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Access to alcohol and heart disease among patients in hospital: observational cohort study using differences in alcohol sales laws

BMJ 2016; 353 doi: (Published 14 June 2016) Cite this as: BMJ 2016;353:i2714
  1. Jonathan W Dukes, clinical fellow1,
  2. Thomas A Dewland, assistant professor of medicine2,
  3. Eric Vittinghoff, professor of biostatistics3,
  4. Jeffrey E Olgin, professor of medicine1,
  5. Mark J Pletcher, professor of biostatistics2,
  6. Judith A Hahn, associate professor of medicine4,
  7. Rachel A Gladstone, research assistant1,
  8. Gregory M Marcus, associate professor of medicine1
  1. 1Division of Cardiology, Department of Medicine, University of California, 505 Parnassus Ave, M-1180B, Box 0124, San Francisco, CA 94143-0124, USA
  2. 2Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA
  3. 3Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
  4. 4Department of Medicine, University of California, San Francisco, CA, USA
  1. Correspondence to: G M Marcus marcusg{at}
  • Accepted 20 April 2016


Objective To investigate the relation between alcohol consumption and heart disease by using differences in county level alcohol sales laws as a natural experiment.

Design Observational cohort study using differences in alcohol sales laws.

Setting Hospital based healthcare encounters in Texas, USA.

Population 1 106 968 patients aged 21 or older who were residents of “wet” (no alcohol restrictions) and “dry” (complete prohibition of alcohol sales) counties and admitted to hospital between 2005 and 2010, identified using the Texas Inpatient Research Data File.

Outcome measures Prevalent and incident alcohol misuse and alcoholic liver disease were used for validation analyses. The main cardiovascular outcomes were atrial fibrillation, acute myocardial infarction, and congestive heart failure.

Results Residents of wet counties had a greater prevalence and incidence of alcohol misuse and alcoholic liver disease. After multivariable adjustment, wet county residents had a greater prevalence (odds ratio 1.05, 95% confidence interval 1.01 to 1.09; P=0.007) and incidence (hazard ratio 1.07, 1.01 to 1.13; P=0.014) of atrial fibrillation, a lower prevalence (odds ratio 0.83, 0.79 to 0.87; P<0.001) and incidence (hazard ratio 0.91, 0.87 to 0.99; P=0.019) of myocardial infarction, and a lower prevalence (odds ratio 0.87, 0.84 to 0.90; P<0.001) of congestive heart failure. Conversion of counties from dry to wet resulted in statistically significantly higher rates of alcohol misuse, alcoholic liver disease, atrial fibrillation, and congestive heart failure, with no detectable difference in myocardial infarction.

Conclusions Greater access to alcohol was associated with more atrial fibrillation and less myocardial infarction and congestive heart failure, although an increased risk of congestive heart failure was seen shortly after alcohol sales were liberalized.


  • Contributors: All authors were involved in the study design, data analysis, and revision of the manuscript. JWD and GMM wrote the manuscript. All authors read and approved the final manuscript. JWD is the guarantor.

  • Funding: Research reported in this publication was supported by the National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health under award number R01AA022222 (GMM). The funders of the study had no role in the study design, data collection, data analysis, data interpretation, writing of the report, or the decision to submit the article for publication

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at and declare: no support from any organization for the submitted work other than that described above; GMM has received research support from Medtronic and Pfizer and is a consultant and equity holder in InCarda; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: Use of the Texas Inpatient Research Data File was approved by the Texas Department of State Health Services Institutional Review Board and certified by the University of California, San Francisco Committee on Human Research.

  • Data sharing: No additional data available.

  • Transparency: The lead author affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

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