Do “Moderate” Drinkers Have Reduced Mortality Risk? A Systematic Review and Meta-Analysis of Alcohol Consumption and All-Cause Mortality
Objective
Previous meta-analyses of cohort studies indicate a J-shaped relationship between alcohol consumption and all-cause mortality, with reduced risk for low-volume alcohol users. However, low-volume alcohol users may appear healthy only because the “abstainers” with whom they are compared are biased toward ill health. The purpose of this study was to determine whether misclassifying former and occasional alcohol users as abstainers and other potentially confounding study characteristics underlie observed positive health outcomes for low-volume alcohol users in prospective studies of all-cause mortality.
Method
A systematic review and meta-regression analysis of studies investigating alcohol use and mortality risk after controlling for quality-related study characteristics was conducted in a population of 3,998,626 individuals, among whom 367,103 deaths were recorded.
Results
Without adjustment, meta-analysis of all 87 included studies replicated the classic J-shaped curve, with low-volume alcohol users (1.3–24.9 g ethanol per day) having reduced mortality risk (RR = 0.86, 95% CI [0.83, 0.90]). Occasional alcohol users (<1.3 g per day) had similar mortality risk (RR = 0.84, 95% CI [0.79, 0.89]), and former alcohol users had elevated risk (RR = 1.22, 95% CI [1.14, 1.31]). After adjustment for abstainer biases and quality-related study characteristics, no significant reduction in mortality risk was observed for low-volume alcohol users (RR = 0.97, 95% CI [0.88, 1.07]). Analyses of higher-quality bias-free studies also failed to find reduced mortality risk for low-volume alcohol users. Risk estimates for occasional alcohol users were similar to those for low- and medium-volume alcohol users.
Conclusions
Estimates of mortality risk from alcohol are significantly altered by study design and characteristics. Meta-analyses adjusting for these factors find that low-volume alcohol consumption has no net mortality benefit compared with lifetime abstention or occasional alcohol use. These findings have implications for public policy, the formulation of low-risk alcohol use guidelines, and future research on alcohol and health.