Alcohol drinking pattern and subjective health in a population-based study

RESEARCH REPORT

doi:10.1111/j.1360-0443.2006.01517.x

© 2006 The Authors. Journal compilation © 2006 Society for the Study of Addiction

Addiction,

101

, 1265–1276

Blackwell Publishing Ltd

Oxford, UK

ADDAddiction

0965-2140© 2006 The Authors. Journal compilation © 2006 Society for the Study of Addiction

2006

101

••••

Original Article

Drinking pattern and subjective healthSaverio Stranges et al.

Correspondence to:

Saverio Stranges, Department of Social and Preventive Medicine, School of Public Health and Health Professions, State University of New York at Buffalo, 3435 Main Street, Farber Hall, Room 272, Buffalo, NY 14214, USA. E-mail: [email protected]

Submitted 15 September 2005; initial review completed 30 November 2005; final version accepted 3 March 2006

RESEARCH REPORT

Alcohol drinking pattern and subjective health in a population-based study

Saverio Stranges

1

, James Notaro

2

, Jo L. Freudenheim

1

, Rachel M. Calogero

3

, Paola Muti

1

, Eduardo Farinaro

4

, Marcia Russell

5

, Thomas H. Nochajski

6

& Maurizio Trevisan

1

Department of Social and Preventive Medicine, School of Public Health and Health Professions, State University of New York at Buffalo, Buffalo, NY, USA,

1

Department of Health Systems Administration, D’Youville College, Buffalo, NY, USA,

2

Department of Psychology, University of Kent, Canterbury, UK,

3

Department of Preventive Medical Sciences, ‘Federico II’ University of Naples Medical School, Naples, Italy,

4

Prevention Research Center, Berkeley, CA, USA

5

and

School of Social Work, State University of New York at Buffalo, Buffalo, NY, USA

6

ABSTRACT

Aims

Some patterns of alcohol consumption (e.g. binge drinking, drinking outside of meals) have been associatedwith detrimental effects on health outcomes. Subjective health provides a global assessment of health status and is astrong predictor of total mortality; however, little is known about its relationship with alcohol drinking pattern. Theassociation between several drinking patterns (i.e. drinking intensity and frequency, frequency of intoxication, drink-ing outside of meals, and beverage type) and subjective health was examined in a random sample of 3586 women andmen.

Design

A population-based cross-sectional study.

Methods

Subjective health was assessed using the physicaland mental health component summaries of the Short Form-36 health survey questionnaire. Alcohol consumptionrefers to the 30 days before the interview. Analysis of covariance compared gender-specific mean scores across alcoholdrinking patterns.

Findings

Overall, non-current drinkers reported poorer physical and mental health than life-timeabstainers and current drinkers, while no consistent differences were found between life-time abstainers and currentdrinkers. In female current drinkers, daily drinking, beer and mixed beverage consumption were associated with bettermental health. In male current drinkers, moderate alcohol consumption (2–2.9 drinks per day), wine and mixed bev-erage consumption were associated with better physical health. Intoxication and liquor consumption were associatedwith poorer mental health in women and poorer physical health in men. No consistent associations were found fordrinking outside meals.

Conclusions

Aspects of drinking pattern may affect subjective health differentially in womenand men. Overall, intoxication and liquor drinking are associated with poorer self-perceived health status than regular,moderate consumption of other alcoholic beverages.

Keywords

Alcohol, drinking pattern, epidemiology, SF-36, subjective health.

INTRODUCTION

While there is substantial and consistent evidence thatregular light to moderate consumption of alcohol reducesthe risk of total mortality by protecting from coronaryheart disease (CHD), some patterns of alcohol use havebeen associated with detrimental effects on health out-comes, including total mortality and CHD [1]. Thus, overthe last decade, epidemiological and social researchershave gone beyond measures of ‘average volume con-sumed’ to examine the importance of drinking patternsin explaining the beneficial or detrimental consequences

of alcohol consumption on human health. For example, apattern of binge or episodic heavy drinking has been asso-ciated with several adverse health consequences, includ-ing poor health status and higher risk of total mortalityand CHD, even in individuals who consume, on average, alight to moderate volume of alcohol [2–6]. Similarly,drinking outside meals has been shown to counteract thebenefits of moderate alcohol use on the cardiovascularsystem and increase the risk of total mortality [5,7–9].The evidence on the role of specific alcoholic beverages inthe relationship between alcohol consumption andhuman health is more controversial, with a number of


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et al.

observational studies supporting similar benefits for CHDrisk and general health from the consumption of wine,beer or liquor [10–13]. Thus, much remains to be uncov-ered about the benefits and detriments of specific drinkingpatterns on various health outcomes.

