28
Alcohol consumption and life insurance
Dr. Kevin Somerville, MD
Swiss Reinsurance Company
Global Life & Health Underwriting, London
Dr. sc. nat. Beatrice Baldinger
Swiss Reinsurance Company
Life & Health Products, Zürich
Abstract
Alcohol use is common. The culture of
drinking differs substantially between
societies and the mortality and morbidity risk depends upon the circumstances in which alcohol is taken as well as
the quantity and pattern of consumption. There are two defined excess alcohol use syndromes, alcohol abuse
(DSMIV)/harmful use (ICD10) and
the more severe alcohol dependence
(DSMIV and ICD10). The additional concept of hazardous drinking is frequently
used to describe excessive alcohol use
which is potentially injurious to health;
in this the morbidity and mortality risks
are increased but there is none of the
physical, social or psychological effects
associated with alcohol abuse/harmful
use or dependence.
Clinical and epidemiological studies
show that the acute effects of alcohol
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excess (intoxication) are of particular
importance in the young and that episodic heavy alcohol use (binge drinking)
is more problematic than regular modest to high alcohol intake. Obtaining evidence about such a pattern of alcohol
use is not straightforward and insurance
application forms often do not ask.
Alcohol intake is not without its benefits. The incidence of ischaemic heart
disease (IHD) appears to be lowered by
regular modest alcohol use and this is
of particular relevance in high cardiovascular disease risk areas. This has
an impact on critical illness risk assessment especially in older men where increased cancer and neuropsychiatric
risk is offset, at least in part, by the lower IHD risk. Furthermore, modest alcohol intake is also used as part of social
discourse and even business deals.
Risk assessment needs to be placed in
the context of the individual as well as
society particularly as alcohol abuse/
dependence may be difficult to identify.
However, once alcohol dependence has
been diagnosed the mortality and morbidity risks are very high and only those
with a well documented and sustained
29
recovery will be eligible for an offer of
insurance.
Introduction
Alcohol use is widespread and common. Excessive alcohol use is regarded as a major health public hazard. The
World Health Organisation (WHO) ranks
harmful use of alcohol as the fifth leading risk factor for premature death and
disability in the world. It estimated that
worldwide in 2002 at least 2.3 million
people died of alcohol-related causes
(3.8% of global mortality) and that alcohol consumption caused 4.6% of the
global burden of disease. The Institute
for Alcohol studies in the UK estimates
that the estimated social costs of alcohol are between 1% and 3% of GDP and
for the European Union in 1998 are between $65 and $195 billion at 1990 prices, comparable to government expenditures on social security and welfare,
and approximating to 25% of health
service expenditure.
The acute and chronic unwanted effects
of high alcohol intake affect society, the
family and the individual and these
have been subdivided into:
1.Acute intoxication: accidents, suicide, inappropriate behaviour, family and social impact, and poor work
performance.
2.Chronic excessive use: liver disease, neurological disorders, cardiomyopathy, family and social impact, unemployment, and poor work
performance.
In general, unintentional injuries associated with acute intoxication contribute most to alcohol-attributable mortality while neuropsychiatric disorders
caused by chronic alcohol use contributed most to alcohol-attributable
disease. The two defined clinical syndromes that reflect these problems are
alcohol abuse/harmful use and alcohol
dependence.
Both the DSM IV and ICD 10 have similar
definitions for alcohol dependence but
the criteria for the less severe category of alcohol abuse (DSM IV) or harmful use (ICD 10) differ. The ICD10 category of harmful use is not specific to
alcohol but is used for all psychoactive
substances where use or excessive use
causes harm. Broadly, alcohol dependence equates to the problems of chron-
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30
ic use and alcohol abuse/harmful use
to the acute effects of repeated overuse
although there is considerable overlap.
