Alcohol abstention in early adulthood and premature mortality: Do early life factors, social support, and health explain this association?
Introduction
An inverted J-shaped curve linking adult alcohol use with concurrent and prospective health has been found in numerous studies (e.g., Klatsky, 1999, Rehm et al., 2001, Gunzerath et al., 2004, Ronksley et al., 2011). That is, light-to-moderate drinkers experience lower morbidity and mortality across numerous health indicators (e.g., chronic illness, cardiovascular disease, accidents/injuries) compared to heavy drinkers and, to a lesser extent, abstainers. A number of plausible mechanisms underlying the increased risk for poor health and mortality among adult chronic heavy alcohol users have been articulated (Bouchery et al., 2011, Rehm et al., 2009, World Health Organization., 2010). Alcohol is nutritionally unnecessary, a toxin, and addictive; and heavy episodic and chronic heavy use are associated with increased risks of fatal injury, cancer, hypertension, and stroke (e.g., Brien et al., 2014, Jayasekara et al., 2016). Thus, it is clear that chronic heavy consumption may increase risk for morbidity and mortality.
Despite substantial evidence of the dangers of heavy alcohol consumption, at least in comparison to light drinking, the increased risk of poor health and mortality among adult alcohol abstainers remains an issue of contention in the literature. Extrapolating from abstainer health “costs,” Pearson and Terry (1994) estimated that there would be approximately 80,000 additional deaths per year in the US from coronary heart disease if all alcohol use were discontinued. Such findings receive considerable media attention about the benefits of light-to-moderate alcohol use (e.g., Rabin, 2009), and health guidelines in some countries have conceded that moderate alcohol use (defined in the U.S., for example, as one drink per day for women and two for men, e.g., one 12-ounce 5% ABV beer) may be beneficial for some people or some aspects of health (USDA & USDHHS, 2015). Still, guidelines typically caution against initiating or increasing alcohol use due to the increased risk for injuries and multiple cancers (Department of Health (2016); USDA & USDHHS, 2015) and because the degree to which confounding of this relationship has been addressed remains controversial in the literature (Chikritzhs et al., 2015, Fekjaer, 2013, Stockwell et al., 2016). Thus, the increased risk of mortality among abstainers raises important challenges for public health policy and education strategies. Below we outline three important gaps in the current literature and then state our aims and describe our analytic approach.
The first overarching limitation in the current research is a lack of accounting for differences between adult drinkers that emerge much earlier in childhood or adolescence, which may represent the underlying causes of both alcohol use and later mortality (Corrao et al., 2000, Jackson et al., 2005, Ng Fat et al., 2014). For instance, higher cognitive performance, social adaptation, and socioeconomic status in childhood are positively linked to better long-term health and lower risk of mortality (Batty et al., 2007, Bengtsson and Mineau, 2009, Galobardes et al., 2004, Hayward and Krause, 2013, Juon et al., 2014, Power et al., 2005), as well as to light-to-moderate alcohol use in adulthood (Crum et al., 2006, Maggs et al., 2008). Therefore, the observed protective relationship between adult light-to-moderate alcohol use and mortality may reflect differences in child and early adult cognitive, social, behavioral, and economic advantages between these groups. Studies using cross-sectional or short-term follow-up designs in adulthood only are unable to account for these differences in drinking groups that may have their origins earlier in life. If such differences explain the observed higher mortality among abstainers, the apparent risk of abstention may be spurious (Batty et al., 2007, Greenfield et al., 2002, Klatsky, 2002, Smothers and Bertolucci, 2001).
