen WG, Manson JE, et al. A prospective study of alcohol consumption and the risk of age-related macular degeneration. Ann Epidemiol 1999;9:172-177.

Alcohol intake was not associated with an increased risk of developing age-related macular degeneration (AMD) according to this prospective study of 22,017 males between the ages of 40 and 84 years at baseline. At a 12.5 year follow up, there were 278 cases of AMD confirmed by medical record review. The relative risk for AMD by alcohol consumption levels are presented in Table 8. This study was based on the Physicians' Health Study cohort.

* Cho E, Hankinson SE, Willett WC, et al. Prospective study of alcohol consumption and risk of age-related macular degeneration. Arch Ophthalmol 2002;118:681-688.

Moderate alcohol consumption does not appear to reduce the risk of age-related macular degeneration (AMD) (see Table 9). This finding is based on a prospective study of 62,252 health care professionals (32,764 women, 29,488 men). After 697,498 person years of follow up, there were 298 cases of AMD in women and 153 cases in men. There were no protective effects for specific types of alcohol.

Eye disease: cataracts

* Chasen-Taber L, Willett WC, Seddon JM, et al. A prospective study of alcohol consumption and cataract extraction among U.S. women. Ann Epidemiol 2000;10:347-353.

Alcohol intake is not associated with an increased risk of cataract according to this prospective study of 77,466 female registered nurses. After a 12-year follow up, there were 1,468 cases of cataract in the cohort. Even at alcohol consumption levels of 2 drinks per day, there was no increased risk of cataract after controlling for cigarette smoking, body mass index, and diabetes. When isolating subtypes of cataract, only individuals in the highest category of alcohol consumption had an increased relative risk of 1.10 for nuclear cataracts and 1.50 for posterior subcapsular cataracts.

Additional reading

1. Klein R, Klein BE, Tomany SC, et al. Ten-year incidence of age-related maculopathy and smoking and drinking: The Beaver Dam Study. Am J Epidemiol 2002;165:589-598.

Hearing

* Nakamura M, Aoki N, Nakashima T, et al. Smoking, alcohol, sleep and risk of idiopathic sudden deafness: a case-control study using pooled controls. J Epidemiol 2001;11:81-86.

The consumption of alcohol in addition to a lack of sleep may increase the risk of idiopathic sudden deafness. This suggestion is based on a study conducted in Japan between October 1996 and August 1998 that examined the possible links between idiopathic sudden deafness and smoking, alcohol consumption, and sleep habits. After analyzing data gleaned from self-administered questionnaires completed by 164 patients with sudden deafness and 20,313 controls obtained from a nationwide database, it was determined that those who drank two or more units of alcohol per day (OR, 1.90; 95% CI, 1.12-3.21) and who had fewer than seven hours of sleep per night (OR, 1.61; 95% CI, 1.09-2.37) had a greater risk of developing idiopathic sudden deafness than those who did not. Smoking was not observed to be a factor in developing sudden deafness.

* Popelka MM, Cruickshanks KJ, Wiley TL, et al. Moderate alcohol consumption and hearing loss: a protective effect. J Am Geriatr Soc 2000;48:1273-1278.

The consumption of less than 140 grams/week of alcohol reduces the risk of sustaining hearing loss, regardless of age or gender. The reported odds ratio was 0.71 where pure tone average is 0.5, 1, 2, 4 > 25 dB hearing loss (95% CI, 0.52-0.97) and 0.49 for 0.5, 1, 2, 4 > 40 dB, which is considered moderate hearing loss (95% CI, 0.32-0.74). Individuals who have 4 or more drinks per day are at increased risk of high frequency hearing loss, with an odds ratio of 1.35 (95% CI, 1.04-1.75). Results are based on a cross-sectional population-based cohort study of 3,722 residents of the midwestern community of Beaver Dam, Wisconsin, who were 43 to 84 years of age. Measurements were obtained by pure tone air and bone conduction audiometry (250-8000 Hz). Confounding variables were adjusted for in the analyses.

Stroke: risk of stroke

* Djousse L, Ellison RC, Beiser A, et al. Alcohol consumption and risk of ischemic stroke: The Framingham Study. Stroke 2002;33:890-891.

Drinking alcohol, especially wine, may lower the risk of ischemic stroke in both men and women 60 to 69 years of age. This conclusion is based on a study of 441 adults divided into categories of never drinkers, drinkers of 0.1-11 g/day, drinkers of 12-23 g/day, drinkers of [greater than or equal to]24 g/day of ethanol, and former drinkers of 0.1-11 and [greater than or equal to]12 g/day.

* Klatsky AL, Armstrong MA, Friedman GD, et al. Alcohol drinking and risk of hemorrhagic stroke. Neuroepidemiology 2002;21:115-122.

Light drinking (1-2 drinks per day) does not increase the risk of hemorrhagic stroke (HS) and may actually reduce the risk by 20 percent or more. Heavy drinkers (those who consume 6 or more drinks per day) almost double their risk of HS. These are the conclusions of a study which examined the association between alcohol consumption and subsequent hospitalization for HS in 431 people. Relative risk of HS for different rates of alcohol consumption is shown in Table 10.

* Malarcher AM, Giles WH, Croft JB, et al. Alcohol intake, type of beverage, and the risk of cerebral infarction in young women. Stroke 2001;32:77-83.

Consuming up to 24 g alcohol per day lowers the risk of ischemic stroke in women 15 to 44 years of age. This conclusion is based on a population-based case-control study of 616 patients in the Baltimore-Washington area. Data studied included lifetime alcohol consumption, as well as type of consumption in the previous year, week, and day. Wine consumption, as opposed to beer and liquor, indicated a protective effect in the previous year. Relative risk compared to those who never drank is shown in Table 11.

* Reynolds K, Lewis B, Nolen JD, et al. Alcohol consumption and risk of stroke: a meta-analysis. JAMA 2003;289:579-588.

According to this meta-analysis of 35 studies, there is a U-shaped relationship between alcohol consumption and risk of stroke. With heavy drinking (>60 g/day), there is an increased risk of stroke compared to abstainers, and with light to moderate drinking (<12 g/day), there is a decreased risk of stroke when compared to the same group. The relative risk values are presented in Tables 12 and 13.

Additional reading

1. Berger K, Ajani UA, Kase CS, et al. Light to moderate alcohol consumption and risk of stroke among U.S. male physicians. N Engl J Med 1999;341:1557-1564.

2. Djousse L, Ellison RC, Beiser A, et al. Alcohol consumption and risk of ischemic stroke: The Framingham Study. Stroke 2002;33:907-912.

3. Lee SC, Park SJ, Ki HK, et al. Prevalence and risk factors of silent cerebral infarction in apparently normal adults. Hypertension 2001;36:73-77.

4. Mazzaglia G, Britton AR, Altmann DR, et al. Exploring the relationship between alcohol consumption and non-fatal or fatal stroke: a systematic review. Addiction 2001;96:1743-1756.

5. Sacco RL, Elkind M, Boden-Albata B, et al. The protective effect of moderate alcohol consumption on ischemic stroke. JAMA 1999;28:53-60.

Stroke: stroke mortality

* Hansagi H, Romelsjo A, Gerhardsson ve Verdier M, et al. Alcohol consumption and stroke mortality. 20-year follow-up of 15,077 men and women. Stroke 1995;26:1768-1773.

Infrequent alcohol consumption (a few times a year or less often) was associated with an increased risk of ischemic stroke in men (RR, 2.0; 95% CI, 1.3-3.2). Also at an increased risk of ischemic stroke were men reporting binge drinking a few times a year (RR, 1.8; 95% CI, 1.1-2.8) or infrequent intoxication (RR, 1.6; 95% CI, 1.1-2.5). In women, former drinkers had an increased risk of fatality from ischemic stroke (RR, 3.3; 95% CI, 1.5-7.2). Risk of ischemic stroke was reduced in those women reporting 0 to 5 grams per day of pure alcohol (RR, 0.6; 95% CI, 0.5-0.8), in those who do not drink daily (RR, 0.7; 95% CI, 0.5-0.9), in those who never binge drink (RR, 0.6; 95% CI, 0.5-0.8), and in those whomever felt intoxicated (RR, 0.7; 95% CI, 0.5-0.9). There was no association between alcohol consumption and risk of hemorrhagic stroke. These findings are based on a 20 year follow-up study of 15,077 men and women.

* Jackson VA, Sesso HD, Buring JE, et al. Alcohol consumption and mortality in men with preexisting cerebrovascular disease. Arch Intern Med 2003;163:1189-1193.

Light to moderate alcohol consumption reduced the risk of mortality in men with a history of stroke in this prospective study of 112,528 men from the Physicians' Health Study. The study also examined risk of mortality from the following conditions: cardiovascular disease, cancer, myocardial infarction, stroke, or ischemic cardiovascular heart disease. Of these, only total mortality and cardiovascular disease were significantly associated with alcohol consumption (P = 0.03 and P = 0.008, respectively). Relative risk data for total mortality and cardiovascular disease are presented in Tables 14 and 15. There were 1,320 men with a history of stroke at this study baseline.

The Reproductive System

Female fertility

* Gill J. The effects of moderate alcohol consumption on female hormone levels and reproductive function. Alcohol Alcohol 2000;35:417-423.

Moderate alcohol consumption may induce an increase in natural or synthetic estrogen levels in women according to this review of current literature. This may be due to increased aromatization of testosterone or a decrease in estradiol to osterone oxidation. Moderate alcohol consumption may also be related to decreased progesterone levels in premenopausal women. These conclusions and their implications in women's health are discussed in this review.

* Grodstein F, Goldman MB, Cramer DW. Infertility in women and moderate alcohol use. Am J Public Health 1994;84:1429-1432.

Alcohol consumption was linked to an increased risk of infertility due to ovulatory factors for moderate drinkers (OR, 1.3; 95% CI, 1.0-1.7) and heavy drinkers (OR, 1.6; 95% CI, 1.1-2.3) in this case-control study. The trend for increased risk of infertility with increased levels of drinking was significant (P = 0.005). Additionally, there was a link between alcohol consumption and increased risk for infertility due to endometriosis in moderate drinkers (OR 1.6, 95% CI, 1.1-2.3) and heavy drinkers (OR, 1.5; 95% CI, 0.8-2.7). No P value was reported for this trend. This study was based on 3,833 controls and 1,050 cases.

* Juhl M, Nyboe AM, Gronbaek M, et al. Moderate alcohol consumption and waiting time to pregnancy. Hum Reprod 2001;16:2705-2709.

Moderate alcohol consumption was not related to significant reductions in fecundity. In nulliparous women, there was no relationship between moderate or high intake of alcohol and reduced fecundity. There was a relationship between waiting time to pregnancy and high alcohol intake (>14 drinks per week) in parous women (OR, 1.3; 95% CI, 1.0-1.7). Women who reported no alcohol intake had reduced fecundity (OR, 1.2; 95% CI, 1.1-1.3). This information was obtained from a study of 39,612 women recruited from the Danish National Birth Cohort who were studied to determine the effect of alcohol intake on waiting time to pregnancy. Alcohol consumption and waiting time to pregnancy were assessed via self-report.

Additional reading

1. Emanuele MA, Wezeman F, Emanuele NV. Alcohol's effects on female reproductive function. Alcohol Res Health 2002;26:274-281.

2. Tolstrup JS, Kjaer SK, Holst C, et al. Alcohol use as a predictor for infertility in a representative population of Danish women. Acta Obstet Gynecol Scand 2003;82:744-749.

Male fertility

* Chia SE, Lim ST, Tay SK, et al. Factors associated with male infertility: a case-control study of 218 infertile and 240 fertile men. BJOG 2000;107:55-61.

Alcohol consumption is not a significant predictor of male infertility according to a case-control study of 218 infertile men and 240 fertile men. Semen parameters (density, total sperm counts, motility, viability, and morphology) and lifestyle factors (alcohol consumption, smoking, and profession) were measured in all participants. Risk of infertility was significantly associated with smoking.

* Horak S, Polanska J, Widlak P. Bulky DNA adducts in human sperm: relationship with fertility, semen quality, smoking, and environmental factors. Mutat Res 2003;537:53-65.

