AMKBICAN JOURNAL or EPIDIMIOLOOT
Copyright O 1978 by The Johns Hopkins University School of Hygiene and Public Health All rights reserved
Vol. 107, No. 6 Printed in USA.
ON CONSIDERING ALCOHOL AS A RISK FACTOR IN SPECIFIC DISEASES1 JACOB A. BRODY1 AND GEORGE S. MILLS ALCOHOL AND ILL HEALTH
It is widely held that too much alcohol is bad for the health. Thus, Sundby, in his 1967 monograph, Alcoholism and Mortality (1), was surprised to find that the influence of alcoholism on general morbidity and mortality was "an example of neglected epidemiological problems." Indeed his first impression was that he had "hit upon a white spot in alcohol research." It appears now that we are in a transition from a "white spot" to a gray area. While there is a general concensus concerning the deleterious effects of alcohol, data from various sources have not been useful in answering several important questions. These include how much alcohol is harmful for which populations, and for which diseases. The latter point leads to the theme we wish to develop. Current thinking, while accepting the idea of simple cause, now encompasses the concept of risk factors which contribute to major diseases. Thus, while smoking is probably causally related to emphysema and lung cancer, its most important health effect is to increase the risk of developing cardiovascular diseases. Similarly, while cirrhosis is causally related to alcohol consumption, this condition accounts for only a small portion of the overall morbidity and mortality associated with alcohol. We believe that quantitative information is lacking to assess the impact which alcohol
1 From the National Institute on Alcohol Abuse and Alcoholism, 5600 Fishers Lane, Rockville, MD. 1 Present address: Epidemiology, Demography, and Biometry, National Institute on Aging, NIH, Bldg. 31, Room 6C02, Bethesda, MD 20014 (address for reprint requests). Modified from a manuscript prepared for presentation at the annual meeting of the Society for Epidemiologic Research, Seattle, Washington, June 1977.
462
exerts on specific diseases. Without these data, clinicians cannot advise their patients intelligently about their drinking, and epidemiologists cannot provide useful information about ill health. MORBIDITY AND MORTALITY AMONG ALCOHOLICS
Morbidity studies have been conducted among alcoholics who are identified by various, but generally acceptable, criteria. These documented that patterns of health problems tended to vary in different alcoholic populations. Among the most important studies were those by: (a) Pell and LVAlonzo (2) of 922 non-hospitalized people in an industrial setting which included known alcoholics, suspected alcoholics, and recovered alcoholics; (b) Wilkinson et al. (3), which included 1000 patients hospitalized for alcoholism; and (c) Ashley et al. (4), which included 871 people voluntarily hospitalized for alcoholism, but specifically excluded the skid row type of alcoholic. Of note was that in the non-hospitalized group, cardiovascular disease was found in 59 per cent of the people, while in the hospitalized groups, it appeared in 20 and 10 per cent, respectively. Acute alcoholic liver disease was not reported in the nonhospitalized group, while documented in about a quarter of the patients in the hospitalized groups. Cirrhosis was diagnosed in about 5 per cent of all groups, and peptic ulcers or gastritis in about 10 per cent of all groups. Other prominent findings were chronic respiratory diseases in from 10 to 25 per cent, and peripheral neuropathy in from 2 to 20 per cent. Evidence of trauma was found in 12 per cent of the hospitalized series. In about 25 per cent of those studied no symptoms of disease were recorded.