Subjective health, the way individuals perceive theirhealth, represents a global measure of health status andhas been shown to be a strong predictor of total mortality[14–16]. In a review of 27 community studies of self-rated health and mortality, Idler & Benyamini reportedthat self-ratings of health consistently predicted survivalbeyond other health indicators of mortality risk (e.g.blood pressure, serum cholesterol level, body mass index,prescription medication use, chronic conditions) [17].Thus, subjective health ratings may be particularly usefulindicators of health status because they are a more inclu-sive measure of the impact, severity and temporality of afull array of pre-morbid and morbid conditions experi-enced by individuals. Consequently, over the last decadethere has been an increased interest in understanding therelationship between alcohol consumption and people’ssubjective health [11–13,18–20]. However, the differentand complex components of drinking pattern such asintensity and frequency of consumption, binge drinking,consumption of alcohol with or without food, and theimportance of beverage type have not been sufficientlyaddressed in relation to subjective health.

Furthermore, while gender differences in the use andeffects of alcohol have been documented consistently, theinformation on potential gender differences in the associ-ation between alcohol consumption, drinking patternsand subjective health is poorly understood and limited.For example, in a recent study, Green and colleaguesexamined gender differences in the relationship betweenseveral measures of alcohol consumption (i.e. drinkingfrequency, quantity per occasion, and average volume)and measures of physical and mental health in over5000 men and women [21]. While many consistencieswere demonstrated between men and women acrossdrinking measures, light to moderate alcohol consump-tion and more frequent drinking were associated morestrongly with better physical health in women comparedto men. However, no gender differences were reported inthe association between alcohol consumption and men-tal health.

A further issue to be considered when examining theassociations between alcohol consumption and healthoutcomes is the selection of specific comparison groups.Clearly, life-time abstainers, non-current (or former)drinkers and current drinkers represent different types ofdrinking groups; however, the distinction between thesegroups has been inconsistent across research studies. Forexample, the inclusion of former drinkers in the categoryof life-time abstainers may confound results because

some former drinkers may have stopped drinking dueto health problems that increase their mortality risk.Indeed, research has demonstrated distinct differencesbetween drinking groups on a variety of life-stylebehaviors, social characteristics and health indicators,including smoking, use of drugs, socio-economic status,religion and general health [22,23]. Thus, the compari-son of these different categorizations of drinking groups(or drinking status) also warrants further investigation inrelation to health outcomes.

The present large, population-based study attempts toaddress several of these open issues on the relationshipbetween alcohol consumption and subjective health. Inparticular, this study focuses on several drinking patternsincluding average volume consumed, the intensity andfrequency of drinking, frequency of intoxication,drinking in relation to food consumption and alcoholicbeverage type. Subjective health was assessed using thephysical and mental health component summaries of theShort Form-36 health survey questionnaire (SF-36). Inorder to examine potential differences by gender anddrinking status in the association between patterns ofalcohol use and subjective health, gender-specific analy-ses were conducted across the full spectrum of drinkingcategories (i.e. life-time abstainers, non-current drinkers,several categories of current drinkers), with the inclusionof a number of potential confounding variables.

METHODS

Study population

Participants in this report were originally enrolled ashealthy control participants in the Western New YorkHealth Study, a series of case–control studies to examinethe complex issue of alcohol drinking pattern andchronic disease risk (e.g. CHD, breast and lung cancer).The study protocol was approved by the University at Buf-falo Institutional Review Board. The following eligibilitycriteria were used to identify potential controls: (1) resi-dents of Erie and Niagara Counties; (2) age 35–79 years;(3) no cancer. Potential participants were identifiedthrough two sources: (a) Department of Motor Vehicles ofNew York State for participants aged 35–64 years: thissource was used because it is known that 95% of NewYork residents in this age group have a driver’s license;and (b) Health Care Financing Administration (HCFA)lists for participants aged 65–79 years. This source wasused because it includes virtually all individuals in theage range of interest. Between 1995 and 2001, a total of6837 potential participants were identified, contactedand deemed eligible for our study. Of these, a total of 4065agreed to participate and were examined, for a participa-tion rate of 59.5%.