Alcohol consumption does not alter DNA structure in a way that affects fertility in men according to this study of 179 males with impaired fertility. A certain structural change called adducts can occur in the DNA of spermatogenic cells in response to genotoxins. The genotoxic potential of alcohol is not well understood, so this study measured DNA adduct levels and compared them to lifestyle factors (alcohol consumption, coffee consumption, and tobacco use). The authors reported no significant correlations between alcohol or coffee consumption and DNA adduct levels. Smokers had a 1.7-fold increase in DNA adduct levels compared to non-smokers (P = 0.008). There was a significant relationship between DNA adduct levels and other markers of infertility (sperm concentration and sperm motility) among patients with impaired infertility (r = -0/225; P < 0.029).

IVF/GIFT outcomes

* Klonoff-Cohen H, Lam-Kruglick P, Gonzalez C. Effects of maternal and paternal alcohol consumption on the success rates of in vitro fertilization and gamete intrafallopian transfer. Fertil Steril 2003;79:330-339.

Alcohol consumption was significantly associated with decreased success rates for in vitro fertilization (IVF) and gamete intrafallopian transfer (GIFT). This multisite study of 221 couples undergoing IVF or GIFT measured past and present alcohol consumption in both the women and men. Maternal alcohol consumption during the year before IVF/GIFT was negatively correlated with oocyte retrieval (RR, 0.87; 95% CI, 0.77-0.98), even when controlling for age, race, educational background, parity, indications for IVF/GIFT, type of procedure, and number of procedures. Women consuming alcohol during the first week of the fertility intervention had an increase in the number of eggs fertilized (RR, 1.59; 95% CI, 1.11-2.28). Maternal alcohol consumption [greater than or equal to]12 g/day had a 2.86 fold increase in the risk of not becoming pregnant (95% CI, 0.99-8.24). Paternal alcohol consumption was also related to IVF/GIFT success. It is important to note that the authors reported no statistical relationship between maternal alcohol consumption and live births, gestational age, or multiple gestations.

Editors' Note: This study may be limited by the large number of statistical analyses that were performed. Additionally, it is important to keep in mind that couples undergoing IVF or GIFT are a specialized group of patients, and this information is not readily applicable to the general population.

Ovarian cancer

* Goodman MT, Tung KH. Alcohol consumption and the risk of borderline and invasive ovarian cancer. Obstet Gynecol 2003;101:1221-1228.

According to this case-control study of 1,165 women (558 cases, 607 controls), type of alcohol consumed and timing of alcohol exposure may be related to risk of ovarian cancer.

In this study, women who currently drank alcohol had a significantly reduced odds ratio for invasive ovarian cancer compared with abstainers (OR, 0.69; 95% CI, 0.50-0.96). Additionally, women who drank red wine had a significantly reduced odds ratio for ovarian cancer compared to abstainers (OR, 0.61; 95% CI, 0.39-0.94). There was a significant increased risk of borderline serious tumors associated with the consumption of spirits (OR, 2.66; 95% CI, 1.46-4.85).

Additional reading

1. Kuper H, Titus-Ernstoff L, Harlow BL, et al. Population based study of coffee, alcohol, and tobacco use and risk of ovarian cancer. Int J Cancer 2000;88:313-318.

2. La Vecchia C, Negri E, Franceschi S, et al. Alcohol and epithelial ovarian cancer. J Clin Epidemiol 1992;45:1025-1030.

3. Tavani A, Gallus S, Dal Maso L, et al. Coffee and alcohol intake and risk of ovarian cancer: an Italian case-control study. Nutr Cancer 2001;39:29-34.

Sexually transmitted diseases

* Cook RL, Pollock NK, Rao AK, et al. Increased prevalence of herpes simplex virus type 2 among adolescent women with alcohol use disorders. J Adolesc Health 2002;30:169-174.

Young women suffering from alcohol use disorders (AUDs) are at significantly increased risk of contracting herpes simplex virus type 2 (HSV-2). This conclusion is based on a four-year study of 240 sexually active adolescents (mean age of 17.5 years). Participants provided demographic and sexual activity information, as well as a serum sample tested for HSV-2, hepatitis B virus, and human immunodeficiency virus. Among study participants, 15% of women with an AUD tested positive for HSV-2, compared to 10.5% in women without an AUD (OR, 8.1; 95% CI, 1.5-44.8; P = 0.017).

The Respiratory System

Lung cancer

Djousse L, Dorgan JF, Zhang Y, et al. Alcohol consumption and risk of lung cancer: The Framingham Study. J Natl Cancer Inst 2002;94:1877-1882.

Alcohol consumption was not statistically associated with risk of lung cancer, after a mean follow up time of 32.8 years, in this study using the Framingham Study cohort (n = 4,265 original participants, n = 4,973 offspring). Using a multiple logistical regression model, the authors did not find any significant relationship between alcohol consumption and lung cancer after adjusting for age, sex, pack-years of smoking, smoking status, and year of birth. The authors pointed out that the majority of the participants reported light to moderate drinking (<12 g/day).

* Neuenschwander AU, Pedersen JH, Kransnik M, et al. Impaired postoperative outcome in chronic alcohol abusers after curative resection for lung cancer. Eur J Cardiothorac Surg 2002;22:287-291.

Alcohol intake of five or more drinks per day increased 30-day mortality in postoperative lung resection patients (OR, 13.80; 95% CI, 2.06-92.68; P = 0.007). Additionally, those patients drinking at least five alcoholic beverages a day experienced more major complications following surgery (OR, 3.38; 95% CI, 1.02-11.25; P = 0.047). These findings were reported by a retrospective study of 107 Danish patients (42 women, 65 men) who underwent curative lung resection for lung cancer.

Additional reading

1. Freudenheim JL, Ram M, Nie J, et al. Lung cancer in humans is not associated with lifetime total alcohol consumption or with genetic variation in alcohol dehydrogenase 3 (ADH 3). J Nutr 2003;133:3619-3624.

2. Gajalakshmi V, Hung RJ, Mathew A, et al. Tobacco smoking and chewing, alcohol drinking and lung cancer risk among men in southern India. Int J Cancer 2003;107:441-447.

Obstructive sleep apnea

* Scanlan MF, Roebuck T, Little PJ, et al. Effect of moderate alcohol upon obstructive sleep apnea. Eur Respir J 2000;16:909-913.

A moderate amount of alcohol significantly increased obstructive sleep apnea frequency and heart rate, but not apnea length or snoring intensity, in this study of 21 males. A mean blood alcohol concentration of 0.07 g/dL increased the mean apnea/hypopnea index from 7.1 ([+ or -]1.9) to 9.7 ([+ or -]2.1). Mean sleep cardiac frequency increased from 53.9 ([+ or -]1.4) to 59.9 ([+ or -]1.9) beats per minute (P < 0.001) when 0.5 g alcohol per kilogram of body weight was consumed 90 minutes before sleeping. Participants in this study underwent polysomnography with and without alcohol.

The Skeleton

Editor's Note: There is an enormous amount of research involving the effects of alcohol on bone loss. The majority of the basic science research supports the notion that large amounts of alcohol are detrimental to bone health. Alcohol appears to act on the skeleton both directly and indirectly. Alcohol (ethanol) acts directly by reducing bone formation and by decreasing osteoblast proliferation. Alcohol also acts indirectly via the mineral regulating hormones parathyroid hormone, calcitonin, and the vitamin D metabolites. The epidemiological evidence, however, appears to support the notion that light to moderate alcohol consumption improves bone health. The U-shaped relationship between alcohol consumption and skeletal health appears to be a common theme in most of the existing research.

For more background information on this topic, please refer to one of these excellent review articles:

1. Sampson HW. Alcohol, osteoporosis, and bone regulating hormones. Alcohol Clin Exp Res 1997;21:400-403.

2. Turner RT. Skeletal response to alcohol. Alcohol Clin Exp Res 2000;24:1693-1701.

Alcohol and fractures

* Baron JA, Farahmand BY, Weiderpass E, et al. Cigarette smoking, alcohol consumption, and risk of hip fracture in women. Arch Intern Med 2001;161:983-988.

Alcohol was weakly associated with risk of hip fracture in postmenopausal white women (age-adjusted OR, 0.80; 95% CI, 0.69-0.93). This finding is based on a case-control study of postmenopausal women between the ages of 50 and 81 years. Cases consisted of women who sustained hip fractures secondary to minor trauma. Medical history and lifestyle habits were assessed via questionnaire.

* Mussolino ME, Looker AC, Madans JH, et al. Risk factors for hip fracture in white men: the NHANES I Epidemiologic Follow-Up Study. J Bone Miner Res 1998;13:918-924.

Alcohol consumption was not associated with an increased risk of hip fracture in white men aged 45 to 74 years. This study included 2,879 white noninstitutionalized men. There were 71 hip fractures reported in this cohort. Weight loss and one or more chronic conditions were significantly predictive of hip fracture. This analysis was based on data from the first National Health and Nutrition Examination Survey. Baseline data was collected from 1971 to 1975 and follow up was conducted in 1992.

* Scane AC, Francis RM, Sutcliffe AM, et al. Case-control study of the pathogenesis and sequelae of symptomatic vertebral fractures in men. Osteoporos Int 1999;9:91-97.

Alcohol consumption more than 250 grams per week was significantly associated with risk of vertebral fracture in men (OR, 3.8; 95% CI, 1.2-6.7). This finding is based on a case-control study of men (cases = 91, controls = 91) between the ages of 27 and 79 years (mean age 64 years). Cases included men with vertebral fractures, and controls were healthy and age-matched. Potential causes of secondary osteoporosis were found in 41% of cases. Other factors significantly associated with risk of vertebral fracture were oral corticosteroid therapy, current smoking, family history of bone disease, and the free androgen index.

Additional reading

Albrand G, Munoz F, Sornay-Rendu E, et al. Independent predictors of all osteoporosis-related fractures in healthly postmenopausal women: the OFELY study. Bone 2003;32:78-85.

Peak bone mass attainment

Editor's Note: It is generally accepted that alcohol consumption in large quantities during the years of bone accrual can be detrimental to peak bone mass attainment. The majority of the research behind this notion was performed in animal models, mainly the rat model. For a review of peak bone mass attainment and its determinants, please refer to these articles:

1. Bailey DA, Faulkner RA, McKay HA. Growth, physical activity, and bone mineral acquisition. Exerc Sport Sci Rev 1996;24:233-266.

2. Rizzoli R, Bonjour JP. Determinants of peak bone mass and mechanisms of bone loss. Osteoporos Int 1999;9 Suppl 2:S17-S23.

* Elgan C, Dykes AK, Samsioe G. Bone mineral density and lifestyle among female students aged 18-24 years. Gynecol Endocrinol 2002;16:91-98.

Alcohol consumption was not predictive of bone mineral density in this cross-sectional study of 218 young women (18-24 years old). Physical activity, hormonal age, regular menstruation, and body weight were the best predictors of bone mineral density in the multiple regression analysis. Smoking and current calcium intake were also not predictive of bone mineral density. Heel bone mineral density was measured via dual-energy x-ray absorptiometry. Mean BMD was 0.568 g/c[m.sup.2].

* Hawker GA, Forsmo S, Cadarette SM, et al. Correlates of forearm bone mineral density in young Norwegian women: the Nord-Trondelag Health Study. Am J Epidemiol 2002;156:418-427.

Alcohol consumption was not predictive of forearm bone mineral density (BMD) according to this cross-sectional analysis of data from 963 young women (19-35 years old). In a multiple regression analysis controlling for age and weight, late onset menarche and lack of milk consumption were predictive of lower BMD values. Physical activity, smoking, vitamin D intake, amenorrhea, oral contraceptive use, number of pregnancies, history of breast feeding, and family history of osteoporosis were not predictive of BMD. Forearm BMD was assessed via single x-ray absorptiometry. Data were collective from 1995 to 1997.

Additional readings

1. Anderson JJ, Tylavsky FA, Halioua L, et al. Determinants of peak bone mass in young adult women: a review. Osteoporos Int 1993;3(supp 1):32-36.

