Association between alcohol consumption and mortality, myocardial infarction, and stroke in 25 year follow up of 49 618 young Swedish menBMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7213.821 (Published 25 September 1999) Cite this as: BMJ 1999;319:821
Subjects and methods (for the eBMJ)
This study is based on 50 465 Swedish men conscripted between 1 July 1969 and 30 June 1970,(1)(2) of whom those born between 1949 and 1952 (n=49 618) were selected for analysis. At conscription, all men were given two questionnaires with questions covering social background, behaviour, and use of alcohol and tobacco, and all met with a psychologist for a structured interview. The percentage of non-responders was between 1% and 2% for most items. The conscripts were informed that their answers would not affect their military service.
Measures of alcohol consumption and risky alcohol use
From questions about quantity and frequency of consumption of spirits (the predominant alcoholic beverage in Sweden at that time), wine or strong wine, and medium strength or strong beer, we calculated subjects’ alcohol consumption in terms of grams of 100% ethanol a day and categorised subjects into different consumption groups.(1) Those who answered "Never" to the questions about frequency of alcohol consumption were characterised as abstainers (reference category).
We considered high alcohol consumption (³30 g ethanol/day, consistent with international recommendations(3)) to be an indicator of risky alcohol use.
In earlier studies of this cohort of conscripts some social, psychosocial, and behavioural variables were associated with alcohol consumption and mortality.(1)(2) We considered these to be possible confounders for all outcomes as knowledge of such factors in relation to myocardial infarction and stroke is scant,(4)(5)(6) particularly among young people.
Blood pressure at conscription—Diastolic and systolic blood pressure were treated as continuous variables.
Body mass index (weight (kg)/(height (m))2) was treated as a continuous variable.
Father’s social class was treated as a categorical variable (low or middle class v high social class).
Running away from home, poor school wellbeing, and parental divorce are behavioural indicators of insufficient social and emotional support during upbringing that were associated with high alcohol consumption and mortality in this cohort(1)(2) and may be associated with myocardial infarction.(6)
Poor emotional control (based on assessment by psychologists) was associated with high alcohol consumption and mortality.(2)(7) Poor emotional control may imply increased sensitivity to stressors later in life.
Few friends (0-1(1)). A weak social network is associated with increased risk of myocardial infarction.(6)
Unemployment for more than 3 months.
Health status was dichotomised into good and very good versus poor and very poor.
Smoking was categorised as 0, 1-10, and ³11 cigarettes/day.
Using the Swedish personal identification number, we linked the questionnaire data to the Swedish register of causes of deaths and to the new national inpatient care register for 1970-95. The register of causes of deaths covers at least 99% of all deaths in Sweden.(7) The national inpatient care register has covered all 25 counties of Sweden from 1987 onwards.(8) In 1972 it covered about 10 counties (including the largest in population size), and in 1980 it covered about 20 counties. The register has a high level of quality(8): the percentage of missing main diagnoses was about 1% from 1987 to 1994, when nearly all the cases of myocardial infarction and stroke occurred.
Total mortality—A total of 1473 deaths occurred in our cohort: 849 (57.6%), were due to external causes, 218 (14.8%) were due to cancer, and 99 (6.7%) were due to alcoholism, alcohol misuse, alcohol intoxication, alcohol psychosis, or liver cirrhosis.
Myocardial infarction—We recorded 279 cases of myocardial infarction as the underlying cause of death or as the main diagnosis at hospitalisation. Thirty eight (13.6%) infarctions were fatal. Previous studies have mainly focused on mortality from ischemic heart disease (ICD codes 410-414). Myocardial infarction (ICD code 410) is the largest and most severe category of ischemic heart disease and is better defined.
Stroke—We recorded 223 cases of stroke as the underlying cause of death or as the main diagnosis at hospitalisation. Thirty cases (13.5%) were fatal. All cases were separated into haemorrhagic (n=127) and ischemic stroke (n=112). Sixteen subjects had, on different occasions, both kinds of stroke.
We first conducted bivariate analyses of the relative risk for different volumes of alcohol consumption (with abstention as the reference value) and for frequent high alcohol intake and for presumptive confounders. Variables assessed at conscription that were correlated with alcohol consumption and with the outcome variables in the bivariate analyses were included in multivariate logistic regression models. From these we calculated the relative risks and 95% confidence intervals,(9) and we also calculated attributable proportions.
- Andréasson S, Allebeck P, Romelsjö A. Alcohol and mortality among young men. BMJ 1988;296:1021-5.
- Andréasson S, Romelsjö A, Allebeck P. Alcohol, social factors and mortality among young men. Br J Addict 1991;86:877-87.
- Addiction Research Foundation of Ontario, Canadian Centre on Substance Abuse, Interdepartmental Division of Drug and Alcohol Studies, Department of Preventive Medicine and Biostatistics, University of Toronto. Moderate drinking and health. Report of an international symposium. Toronto, Ontario, 29 April-1 May, 1993. Can Med Assoc J 1994;151(6):special supplement.
- Edwards G, Anderson P, Babor T, Casswell S, Ferrence R, Giesbrecht N, et al. Alcohol policy and the public good. Oxford: Oxford University Press, 1994.
- Anderson P. Alcohol and the risk of physical harm. In: Holder H, Edwards G. Alcohol and public policy. Evidence and issues. Oxford: Oxford University Press, 1995:82-114.
- Kaplan G, Keil J. Socioeconomic factors and cardiovascular disease: a review of the literature. Dallas, TX: American Heart Association, 1993.
- Socialstyrelsen. Dödsorsaker 1994. Stockholm: Socialstyrelsen, 1996. (National Board of Health and Welfare. Causes of death 1994. In Swedish with English summary.)
- Socialstyrelsen, Epidemiologiskt centrum. Patientregistret 1987-1994. Kvalitet och innehåll. Stockholm: Socialstyrelsen, Epidemiologiskt centrum, 1996. (National Board of Health and Welfare, Centre of Epidemiology. Patient register 1987-94. Quality and content. In Swedish.)
- Rothman K, Greenland S. Modern epidemiology. 2nd ed. Philadelphia: Lippincott-Raven, 1998.
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