None of the definitions include the quantity of alcohol consumed as a guide or
one of the essential criteria for diagnosis. The emphasis is upon the effects of
alcohol use upon the health, performance and social network of the affected
individual. Rehm et al (2004) provide a
broad diagrammatic representation of
the acute and chronic effects of alcohol
consumption.
However, the effects of alcohol consumption and its role in society are not
universally deleterious; alcoholic beverages are ubiquitous and have a major role in social discourse as well as a
cardioprotective effect in those at risk
of ischaemic heart disease (IHD).
How is alcohol consumption measured?
Because there is a broad relationship
between the pattern of alcohol use and
the development of adverse effects, authorities have attempted to categorise
both the acceptable and the potentially
injurious levels of alcohol use in terms
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of the average drink or quantity of alcohol consumed. However, the social
circumstances in which alcohol is used
(taken with meals or standing at a bar,
emphasis on drinking as distinct from
emphasis on socialisation) appear to
have a major modifying effect.
The amount of alcohol consumed can
be quantified by weight (grams) or by
volume (litres of pure alcohol). However, this is not straightforward as the
concentration of alcohol varies between
and within drink classes (beer, wine,
spirits); there is no easy linear relationship between the type of alcohol consumed along with the volume served
with the quantity of alcohol consumed.
The variation within typical different
drink classes for a standardised serving
is shown in the table (Table 1, P. 31).
To compound the difficulty the average or standard drink volume varies between countries; this is frequently set by
the average serving in the country concerned. No internationally recognised
set of standards has been adopted. The
table below shows the average or standard drink in a range of countries (Table 2,
P. 31).
31
Table 1
Alcohol type
Wine
Wine
Mid strength beer
Spirits
Spirits
Alcohol serving
1 glass
1 bottle
1 pint
1 measure (1/5 gill)
1 bottle
Metric measure
125 ml
750 ml
587 ml
30 ml
750 ml
Grams of alcohol
8 – 12
48 – 70
16
8 – 10
200 – 250
Alcohol measure
Unit
Standard drink
Standard drink
Grams of alcohol
8
9.9
10
Table 2
Country
United Kingdom, Ireland
Netherlands
Australia, Austria, Italy, New Zealand,
Poland, Spain
Finland
Denmark, France, South Africa
Canada
USA, Portugal
Japan (males)
There are substantial differences between countries when average per
capita consumption of alcohol is measured. In some predominantly Islamic
countries the restricted availability of
alcohol and the prevailing social and
religious mores mean that alcohol intake is uncommon. Even in Europe the
area that has the highest per capita
Standard drink
Standard drink
Standard drink
Standard drink
Standard drink
11
12
13.6
14
19.75
alcohol intake in the world there are
major inter-country differences ranging from Norway 4.4 l to Luxemburg at
11.9 l in 2002. However, particularly in
Eastern European countries, a substantial amount of alcohol consumption is
unrecorded.
These differences bedevil observational
studies of the effect of alcohol on acute
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32
and chronic disease particularly as they
usually rely upon self report; there are
no randomised controlled trials! Broadly, those who abstain from alcohol are
compared with those who use alcohol.
There are inherent problems with such
observational studies and questionnaires which include:
1.As noted above, different alcoholic
beverages have variable concentrations of alcohol so quantification is
difficult.
2.Studies use different standards of
measurement of consumption such
as blood alcohol concentration or estimates of the amount of alcohol consumed. The same term eg drink or unit
can be used for different amounts of
pure alcohol; authors are not always
consistent.
3.Alcohol use is frequently assessed
by very few questions; frequently
the pattern of use is not measured
despite binge drinking appearing to
be particularly hazardous. Insurance
companies use non-standardised
questionnaires which ask about average intake over days or weeks.
4.Alcohol use may change over time.
5.Recall bias may occur amongst those
questioned about their drinking hab-
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its. Asked to recall a typical day an interviewee is apt to state the intake on
an atypical (low volume ) day.
6.The effect of alcohol could theoretically vary by beverage type eg does
red wine have a greater beneficial effect on CVD than other types of alcoholic beverage?