2. Baker D, Roberts R, Towell T. Factors predictive of bone mineral density in eating-disordered women: a longitudinal study. Int J Eat Disord 2000;27:29-35.

3. Barr SI, McKay HA. Nutrition, exercise, and bone status in youth. Int J Sport Nutr 1998;8:124-142.

4. Young D, Hopper JL, Nowson CA, et al. Determinants of bone mass in 10- to 26-year-old females: a twin study. J Bone Miner Res 1995;10:558-567.

Skeletal health

* Ganry O, Baudoin C, Fardellone P. Effect of alcohol intake on bone mineral density in elderly women: The EPIDOS Study. Am J Epidemiol 2000;151:773-780.

Moderate consumers of alcohol exhibited higher bone mass at the trochanteric site (P = 0.0017) when compared to abstainers. Moderate alcohol consumption was defined as 1 to 3 glasses of wine per day (11-29 grams). Alcohol consumption greater than 30 grams per day increases the risk of negative effects on bone mass. These findings were independent of estrogen replacement therapy, dietary calcium intake, smoking status, physical activity, education, income level, or general health. This cross-sectional analysis was based on 7,598 ambulatory women (average age 79.9 years). Data was collected between 1992 and 1994.

* Turner RT, Sibonga JD. Effects of alcohol use and estrogen on bone. Alcohol Res Health 2001;25:276-281.

Women who consume alcohol are more likely to have greater bone mass than those who abstain. This finding is particularly apparent in postmenopausal women, which implies an association between alcohol and estrogen. According to this, alcohol consumption may decrease the risk of bone loss by amplifying the circulating levels of estrogen in post-menopausal women, or it may react with bone cells to lessen bone remodeling.

Additional readings

1. Berger H, de Laet CE, van Daegle PL, et al. Risk factors for increased bone loss in an elderly population: the Rotterdam Study. Am J Epidemiol 1998;147:871-879.

2. Felson DT, Zhang Y, Hannan MT, et al. Alcohol intake and bone mineral density in elderly men and women. The Framingham Study. Am J Epidemiol 1995;142:485-492.

3. Feskanich D, Korrick SA, Greenspan SL, et al. Moderate alcohol consumption and bone density among post-menopausal women. J Women Health 1999;8:65-73.

4. Flicker L, Hopper JL, Rodgers L, et al. Bone density determinants in elderly women: a twin study. J Bone Miner Res 1995;10:1607-1613.

The Urinary System

Bladder cancer

* Djousse L, Schatzkin A, Chibnik LB, et al. Alcohol consumption and the risk of bladder cancer in the Framingham Heart Study. J Natl Cancer Inst 2004;96:1397-1400.

Alcoholic beverage consumption was not related to increased risk of bladder cancer in this case-control study based on 10,125 participants from the Framingham Heart Study (P = 0.3 for trend). In beverage-specific analyses, beer consumption was statistically linked to a reduced risk of bladder cancer (P = 0.03); however wine (P = 0.7) and spirits (P = 0.2) were not. For this study, each bladder cancer case was matched to up to 5 controls, matched for major confounders. The mean follow up time was 27.3 years.

* Zeegers MP, Volovics A, Dorant E, et al. Alcohol consumption and bladder cancer risk: results from The Netherlands Cohort Study. Am J Epidemiol 2001;153:38-41.

Alcohol consumption did not increase the risk for bladder cancer in this case-control study based on a cohort of 120,852 individuals aged 55 to 69 years at baseline. After a 6.3 year follow up, a case-control analysis was performed on 594 cases and 3,170 cases. After correcting for age and smoking, the incidence rate ratios were not significant (P for trend = 0.13).

Additional reading

1. Pelucchi C, Negri E, Franceschi S, et al. Alcohol drinking and bladder cancer. J Clin Epidemiol 2002;55:637-641.

Prostate cancer

* Sesso HD, Paffenbarger RS Jr, Lee IM. Alcohol consumption and risk of prostate cancer: The Harvard Alumni Health Study. Int J Epidemiol 2001;30:749-755.

The rate of prostate cancer is doubled in moderate drinkers compared to almost-never drinkers according to this prospective study (n = 7612). Self-reported wine and beer consumption was low and did not exhibit a significant correlation to prostate cancer. The incidence of prostate cancer was positively associated with liquor consumption (whiskey, spirits), displaying an increased occurrence rate of 61-67% when compared to almost-never drinkers (P for non-linear trend < 0.001). The follow-up period was approximately 5 years, and 366 cases of prostate cancer were reported.

* Schuurman AG, Goldbohm RA, van den Brandt PA. A prospective cohort study on the consumption of alcoholic beverages in relation to prostate cancer incidence (The Netherlands). Cancer Causes Control 1999;10:597-605.

There was no significant association between alcohol consumption and risk of prostate cancer in this prospective study of 58,279 Dutch men, aged 55 to 69 years at baseline. After 6.3 years of follow up, there were 680 cases of primary prostate cancer in the cohort. No significant associations were reported for abstaining from alcohol or consuming alcohol from liqueur. A nonsignificant trend existed for alcohol consumption of 15 grams or more per day from wine; this data is presented in Table 16. Data was adjusted for age, family history of prostate cancer, socioeconomic status, and total alcohol intake.

Additional readings

1. Breslow RA, Wideroff L, Graubard BI, et al. Alcohol and prostate cancer in the NHANES I epidemiological follow-up study. First National Health and Nutrition Examination Survey of the United States. Ann Epidemiol 1999;9:254-261.

2. Dennis LK. Meta-analysis for combining relative risks of alcohol consumption and prostate cancer. Prostate 2000;42:56-66.

3. Ellison LF. Tea and other beverage consumption and prostate cancer risk: a Canadian retrospective cohort study. Eur J Cancer Prev 2000;9:125-130.

4. Sharpe CR, Siemiatycki J. Case-control study of alcohol consumption and prostate cancer risk in Montreal, Canada. Cancer Causes Control 2001;12:589-598.

5. Schoonen WM, Salinas CA, Kiemeney LA, et al. Alcohol consumption and risk of prostate cancer in middle-aged men. Int J Cancer 2005;113:133-140.

Renal cancer

* Parker AS, Cerhan JR, Lynch CF, et al. Gender, alcohol consumption, and renal cell carcinoma. Am J Epidemiol 2002;155:455-462.

This case-control study reported an inverse correlation between alcohol consumption and the development of renal cell carcinoma in women. No correlation was reported for men. Decreased risk was found for women who consumed more than 3 servings of alcohol per week (OR, 0.05; 95% CI, 0.2-0.9) when compared to abstainers. Beer seemed to demonstrate the most significant relationship to this finding. This study included 406 cases (261 men, 145 women) and 2,429 controls (1,598 men, 831 women).

Additional reading

Pelucchi C, La Vecchia C, Negri E, et al. Alcohol drinking and renal cell carcinoma in women and men. Eur J Cancer Prev 2002;11:543-545.

Table 1.

Drinks per day                      Relative risk (95% CI)

[less than or equal to]0.25         0.96 (0.89-1.03)
0.26-0.50                           0.86 (0.75-0.98)
0.51-1.00                           0.92 (0.82-1.04)
1.01-1.50                           1.00 (0.80-1.24)
1.51-2.00                           1.20 (0.92-1.58)
>2.00                               1.31 (1.02-1.68)

Table 2.

Outcome                  Alcoholics                 Nonalcoholics

Relapse (P < 0.001)      50%                         2%
Rejection episodes       10%                        44%
  (P < 0.05)
Post-surgery diabetes    40%                         2%
  (P < 0.05)
Unrelated complications  20%                         0%
  (P < 0.05)
Marital separations      20%                         0%
  (P < 0.05)
Post-surgery abstinence  14.7 [+ or -] 17.2 months  26.3 [+ or -] 23.0
  (P < 0.05)                                          months
Missed office visits      2.7 [+ or -] 3.5           1.0 [+ or -] 1.9
  (P < 0.05)

Table 3.

Alcohol consumption                    Relative risk (95% CI)

1-15 g/day                             0.87 (0.25-2.51)
16-30 g/day                            0.00 (0.00-0.92) (a)
[greater than or equal to]30 g/day     0.37 (0.01-2.42)

(a) P < 0.05.

Table 4.

Alcohol consumption  Relative risk (95% CI) (a)

<0.5 drinks/day      0.78 (0.52-1.15) (b)
0.5-2 drinks/day     0.62 (0.40-1.00)
>2 drinks/day        0.48 (0.25-0.94)

(a) Adjusted for BMI, smoking, hypertension, physical activity, and
duration of diabetes mellitus.
(b) P for trend = 0.03.

Table 5.

Alcohol consumption                    Relative risk (95% CI)

[greater than or equal to]1 drink/day  0.57 (0.45-0.73) (a)
5-6 drinks/week                        0.67 (0.51-0.89)
2-4 drinks/week                        0.74 (0.59-0.93)
1 drink/week                           0.89 (0.70-1.14)
1-3 drinks/month                       1.03 (0.80-1.33)
rarely/never                           1.00 (referent)

(a) P for trend < 0.001.

Table 6. (a)

Alcohol intake
(g/day)         0            0.1-1.4      1.5-4.9     5.0-29.9

Pooled data     1.0          0.78         1.15        1.00
RR (95% CI)    (reference)  (0.47-1.30)  (0.8-1.69)  (0.69-1.44)

Alcohol intake
(g/day)         [greater than or equal to]30

Pooled data     1.00
RR (95% CI)    (0.57-1.76)

(a) P value for the trend was 0.94.

Table 7.

Alcohol amount                            Relative risk (95% CI)

<1 drink/week                             0.65 (0.41-1.02)
1-6 drinks/week                           0.46 (0.27-0.77)
7-13 drinks/week                          0.69 (0.37-1.31)
[greater than or equal to]14 drinks/week  1.22 (0.60-2.49)

Table 8.

Alcohol consumption level  Relative risk (95% CI)

1 drink/week (a)           1.00 (0.65-1.55)
2-4 drinks/week            0.68 (0.44-1.04)
5-6 drinks/week            1.32 (0.89-1.95)
1 or more drinks/day       1.27 (0.93-1.73)

(a) Less than 1 drink/week was the referent group.

Table 9. (a)

Alcohol consumption (b)  Relative risk (95% CI)

0.1-4.9 g/day             1.0 (0.7-1.2)
5-14.9 g/day              0.9 (0.6-1.4)
15-29.9 g/day             1.1 (0.7-1.7)
30 or more g/day          1.3 (0.9-1.8)

(a) Adjusted for age, smoking, and other risk factors.
(b) Compared to nondrinkers.

Table 10.

Alcohol consumption                     Relative risk (95% CI)

None                                    1.0 (ref)
Former drinkers                         0.9 (0.5-1.5)
<1 drink/month                          1.1 (0.8-1.4)
<1 drink/day                            0.7 (0.5-0.9)
1-2 drinks/day                          0.8 (0.6-1.1)
3.5 drinks/day                          1.0 (0.6-1.5)
[greater than or equal to]6 drinks/day  1.9 (1.0-3.5)

Table 11.

Alcohol consumption  Relative risk (95% CI)

<12 g/day            0.57 (0.38-0.86)
12-24 g/day          1.38 (0.17-0.86)
>24 g/day            0.95 (0.43-2.10)

Table 12. Risk of stroke for heavy drinkers (>60 g/day)

Outcome             Relative risk (95% CI) (a)

Total stroke        1.64 (1.39-1.93)
Ischemic stroke     1.69 (1.34-2.15)
Hemorrhagic stroke  2.18 (1.48-3.20)

(a) Compared to abstainers.

Table 13. Risk of stroke for light to moderate drinkers (<12 g/day)

Outcome             Relative risk (95% CI) (a)

Total stroke        0.83 (0.75-0.91)
Ischemic stroke     0.80 (0.67-0.96)
Hemorrhagic stroke  0.72 (0.57-0.91)

(a) Compared to abstainers.