ALCOHOL AS A RISK FACTOR IN SPECIFIC DISEASES
Admissions to various psychiatric services for alcohol disorders comprise from 10 to 50 per cent of all admissions (5-8). They accounted for half the admissions to state mental hospitals for males age 35-64 (5). Most of the admissions were classified as alcohol addiction, while about a quarter were diagnosed alcoholic psychosis or nonpsychotic organic brain syndrome with alcohol. Several studies of mortality among alcoholics and heavy drinkers have been conducted (1, 9-14 and summaries 15, 16). It is worthy of note that the overall results of these studies were compatible even though the data were collected from different sources including insurance company records, follow-up of people hospitalized for mental illness associated with alcohol, hospitalized alcoholics, and alcoholics identified in open industrial surveys. In general, alcoholics died of a variety of causes from eight to 12 years prematurely, at somewhere between two and three times the expected rate. Cirrhosis was certified as the cause of death in from 5 to 15 per cent of alcoholics. Acute alcoholism was diagnosed in a somewhat smaller group. About 20 per cent died from violent causes including homicide, suicide, and accidents. A smaller group died from pneumonia and cancers of the upper gastrointestinal and respiratory tracts at several times the expected rate. The greatest killer by far was cardiovascular disease which accounted for 30-50 per cent of the deaths, and, when age corrected, was two times the expected value. Thus, the overall picture we get from reviewing morbidity and mortality data collected from alcoholic populations is that many people are suffering and dying from cirrhosis and other directly associated complications of excessive drinking. However, a far greater number are sick, and dying prematurely, largely from heart disease and stroke, with a heavy representation of violent deaths, and smaller concentrations of deaths from certain cancers and pneumonia.
463
GENERAL POPULATION STUDIES
In view of the frequency of alcoholism and the elevated morbidity and mortality in alcoholic populations, studies in open populations have been conducted. The most common types of studies were 1) random surveys of drinking practices and follow-up for variable lengths of time to detect excess mortality and 2) prospective studies of morbidity and mortality in people who were examined prior to illness to determine potential precursors of disease. Neither approach has been particularly useful in demonstrating the extent to which alcohol was a risk factor in specific diseases. 1) Surveys of drinking practices attempted to achieve randomization (15, 17). However, there was a consistent underreporting of consumption in these studies of up to 50 per cent, and this under-reporting was most pronounced among the heavier-drinking groups (18-20) and higher social status groups (21). Thus, the highest risk groups were incompletely represented. These discrepancies were confounded by the fact that many alcoholics were already institutionalized and not available for the surveys. Further, the follow-up over any great period of time tended to be most difficult in the population which drank excessively. Different studies treated the population lost to follow-up in various ways. Most commonly they were presumed to be alive at the end of the study, and, thus, a group known to have a very high risk for a negative outcome went into the denominator, lowering the rate of all outcomes. Random surveys which included a follow-up generally showed an association of higher mortality rates among the heaviest drinkers and a curious phenomenon whereby the most moderate drinkers had lower death rates than abstainers (15, 16). Because of small numbers, specific disease relationships could not be developed. The bulk of data concerned persons who drank at levels at which alcohol appeared to have little or no
464
BRODY AND MILLS
