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Association between clinically recorded alcohol consumption and initial presentation of 12 cardiovascular diseases: population based cohort study using linked health records

BMJ 2017; 356 doi: (Published 22 March 2017) Cite this as: BMJ 2017;356:j909

The impact on cardiovascular outcomes and the harms from alcohol use in Saudi Arabia


Cardiovascular diseases were responsible for the deaths of over 41000 people in Saudi Arabia (SA) in 2014.[1] This represents 46% of all cause mortality.[1] So any intervention which improves the outcomes of cardiovascular diseases would significantly reduce morbidity and mortality in SA.

We therefore read with great interest the study of the nearly 2 million adults in the United Kingdom (UK) reported by Bell et al.[2] and the accompanying editorial.[3] These highlight the association of moderate alcohol consumption with improvement in the outcomes of several cardiovascular diseases.

The UK chief medical officer recently released new guidelines on ethanol intake.[4] These recommend that men and women should limit their alcohol intake to14 standard alcoholic drinks (i.e. units of alcohol) per week.[4] However, the data presented by Bell et al.[2] were collected in the context of the previous UK guidelines that recommended men ‘drink’ under 21 units per week and women ‘drink’ less than 14 units per week.[5]

The unit system can certainly quantify consumption conveniently and offers a simple way to give practical guidance.[6] However it has several limitations which impact upon compliance. Importantly there is no universally accepted definition for the amount of ethanol in one unit.[6] Whilst a UK unit contains 8g of ethanol an American unit contains 14g.[6] This makes international comparisons difficult and if this was not confusing enough, recommendations on alcohol intake also vary worldwide.

Furthermore, the aliquots of alcohol consumed in homes bear little relationship to standard measures and the ethanol content varies considerably between brands of alcoholic beverage.[6] A ‘pint’ may contain 2-5 UK units as the ethanol content of beers and ales is in the range 0.5–9.0%.[6] When these complexities are added to the stigma associated with alcohol misuse it is no wonder that self-reported alcohol intake is notoriously unreliable.[7]

To complicate matters further, the data presented by Bell et al.[2] are based on healthcare professionals’ interpretation of patients’ self-reported alcohol intake. The terms “drinks rarely” or “drinks occasionally” (used to identify occasional drinkers) and “light drinker” (used to identify current moderate drinkers) have no clear definition. So, even if the alcohol histories were accurate, their interpretation was dependent on the biases of the coders. This is relevant because the incidence of alcohol misuse amongst healthcare professionals is so high[8] that alcoholics are humorously defined as ‘those who drink more than their doctors’.

Regardless, the observations of Bell et al.[2] do suggest that, in comparison to abstinence, alcohol consumption is associated with improvement in cardiovascular outcomes. Now, although alcohol is freely available throughout most of the world, the consumption of alcohol is prohibited within SA. Despite this the WHO estimated that the average total amount of ethanol consumed within SA was 0.3L of pure ethanol per capita in 2010.[9]

Given that over 94% of the population do not consume any;[9] these data suggest that large amounts of alcohol are being consumed by relatively few individuals in SA. Some of this ‘drinking’ occurs legally, mainly during diplomatic functions. However, worryingly, the WHO estimated that two thirds of the alcohol consumed in SA was undocumented.[9] Much of the alcohol available in SA is ‘moonshine’ (i.e. produced illegally) which may be significantly more toxic than the commercial beverages. Also, a large proportion of the population are expatriates who may ‘drink’ occasionally or binge whenever they leave SA.

Legal implications make alcohol histories extremely sensitive and almost completely unreliable. This taboo must be broken before healthcare professionals can effectively identify, support and treat those patients who misuse ethanol or consume ‘moonshine’.

Guidance on ethanol use in SA is urgently required; at least for those who do drink. The question is now whether to advise these individuals to abstain or whether, in the light of the data presented by Bell et al.[2], moderate alcohol consumption should in fact be advocated. To answer this query the potential benefit must be balanced against the potential harm.
In this regard, even small amounts of ethanol may be teratogenic,[10] carcinogenic[11] and arrhythmogenic.[12]

In 2012 the alcohol-attributable years of life lost score was 1 (the lowest possible score) in SA.[9] Recommending even a slight increase alcohol intake can only worsen this. This has been shown in several socio-political experiments which have illustrated the interrelationships between alcohol availability, consumption and harm. For example, a Russian campaign against alcohol resulted in a dramatic fall in mortality between 1985 and 1988.[13] Unfortunately, this was followed by a sharp rise in mortality as alcohol consumption increased after the socio-economic upheaval of the early 1990s.[13] So, advocating an increase in the consumption of alcohol is certainly not a benign intervention.

The harm associated with alcohol is significant. In 2012, the deaths of around 3.3 million people (5.9% of all-cause mortality worldwide) and 139 million disability-adjusted life years (5.1% of the global burden of disease and injury) were caused by consumption of alcohol.[14]

So, to paraphrase the American Heart Association ‘despite the biological plausibility of observational data, these are insufficient to prove causality. Alcohol ingestion poses a number of health hazards. Without a large, randomized, clinical trial of alcohol consumption, there is little justification to recommend alcohol as a cardioprotective strategy.’[15]

So, the statement that ‘moderate alcohol consumption may be beneficial’ is difficult to swallow in SA. In an environment where abstinence is the norm, advocating even light alcohol consumption could cause significant harm. However, where alcohol intake is common, moderation of intake may be beneficial. It is therefore the authors’ current practice to advocate that patients abstain whilst in SA. However we advise those patients who do ‘drink’ to avoid ‘moonshine’ and consider the actual amount of ethanol they consume in the context of the current UK guidance.


1. World Health Organisation. Saudi Arabia, Noncommunicable Diseases Country Profiles, 2014. World Health Organisation, 2014, Switzerland. Available at: (accessed 29/04/17).
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3. Mukamal K, Lazo M. Alcohol and cardiovascular disease. BMJ 2017;356:j1340.
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Competing interests: No competing interests

04 May 2017
Abdulrahman T. Khojah
Resident Physician in Internal Medicine
Abdulrahman Tawfiq Khojah, Hanouf Al Mutairi, Abdulmajeed Al Sadhan, Rajkumar Rajendram
Department of Medicine
King Abdulaziz Medical City, National Guard Hospital Affairs, Riyadh, Saudi Arabia