7.Those who abstain belong to a heterogenous group which contains lifelong abstainers, reformed alcoholics,
and those who have been advised
to abstain for other health reasons
(eg to avoid alcohol/pharmaceutical
interactions). Few studies have attempted to correct for this “unhealthy
abstainer” bias.
8.Societal differences in the type and
quantity of alcohol consumed; cultural influences seem to modify whether
alcohol related health & social problems occur.
9.Alcohol use may be associated with
other potentially confounding factors.
The most important of these are:
a.Smoking: alcohol abuse/harmful
use and alcohol dependence are
strongly correlated with cigarette
smoking and without accounting
for smoking the morbidity and mortality risk estimates for alcohol will
33
be inflated.
b.Social class: alcohol consumption
especially moderate alcohol intake
is more common amongst the middle classes.
c.Diet: This influences both average
intake and pattern of alcohol use
(Breslow et al, 2006).
d.Cardiovascular risk factors: blood
pressure is higher in those who
take excessive amounts of alcohol. A different and sometimes
lowered prevalence of other associated cardiovascular risk factors
such as obesity, diabetes mellitus,
and physical activity can also act as
confounding factors, ie it is these
rather than the alcohol intake that
are directly responsible for the ill
health (Naimi et al, 2005).
10.The poor reliability of the diagnosis of
the alcohol abuse (DSMIV) and harmful use (ICD10) syndromes; this correlates with the poor reliability of the
current risk stratification systems.
Alcohol: beneficial and harmful effects
Moderate alcohol use has been shown
to have beneficial effects on many cardiovascular diseases although some of
this may be artifactual, a result of poor
recognition of and control for important confounding factors (Jackson R et
al, 2005). In part this is because alcohol use appears to be associated with
a lower prevalence of important cardiovascular risk factors such as obesity,
diabetes mellitus, physical activity although hypertension is more common
(Naimi et al, 2005). However, studies
in many countries, some of which have
controlled for the unhealthy alcohol abstainer effect, have consistently shown
that modest alcohol use reduces cardiovascular mortality. By contrast, the association of alcohol excess with acute
and chronic problems such as accidents, suicide, psychosis, various types
of cancer, liver disease, pancreatitis,
cardiomyopathy, and brain disorders is
well documented and of major public
health and societal concern. Rehm et al
(2004) produced an outline of the protective and adverse effects of alcohol.
What are the “safe” levels of alcohol
intake?
Research comparing countries in North
America and Europe has produced a
classic subdivision into ‘wet’ and ‘dry’
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34
cultures. In the former, alcohol is integrated into daily life, in particular wine
at meal times, and abstinence is uncommon. In the latter, access to alcohol
is less integrated, use of alcohol is more
frequently associated with excess and
intoxication, and beer rather than wine
is the beverage of choice. However, this
distinction is disappearing with harmonisation of drinking patterns within
Europe apart from the recent notable
exception of Eastern Europe where excessive alcohol intake has become a
major social problem. This phenomenon
is occurring to a lesser extent within the
remnants of the dry culture in Northern
European countries such as the UK and
Ireland. Other measures of alcohol use
to average daily intake such as the pattern of drinking especially binge drinking and the frequency of drunkenness
have also been introduced into some
national guidelines. In ‘dry’ cultures
binge drinking is more common, beer
and spirits predominate, and the risk to
the population per unit of alcohol appears greater (Rehm, 2001).
In both the academic literature and publications issued by a number of government agencies in many countries ‘safe’
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or ‘desirable’ levels of consumption
based upon grams of alcohol have been
produced. Published risk level recommendations by the amount of alcohol
consumed include the following:
World Health Organisation (WHO,
2000):
Criteria for risk of consumption on a
single drinking day – WHO recommend
that this be used for comparative research purposes only
Category
Low Risk
Medium Risk
High Risk
Very High Risk
Males
1 to 40g
41 to 60g
61 to 100g
101+g
Females
1 to 20g
21 to 40g
41 to 60g
61+g
The number of standard drinks corresponding to these thresholds varies
(see above).