Table 14. Risk of total mortality (a)

Alcohol                          Relative risk
consumption (drinks)               (95% CI)

Rarely or never                  1.00 (referent)
<1/week                          0.88 (0.60-1.28)
1-6/week                         0.64 (0.48-0.85)
[greater than or equal to]1/day  0.71 (0.54-0.94)

(a) Adjusted for smoking, diabetes mellitus, BMI, exercise, angina, and
myocardial infarction.

Table 15. Risk of mortality from cardiovascular disease (a)

Alcohol                          Relative risk
consumption (drinks)             (95% CI)

Rarely or never                  1.00 (referent)
<1/week                          0.89 (0.58-1.36)
1-6/week                         0.56 (0.40-0.79)
[greater than or equal to]1/day  0.64 (0.46-0.88)

(a) Adjusted for smoking, diabetes mellitus, BMI, exercise, angina, and
myocardial infarction.

Table 16.

Wine type   Relative risk (95% CI)

Red             0.8 (0.4-1.7)
White           3.3 (1.2-9.2)
Fortified       2.3 (1.2-4.7)

5. Alcohol and Cancer

Editor's Note: The wealth of animal research does not support the notion that alcohol is carcinogenic (ie, causes cancer); however, human epidemiological studies do support this idea. The link between alcohol and cancer is difficult to study in humans, because this link may be indirect, as appears to be the case with liver cancer, which can be the result of hepatitis C virus or cirrhosis. Due to advances in molecular research, this relationship will probably become clearer in the near future. One important common theme in the alcohol-cancer research is the U-shaped relationship between alcohol consumption and risk of cancer. This is perhaps the most important message to take away from this selection of studies.

Bladder Cancer

Refer to Urinary System section.

Breast Cancer

Benign breast disease

* Byrne C, Webb PM, Jacobs TW, et al. Alcohol consumption and incidence of benign breast disease. Cancer Epidemiol Biomarkers Prev 2002;11:1369-1374.

Recent alcohol consumption was not associated with an increased incidence of benign breast disease, a precursor to breast cancer. This prospective study used the Nurses' Health Study II cohort of 75,826 women. Alcohol consumption at levels less than 15 grams per day were not associated with any type of benign breast disease; however, alcohol consumption of 15 or more grams per day between the ages of 18 and 22 was associated with a significantly higher risk of nonproliferative benign breast disease (RR, 1.46; 95% CI, 1.09-1.96) and proliferative breast disease (RR, 1.33; 95% CI, 1.05-1.69). There was no significant relationship for atypical hyperplasia. This study suggests that timing of exposure may be crucial in determining the relationship between alcohol exposure and benign breast disease.

Breast cancer

* Hamajima N, Hirose K, Tajima K, et al. Alcohol, tobacco, and breast cancer--collaborative reanalysis of individual data from 53 epidemiological studies, including 58,515 women with breast cancer and 95,067 women without disease. Br J Cancer 2002;87:1234-1248.

Women consuming 35 or more grams of alcohol per day had a significantly increased risk of breast cancer when compared to nondrinkers in this collaborative analysis of 53 studies. The relative risk of breast cancer was 1.32 (95% CI, 1.19-1.45; P < 0.00001) for women drinking 35 to 44 grams per day and 1.46 (95% CI, 1.33-1.61; P < 0.00001) for women drinking 45 or more grams per day. According to this study, for each additional 10 grams of alcohol, the breast cancer risk increased 7% (95% CI, 5.5-8.7%; P < 0.00001). This analysis contained 58,515 women with breast cancer and 95,067 women without disease.

* Rohan TE, Jain M, Howe GR, et al. Alcohol consumption and risk of breast cancer: a cohort study. Cancer Causes Control 2000;11:239-247.

A moderately high consumption of alcohol is possibly linked to a greater risk of breast cancer. This conclusion is based on a case-cohort analysis comprised of 56,837 women who were a part of the Canadian National Breast Screening Study and who independently completed dietary questionnaires. The final study was based on 1,336 cases and 5,238 controls. The adjusted incidence rate ratios are presented in Table 1, the values are relative to nondrinkers.

Fatal breast cancer

* Feigelson HS, Calle EE, Robertson AS, et al. Alcohol consumption increases the risk of fatal breast cancer (United States). Cancer Causes Control 2001;12:895-902.

Menopausal status is an important factor in determining the relationship between alcohol consumption and risk of fatal breast cancer. According to this prospective study of 242,010 women followed for 14 years, low-to-moderate intake levels of alcohol do not increase the risk of fatal breast cancer in pre- or perimenopausal women. Even light consumption of alcohol (0.20 to < 1 drink/day) was associated with increased risk of fatal breast cancer among postmenopausal women (RR, 1.3; 95% CI, 1.1-1.6). Liquor, beer, and wine were examined separately, and each increased the risk of fatal breast cancer in post-menopausal women. This analysis was based on the American Cancer Society Cancer Prevention Study II. Over the follow-up period, 1,442 cancer deaths were observed.

Postmenopausal breast cancer

* Tjonneland A, Christensen J, Thomsen BL, et al. Lifetime alcohol consumption and postmenopausal breast cancer rate in Denmark: a prospective cohort study. J Nutr 2004;134:173-178.

Recent alcohol intake was significantly related to increased risk of breast cancer in this cohort study of 28,875 women (RR 1.09, 95% CI: 1.00-1.18). Early lifetime exposure to alcohol was not related to an increased risk of breast cancer. Relative risk for alcohol consumption during the women's twenties, thirties, forties, and fifties was calculated, and only the forties was significant (RR 1.12, 95% CI: 1.05-1.19). After the authors adjusted for alcohol intake at study baseline, this relationship was no longer significant. There was also no significant relationship between early drinking start or drinking before their first child and increased risk for breast cancer.

Additional Reading

1. Baumgartner KB, Annegers JF, McPherson RSS, et al. Is alcohol intake associated with breast cancer in Hispanic Women? The New Mexico Women's Health Study. Ethn Dis 2002;12:460-469.

2. Coutelle C, Hohn B, Benesova M, et al. Risk factors in alcohol associated breast cancer: Alcohol dehydrogenase polymorphism and estrogens. Int J Oncol 2004;25:1127-1132.

3. Ellison RC, Zhang Y, McLennan CE, et al. Exploring the relation of alcohol consumption to risk of breast cancer. Am J Epidemliol 2001;154:740-747.

4. Kropp S, Becher H, Nieters A, et al. Low-to-moderate alcohol consumption and breast cancer risk by age 50 years among women in Germany. Am J Epidemiol 2001;154:624-634.

5. Lenz SK, Goldberg MS, Labreche F, et al. Association between alcohol consumption and postmenopausal breast cancer: results of a case-control study on Montreal, Quebec, Canada. Cancer Causes Control 2002;13:707-710.

6. Mannisto S, Virtanen M, Kataja V, et al. Lifetime alcohol consumption and breast cancer: a case-control study in Finland. Public Health Nutr 2000;3:11-18.

7. Tjonneland A, Thomsen BL, Stripp C, et al. Alcohol intake, drinking patterns and risk of postmenopausal breast cancer in Denmark: a prospective cohort study. Cancer Causes Control 2003;14:277-284.

Colon Cancer

Refer to Digestive System section.

Esophageal Cancer

Refer to Digestive System section.

Gastrointestinal Cancer

Refer to Digestive System section.

Liver Cancer

Refer to Digestive System section.

Lung Cancer

Refer to Respiratory System section.

Non-Hodgkin Lymphoma

* Briggs NC, Levine RS, Bobo LD, et al. Wine drinking and risk of non-Hodgkin's lymphoma among men in the United States: a population-based case-control study. Am J Epidemiol 2002;156:454-462.

Wine consumption, but not consumption of beer or spirits, significantly reduced the risk of non-Hodgkin lymphoma in American men. This was a case-control study of 1,717 men (cases = 960, controls = 757) with non-Hodgkin lymphoma. Odds ratio data is presented in Table 2. Timing also affected the risk of non-Hodgkin lymphoma. Men who began consuming alcohol at age 16 or prior had a reduced risk of non-Hodgkin lymphoma at both levels of wine consumption. This information is also presented in Table 2. Cases for this study were obtained from the Selected Cancers Study, and controls were obtained via random digit dialing.

* Morton LM, Holford TR, Leaderer B, et al. Alcohol use and risk of non-Hodgkin's lymphoma among Connecticut women (United States). Cancer Causes Control 2003;13:687-694.

Wine consumption was linked to reduced risk of non-Hodgkin lymphoma in this case-control study of 1,319 women (cases = 601, controls = 718). Women drinking at least 12 alcohol beverages of any kind per year had a reduced risk of non-Hodgkin lymphoma (OR, 0.82; 95% CI, 0.65-1.04). Once alcohol type was categorized, this reduced risk was exclusive to wine (OR, 0.75; 95% CI, 0.59-0.96). Consumption of wine for 40 or more years was linked to a 40% reduction in risk of non-Hodgkin lymphoma.

Additional reading

1. Tavani A, Gallus S, La Vecchia C, et al. Alcohol drinking and risk of non-Hodgkin's lymphoma. Eur J Clin Nutr 2001;55:824-826.

2. Willett EV, Smith AG, Dovey GJ, et al. Tobacco and alcohol consumption and the risk of non-Hodgkin lymphoma. Cancer Causes Control 2004;15:771-780.

Oral Cancer

Refer to Digestive System section.

Ovarian Cancer

Refer to Reproductive System section.

Pancreatic Cancer

Refer to Endocrine System section.

Prostate Cancer

Refer to Reproductive System section.

Renal Cancer

Refer to Urinary System section.

Table 1.

Alcohol             Adjusted incidence
consumption level   rate ratios (95% CI)

1 to 10 g/day        1.01 (0.84-1.22)
11 to 20 g/day       1.16 (0.91-1.47)
21 to 30 g/day       1.27 (0.91-1.78)
31 to 40 g/day       0.77 (0.51-1.16)
41 to 50 g/day       1.00 (0.57-1.75)
> 50 g/day           1.70 (0.97-2.98)

(a) P value for trend was 0.351.

Table 2.

Wine consumption                          Odds ratio
level                                     (95% CI)

< 1 drink daily                           0.8 (0.51-1.3)
[greater than or equal to] 1 drink daily  0.4 (0.2-0.9)

        Alcohol consumption beginning at or before age 16
< 1 drink daily                           0.4 (0.2-0.97)
[greater than or equal to] 1 drink daily  0.3 (0.1-0.8)

6. Alcohol and Pregnancy

Editors' Note: Alcohol is a known teratogen, and fetal alcohol exposure is a primary, completely preventable cause of birth defects. We have included a large number of articles dealing with prenatal alcohol exposure because this problem has large public health implications. Due to the nature of this type of research, however, many studies have small sample sizes and, therefore, the findings may not be definitive. Certainly these articles do provide some food for thought, and may be useful from a patient-education perspective.

Fetal Alcohol Syndrome, Alcohol-Related Neurodevelopmental Disorder, and Alcohol-Related Birth Defects

* Maier SE, West JR. Alcohol patterns and alcohol-related birth defects. Alcohol Res Health 2001;25:168-174.

Significant behavioral and cognitive deficiencies have been detected among children born to binge-drinking mothers. As this type of drinking pattern results in a high blood alcohol concentration (BAC) over a brief time, it is potentially more harmful to an unborn fetus than the consumption of larger quantities of alcohol over a lengthier period. Additionally, binge drinking is particularly harmful, as it is linked to recurring withdrawal periods and may take place during crucial stages of brain development.

* May PA, Gossage JP. Estimating the prevalence of fetal alcohol syndrome. A summary. Alcohol Res Health 2001;25:159-167.

The rate of occurrence of fetal alcohol syndrome during the 1980s and 1990s was 0.5 to 2.0 instances per every 1000 births in the United States. According to studies conducted since the late 1970s, common risk indicators include the age of the mother, social and economic status, frequency of excessive alcohol consumption, drinking habits of close acquaintances, and various psychological indicators. The findings are based on data obtained from passive surveillance, clinic-based studies, and active case ascertainment to determine the causes and effects of fetal alcohol syndrome, alcohol-related birth defects, and alcohol-related neurodevelopmental disorders.

