Alcohol abstinence and mortality in a general population sample of adults in Germany: A cohort study

Abstract

Background Evidence suggests that people who abstain from alcohol have a higher mortality rate than those who drink low to moderate amounts. However, little is known about factors that might be causal for this finding. The objective was to analyze former alcohol or drug use disorders, risky drinking, tobacco smoking, and fair to poor health among persons who reported abstinence from alcohol drinking in the last 12 months before baseline in relation to total, cardiovascular, and cancer mortality 20 years later. Methods and findings A sample of residents aged 18 to 64 years had been drawn at random among the general population in northern Germany and a standardized interview conducted in the years 1996 to 1997. The baseline assessment included 4,093 persons (70.2% of those who had been eligible). Vital status and death certificate data were retrieved in the years 2017 and 2018. We found that among the alcohol-abstinent study participants at baseline (447), there were 405 (90.60%) former alcohol consumers. Of the abstainers, 322 (72.04%) had met one or more criteria for former alcohol or drug dependence or abuse, alcohol risky drinking, or had tried to cut down or to stop drinking, were daily smokers, or self-rated their health as fair to poor. Among the abstainers with one or more of these risk factors, 114 (35.40%) had an alcohol use disorder or risky alcohol consumption in their history. Another 161 (50.00%) did not have such an alcohol-related risk but were daily smokers. The 322 alcohol-abstinent study participants with one or more of the risk factors had a shorter time to death than those with low to moderate alcohol consumption. The Cox proportional hazard ratio (HR) was 2.44 (95% confidence interval (CI), 1.68 to 3.56) for persons who had one or more criteria for an alcohol or drug use disorder fulfilled in their history and after adjustment for age and sex. The 125 alcohol-abstinent persons without these risk factors (27.96% of the abstainers) did not show a statistically significant difference from low to moderate alcohol consumers in total, cardiovascular, and cancer mortality. Those who had stayed alcohol abstinent throughout their life before (42; 9.40% of the alcohol-abstinent study participants at baseline) had an HR 1.64 (CI 0.72 to 3.77) compared to low to moderate alcohol consumers after adjustment for age, sex, and tobacco smoking. Main limitations of this study include its reliance on self-reported data at baseline and the fact that only tobacco smoking was analyzed as a risky behavior alongside alcohol consumption. Conclusions The majority of the alcohol abstainers at baseline were former alcohol consumers and had risk factors that increased the likelihood of early death. Former alcohol use disorders, risky alcohol drinking, ever having smoked tobacco daily, and fair to poor health were associated with early death among alcohol abstainers. Those without an obvious history of these risk factors had a life expectancy similar to that of low to moderate alcohol consumers. The findings speak against recommendations to drink alcohol for health reasons.

Association between Alcohol Consumption and Health-Related Quality of Life among Hospital and Ambulatory Care Patients with Past Year Depressive Symptoms

“…These cases may be found predominantly in the group of non-drinking individuals. Overall, the data provided here support the assumption that groups of non-drinkers represent particularly morbid groups [ 29 ] and that existing health impairments might be the initial reason for choosing abstinence [ 26 ]. This sick-quitter phenomenon could also explain why drinking status is associated with better HRQOL in this sample of hospital and ambulatory care patients with past-year depressive symptoms, while average daily consumption is not.…”

“…Misclassifying sick quitters as abstainers and the non-consideration of other health-risk behaviors aside from consuming alcohol are identified as major reasons for the frequently found J-shaped association between alcohol consumption and health and mortality outcomes [ 27 , 29 ], in which low-level alcohol consumption has been interpreted to have beneficial effects on health compared to abstinence and heavy consumption. Some studies provided evidence that comparable non-linear associations exist between alcohol consumption and HRQOL [ 18 , 19 , 20 , 21 ].…”

“…It is caused by the misclassification of former and occasional drinkers, who often suffer from ill health, as abstainers [ 27 , 28 ]. A recent longitudinal study by John et al [ 29 ] provided further evidence for this notion. In a random general population sample, they showed that among alcohol abstainers, many former drinkers are to be found.…”

Severity of alcohol dependence and mortality after 20 years in an adult general population sample

“…In contrast to persons with low to moderate drinking those who said that they currently do not drink alcohol have a higher mortality according to evidence. Among them, the majority turned out to have known risk factors for early death including former alcohol or drug dependence and tobacco smoking (John et al., 2021 ).…”

The association between substance use and subsequent employment among students: prospective findings from the CONSTANCES cohort

“…In addition, alcohol use at lower risk corresponds to the most commonly pattern of alcohol use in the general population whereas both at-risk alcohol use and non-alcohol use correspond to unusual patterns of use, at least in European countries [31]. Regarding non-alcohol users, previous studies have shown that alcohol abstinence is associated with poor health status which contraindicates alcohol use, and at least for some people because of the consequences of previous excessive use [32].…”