35
The WHO criteria appear to be based
upon a paper by Rehm et al in the International Journal of Epidemiology in
1999. This group have published extensively on the subject of alcohol risk,
their criteria are as follows:
Category
Abstention
and very light
drinking
Low Risk
Hazardous
drinking
Harmful
drinking
Males
0 – 2.5 g
pure
ethanol
per day
2.6 to 40g
40.1 to
60g
≥ 60g
Females
0 – 2.5 g
pure
ethanol
per day
2.6 to 20g
20.1 to
40g
≥ 40g
Hazardous drinking is regarded as
putting the user at risk for adverse effects whereas harmful drinking is associated with physical, mental or social
damage and conforms more closely to
the alcohol abuse/harmful use syndromes defined by DSM IV and WHO
respectively.
Males
Harmful/
≥ 50 g,
hazardous
7 days
drinking
per week
or ≥ 70 g,
4-6 days
per week
or › 120 g,
2 – 3 days
per week
Binge drinking › 70 g no
more than
1 day per
week
Heavy
≥ 50 g
drinking
usually
Moderate
Less than
drinking
those
above
Females
≥ 30 g,
≥4 days
per week
or ≥ 50 g,
2 – 3 days
per week
or › 60 g,
≥ 2 days
per week
› 50 g no
more than
1 day per
week
≥ 30 g
usually
Less than
those
above
Makkai & McAllister (Australia), 1998 produced a set of recommendations which
include binge drinking and also took the
pattern of drinking into account:
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36
The National Institute on Alcohol Abuse
and Alcoholism (NIAAA), USA, has
adopted the following guidelines:
Heavy drinking:
Males
≥ 5 drinks (60 g)
(‹ 65 years)
in one day
or ≥ 14 drinks
(168 g) in one
week
ie an average
of 2 drinks
(24 g) per day
Females or
≥ 4 drinks (48 g)
males
in one day
(≥ 65 years)
or ≥ 8 drinks
(96 g) in one
week
ie an average
of 1.2 drinks
(14 g) per day
In the United Kingdom the recommended safe limits are 3 – 4 units (24 – 32 g)
per day for a man and 2 – 3 units (16 –
24 g) per day for a woman.
In summary, there are substantial differences to recommendations about
safe limits of alcohol intake in the approach taken by governments and pub-
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lic health bodies and no clear relationship between the pattern or volume of
alcohol consumed and the diagnosis
of the alcohol syndromes.
Screening for alcohol abuse
Alcohol questionnaires
The NIAAA recommends either a single
screening question: “How many times
in the past year have you had 5 or more
drinks (4 or more for a woman) on a
single occasion” or the more comprehensive AUDIT screening questionnaire
before asking further questions about
pattern of alcohol use or symptoms indicating abuse or dependence.
The AUDIT (Alcohol Use Disorder Identification Test) produced by WHO in 1989
has ten questions about the quantity as
well as pattern and experience of alcohol use. Two supplementary questions
are asked about alcohol related injury
(self or others) and advice to cut-down
alcohol intake. While it has reasonable
sensitivity and specificity for the detection of hazardous drinking or alcohol abuse, it is predominantly used in
research settings or in specialty clinics
rather than as a population screening
37
tool. A simpler more practical form of
the AUDIT using 3 questions (AUDITC) has been produced and preliminary
studies suggest that there is little loss
of utility but it has not been well studied. These questions are
•How often did you have a drink containing alcohol in the past year?
•How many drinks did you have on a
typical day when you were drinking in
the past year?
•How often did you have 6 or more drinks
on one occasion in the past year?
A short questionnaire alternative is the
CAGE questionnaire; an acronym based
upon the 4 questions asked:
•Have you ever felt the need to Cut
down on drinking?