Central Nervous System Development and Function

* Schonfeld AM, Mattson SN, Lang AR, et al. Verbal and nonverbal fluency in children with heavy prenatal alcohol exposure. J Stud Alcohol 2001;62:239-246.

Verbal and nonverbal fluency is adversely affected in children exposed to prenatal alcohol consumption. This finding is based on a study that was conducted to determine executive function deficits in children whose mothers regularly consumed alcohol while pregnant. After comparing 18 children with a history of prenatal alcohol exposure to 10 children who had no exposure to alcohol before birth, it was concluded that impairments in verbal and nonverbal fluency were common in higher functioning children who were exposed to alcohol before birth.

* Wass TS, Persutte WH, Hobbins JC. The impact of prenatal alcohol exposure on frontal cortex development in utero. Am J Obstet Gynecol 2001;185:737-742.

Reduced frontal brain size, assessed via ultrasound, was related to alcohol exposure in fetuses. Four percent of nonexposed and 23% of exposed fetuses had a frontal cortex measurement below the tenth percentile. These findings are based on a study of 167 fetuses assessed at multiple ultrasounds.

Additional readings

1. Linnet KM, Dalsgaard S, Obel C, et al. Maternal lifestyle factors in pregnancy risk of attention deficit hyperactivity disorder and associated behaviors: review of the current evidence. Am J Psychiatry 2003;160:1028-1040.

2. Mick E, Biederman J, Faraone SV, et al. Case-control study of attention-deficit hyperactivity disorder and maternal smoking, alcohol use, and drug use during pregnancy. J Am Acad Child Adolesc Psychiatry 2002;41:378-385.

3. Roebuck TM, Mattson SN, Riley EP Interhemispheric transfer in children with prenatal alcohol exposure. Alcohol Clin Exp Res 2002;26:1863-1946.

4. Schonfeld AM, Mattson SN, Lang AR, et al. Verbal and nonverbal fluency in children with heavy prenatal alcohol exposure. J Stud Alcohol 2001;62:239-246.

5. Testa M, Quigley BM, Eiden RD. The effects of prenatal alcohol exposure on infant mental development: a meta-analytical review. Alcohol 2003;38:295-304.

6. Wass T, Simmons R, Thomas J, et al. Timing accuracy and variability in children with prenatal exposure to alcohol. Alcohol Clin Exp Res 2002;26:1887-1896.

Lactation and Breastfeeding

* Mennella JA, Garcia-Gomez PL. Sleep disturbances after acute exposure to alcohol in mother's milk. Alcohol 2001;25:153-58.

This study of 23 breastfed infants (age 3-5 months) reported that the infants spent statistically less time in active sleep following alcohol exposure through the mother's milk. Activity during sleep was measured using an Actigraph, and sleep activity was measured under two conditions: milk alone and milk plus alcohol. Sleep was measured over a 24 hour period and broken into two time frames, the first 3.5 hours and the following 20.5 hours. There were significant short-term and long-term effects on sleep activity, as shown in Table 1.

* Mennella, JA. Regulation of milk intake after exposure to alcohol in mother's milk. Alcohol Clin Exp Res 2001;25:590-593.

Exposure to small quantities of alcohol in breast milk creates noticeable differences in the eating habits of infants. This finding is based on a study that evaluated 12 mothers and their breastfed infants on 2 different days, one on which alcohol was consumed in small doses by the mother just before breastfeeding, and one on which no alcohol was consumed at all. After monitoring the behavior of the infants for 16 hours after feeding, it was observed that those who were breastfed just after their mothers consumed alcohol drank substantially less when compared to the breastfeeding patterns that occurred when there was no alcohol intake. It was further noted that the infants would try to compensate in the hours following their mothers' intake of alcohol for the food they lost during their initial feeding by subsequently eating more and for a longer period of time.

Long-term Effects of Alcohol Exposure

* Baer JS, Sampson PD, Barr HM, et al. A 21-year longitudinal analysis of the effects of prenatal alcohol exposure on young adult drinking. Arch Gen Psych 2003;60:377-385.

Prenatal alcohol exposure is a risk factor for developing alcohol dependence later in life. This longitudinal study of 433 young adults followed children with (n = 31) and without (n = 402) prenatal alcohol exposure from birth to 21 years of age. Of the 433 offspring in this study, 82.9% (n = 359) reported current drinking, 17.1% (n = 74) reported abstinence, and 8.1% (n = 35) reported drinking consistent with at least mild dependence. Logistic regression analysis showed a significant relationship between maternal alcohol drinking and offspring alcohol dependence (t = 2.65; P = 0.008). Prenatal alcohol exposure was examined by questionnaire during pregnancy. Offspring alcohol use was assessed at 14 and 21 years using the Alcohol Dependence Scale and by measuring frequency of alcohol consumption.

* Day NL, Leech SL, Richardson GA, et al. Prenatal alcohol exposure predicts continued deficits in offspring size at 14 years of age. Alcohol Clin Exp Res 2002;26:1584-1591.

Growth deficits, a hallmark feature of fetal alcohol syndrome, were still identifiable at 14 years of age in children with prenatal alcohol exposure. Height, weight, skinfold thickness, and head circumference were significantly reduced even after controlling for other factors that predict size (eg, pubertal status, race, gender). A dose-response relationship was exhibited between size parameters and amount of alcohol exposure; for example, weight was directly proportionate to maternal alcohol intake, as presented in Table 2. These findings are based on a prospective study of 850 mother-child pairs.

* Simmons RW, Wass T, Thomas JD, et al. Fractionated simple and choice reaction time in children with prenatal exposure to alcohol. Alcohol Clin Exp Res 2002;26:1412-1419.

Children with prenatal alcohol exposure had significantly slower reaction times than nonexposed children during tasks which required that a choice be made (585.1 vs 491.2 msec). This study further broke down reaction time into premotor reaction time and motor reaction time, and alcohol-exposed children were slower than nonexposed children in both respects. The authors concluded that unlike previous research, this shows that alcohol-exposed children have both motor and cognitive deficits. Premotor reaction time was defined as the time between stimulus and the onset of muscle activity. The choice activity involved trials which required the child to make a decision on which keys to depress on an apparatus.

* Mick E, Biederman J, Faraone SV, et al. Case-control study of attention-deficit hyperactivity disorder and maternal smoking, alcohol use, and drug use during pregnancy. J Am Acad Child Adolesc Psychiatry 2002;41:378-385.

Attention-deficit/hyperactivity disorder (ADHD) may result from exposure to prenatal alcohol consumption and/or cigarette use. This finding is based on a study conducted to determine the association between ADHD and various prenatal conditions. After methodically conducting rigid diagnostic interviews with 280 ADHD cases and 242 non-ADHD patients of both sexes, it was determined that those who were exposed to cigarettes before birth were 2.1 times (95% CI, 1.1-4.1) more likely to develop ADHD than those who were not exposed, while those who were exposed to alcohol before birth were 2.5 times (95% CI, 1.1-5.5) more likely to develop ADHD than those who were not exposed.

Additional readings

1. Hill SY, Lowers L, Locke-Wellman J, et al. Maternal smoking and drinking during pregnancy and the risk for child and adolescent psychiatric disorders. J Stud Alcohol 2000;61:661-668.

2. Covington CY, Nordstrom-Klee B, Ager J, et al. Birth to age 7 growth of children prenatally exposed to drugs: a prospective cohort study. Neurotoxicol Teratol 2002;24:489-496.

Pregnancy Outcome

* Rasch V. Cigarette, alcohol, and caffeine consumption: risk factors for spontaneous abortion. Acta Obstet Gynecol Scand 2003;82:182-188.

Consumption of 5 or more units of alcohol per week increased the risk of spontaneous abortion (OR, 4.84; 95% CI, 2.87-8.16) after adjusting for age, parity, occupation, cigarette smoking, and caffeine consumption. Alcohol intake below 5 units per week, including total abstinence, did not have an association with spontaneous abortion when compared to the controls. This case control study included 330 women with a spontaneous abortion and 1,168 controls. The case participants were women who presented to a Danish university hospital with a spontaneous abortion in week 6 through 10; controls were pregnant women of the same gestational point from the same facility.

* Kesmodel U, Wisborg K, Olsen SF, et al. Moderate alcohol intake during pregnancy and the risk of stillbirth and death in the first year of life. Am J Epidemiol 2002;155:305-312.

Whereas the risk of stillbirth increases for women who consume substantial quantities of alcohol, there is little or no association between prenatal alcohol consumption and infant death during the first year of life. These findings are based on a study conducted between 1989 and 1996 that evaluated women undergoing routine antenatal care in Denmark. After analyzing data related to 24,768 singleton pregnancies obtained via questionnaires and hospital files on various lifestyle and pregnancy-related factors, it was determined that women who consumed 5 or more drinks per week while pregnant were 2.96 times (95% CI, 1.37-6.41) more likely to have a stillbirth delivery when compared to those who abstained. Additionally, the risk of stillbirth caused by fetoplacental dysfunction increases as alcohol consumption increases (8.83 stillbirths per 1,000 deliveries among women consuming [greater than or equal to]5 drinks/week compared to 1.37 per 1,000 deliveries among women who abstained).

Additional reading

1. Henriksen TB, Hjollund NH, Jensen TK, et al. Alcohol consumption at the time of conception and spontaneous abortion. Am J Epidemiol 2004;160:661-667.

Binge Drinking

Refer to Binge Drinking section.

General Additional Readings:

1. Albertsen K, Anderson AM, Olsen J, et al. Alcohol consumption during pregnancy and the risk of preterm delivery. Am J Epidemiol 2004;159:155-161.

2. Hannigan JH, Armant DR. Alcohol in pregnancy and neonatal outcome. Semin Neonatol 2000;5:243-254.

3. Logan TK, Walker R, Nagle L, et al. Rural and smalltown attitudes about alcohol use during pregnancy: a community and provider sample. J Rural Health 2003;19:497-505.

Table 1.
                    0 to 3.5 hours
                    Milk only            Alcohol + milk

Active sleep (min)  41.5 ([+ or -] 5.4)  33.5 ([+ or -] 5.3) (a)

                    3.5 to 24 hours
                    Milk only              Alcohol + milk

Active sleep (min)  329.4 ([+ or -] 20.0)  358.4 ([+ or -] 22.6) (a)

(a) P [less than or equal to] 0.05 compared with only milk.

Table 2.

Maternal alcohol          Offspring weight at
consumption               14 years (lb.)

Abstainers                152
>0 to <0.2 drinks/day     149
>0.2 to <0.89 drinks/day  143
>0.89 drinks/day          136

7. Behavior and Psychology

Behavior

* Makela K, Mustonen H. Relationships of drinking behavior, gender and age with reported negative and positive experiences related to drinking. Addiction 2000;95:727-736.

Men and women report differing opinions on the benefits of alcohol consumption, according to this cross-sectional survey of Finnish men and women aged 15 to 69. In this study, women frequently reported that alcohol helped them to cope with interpersonal conflicts and feel more enthusiastic about life. Men reported that alcohol contributed to a more fulfilling social life and extroverted personality. Both sexes reported occasions of reckless behavior associated with alcohol consumption; men most notably reported driving under the influence. Other than detrimental effects on their health, younger consumers frequently reported both positive and negative experiences with alcohol. This study was conducted in 1992.

* Wells S, Graham K, West P. Alcohol-related aggression in the general population. J Stud Alcohol 2000;61:626-632.

Intoxication resulting from alcohol consumption is linked closely to aggression. This conclusion is based on a study conducted via telephone surveys of 1001 adults aged 18 years or older who responded to questions focusing on drinking patterns and personal involvement in aggressive encounters ranging from serious arguments to occurrences of verbal threat or physical aggression during the past year. Of the respondents, 19.8% had been involved in serious disputes, 11.8% reported occurrences of verbal threats, and 12.0% claimed involvement in at least one act of physical aggression. Drinking was a factor in 38.1% of serious arguments, 56.5% of verbal threats, and 67.9% of physically aggressive encounters. The consumption of five or more drinks corresponded to greater occurrences of physical aggression versus verbal aggression or no aggression at all. This study was controlled for gender, age, education level, marital status, and employment.