direct effect on health. 2) There were two general types of prospective studies in populations. Both have found their widest use in detecting risk factors for cardiovascular diseases. One type of study used data in prepaid insurance plans, where, during admission examinations, some questions about alcohol were asked (22). It was likely that very heavy drinkers tended not to try to qualify for a prepaid insurance scheme, or, if applying, tried to minimize the amount they consumed. The second type of prospective study was conducted in an entire population and involved administering a series of questions and a physical and laboratory examination in two-year cycles over many years, such as, Framingham (23), Tecumseh (24), Los Angeles Civil Servants (25), and Hawaiians of Japanese origin (26). The procedures required a very high degree of motivation among the subjects whose voluntary cooperation over the years was essential to meet the requirements of the investigation. The potential for systematic under-representation of heavier drinkers in such a design was great. In these prospective population studies the mean consumption in the heaviest drinking groups did not exceed 50 ml of pure ethanol per day, while Schmidt and Popham (27), in their classic studies, find that 96 per cent of alcoholics drink more than 150 ml of ethanol per day, and the threshold for bodily harm is about 75 ml per day. At the levels of drinking in prospective studies, no strong positive association has been found between alcohol and cardiovascular disease or other specific disease outcomes. The known hypertensive action of alcohol was encountered at these low levels of consumption (28), as well as an association with alcohol of increased high density lipoprotein cholesterol which may have a beneficial effect (29, 30). DISCUSSION
It appeared that general population studies, either random surveys or prospec-
tive investigations, have not been useful in describing the effects of alcohol on specific disease outcomes. It was further suggested that inherent systematic limitations of these approaches render them relatively unprofitable. Therefore, we are left with a pressing problem. Morbidity and mortality studies among alcoholics overwhelmingly indicated that the health hazards associated with alcohol are considerable. The argument can be made that cirrhosis is now the seventh largest cause of death in the United States (31). Among alcoholics, however, cirrhosis accounted for only 5 to 10 per cent of all deaths, while cardiovascular diseases accounted for five times this number. Clearly, something is wrong. In the United States there were approximately two million deaths a year. Of these, 30,000 were from cirrhosis. Could it be that upwards of 100,000 deaths occurred in people whose death certificates mention only cardiovascular diseases but in whom alcohol was a major contributing factor? It is unlikely that this bit of statistical gymnastics merits more consideration than to focus our attention on the problems of alcohol-related morbidity and mortality. The epidemiologist may already have tools to proceed through a series of stages toward a better understanding of these problems. Stage one would be to select a population in which heavy drinking is common. Stage two would be to determine the cause-specific mortality for the alcoholic population in a fashion similar to studies described above concerning mortality and alcoholism. Stage three is a simple case-control study in an enriched sample. Once the major causes of death associated with alcoholism have been identified in stage two, it would be necessary in the same population and health care system to conduct disease-specific studies across the entire range of alcohol consumption. Thus, if it were found that most of the cardiovascular disease being reported were indeed deaths from myocardial infarctions, the -proper procedure
ALCOHOL AS A RISK FACTOR IN SPECIFIC DISEASES
would be to study the drinking patterns in the entire population of myocardial infarction patients and appropriate controls. The comparison would reveal whether or not alcohol is a risk factor for myocardial infarction; and, perhaps, in terms of quantity and frequency of drinking, a dose response relationship could be recognized and the absolute and attributable risk calculated. These studies would be time consuming and difficult, but less costly and much more likely to yield useful information than general population studies. Such investigations are timely and important since experience teaches us that people rarely alter bad habits unless the potential outcome is felt personally and immediately. Neither cirrhosis nor delirium tremens causes much concern among physicians or heavy drinkers. If it were shown, as seems likely from existing data, that alcohol is a risk factor for many common illnesses, and, principally, cardiovascular diseases, attitudes are likely to change, as we have already noted concerning smoking, obesity, lethargy, and eggs. REFERENCES