•Have you ever felt Annoyed by criticism of your drinking?
•Have you ever had Guilty feelings
about your drinking?
•Do you ever take a morning Eye opener (a drink first thing in the morning
to steady your nerves or get rid of a
hangover)?
Although commendably short, it has
been criticized as lacking sensitivity.
The unsatisfactory role of and difficul-
ty with questionnaire based screening
is apparent from the number of screening instruments available with a wide
variety of title or acronyms: MAST;
TWEAK, T-ACE, CRAFFT… However, insurance application forms which typically contain just one question about
average alcohol intake have not been
formally studied as to their sensitivity
or specificity. The positive and negative
predictive value of screening questionnaires depends upon the prevalence of
hazardous drinking and alcohol abuse/
dependence in the population being
asked and information about this in
turn mostly comes from the questionnaires themselves.
Evidence that should raise the suspicion of an alcohol problem include
convictions for drunk driving, martial
breakdown, job loss or frequent absenteeism, arrest by the police for an alcohol related offence, repeated falls with
or without fracture, and physical problems which raise the possibility of alcohol excess. These last include such as
pancreatitis or cardiac problems including paroxysmal atrial fibrillation.
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As screening tests in insurance applicants routine blood tests have a very
low yield and in a population at low risk
of alcohol abuse the potential for a high
false positive rate. However, these can
be useful if there is a feature suspicious
for excessive alcohol use in the past or
current history. Routine laboratory tests
which increase the likelihood of an alcohol problem include unexplained
macrocystosis, a high HDL cholesterol,
elevated triglycerides and elevated liver
function tests, in particular the gamma
glutamyl transpeptidase (GGT). While
all of these tests are non-specific, in a
context where alcohol abuse has been
considered they help to raise or lower
the possibility. In the past GGT has been
discounted as a major mortality risk factor but recent research from insurance
laboratories in the USA suggest that it
is a better mortality marker than ALT or
AST; some of this could be related to alcohol abuse increasing the level of the
enzyme.
Alcohol markers such as carbohydrate
deficient transferrin (CDT) and haemoglobin acetaldehyde (HAA) are extensively used as reflex tests for heavy
alcohol use by insurance applicants in
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North America. The sensitivity of CDT
for alcohol problems is about 70% and
the false positive rate is about 15%
which is not good enough for a population of low prior probability of alcohol
abuse. The performance of the HAA is
not as good as the CDT but the latter is
a better reflex screening test than GGT
or HDL cholesterol.
Chronic Effects of alcohol
There are numerous summaries of the
relative risks for individual diseases in
the clinical literature for given levels
of alcohol intake. That of Corrao et al
(1999) is widely quoted; these authors
also produced a follow up report in 2004
where their database was extended to
publications up until 1998. The table
below gives a summary of the relative
risks (RRs) for IHD, stroke and various
cancers for various levels of average alcohol intake estimated from the 1999
Corrao report by Britton & McPherson
(2001) for average alcohol intake up to
50 grams per day. The full list of Corrao
et al (1999 & 2004) estimates is too extensive to be reproduced in this paper.
39
Alcohol consumption
None
1 – 10
10 – 20
g/day*
g/day
0.832
0.778
IHD men
1 (referent)
IHD women
1
0.857
0.853
Colon cancer 1
1.067
1.215
Breast cancer 1
1.039
1.122
Haemorrhagic 1
1.078
1.252
stroke
Disorder
20 –30
g/day
0.768
0.896
1.384
1.211
1.455
30 – 40
g/day
0.775
0.962
1.575
1.308
1.690
40 – 50
g/day
0.793
1.047
1.794
1.412
1.964
*Midpoint in each category used to calculate relative risks.