* Sareen J, McWilliams L, Cox B, et al. Does a U-shaped relationship exist between alcohol use and DSM-III-R mood and anxiety disorders? J Affect Disord 2004;82:113-118.

Alcohol abstainers were not more likely to have mood or anxiety disorders than moderate alcohol consumers in this study of over 13,000 adults. Problem drinking was associated with an increased risk of mood and anxiety disorders. Findings were based on data obtained from the National Comorbidity Survey (NCS; n = 6,780) and the Mental Health Supplement of the Ontario Health Survey (OHS-MHS; n = 7,001). The University of Michigan Revision of the Composite International Diagnostic Interview (UM-CIDI) was used to make DSM-III-R psychiatric diagnoses in both surveys.

Risky Behavior

* Howard DE, Wang MQ. Risk profiles of girls who are victims of dating violence. Adolescence 2003;38:1-14.

Binge drinking doubles the risk of dating violence. Almost 10% of American high school girls have been the victims of dating violence according to this study of the 1999 Youth Risk Behavior Surveillance System (YRBSS). Girls in twelfth grade were more likely to have experienced dating violence. This study reported that dating violence was related to several other risk factors, which are illustrated in the Table. The YRBSS is a national school-based survey sponsored by the Centers for Disease Control and Prevention (CDC). The survey study is conducted by the CDC and state and local agencies.

* White AM, Jamieson-Drake DW, Swartzwelder HS. Prevalence and correlates of alcohol-induced blackouts among college students: results of an e-mail survey. J Am Coll Health 2002;51:117-119;122-131.

The majority of college students (51%) who had ever consumed alcohol reported experiencing a blackout. This finding is from a cross-sectional study of American college students. Of those students who had drunk within the two weeks prior to the survey, 9% had experienced a blackout during that same period. Many of those reporting blackouts also reported learning that they had vandalized property, driven an automobile, had sexual intercourse, or engaged in other risky behaviors during the "blackout" period. Reporting 3 or more blackouts was associated with lower grades, heavier drinking, and earlier age of drinking onset. The data for this study was obtained using an email survey of 772 college students.

Additional readings

1. Guilamo-Ramos V, Turrisi R, Jaccard J, et al. Progressing from light experimentation to heavy episodic drinking in early and middle adolescence. J Stud Alcohol 2004;65:494-500.

2. Welte JW, Barnes GM, Wieczorek WF, et al. Simultaneous drinking and gambling: a risk factor for pathological gambling. Subst Use Misuse 2004;39:1405-1422.

Sleep Quality

* Fabsitz RR, Sholinsky P, Goldberg J. Correlates of sleep problems among men: the Vietnam Era Twin Registry. J Sleep Res 1997;6:50-56.

Alcohol consumption is related to risk of sleep problems in this study of 8,870 male participants. Alcohol consumption of 13 or more drinks (during the two week period preceding assessment) was significantly associated with higher risk of trouble falling asleep (OR, 1.18; 95% CI, 1.03-1.36), waking often (OR, 1.49; 95% CI, 1.30-1.70), trouble staying asleep (OR, 1.52; 95% CI, 1.32-1.74), and waking tired (OR, 1.21; 95% CI, 1.06-1.38). Significance levels (P values) for the individual odds ratios were not reported. The data from this study was based on the Vietnam Era Twin Registry (VET), which includes 14,800 male twins born between 1939 and 1955 and who served in the military between 1964 and 1975. In this study, sleep quality was measured using the Jenkins Sleep Questionnaire. This questionnaire assesses four aspects of sleep disturbance one or more times over the past month.

Editor's Note: It is important to note that this study was based on a cohort of male subjects, all of whom were active duty soldiers in Southeast Asia from 1964 to 1975. As such, there may be many confounding factors (eg, post-traumatic stress disorder) that influence the relationship between alcohol consumption and sleep quality in this study.

* Brower KJ, Aldrich MS, Robinson EA, et al. Insomnia, self-medication, and relapse to alcoholism. Am J Psychiatry 2001;158:399-404.

Alcoholic patients are likely to frequently use alcohol as a sleep aid, and treatment programs should include questions regarding sleep. Data for this study were obtained from 172 adults receiving treatment for alcohol dependence. After [greater than or equal to]2 weeks of abstinence, 55% of patients with insomnia reported frequent alcohol use for sleep, compared with 28% of patients without insomnia. Those with insomnia reported more severe alcohol dependence and depression. Twice as many insomniacs relapsed in alcoholic treatment intervention (60% with insomnia, versus 30% without insomnia).

* Brower KJ, Hall JM. Effects of age and alcoholism on sleep: a controlled study. J Stud Alcohol 2001;62:335-343.

Alcoholism is a source of sleep problems in the elderly. In a study of 226 subjects divided into two groups of over and under 55 years of age, alcoholics and older adults averaged less sleeping time and more respiratory distress. Older alcoholics have more sleep disturbances compared to younger alcoholics and nonalcoholics in both age groups. Data were obtained from polysomnography, psychiatric diagnostic interviews, validated rating scales, and alcohol histories.

* Foster JH and Peters TJ. Impaired sleep in alcohol misusers and dependent alcoholics and the impact upon outcome. Alcohol Clin Exp Res 1999;23:1044-1051.

Sleep quality was significantly reduced in alcoholics (n = 31) compared to controls (n = 49) in this longitudinal study. Sleep quality was also significantly correlated with depression (r = 0.68; P < 0.001), measured by the Beck Depression Inventory, but not with alcohol-dependence severity. After abstaining from alcohol, if sleep disturbance remained, former alcoholics were more likely to relapse.

Additional readings

1. Imaki M, Hatanaka Y, Ogawa Y, et al. An epidemiological study on relationship between the hours of sleep and life style factors in Japanese factory workers. J Physiol Anthropol Appl Human Sci 2002;21:115-120.

2. Miyata S, Noda A, Ito N, et al. REM sleep is impaired by a small amount of alcohol in young women sensitive to alcohol. Intern Med 2004;43:679-684.

3. Brower KJ. Alcohol's effects on sleep in alcoholics. Alcohol Res Health 2001;25:110-125.

4. Foster JH, Peters TJ, Kind P. Quality of life, sleep, mood, and alcohol consumption: a complex interaction. Addict Biol 2002;7:55-65.

Stress

* Jose BS, van Oers HA, van de Mheen HD, et al. Stressors and alcohol consumption. Alcohol Alcohol 2000;35:307-312.

People experiencing stress either abstain from alcohol altogether or drink heavily rather than drinking in moderation. These findings are based on a study conducted in the Netherlands where the authors examined life stressors such as financial difficulties, unfavorable employment status or unfavorable marital status.

Suicide

* Conner KR, Meldrum S, Duberstein PR, et al. The role of drinking in suicidal ideation: analyses of Project MATCH data. J Stud Alcohol 2003;64:402-408.

Suicidal ideation is common among treated alcoholics according to this longitudinal study of 1,561 alcohol-dependent individuals (374 women, 1,187 men). In men, drinking intensity was significantly associated with suicidal ideation at baseline (P < 0.001). Additionally, in women, nonintense but regular drinking was significantly associated with suicidal ideation (P < 0.05). Finally, depression was significantly linked to suicidal ideation in both men and women (P < 0.001). Data for this study was obtained from project MATCH, which was a large clinical trial of psychosocial treatments of alcoholism. Suicidal ideation was assessed at baseline and at 3, 9, and 15 month follow-ups after entry into a 12-week treatment program.

* Powell KE, Kresnow M, Mercy JA, et al. Alcohol consumption and nearly lethal suicide attempts. Am Assoc Suicidology 2001;32:30-41.

Alcohol consumption is linked to many nearly fatal suicide attempts. This finding is based on a study that closely examined drinking occurrence, quantity of consumption, binge drinking, alcoholism, onset of consumption, and intake of alcohol within 3 hours of a suicide attempt among subjects aged 13 to 34. All of these variables were related to nearly fatal suicide attempts with odds ratios ranging from 2.4 to 7.0.

Additional readings

1. Grant BF, Hasin DS. Suicidal ideation among the United States drinking population: results from the National Longitudinal Alcohol Epidemiological Survey. J Stud Alcohol 1999;60:422-429.

2. Kung HC, Pearson JL, Liu X. Risk factors for male and female suicide decedents ages 15-64 in the United States. Results from the 1993 National Mortality Followback Survey. Soc Psychiatry Psychiatr Epidemiol 2003;38:419-426.

3. May PA, Van Winkle NW, Williams MB, et al. Alcohol and suicide among American Indians of New Mexico. 1980-1998. Suicide Life Threat Behav 2002;32:240-255.

4. Nemtsov A. Suicides and alcohol consumption in Russia, 1965-1999. Drug Alcohol Depend 2003;71:161-168.

5. Prikola SP, Isometsa ET, Heikkinen ME, et al. Suicides of alcohol misusers and non-misusers in a nationwide population. Alcohol Alcohol 2000;35:70-75.

Table 1.

Risk factors               Odds ratio (95% CI)

Sad feelings/hopelessness  2.13 (1.49-3.06) (a)
Binge drinking             1.96 (1.17-3.28) (b)
Cocaine/inhalant use       2.90 (1.05-8.00) (b)
Multiple sex partners      2.38 (1.24-4.56) (b)
Nonuse of condoms          1.53 (1.01-2.32) (b)
Hispanic ethnicity         1.82 (1.04-3.19) (b)
Black ethnicity            2.32 (1.43-3.76) (a)

(a) P < 0.01.
(b) P < 0.05.

8. Alcohol and Older Adults

Editor's Note: Research on alcohol consumption and its complications in older adults is sparse when compared to research on youth and middle-aged populations. This is an important area that is frequently overlooked. We have attempted to include as many areas of concern as possible; however, many topics lacked quality research from which a conclusion could be drawn. For an excellent review of this topic and the current literature, please refer to the source listed below.

* Reid MC, Boutros NN, O'Conner PG, et al. The healthrelated effects of alcohol use in older persons: a systematic review. Subst Abus 2002;23:149-164.

Age-Related Macular Degeneration

Refer to Eye Diseases in the Nervous System section.

Dementia

Refer to Central Nervous System section.

Depression

* Osborn DP, Fletcher AE, Smeeth L, et al. Factors associated with depression in a representative sample of 14,217 people aged 75 and over in the United Kingdom: results from the MRC trial of assessment and management of older people in the community. Int J Geriatr Psychiatry 2003;18:326-630.

High alcohol intake was not predictive of depression in older adults according to this cross-sectional analysis of data from the MRC trial cohort of 14,217 older adults ([greater than or equal to]75 years of age). Several factors were predictive of depression, including no confiding relationship (OR, 3.4), smoking (OR, 1.6), and having two or more physical illnesses (OR, 1.6). Other important findings were that increasing age was associated with an increased risk of depression, but living alone was not predictive of depression.

Drug Interactions

Editor's Note: The importance of assessing patient consumption of alcohol is frequently overlooked when prescribing pharmacological agents. Many therapeutic agents can interact with alcohol, including such common medications as hormone replacement therapy, antibiotics, antihistamines, histamine H2 receptor agonists, antiinflammatory agents, and warfarin. Pharmacokinetic interactions occur most frequently in the liver, where alcohol and many drugs are metabolized. Synergistic interactions, however, can occur in the central nervous system, such as those that take place with alcohol and sedatives. Additionally, alcohol may undermine pharmacological management of a condition when it contributes to the disease process, such as with diabetes, where alcohol may impair gluconeogenesis. It is essential to assess alcohol consumption in terms of frequency, duration, and type prior to beginning pharmacological therapy.

* Adams WL. Potential for adverse drug-alcohol interactions among retirement community residents. J Am Geriatr Soc 1995;43:1021-1025.

Based on a cross-sectional mailed survey study of 311 independent living community residents, 38% of the sample reported using both alcohol and medications known to interact. Table 1 isolates the concurrent use of each class of medications known to be implicated in drug-alcohol interactions examined in this study. Given the high rate of simultaneous alcohol/drug use in retirement community dwellers, there is a large potential for adverse outcomes.