1. Sundby P. Alcoholism and Mortality. Universitetsforlaget, Blindem, Oslo 3, Norway 1967, p. 10 2. Pell S, D"Alonzo CA: The prevalence of chronic disease among problem drinkers. Arch Environ Health 16:679-684, 1968 3. Wilkinson P, Kornsczewski A, Bankin JG, et al: Physical disease in alcoholism initial survey of 1,000 patients. Med J Aust 2:1217-1223, 1971 4. Ashley MJ, Olin JS, LeRiche WH, et al: Morbidity in alcoholics: evidence for accelerated development of physical disease in women. Arch Intern Med 137:883-887, 1977 5. National Institute of Mental Health: Utilization of Mental Health Facilities by Persons Diagnosed with Alcohol Disorders. DHEW Publication No HSM 73-9114, US GPO, Washington, DC, 1972, pp 3, 17 6. Moore RA: Alcoholism treatment in private psychiatric hospitals; a national survey. Quarterly Journal of Studies on Alcohol 32:1083-1085, 1971 7. McCourt WF, Williams AF, Schneider L: Incidence of alcoholism in a state mental hospital population. Quarterly Journal of Studies on Alcohol 34:1085-1088, 1971 8. Gorwitz K, Bahn AK, Klee G, et al: Release and return rates for patients in state mental hospitals of Maryland. Public Health Rep 81:10951108, 1966
465
9. Tashiro M, Ldpscomb WR: Mortality experience of alcoholics. Quarterly Journal of Studies on Alcohol 24:203-212, 1963 10. Pell S, D'Alonzo CA: A five-year mortality study of alcoholics. Journal of Occupational Medicine 15:120-125, 1973 11. Nicholls P, Edwards G, Kyle E: Alcoholics admitted to four hospitals in England. II. General and cause-specific mortality. Quarterly Journal of Studies on Alcohol 35:841-855, 1974 12. Schmidt W, deLint J: Causes of death of alcoholics. Quarterly Journal of Studies on Alcohol 33:171-185, 1972 13. Gorwitz K, Bahn A, Warthen FJ, et al: Some epidemiological data on alcoholism in Maryland. Based on admissions to psychiatric facilities. Quarterly Journal of Studies on Alcohol 31:423-443, 1970 14. Gillis LS: The mortality rate and causes of death of treated chronic alcoholics. S Aft- Med J 43:230-232, 1969 15. National Institute on Alcohol Abuse and Alcoholism; Alcohol and Health U. DHEW Publication No (ADM) 75-212, US GPO, Washington DC, 1975, pp 79-92 16. deLint J: Current trends in the prevalence of excessive alcohol use and alcohol-related health damage. Br J Addict 70:3-14, 1975 17. Belloc NB: Relationship of health practices and mortality. Prev Med 2:67-81, 1973 18. Pernanen K: Validity of survey data on alcohol use. In: Advances in Alcohol and Drug Problems. Vol 1. Edited by Gibbins RJ, Israel Y, Kalant H, et al. New York, John Wiley and Sons, 1974, pp 355-374 19. Room R Survey vs. sales data for the U.S. The Drinking and Drug Practices Surveyor 3:15-16, 1971 20. Room R: Validity of alcohol expenditures data in consumer expenditure surveys. The Drinking and Drug Practices Surveyor 4:8, 1971 21. Edwards G: Epidemiology applied to alcoholism. Quarterly Journal of Studies on Alcohol 34:2856, 1973 22. Klataky AL, Friedman GD, Siegelaub AB: Alcohol consumption before myocardial infarction: Resulta from the Kaiser-Permanente Epidemiologic Study of Myocardial Infarction. Ann Intern Med 81:294-301, 1974 23. Shurtleff D: The Framingham Study, an epidemiological investigation of cardiovascular disease. Edited by Kannel WB, Gordon T. Section 26, US GPO, Washington, DC, 1970 24. Francis T: Aspects of the Tecuinseh Study. Public Health Rep 76:963, 1961 25. Chapman JM, Goerke LS, Dixon W, et al: The clinical status of a population group in Los Angeles under observation for two to three years. Am J Public Health 47:33-42, 1957 26. Worth RM, Kagan A: Ascertainment of men of Japanese ancestry in Hawaii through World War II Selective Service Registration. J Chronic Dis 23:389-397, 1970 27. Schmidt W, Popham RE: Heavy alcohol consumption and physical health problems: A review of the epidemiological evidence. Drug and
466
BRODY AND MILLS
Alcohol Dependence 1:27-50, 1975/76 and risk of coronary heart disease among Japa28. Klatsky AL, Friedman GD, Siegelaub AB, et al: nese men living in Hawaii. N Engl J Med Alcohol consumption and blood pressure — Kai297:405-409, 1977 ser-Permanente Multiphasic Health Examina- 31. National Center for Health Statistics: Provition Data. N Engl J Med 296:1194-1199, 1977 sional Statistics Annual Summary for the 29. Castelli WP, Gordon T, Hjortland MC, et al: United States. Publication HRA-76-1120, Vol Alcohol and blood lipids. Lancet 2:153-155, 1977 24, US GPO, Washington, DC, 1976, p 13 30. Yano K, Rhoads GG, Kagan A: Coffee, alcohol
Copyright O 1978 by The Johns Hopkins University School of Hygiene and Public Health All rights reserved
Vol. 107, No. 6 Printed in USA.