Taken from Britton A and McPherson K 2001 and based upon Corrao et al, 1999
The relative risk estimates given by Corrao et al, 2004, include measures up to 100g
of alcohol per day:
Colon
Rectum
Liver
Breast
IHD
Ischaemic
stroke
Haemorrhagic
stroke
Cirrhosis
RR and 95% CI compared to non-drinkers
25g/day
50g/day
100 g/day
RR
95%CI
RR
95%CI
RR
1.05
1.01 – 1.09
1.1
1.03 – 1.18
1.21
1.09
1.09 – 1.12
1.19
1.14 – 1.24 1.42
1.19
1.12 – 1.27
1.4
1.24 – 1.56
1.81
1.25
1.20 – 1.29
1.55 1.44 – 1.67 2.41
1.13
0.81 0.79 – 0.83 0.87 0.84 – 0.90
0.9
0.75 – 1.07
1.17
0.97 – 1.44 4.37
95%CI
1.05 – 1.39
1.30 – 1.55
1.50 – 2.19
2.07 – 2.80
1.06 – 1.21
2.28 – 8.37
1.19
0.97-1.49
1.82
1.46 – 2.28
4.7
3.35 – 6.59
2.9
2.71-3.09
7.13
6.35 – 8.00
26.52
22.26 – 31.6
An extensive overview on chronic alcohol use and individual diseases was included in the original article. The full version can be obtained from the authors.
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40
Summary of the acute adverse effects
of alcohol:
There is a substantial and verified increase in the risk of trauma and traumatic death and disability as a result
of heavy drinking and there is some
evidence that even modest intakes reduce reaction times and increase in motor vehicle accident rates. Drowning,
sudden cardiac death and dysrhythmia are more common after episodic
heavy drinking especially if on a background of low average use of alcohol.
However in many cultures, episodes of
heavy drinking are common especially
in young adults which reduces the discriminatory power of this phenomenon.
It is only when alcohol intake either as
a high daily intake or a pattern of binge
drinking, affects the individual’s health
and social discourse including the ability to work satisfactorily that an alcohol
related problem can be identified.
Alcohol syndromes and all cause
mortality
Insurance studies
Alcohol abuse and liver enzymes: results
of an intercompany study of mortality
(Cliff Titcomb) JIM 2001; 33: 277 – 289
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This is a pooled study of 82262 (after
exclusions; 131'394 were originally considered) policies issued between 1989
and 1995 with exposure until the 1997
anniversary. Maximum exposure was 8
years; average 2.5 – 3 years. The Medical Insurance Bureau (MIB) database
was searched for one of 4 diagnostic
codes: alcohol use significant to health
and longevity; adverse driving record or
multiple moving violations; abnormal
transaminases; and abnormal GGT. As
exposure in females was low (9.5% of
claims) the analysis was restricted to
males. Because the numbers of those
with both abnormal LFTs, and alcohol
and/or driving problems were low an
analysis of individuals with both was
not carried out (it is likely that most of
these had been declined an offer of insurance). The basis for expected mortality was the 1990 – 95 Basic Table (BT).
For those men with a rating of either abnormal alcohol use or driving problems
(and normal LFTs), a standard rating
was associated with a mortality ratio
(MR) of 217, a substandard 175- there
was no age gradient. Mortality ratios
were highest when the face amount
was less than $50,000 and in smokers:
41
Smoker
status:
Unknown
NonSmoker
Smoker
Total
Actual
deaths
46
72
83
201
Expected MR
Deaths
15
307%
47
153%
25
87
332%
231%
Although not stated BT 1990-95 had a
smoker/non-smoker split so that the
expected deaths recorded above are
unlikely to be based upon aggregate
mortality data.
The MIB codes do not correlate absolutely with either of the clinically defined alcohol syndromes but the cases
above represent a combination of alcohol abuse and alcohol dependence.
Titcomb commented that the observed
high MRs with low face amount and
smoking probably represented behavioural and socio-economic factors; in
addition those with larger sums assured were more likely to be medically
scrutinised. These data suggest that
the risk in non-smokers is substantially
lower than in smokers.
Unfortunately there is no age stratification for the alcohol syndromes; but
there is an age breakdown for the entire group (abnormal LFTs and alcohol).