Abstaining may be associated with higher rates of mortality if abstainers have less social support than light-to-moderate drinkers (Batty et al., 2007). A lack of social support is associated with higher risk of mortality generally (Holt-Lunstad et al., 2010, House et al., 1988), with multidimensional measures of social support having a stronger relationship with health and mortality than unidimensional measures (Holt-Lunstad et al., 2010). A lack of social support is also associated with abstaining from alcohol (Klatsky, 2002, Fillmore et al., 1998) and light-to-moderate drinkers enjoy social benefits associated with their drinking (Hayward and Krause, 2013). However, social support is often not assessed in large national surveys focusing on physical health. Not considering social support as a potential confounding factor may cause selection bias in the alcohol-mortality relationship if it is a common antecedent of both abstaining and mortality risk. An important exception is the Greenfield et al. (2002) analysis of the National Alcohol Survey, which found that socially isolated individuals (i.e., those with little or no social contact) were more likely to be abstainers, but observed no effect of social isolation on the alcohol-mortality relationship. Additional research is needed to examine if social support received rather than simply social contact may serve a confounding role in the alcohol-mortality relationship. Further, scholars have not yet examined distinct dimensions of social support (e.g., instrumental vs. emotional support), which may provide additional insight into the role of social support in the alcohol-mortality relationship.
Third, the largest body of evidence for cross-sectional, J-shaped associations with alcohol use demonstrates that abstainers report poorer physical health compared to light-to-moderate drinkers (Chikritzhs et al., 2009, Gunzerath et al., 2004, Ng Fat et al., 2014, Rehm et al., 2001). However, the direction of effects is difficult to determine because many studies have measured alcohol use and physical health concurrently or only a couple of years apart. On the one hand, abstaining could increase the risk of death. On the other, physical health in early life or adulthood may be an important driver of becoming an abstainer, such that individuals who have serious or chronic illness may be less likely to drink due to medication restrictions and other factors (i.e., “sick quitter” hypothesis [Fillmore et al., 2007, Shaper et al., 1988]). Indeed, a previous study using the National Child Development Study (NCDS) found that respondents with poorer health at age 16 and 23 were more likely to abstain from alcohol at age 33 and age 42 (Ng Fat et al., 2014). Following this important research, we also use the NCDS to assess whether prior health problems (measured before abstaining or alcohol use is initiated) account for the J-shaped mortality curve in adulthood.
The present analyses use prospective child, adolescent, and adult data from the ongoing NCDS, first to show how drinking status at age 33 predicts all-cause mortality through age 51. We focus on age-33 alcohol use because the J-shaped curve linking alcohol use and mortality does not emerge until mid-adulthood (Gunzerath et al., 2004, Romelsjö et al., 2012). We then assess whether (a) early life factors, (b) adult social support, and (c) physical illness in early life and at age 33 account for the increased risk of mortality in the subsequent two decades among abstainers.
Section snippets
National Child Development Study (NCDS)
Data for the present study come from the NCDS, a prospective, longitudinal cohort study of all children born in Britain during one week in 1958 (Power and Elliott, 2006). The study began in infancy with a focus on perinatal mortality and has expanded to include a broader focus on development and health from early childhood to midlife. Multiple sources of data have been collected, including parent and teacher interviews, cognitive testing and school records, repeated interviews of the cohort
Results
Table 2 presents odds ratios and 95% confidence intervals from a series of multinomial logistic regressions estimating age-33 alcohol use as a function of each predictor. As shown in the first column, age-33 abstainers differed from light drinkers on many factors, highlighting the importance of controlling for these potential confounders in analyses predicting premature mortality. For example, abstainers had greater social maladjustment and lower academic ability at age 11; had more
Discussion
The present study makes three important advances to the literature on alcohol and mortality. First, poor physical health, but not adult social support, significantly explained at least part of the increased risk of mortality seen among abstainers. Second, by using long-term prospective national data, we demonstrated that the increased risk of mortality among abstainers was not reduced when we controlled for a host of relevant early life factors that distinguished abstainers from
Conclusion
This study contributes to the literature linking adult alcohol abstention with mortality using longitudinal birth cohort data to prospectively examine factors not previously explored, including early life factors. The alcohol-mortality relationship differed by age of alcohol use, pointing to the need for additional research to determine when in development the J-shaped curve emerges.
Acknowledgements
Authors were supported by grant R01AA019606 from the National Institute on Alcohol Abuse and Alcoholism (NIAAA), grant RES-579-0001 from the Economic and Social Research Council (ESRC), and grants T32DA017629 and P50DA010075 from the National Institute on Drug Abuse (NIDA). NCDS data collection was supported primarily by grants from the ESRC. NIAAA, ESRC, NIDA and the UK Data Archive had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or
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