ON CONSIDERING ALCOHOL AS A RISK FACTOR IN SPECIFIC DISEASES1 JACOB A. BRODY1 AND GEORGE S. MILLS ALCOHOL AND ILL HEALTH
It is widely held that too much alcohol is bad for the health. Thus, Sundby, in his 1967 monograph, Alcoholism and Mortality (1), was surprised to find that the influence of alcoholism on general morbidity and mortality was "an example of neglected epidemiological problems." Indeed his first impression was that he had "hit upon a white spot in alcohol research." It appears now that we are in a transition from a "white spot" to a gray area. While there is a general concensus concerning the deleterious effects of alcohol, data from various sources have not been useful in answering several important questions. These include how much alcohol is harmful for which populations, and for which diseases. The latter point leads to the theme we wish to develop. Current thinking, while accepting the idea of simple cause, now encompasses the concept of risk factors which contribute to major diseases. Thus, while smoking is probably causally related to emphysema and lung cancer, its most important health effect is to increase the risk of developing cardiovascular diseases. Similarly, while cirrhosis is causally related to alcohol consumption, this condition accounts for only a small portion of the overall morbidity and mortality associated with alcohol. We believe that quantitative information is lacking to assess the impact which alcohol
1 From the National Institute on Alcohol Abuse and Alcoholism, 5600 Fishers Lane, Rockville, MD. 1 Present address: Epidemiology, Demography, and Biometry, National Institute on Aging, NIH, Bldg. 31, Room 6C02, Bethesda, MD 20014 (address for reprint requests). Modified from a manuscript prepared for presentation at the annual meeting of the Society for Epidemiologic Research, Seattle, Washington, June 1977.
462
exerts on specific diseases. Without these data, clinicians cannot advise their patients intelligently about their drinking, and epidemiologists cannot provide useful information about ill health. MORBIDITY AND MORTALITY AMONG ALCOHOLICS
Morbidity studies have been conducted among alcoholics who are identified by various, but generally acceptable, criteria. These documented that patterns of health problems tended to vary in different alcoholic populations. Among the most important studies were those by: (a) Pell and LVAlonzo (2) of 922 non-hospitalized people in an industrial setting which included known alcoholics, suspected alcoholics, and recovered alcoholics; (b) Wilkinson et al. (3), which included 1000 patients hospitalized for alcoholism; and (c) Ashley et al. (4), which included 871 people voluntarily hospitalized for alcoholism, but specifically excluded the skid row type of alcoholic. Of note was that in the non-hospitalized group, cardiovascular disease was found in 59 per cent of the people, while in the hospitalized groups, it appeared in 20 and 10 per cent, respectively. Acute alcoholic liver disease was not reported in the nonhospitalized group, while documented in about a quarter of the patients in the hospitalized groups. Cirrhosis was diagnosed in about 5 per cent of all groups, and peptic ulcers or gastritis in about 10 per cent of all groups. Other prominent findings were chronic respiratory diseases in from 10 to 25 per cent, and peripheral neuropathy in from 2 to 20 per cent. Evidence of trauma was found in 12 per cent of the hospitalized series. In about 25 per cent of those studied no symptoms of disease were recorded.
