Addiction (2000) 95(2), 173± 174

BRIEF EDITORIAL

Is alcohol really good for the heart?

The alcohol ® eld has in large part endorsed thenotion that moderate drinking is protectiveagainst premature death in general and cardio-vascular disease in particular. This endorsementis due in part to the large number of prospectivestudies replicating the J-shaped curve and to thebiological plausibility of it.1± 3 So pervasive isthis acceptance that studies evaluating theeconomic costs of alcohol now typically factor inthe ª bene® tsº of lives saved as a result of light/moderate drinking.4

There is no major controversy surrounding theassociation between heavy drinking and in-creased risk of death for many causes; but evennow Ð after publication of numerous studies at-testing to the J-shaped curveÐ there is evidencecasting doubt on the increased risk of deathamong people abstaining from alcohol (comparedto light/moderate drinkers). Because endorse-ment of the light/moderate drinking claim hasconsiderable political, social, economic and ethi-calÐ in addition to scienti® c Ð implications, it isincumbent on the scienti® c community to assessthis evidence carefully.

Challenges to the J-shaped curve often comein the form of seemingly lone studies, the mostrecent from Hart et al. 5 Studying a broad agecohort of employed Scottish men over 21 years,these authors ® nd no elevated risk for all-causemortality among abstainers, compared to light/moderate drinkers and, surprisingly, no associ-ation for coronary heart disease. Why? Theyattribute their ® ndings to their superior measure-ment of social class Ð a major confounder Ð andpossibly that their non-random sample may havecontained fewer men who stopped drinking dueto poor health. However, other studies have beenof the general population where respondentsmight be expected to have reduced their drinkingdue to poor health. Our own, for example, foundno differences between light drinkers and

abstainers for all-cause mortality in multiplestudies, attributed possibly to more precisedrinking measures, general population samplingand more complete assessment of some knownconfounders.6± 8 There are others Ð among themthe NHANES study with excellent coverage ofconfounding factors in a large general populationsample, where a linear effect for all-causemortality is found among men and women underage 60 and only a non-signi® cant curvilineareffect for those over 60.9 In another Americanstudy of the general population, no protectiveeffect was found for moderate drinking whenconfounding factors were (and even were not)controlled.10

These studies are telling us something. Per-haps it is because the strength of the risk associ-ated with light/moderate drinking is so modest.11

Perhaps some systematic error is present in themany prospective studies which report the J-shaped curveÐ studies controlling often inade-quately or not at all for critical confounders.Perhaps it is because there is a self-selection intolong-term abstinence12 vs. the atypical drinkingpattern of light/moderate but frequent drink-ing.13 Perhaps it is because drinking per se be-comes increasingly rare as people age.14 Orperhaps it is attributable to selection into newabstinence due to ill health.15 Clearly, poorlymeasured alcohol consumption dominates thisresearch, and changes in consumption with in-creasing age (in addition to changes in con-founders) are rarely analyzed carefully. There isa need to assess more closely the stability ofdrinking/abstinence in different cultures, the val-idity and reliability of the measures used, thecompeting sources of mortality, the differentialdrinking pattern distributions in samples studiedand the strong possibility of complex interac-tions. Even if these issues are placed underthe microscope, they may be too much to bear

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174 Editorial

for the daunting challenges which prospectivestudies face with respect to establishing causality.

Despite the seemingly consistent results fromnumerous studies replicating the J-shaped curveand its biological plausibility, most of theprospective studies do not meet the rigorouscriteria required to adequately evaluate the ques-tion and, among the few who come close, lin-ear Ð rather than J-shaped Ð associations aremost often found.16 This should give us pause.Suf® cient evidence, thoughtful hypotheses andastute critique lay the groundwork for the possi-bility that alcohol may not be good for the heart.It is time that the research community ® nd waysin which to evaluate this association more care-fully.17

KAYE MIDDLETON FILLMORE

Department of Social & Behavioral Sciences,

University of California, San Francisco,

Box 0612, Laurel HeightsSan Francisco, CA 94143± 0612, USA

Declaration of interests

The US National Institute of Alcohol Abuse andAlcoholism (Grant #RO1 AA07034) supportedthe writing of this editorial. The author spoke ata conference of the Alcohol Beverage MedicalFoundation in 1990 and also attended a meetingof the International Center for Alcohol Policiesin 1998 and was reimbursed for expenses.

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