Additional reading

1. Forster LE, Pollow R, Stoller EP. Alcohol use and potential risk for alcohol-related adverse drug reactions among community-based elderly. J Community Health 1993;18:225-239.

Functional Capacity

* Blow FC, Walton MA, Barry KL, et al. The relationship between alcohol problems and health functioning of older adults in primary care settings. J Am Geriatr Soc 2000;48:225-226.

Light drinkers had significantly better physical functioning than abstainers or at-risk drinkers (main effect P < 0.05). This was true for both males and females after adjusting for a clinically significant difference in measurement scores (5 points). These findings are based on a cross-sectional study of 8,578 older adults (aged 55-97 years). Participants in this study were recruited from primary care clinics at regularly scheduled appointments. Physical functioning was assessed using the Medical Outcomes Study Short Form-36 (MOS SF-36), which is a 36-item questionnaire. At-risk drinking was defined as 9 or more drinks per week for women and 12 or more for men.

* Moore AA, Endo JO, Carter MK. Is there a relationship between excessive drinking and functional impairment in older persons? J Am Geriatr Soc 2003;51:44-49.

Excessive alcohol consumption (>7 drinks/week) and binge drinking were associated with impairments in instrumental activities of daily living (IADL). The odds ratio data is presented in Table 2. These findings were based on a cross-sectional study of 161 older adults ([greater than or equal to]60 years) recruited from internal medicine practices affiliated with an academic medical center.

* Wang L, van Belle G, Kukull WB, et al. Predictors of functional change: a longitudinal study of nondemented people aged 65 and older. J Am Geriatr Soc 2002;50:1525-1534.

Moderate alcohol consumption was associated with a slower rate of functional capacity decline in older adults according to this longitudinal study of 2,581 individuals. At baseline, moderate alcohol use and exercise were associated with better functional outcomes. After a mean follow up time of 3.4 years, exercise and moderate alcohol consumption were associated with decreased rates of functional decline. Increased rate of decline was associated with depression and coronary heart disease. In this study, functional status was determined by assessing both activities of daily living and instrumental activities of daily living. Performance-based functional testing (Guralnik's battery) was used as an objective measure of functional status.

Additional reading

1. Resnick B, Perry D, Applebaum G, et al. The impact of alcohol use in community-dwelling older adults. Community Health Nurs 2003;20:135-145.

Nutrition and Diet

* Walmsley CM, Bates CJ, Prentice A, et al. Relationship between alcohol and nutrient intakes and blood status indices of older people living in the U.K.: further analysis of data from the National Diet and Nutrition Survey of people aged 65 years and older, 1994/5. Public Health Nutr 1998;1:157-158.

Compared to heavy drinking (28 or more units per week) or abstinence, consumption of 0.1 to 14 units of alcohol per week was associated with higher intakes of vitamins C, E, B-1, iron, calcium, energy from food, carbohydrate and nonstarch polysaccharides. Light and heavy drinkers had the lowest concentrations of serum ferritin. This study was based on data from the National Diet and Nutrition Survey, a cross-sectional study of 1,198 adults 65 years and older (623 male, 575 female). Of these older adults, 925 were living in private households and 273 were institutionalized. Nutritional information was obtained from 4-day diet diaries or 12-month diet recalls. In this study, 1 unit of alcohol was equal to 8 grams.

Prevalence of Alcohol Consumption

Refer to Epidemiology section.

Risk of Falling

* Stenbacka M, Jansson B, Leifman A, et al. Association between use of sedatives or hypnotics, alcohol consumption, or other risk factors and a single injurious fall or multiple injurious falls: a longitudinal general population study. Alcohol 2002;28:9-16.

High alcohol consumption and use of sedatives or hypnotics were significantly related with occurrence of injurious falls in women older than 60 years. In men of the same age group, alcohol consumption was not associated with falls. This longitudinal study of 4,023 individuals (1,828 men and 2,195 women) between the ages of 20 and 89 years reported 330 injurious falls during a twelve year follow-up period.

Additional reading

1. Guse CE, Porinsky R. Risk factors associated with hospitalization for unintentional falls: Wisconsin hospital discharge data for patients aged 65 and over. WMJ 2003;102:37-42.

2. Nelson DE, Sattin RW, Langlois JA, et al. Alcohol as a risk factor for fall injury events among elderly persons living in the community. J Am Geriatr Soc 1992;40:658-661.

Table 1.

Class of                     Reported concurrent use
medication                      with alcohol (%)

Antihypertensives                      50
Aspirin                                27
NSAIDS (a)                             20
Antacids/[H.sub.2] blockers            16
Sedatives                              11
Narcotics                               5
Warfarin                                5
Diabetes drugs                          3

(a) NSAIDS, Nonsteroidal anti-inflammatory drugs.

Table 2. (a)

                                             Any IADL impairment
Drinking group                                OR (95% CI) (b)

Lower threshold (8-14 drinks/week) (c)          6.0 (1.5-23.8)
Higher threshold (>14 drinks/week)              8.4 (2.5-28.3)
Binge drinking ([greater than or equal to]3     3.0 (1.1-8.4)
  drinks on one occasion for women,
  [greater than or equal to]4 drinks on one
  occasion for men)

                                             Any AADL impairment
Drinking group                                 OR (95% CI) (b)

Lower threshold (8-14 drinks/week) (c)          1.7 (0.4-6.7)
Higher threshold (>14 drinks/week)              3.7 (1.2-11.0)
Binge drinking ([greater than or equal to]3     1.5 (0.6-3.9)
  drinks on one occasion for women,
  [greater than or equal to]4 drinks on one
  occasion for men)

(a) IADL, instrumental activities of daily living; AADL, advanced
activities of daily living.
(b) Adjusted for prescription medications, having past or present
psychiatric condition, age, gender, educational level,
geriatrician-assessed cognitive impairment, and modified Charlson index.
(c) Referent groups for lower and higher threshold were those reporting
<7 drinks/week. For the binge drinking group, the referent group was
those reporting never binge drinking.

9. Screening and Treatment for Alcohol Misuse

* Arndt S, Schultz SK, Turvey C, et al. Screening for alcoholism in the primary care setting: are we talking to the right people? J Fam Pract 2002;51:41-46.

Healthcare professionals mentioned alcohol to only 1 in 6 patients (16%, 95% CI, 15.4-16.8) in this cross-sectional study of 23,349 adults. Even though white patients consume more alcohol than minorities (8.9 drinks/month vs 6.8 drinks/month, P < 0.005) and high income groups more than lowwage earners, physicians tend to discuss alcohol more often with minority and low-income patients. Physicians are more likely to initiate discussions about alcohol with men, younger people, and unmarried or divorced patients. These data were obtained from the 1997 Centers for Disease Control Behavioral Risk Factors Surveillance System, which is a large, nationally representative survey.

* Hinkin CH, Castellon SA, Dickson-Fuhrman E, et al. Screening for drug and alcohol abuse among older adults using a modified version of the CAGE. Am J Addict 2001;10:319-326.

This retrospective review included clinical records of 976 patients screened by a geriatric substance abuse program. A modified version of a common assessment tool, the CAGE, was administered to a group of participants that included alcohol abuse/dependence, drug abuse/dependence, and normal subjects aged 50 years and older. The modified CAGE correctly differentiated alcohol and drug abusers from controls. The CAGE demonstrated good sensitivity but poor specificity, which improved when the first question was omitted. This assessment tool is included below.

Two positive ("yes") answers of the four CAGE questions may indicate alcoholism:

Ever felt the need to cut down on your drinking? (C)

Ever felt annoyed by criticism of your drinking? (A)

Ever felt guilty about drinking? (G)

Ever take a morning drink (eye-opener)? (E)

Additional readings

1. Auwarter V, Kiessling B, Pragst F. Squalene in hair-a natural reference substance for the improved interpretation of fatty acid ethyl ester concentrations with respect to alcohol misuse. Forensic Sci Int 2004;145:149-159.

2. Jurado C, Soriano T, Gimenez MP, et al. Diagnosis of chronic alcohol consumption; Hair analysis for ethylglucuronide. Forensic Sci Int 2004;145:161-166.

Treatment and Prevention

General/community-based interventions

* Crawford MJ, Patton R, Touquet R, et al. Screening and referral for brief intervention of alcohol-misusing patients in an emergency department: a pragmatic randomized controlled trial. Lancet 2004;364:1334-1339.

A brief intervention was effective in reducing emergency department visits among alcohol misusers compared to alcohol misusers not receiving the intervention (1.2 vs 1.7, P = 0.046). The intervention was not successful in reducing the number of alcoholic beverages consumed (59.7 vs 70.8, P = 0.09). These findings are based on a single-blind study of 599 patients identified for alcohol misuse at an initial emergency department visit. The brief intervention consisted of an informational brochure and a counseling session with an alcohol health worker; the control was the brochure without the session. The follow-up time was 12 months.

* Fleming MF, Mundt MP, French MT, et al. Benefit-cost analysis of brief physician advice with problem drinkers in primary care settings. Med Care 2000;38:7-18.

Physicians' advice to problem drinkers may save thousands of dollars in avoided emergency department visits, hospital stays, crime, and automobile accidents. When brief intervention costs are compared with possible health care utilization, legal, and motor vehicle accident costs, intervention is estimated to cost $205 per person, while savings are $1,151 each. Using data from Project TrEAT (Trial for Early Alcohol Treatment), the total economic benefit from 774 subjects with 6- and 12-month follow-up is $423,519 (95% CI, $35,947-$884,848). The savings include $195,448 emergency/hospital use and $228,071 in avoided crime and accidents.

* Holder HD, Gruenewald PJ, Ponicki WR, et al. Effect of community-based interventions on high-risk drinking and alcohol-related injuries. JAMA 2000;284:2341-2347.

By reducing alcohol consumption, community-based intervention programs may prevent some injuries from automobile crashes and violence. Programs that focus on reinforcement of drinking and driving laws, reduction of underage drinking, encouragement of responsible beverage service, limitation of access to alcohol, and mobilization of the community are effective in reducing the numbers of alcohol-related crashes, assault injuries, and subsequent hospital/emergency care. These are the conclusions of a 4-year longitudinal multiple time series study in California and South Carolina in which intervention sites were compared with nonintervention areas. Information was compiled from 120 telephone surveys per month, traffic data, and emergency departments. Driving over the legal limit declined 51% per 6-month period (0.77 vs 0.38 times) after intervention. Injuries caused by vehicle crashes at night decreased by 10%, and those crashes attributable to drinking and driving declined by 6%. Hospital records showed 43% fewer injuries from assault in the intervention communities, and hospitalizations due to assault injuries were down 2%. Alcohol consumption per occasion declined 6% after intervention.

* Manwell LB, Fleming MF, Mundt MP, et al. Treatment of problem alcohol use in women of childbearing age: results of a brief intervention trial. Alcohol Clin Exp Res 2000;24:1517-1524.

Brief intervention is effective in reducing drinking among women of childbearing age. Among 205 patients screened for problem drinking in Project TrEAT (Trial for Early Alcohol Treatment), one group received two 15-minute counseling sessions with a physician that included advice, education, and workbook, while the other group received none. Brief intervention for 4 years resulted in reducing 7-day alcohol use (p = 0.0039) and binge drinking (p = 0.0021). Odds were almost doubled for decreasing drinking by 20% or more (OR, 1.93; 95% CI, 1.07-3.46).

* Richmond R, Kehoe L, Heather N, et al. Evaluation of a workplace brief intervention for excessive alcohol consumption: the workscreen project. Prev Med 2000;30:51-63.

Employees who wish to change their drinking habits may benefit from intervention programs in the workplace. A study of 1,206 Australian Post network employees which focused on employee health awareness, lifestyle campaign, management support, and brief intervention resulted in a significant reduction in number of drinks among women (P < 0.001). Changes in men and women were analyzed separately after 10 months. Overall, 61% of employees and 58% of excessive drinkers attended health assessments.

* Timko C, Moos RH, Finney JW, et al. Long-term outcomes of alcohol use disorders: comparing untreated individuals with those in alcoholics anonymous and formal treatment. J Stud Alcohol 2000;61:529-540.