ALCOHOL AS A RISK FACTOR IN SPECIFIC DISEASES
Admissions to various psychiatric services for alcohol disorders comprise from 10 to 50 per cent of all admissions (5-8). They accounted for half the admissions to state mental hospitals for males age 35-64 (5). Most of the admissions were classified as alcohol addiction, while about a quarter were diagnosed alcoholic psychosis or nonpsychotic organic brain syndrome with alcohol. Several studies of mortality among alcoholics and heavy drinkers have been conducted (1, 9-14 and summaries 15, 16). It is worthy of note that the overall results of these studies were compatible even though the data were collected from different sources including insurance company records, follow-up of people hospitalized for mental illness associated with alcohol, hospitalized alcoholics, and alcoholics identified in open industrial surveys. In general, alcoholics died of a variety of causes from eight to 12 years prematurely, at somewhere between two and three times the expected rate. Cirrhosis was certified as the cause of death in from 5 to 15 per cent of alcoholics. Acute alcoholism was diagnosed in a somewhat smaller group. About 20 per cent died from violent causes including homicide, suicide, and accidents. A smaller group died from pneumonia and cancers of the upper gastrointestinal and respiratory tracts at several times the expected rate. The greatest killer by far was cardiovascular disease which accounted for 30-50 per cent of the deaths, and, when age corrected, was two times the expected value. Thus, the overall picture we get from reviewing morbidity and mortality data collected from alcoholic populations is that many people are suffering and dying from cirrhosis and other directly associated complications of excessive drinking. However, a far greater number are sick, and dying prematurely, largely from heart disease and stroke, with a heavy representation of violent deaths, and smaller concentrations of deaths from certain cancers and pneumonia.
463
GENERAL POPULATION STUDIES
In view of the frequency of alcoholism and the elevated morbidity and mortality in alcoholic populations, studies in open populations have been conducted. The most common types of studies were 1) random surveys of drinking practices and follow-up for variable lengths of time to detect excess mortality and 2) prospective studies of morbidity and mortality in people who were examined prior to illness to determine potential precursors of disease. Neither approach has been particularly useful in demonstrating the extent to which alcohol was a risk factor in specific diseases. 1) Surveys of drinking practices attempted to achieve randomization (15, 17). However, there was a consistent underreporting of consumption in these studies of up to 50 per cent, and this under-reporting was most pronounced among the heavier-drinking groups (18-20) and higher social status groups (21). Thus, the highest risk groups were incompletely represented. These discrepancies were confounded by the fact that many alcoholics were already institutionalized and not available for the surveys. Further, the follow-up over any great period of time tended to be most difficult in the population which drank excessively. Different studies treated the population lost to follow-up in various ways. Most commonly they were presumed to be alive at the end of the study, and, thus, a group known to have a very high risk for a negative outcome went into the denominator, lowering the rate of all outcomes. Random surveys which included a follow-up generally showed an association of higher mortality rates among the heaviest drinkers and a curious phenomenon whereby the most moderate drinkers had lower death rates than abstainers (15, 16). Because of small numbers, specific disease relationships could not be developed. The bulk of data concerned persons who drank at levels at which alcohol appeared to have little or no
464
BRODY AND MILLS