There was no clear reduction in the MR
with increasing age. This may represent
a differential pattern of alcohol associated mortality with acute intoxication
predisposing to accidental death in the
young and chronic alcohol abuse/dependence causing physical and mental
disorders in older people.
Single Medical Impairment Study
(SMIS) and Multiple Medical Impairment Study (MMIS), 1983
Unfortunately there is no smoker / nonsmoker stratification in this dataset and
as female exposure to major alcohol
misuse is about 4% of the whole, only
MR for males were reported. For those
rated standard the MR was 208%; for
substandard lives the MR was 243%.
Alcohol misuse was defined as “persons who misused alcohol by regular
heavy use, but who are not obvious or
admitted alcoholics”. A small number
of dry former alcoholics were included. The importance of confounding by
smoking is suggested by the MRs of 149
and 197 for heart/circulatory disease in
the SMIS and MMIS respectively.
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42
A trend to reducing MR with age was
observed in both studies:
Issue age
15 – 29
30 – 39
40 – 49
50 – 59
60 – 69
SMIS
272%
282%
234%
216%
147%
MMIS
533%
380%
288%
240%
206%
A further analysis of the SMIS with
weighting the combined standard & substandard policies in the ratio of 4 to 1 to
reflect the proportions of the insurance
issued showed MRs for all durations and
ages of 226% in males and 334% in females (Medical Risks: abstract 327).
Issue age
15 – 39
40 – 49
50 – 59
60 – 69
Total
Males
258%
228%
205%
148%
226
Females
254%
280%
632%
–%
334
Summary insurance studies:
The studies are heterogenous and not
well defined. Risk estimates vary from
no increase to a modest increase in the
mortality ratio. Smoking is a confounder
which has been poorly controlled for.
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Clinical studies:
Alcohol dependence and alcohol abuse/
harmful use (alcoholism) and mortality
have not been extensively studied. The
one exception is the alcohol dependent
admitted to hospital.
Alcohol dependence
Although individual studies do not have
large numbers of patients these studies
show that alcoholics abstaining from alcohol have a lower mortality than those
who relapse or continue to drink. All of
these studies show a high mortality rate
amongst alcoholics. For example Gerdner & Berglund (1997) showed an 8.5
year cumulative mortality of 76% (annualised mortality of 32 per mille) in male
alcoholics (average age 41 years) who
were treated as inpatients. None of those
who abstained from alcohol died during
follow up. A similar finding of improved
outcomes in treated male alcoholics abstaining (stable abstainers) from alcohol
comes from the VA Center in San Diego
(Bullock et al, 1992). Stable abstainers
had similar 11 year mortality (HR 1.25) as
a cohort of age & race matched men from
the general population whereas relapsers
had a significant mortality ratio of 5.
43
Alcohol abuse
Unfortunately, mortality associated
with the recently defined syndrome
of alcohol abuse/harmful use has not
been well studied. In general, clinical
studies tend to be based upon average
alcohol use rather than the clinical syndromes of alcohol abuse/dependence.
Useful reviews of all cause mortality and
levels of alcohol use have been carried
out by the Australian Institute of Health
and Welfare (Single at al, 1999), and by
Rehm et al (2003). In addition, White et
al, 2002, modelled alcohol consumption and mortality for both sexes by age.
A longitudinal study of male doctors in
the UK compared lifelong abstainers
with quitters (ie controlled for stopping
alcohol because of illness which might
confound the all cause mortality and
disease specific mortality rates) (Doll
et al, 2005) and is worth considering
as are a mathematical modelling study
(Bagnardi et al, 2004), a report from
the cancer prevention study in the USA
(Thun et al, 1997), There are few studies
which investigate the pattern of alcohol
intake, intermittent vs binge drinking vs
sustained excessive use. An extension
of the Whitehall II cohort study (Brit-
ton & Marmot, 2004) investigated the
pattern of use as did a report from the
US National Alcohol survey (Rehm et al,
2001).