Persons who receive formal help with a drinking problem are more likely to remain abstinent after several years than are those who receive no help. Alcoholics Anonymous (AA) and formal treatment programs are equally effective, as long as they are initiated quickly. These are the results of a study of 466 drinkers divided into four groups of No Treatment, AA, Formal Treatment, and Combination of AA and Formal Treatment. Only the three treated groups showed continued improvement during 8 years of follow-up.

Pharmacological treatment

* Daeppen JB, Gache P, Landry U, et al. Symptomtriggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal: a randomized treatment trial. Arch Intern Med 2002;162:1117-1121.

Benzodiazepine is a safe, well-tolerated symptom-triggered treatment for alcohol withdrawal and may decrease treatment time as well as medication amounts. These results are based on a prospective, randomized, double-blind, controlled study of 117 alcohol-dependent patients entering a treatment program at two Swiss hospitals. Subjects were divided into two groups, 56 receiving an average dose of 37.5 mg oxazepam for symptom-triggered alcohol withdrawal and the remaining 61 on a fixed schedule of oxazepam every 6 hours with additional doses as needed (average dose 231.4 mg). Twenty-two (39%) of the symptom-triggered group and 100% of the fixed-schedule group received oxazepam (P < 0.001). Average length of treatment was 20 hours in the symptom-triggered group and 62.7 hours in the fixed-schedule group (P < 0.001).

* Johnson BA, Ait-Daoud N, Prihoda TJ. Combining ondansetron and naltrexone effectively treats biologically predisposed alcoholics: from hypotheses to preliminary clinical evidence. Alcohol Clin Exp Res 2000;24:737-742.

Ondansetron combined with naltrexone reduces alcohol consumption in early-onset alcoholics (EOAs). In an 8-week double-blind, controlled clinical trial involving 20 EOAs, subjects receiving 4 [micro]g/kg ondansetron and 25 mg naltrexone twice a day had fewer drinks per day, fewer drinks per drinking day, and increased days abstinent, compared with the placebo group. All subjects received weekly standardized group cognitive behavioral therapy. More research is needed to determine the separate and combined effects of the two medications among other alcoholic subtypes.

* Johnson BA, Roache JD, Javors MA, et al. Ondansetron for reduction of drinking among biologically predisposed alcoholic patients: a randomized controlled trial. JAMA 2000;284:963-971.

Ondansetron, a serotonergic agent, reduces alcohol consumption in individuals with early onset alcoholism. In a study of 321 alcoholics at the University of Texas Health Science Centers in Houston and San Antonio, subjects were divided into 4 groups of receiving cognitive behavioral therapy along with 1 [micro]g/kg, 4 [micro]g/kg, 16 [micro]g/kg ondansetron twice a day, or placebo for 11 weeks. Data included plasma carbohydrate deficient transferrin (CDT) level and self-reported drinks per day, drinks per drinking day, days abstinent, and total days abstinent per study week. Compared with those who did not receive ondansetron, all treatment groups had fewer drinks per day, with the 4 [micro]g/kg twice-a-day dosage showing the best results for increasing days abstinent and total days abstinent per study week. CDT ratios were significantly less in the 1 [micro]g/kg and 4 [micro]g/kg groups compared with placebo.

Additional reading

1. Johnson BA, Ait-Daoud N, Akhtar FZ, et al. Oral topiramate reduces the consequences of drinking and improves the quality of life of alcohol-dependent individuals: a randomized controlled trial. Arch Gen Psychiatry 2004;61:905-912.

Prevention of binge drinking among college students

* Baer JS, Kivlahan DR, Blume AW, et al. Brief intervention for heavy-drinking college students: 4-year follow-up and natural history. Am J Public Health 2001;91:1310-1316.

Brief intervention programs are successful in reducing alcohol intake in heavy-drinking college students. While maintaining their drinking frequency, students enrolled in intervention programs report long-term reduced alcohol consumption and fewer negative consequences. These are the conclusions of a 4-year randomized controlled trial involving college freshmen who were heavy drinkers in high school and who underwent single-session, individualized preventive intervention.

* Borsari B, Carey KB. Effects of a brief motivational intervention with college student drinkers. J Consult Clin Psychol 2000;68:728-733.

Brief intervention programs help college binge drinkers reduce the amount and frequency of alcohol consumption. This randomized controlled trial included 60 college students reporting binge drinking two or more times in the previous 30 days. Subjects either participated in single-session motivational intervention or received no treatment. Students in the treatment group received counseling in several areas, including alcohol-related problems, situations associated with heavy drinking, personal consumption, and perceived drinking norms. After 6 weeks, those who participated in the motivational intervention reported reductions in weekly alcohol consumption, binge drinking, and overall drinking frequency.

* Dejong W. Finding common ground for effective campus-based prevention. Psychol Addict Behav 2001;15:292-296.

"Binge drinking" and other negative terminology that refers to the alcohol consumption habits of college students should be avoided so that strategies aimed at reducing alcohol-related problems can be strengthened. As there is no justifiable basis for which to label college-aged consumption habits as "binge drinking," doing so only demoralizes students and delays preventive action.

Alcohol CME Supplemental Materials

Understanding Alcohol Content Reporting in Research

One standard drink is equal to:

* 12 oz can or bottle of beer/wine cooler

* 5 oz wine

* 1.5 oz spirits

* 0.5 oz pure alcohol

* 12 grams pure alcohol

Table 1. Summary of study findings (a)

Number of studies reporting health benefit from alcohol           35
  consumption
Number of studies with U-shaped relationship between alcohol      15
  and health condition
Number of studies reporting health detriments from alcohol        43
  consumption
Number of studies reporting no relationship between alcohol and   20
  health condition
Number of studies reporting mixed findings                        27
Total number of studies included                                 154

(a) Excludes studies not examining the relationship between alcohol and
health, for example, prevalence articles (n = 42).

Table 2. Summary of selected articles (alphabetical by topic)

                                               Number of
Health topic                                   studies included

Behavior                                               2
Binge drinking                                         7
Bladder cancer                                         2
Breast cancer                                          5
Cardiovascular disease                                16
Central nervous system and cognitive function          3
Dementia                                               2
Driving while impaired                                 5
Eye disease                                            3
Female fertility                                       3
Gastrointestinal bleeding                              2
Gastrointestinal/esophageal cancer                     1
Gastritis                                              2
Hearing                                                2
Immune function                                        2
Insulin dependent diabetes                             2
Liver disease                                          2
Lung cancer                                            2
Male fertility                                         2
Mortality                                              6
Non-Hodgkin lymphoma                                   2
Non-insulin dependent diabetes                         9
Nutrition and diet                                     1
Obstructive sleep apnea                                1
Older adults                                           7
Ovarian cancer                                         1
Pancreatic cancer                                      2
Pregnancy                                             14
Prevalence                                             3
Prostate cancer                                        2
Renal cancer                                           1
Risky behavior                                         2
Screening and treatment                               13
Sexually transmitted diseases                          1
Skeletal health                                        7
Sleep quality                                          4
Socioeconomic impact                                   3
Stress                                                 1
Stroke                                                 6
Suicide                                                2
Thyroid function                                       1

CME Questions: Alcohol

1. Over the past decade, alcohol consumption among underage drinkers in the eighth, tenth, and twelfth grades has:

a. Increased substantially

b. Decreased substantially

c. Remained relatively stable

2. The recommended weekly limit of alcohol consumption for male and female adults is:

a. No more than 12 drinks for men and 9 for women

b. No more than 10 drinks for men and women

c. No more than 14 drinks for men and 7 for women

d. Not established at this time

3. The relationship between alcohol consumption and all-cause mortality is:

a. Direct

b. Indirect

c. There is no relationship between alcohol consumption and all-cause mortality

d. U-shaped

4. Hangover accounts for _____________ in lost productivity and absenteeism in workplaces in the United States.

a. $15 million

b. $90 million

c. $148 billion

d. $200 billion

5. Women consuming 35 or more grams per day of alcohol had:

a. a significantly higher risk of breast cancer

b. a significantly lower risk of breast cancer

c. no change in risk of breast cancer

6. Both studies presented on non-Hodgkin's lymphoma reported that wine consumption was linked to a __________ risk of developing that cancer.

a. Increased

b. Decreased

c. Wine was not linked to any risk change

7. According to studies presented, the prevalence of fetal alcohol syndrome in the United States is:

a. 0.2-0.8 instances per every 1000 births

b. 0.5-2.0 instances per every 1000 births

c. 1.5-4.0 instances per every 1000 births

d. 1.8-2.3 instances per every 1000 births

8. Consumption of alcohol above this level was linked to increased risk of spontaneous abortion:

a. 1 units

b. 5 units

c. 7 units

d. 10 units

9. In the article by Arndt et al, 2002, primary care providers discussed alcohol consumption (eg, frequency, appropriate levels) with only ____________ of their patients:

a. 1 in 3

b. 1 in 6

c. 1 in 10

d. 1 in 20

10. Which of the following drugs were mentioned as having interactions with alcohol, specifically in older adults:

a. Aspirin

b. NSAIDS

c. Antacids/[H.sub.2] blockers

d. Warfarin

e. All of the above

11. The following factors were linked to depression in older adults (Osborn et al, 2003):

a. Alcohol use

b. Limited transportation

c. No confiding relationship

d. All of the above

12. In the study presented, beer consumption was linked to bladder cancer in what way?

a. Beer consumption at all levels increased the risk of bladder cancer.

b. Beer consumption decreased the risk of bladder cancer.

c. Beer consumption did not alter the risk of bladder cancer.

13. In the study presented on Skeletal Health (Ganry et al, 2000), alcohol consumption was linked to _____________ bone mass in elderly women.

a. Increased

b. Decreased

c. No significant association

14. In Grodstein et al, 1994, moderate alcohol consumption was linked to female infertility due to:

a. Endometriosis

b. No association

c. Ovulatory factors

d. Both a and c

15. In Jackson et al, 2003, alcohol consumption was linked to decreased mortality in this group:

a. Women with a history of stroke

b. Women with no history of stroke

c. Men with a history of stroke

d. Both men and women with a history of stroke

16. Alcohol consumption had what effect on male fertility?

a. Decreased fertility due to limited sperm motility and impaired sperm morphology

b. Decreased fertility due to changes in DNA structure of spermatogenic cells

c. No impact on fertility

17. In Ajani et al, 1999, alcohol consumption exhibited a _________ association with age-related macular degeneration:

a. Linear

b. U- or J-shaped

c. No relationship

18. 12 ounces of beer or wine cooler is equivalent to:

a. 5 oz wine

b. 2 oz spirits

c. 18 grams pure alcohol

19. According to van der Gaag et al, 2001, this type of alcohol may reduce the risk of coronary artery disease by increasing HDL:

a. Beer

b. Wine

c. Beer and Wine

20. Alcohol appears to ___________ the risk of non-insulin dependent diabetes mellitus in men:

a. Increase

b. Decrease

Answers to CME Questions:

1. C, 2. C, 3. D, 4. C, 5. A, 6. B, 7. B, 8. B, 9. B, 10. E, 11. C, 12. B, 13. A, 14. D, 15. C, 16. C, 17. B, 18. A, 19. C, 20. B

CME Credit Submission and Evaluation Form

CME Credit-January 2005

Featured CME Topic: Alcohol

To request a CME certificate, complete all sections of this form and mail it with a check (payable to SMA) to: SMA, Attn: SMJ CME, PO Box 190088, Birmingham, AL 35219-0088. Deadline to submit and receive credit for this feature is January 1, 2006. Copies are acceptable. You may also submit electronically via SMA's website at www.sma.org.

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Accepted October 18, 2004

Please see Ronald C. Hamdy and Melissa McManama Aukerman's editorial on page 1 of this issue.

Ronald C. Hamdy, MD and Melissa McManama Aukerman, MS

From the James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN, and the Department of Kinesiology, Pennsylvania State University, University Park, PA.

Reprint requests to Melissa McManama Aukerman, MS, Department of Kinesiology, Pennsylvania State University, 275 Recreation Building, University Park, PA 16802. E-mail: [e-mail]