direct effect on health. 2) There were two general types of prospective studies in populations. Both have found their widest use in detecting risk factors for cardiovascular diseases. One type of study used data in prepaid insurance plans, where, during admission examinations, some questions about alcohol were asked (22). It was likely that very heavy drinkers tended not to try to qualify for a prepaid insurance scheme, or, if applying, tried to minimize the amount they consumed. The second type of prospective study was conducted in an entire population and involved administering a series of questions and a physical and laboratory examination in two-year cycles over many years, such as, Framingham (23), Tecumseh (24), Los Angeles Civil Servants (25), and Hawaiians of Japanese origin (26). The procedures required a very high degree of motivation among the subjects whose voluntary cooperation over the years was essential to meet the requirements of the investigation. The potential for systematic under-representation of heavier drinkers in such a design was great. In these prospective population studies the mean consumption in the heaviest drinking groups did not exceed 50 ml of pure ethanol per day, while Schmidt and Popham (27), in their classic studies, find that 96 per cent of alcoholics drink more than 150 ml of ethanol per day, and the threshold for bodily harm is about 75 ml per day. At the levels of drinking in prospective studies, no strong positive association has been found between alcohol and cardiovascular disease or other specific disease outcomes. The known hypertensive action of alcohol was encountered at these low levels of consumption (28), as well as an association with alcohol of increased high density lipoprotein cholesterol which may have a beneficial effect (29, 30). DISCUSSION
It appeared that general population studies, either random surveys or prospec-
tive investigations, have not been useful in describing the effects of alcohol on specific disease outcomes. It was further suggested that inherent systematic limitations of these approaches render them relatively unprofitable. Therefore, we are left with a pressing problem. Morbidity and mortality studies among alcoholics overwhelmingly indicated that the health hazards associated with alcohol are considerable. The argument can be made that cirrhosis is now the seventh largest cause of death in the United States (31). Among alcoholics, however, cirrhosis accounted for only 5 to 10 per cent of all deaths, while cardiovascular diseases accounted for five times this number. Clearly, something is wrong. In the United States there were approximately two million deaths a year. Of these, 30,000 were from cirrhosis. Could it be that upwards of 100,000 deaths occurred in people whose death certificates mention only cardiovascular diseases but in whom alcohol was a major contributing factor? It is unlikely that this bit of statistical gymnastics merits more consideration than to focus our attention on the problems of alcohol-related morbidity and mortality. The epidemiologist may already have tools to proceed through a series of stages toward a better understanding of these problems. Stage one would be to select a population in which heavy drinking is common. Stage two would be to determine the cause-specific mortality for the alcoholic population in a fashion similar to studies described above concerning mortality and alcoholism. Stage three is a simple case-control study in an enriched sample. Once the major causes of death associated with alcoholism have been identified in stage two, it would be necessary in the same population and health care system to conduct disease-specific studies across the entire range of alcohol consumption. Thus, if it were found that most of the cardiovascular disease being reported were indeed deaths from myocardial infarctions, the -proper procedure
ALCOHOL AS A RISK FACTOR IN SPECIFIC DISEASES
would be to study the drinking patterns in the entire population of myocardial infarction patients and appropriate controls. The comparison would reveal whether or not alcohol is a risk factor for myocardial infarction; and, perhaps, in terms of quantity and frequency of drinking, a dose response relationship could be recognized and the absolute and attributable risk calculated. These studies would be time consuming and difficult, but less costly and much more likely to yield useful information than general population studies. Such investigations are timely and important since experience teaches us that people rarely alter bad habits unless the potential outcome is felt personally and immediately. Neither cirrhosis nor delirium tremens causes much concern among physicians or heavy drinkers. If it were shown, as seems likely from existing data, that alcohol is a risk factor for many common illnesses, and, principally, cardiovascular diseases, attitudes are likely to change, as we have already noted concerning smoking, obesity, lethargy, and eggs. REFERENCES