Mortality Studies based upon the volume of Alcohol Consumption
While there is considerable heterogeneity between the studies there is consensus that the all cause mortality risk
curve is J shaped in most populations
and that the nadir of the J is lowest in
populations where the cardiovascular
risk is high so that any protective effect
of alcohol is higher in men and in older individuals. Episodic heavy drinking
despite a low or modest background intake of alcohol also increases the mortality risk.
Summary of the clinical mortality
studies
These are heterogenous but show limited increases in risk up to an intake of
60 g per day in males and 40 g per day
in females. Heavy episodic drinking appears to as, if not much more, important than average intake especially in
the young with high accident rate and
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44
a significant increase in mortality which
is independent of the average daily consumption. How much of this is already
included in the baseline pricing is uncertain but a substantial amount of
such risk taking behaviour is.
Disability
There are few formal studies of levels of
alcohol intake and disability rates. Both
the alcohol syndromes are defined in
disability terms so that the presence
of these equates to a diagnosis of
disability.
Upmark et al (1999) found that increasing levels of alcohol intake were associated with higher rates of disability pension uptake and more days off work.
Their study was based upon data from
the Stockholm Health of the Population Study and used 3 different measures of alcohol habits: usual alcohol
consumption, consumption during the
previous week, and answers to the four
CAGE questions on problem drinking.
Information from the health survey and
data from a subsequent health examination were related to information from
the National Swedish Social Insurance
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Board for the year 1984 and the years
1986 to 1991 concerning sick leave and
disability pensioning. The study population was aged 20 to 52 years in 1984
and comprised 985 women and 870
men fulfilling the criteria for inclusion
out of 6217 subjects aged 18 years and
over randomly drawn. In both sexes, a
consistent pattern of increased sickness
absence was seen for high alcohol consumers and for those with indications
of problem drinking. In most comparisons, a clearly increased relative risk,
although not always statistically significant, for an average of at least 60 sick
days per year or for a disability pension
during follow up was found. In multivariate analysis, controlling for age, socioeconomic group, smoking habits, and
self reported health, a small reduction
in the relative risks was found, suggesting that these factors could explain only
a small part of the relative risks. The
risks for abstainers were higher than for
low and moderate consumers.
A paper from the same authors showed
that the probability of receiving a disability pension and sickness absence in
young men is directly related to criminal behaviour and drink driving convic-
45
tions. In bivariate regression analysis,
drink driving implied a relative risk (RR)
of a disability pension/high sickness
absence of 3.4 (95% CI: 2.8 – 4.1), and
criminality a RR of 3.6 (95% CI: 3.1 –
4.1). In multivariate logistic regression
analysis, controlling for psychosocial
factors from conscription and for criminality, drink driving remained a strong
predictor (RR 2.1, 95% CI: 1.7 – 2.7) (Upmark et al, 1999).
tant. However excessive use of alcohol
is an important cause or mortality and
morbidity.
The syndrome of alcohol dependence is
now well established but the disorder
may go unrecognised. Using self reported alcohol intake can be unreliable and
the diagnosis of alcohol abuse/harmful
use is often one of inference. However,
despite these difficulties broad conclusions about the risks associated with
alcohol excess can be made.
Conclusion
The risk associated with alcohol excess is complex, heterogenous and difficult to quantify. Alcohol use is almost
ubiquitous and in some cultures heavy
episodic drinking (binge drinking) is
common. Furthermore there are social
benefits as well as health benefits such
as a lower incidence of IHD so that the
background levels of risk are impor-
The choice of comparator is of interest. Traditionally the reference group
has been abstainers but except in some
societies abstention from alcohol is uncommon and the nadir of mortality and
morbidity risk is about to 10 g alcohol
per day especially if the incidence of
cardiovascular disease is high. Abstainers are not representative of the insured
or general population.
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46
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