1. Sundby P. Alcoholism and Mortality. Universitetsforlaget, Blindem, Oslo 3, Norway 1967, p. 10 2. Pell S, D"Alonzo CA: The prevalence of chronic disease among problem drinkers. Arch Environ Health 16:679-684, 1968 3. Wilkinson P, Kornsczewski A, Bankin JG, et al: Physical disease in alcoholism initial survey of 1,000 patients. Med J Aust 2:1217-1223, 1971 4. Ashley MJ, Olin JS, LeRiche WH, et al: Morbidity in alcoholics: evidence for accelerated development of physical disease in women. Arch Intern Med 137:883-887, 1977 5. National Institute of Mental Health: Utilization of Mental Health Facilities by Persons Diagnosed with Alcohol Disorders. DHEW Publication No HSM 73-9114, US GPO, Washington, DC, 1972, pp 3, 17 6. Moore RA: Alcoholism treatment in private psychiatric hospitals; a national survey. Quarterly Journal of Studies on Alcohol 32:1083-1085, 1971 7. McCourt WF, Williams AF, Schneider L: Incidence of alcoholism in a state mental hospital population. Quarterly Journal of Studies on Alcohol 34:1085-1088, 1971 8. Gorwitz K, Bahn AK, Klee G, et al: Release and return rates for patients in state mental hospitals of Maryland. Public Health Rep 81:10951108, 1966
465
9. Tashiro M, Ldpscomb WR: Mortality experience of alcoholics. Quarterly Journal of Studies on Alcohol 24:203-212, 1963 10. Pell S, D'Alonzo CA: A five-year mortality study of alcoholics. Journal of Occupational Medicine 15:120-125, 1973 11. Nicholls P, Edwards G, Kyle E: Alcoholics admitted to four hospitals in England. II. General and cause-specific mortality. Quarterly Journal of Studies on Alcohol 35:841-855, 1974 12. Schmidt W, deLint J: Causes of death of alcoholics. Quarterly Journal of Studies on Alcohol 33:171-185, 1972 13. Gorwitz K, Bahn A, Warthen FJ, et al: Some epidemiological data on alcoholism in Maryland. Based on admissions to psychiatric facilities. Quarterly Journal of Studies on Alcohol 31:423-443, 1970 14. Gillis LS: The mortality rate and causes of death of treated chronic alcoholics. S Aft- Med J 43:230-232, 1969 15. National Institute on Alcohol Abuse and Alcoholism; Alcohol and Health U. DHEW Publication No (ADM) 75-212, US GPO, Washington DC, 1975, pp 79-92 16. deLint J: Current trends in the prevalence of excessive alcohol use and alcohol-related health damage. Br J Addict 70:3-14, 1975 17. Belloc NB: Relationship of health practices and mortality. Prev Med 2:67-81, 1973 18. Pernanen K: Validity of survey data on alcohol use. In: Advances in Alcohol and Drug Problems. Vol 1. Edited by Gibbins RJ, Israel Y, Kalant H, et al. New York, John Wiley and Sons, 1974, pp 355-374 19. Room R Survey vs. sales data for the U.S. The Drinking and Drug Practices Surveyor 3:15-16, 1971 20. Room R: Validity of alcohol expenditures data in consumer expenditure surveys. The Drinking and Drug Practices Surveyor 4:8, 1971 21. Edwards G: Epidemiology applied to alcoholism. Quarterly Journal of Studies on Alcohol 34:2856, 1973 22. Klataky AL, Friedman GD, Siegelaub AB: Alcohol consumption before myocardial infarction: Resulta from the Kaiser-Permanente Epidemiologic Study of Myocardial Infarction. Ann Intern Med 81:294-301, 1974 23. Shurtleff D: The Framingham Study, an epidemiological investigation of cardiovascular disease. Edited by Kannel WB, Gordon T. Section 26, US GPO, Washington, DC, 1970 24. Francis T: Aspects of the Tecuinseh Study. Public Health Rep 76:963, 1961 25. Chapman JM, Goerke LS, Dixon W, et al: The clinical status of a population group in Los Angeles under observation for two to three years. Am J Public Health 47:33-42, 1957 26. Worth RM, Kagan A: Ascertainment of men of Japanese ancestry in Hawaii through World War II Selective Service Registration. J Chronic Dis 23:389-397, 1970 27. Schmidt W, Popham RE: Heavy alcohol consumption and physical health problems: A review of the epidemiological evidence. Drug and
466
BRODY AND MILLS
Alcohol Dependence 1:27-50, 1975/76 and risk of coronary heart disease among Japa28. Klatsky AL, Friedman GD, Siegelaub AB, et al: nese men living in Hawaii. N Engl J Med Alcohol consumption and blood pressure — Kai297:405-409, 1977 ser-Permanente Multiphasic Health Examina- 31. National Center for Health Statistics: Provition Data. N Engl J Med 296:1194-1199, 1977 sional Statistics Annual Summary for the 29. Castelli WP, Gordon T, Hjortland MC, et al: United States. Publication HRA-76-1120, Vol Alcohol and blood lipids. Lancet 2:153-155, 1977 24, US GPO, Washington, DC, 1976, p 13 30. Yano K, Rhoads GG, Kagan A: Coffee, alcohol