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Participation rate is an important concern in epidemi-ological studies. In order to check for significant bias, wecompared individuals who were contacted and agreed toparticipate to those who refused to participate. Bothgroups were asked a brief set of questions regarding socio-demographic and life-style characteristics at the time offirst contact. On average, non-participants were older,less educated, smoked more, drank less and ate less veg-etables and meats than those agreeing to participate. Theobserved differences were consistent with those reportedin the literature on non-response, and they did not indi-cate a major bias in the sampling of our participants. Inaddition, in order to determine the generalizability of oursample, we compared several characteristics of our par-ticipants with those of the National Health and NutritionExamination Survey (NHANES III), conducted in theUnited States between 1988 and 1994. No major differ-ences in the selected variables were reported between par-ticipants in the Western New York Health Study andthose of the NHANES III (data not shown).

For the present analyses, we excluded participantswith missing information on the SF-36 questionnaire(

n

=

226); missing information on drinking habits(

n

=

39) or missing data for various covariates (

n

=

214).The remaining 3586 participants, aged 35–79 years,were included in this study. Compared with those whowere excluded (

n

=

479), participants in the currentreport were significantly younger, more educated andmore likely to be current drinkers and never smokers; nosignificant differences in sex ratio, body mass index (BMI)and average volume of alcohol consumed in the past30 days were reported between excluded and includedparticipants.

Study protocol

All participants came to the Center for PreventiveMedicine at the University at Buffalo for an interviewand physical examination that lasted approximately2.5 hours. The health examination included measure-ments of anthropometric variables, such as height andweight, made by trained and certified interviewers onparticipants wearing light clothing and no shoes. BMIwas calculated as weight (kg) divided by height in m

2

. Aspart of the examination, participants provided informa-tion about various socio-demographic characteristics,life-style habits and their health conditions. Socio-demographic characteristics included years of education,marital status and annual household income. For smok-ing habits, participants reporting current use of ciga-rettes, cigars or pipes were classified as current smokers;participants reporting not having smoked at least 100cigarettes, or 20 cigars or 20 pipes in their life-time wereclassified as never smokers. Other participants were clas-sified as former smokers. Personal medical history was

obtained to determine the prevalence of physician-diagnosed diseases including CHD (prior myocardialinfarction, coronary artery bypass graft surgery, angio-plasty or diagnosed angina pectoris), hypertension,hypercholesterolemia and diabetes.

Subjective health was assessed using the widely usedSF-36 questionnaire, which has been validated in bothwell and diseased populations [24–26]. Participantsrespond to 36 items aggregated to form subscales thatmeasure the respondents’ impression of their health-related functioning in eight areas: physical functioning,role limitations due to physical problems, bodily pain,general health perceptions, vitality, social functioning,role limitations due to emotional problems and mentalhealth. Scales are scored on a 0–100 scale, with higherscores indicating better health and functioning. The firstfour subscales indicate respondents’ physical healthstatus, while the last four indicate mental health status.Factor analysis has been applied to the scales to create aphysical and mental health component summary, whichare standardized as

t

-scores (mean of 50 and standarddeviation of 10) and have higher reliability than the in-dividual scales [27]. Therefore, in the current study,subjective health assessment was based on these twocomponent summaries.

Information about alcohol intake was obtained witha computer-assisted personal interview [28,29]. Threecategories of drinking status were created. Life-timeabstainers were defined as participants who reportedconsumption of less than 12 drinks during their life-timeor in any 1-year period. Non-current drinkers weredefined as participants who reported 12 or more drinksduring their life-time or in any 1-year period, but did notconsume an alcoholic beverage at least once in the past30 days. Current drinkers were defined as participantswho reported consuming at least one alcoholic beveragein the 30 days prior to interview. Measures of currentdrinking patterns employed in the present report werebased on drinking during this past 30-day period. Quan-tity–frequency questions on alcohol drinking were askedfor Fridays, Saturdays, Sundays, weekdays and dayswhen more than usual was consumed. The interviewalso addressed the proportion of drinking that took placewith a meal, while snacking or with no food, the propor-tion of drinks that came from different types of alcoholicbeverage (wine, beer or liquor). The responses to thesemutually exclusive questions had to sum to 100%. Fre-quency of intoxication was also assessed. Responses tothe above questions were used to compute the relevantdrinking variables for the present analyses: (a) averagevolume of alcohol (drinks per day), where a drink wasdefined as a 355 ml beer, 148 ml wine or 37 ml liquor;(b) drinking intensity, measured as the number of drinksconsumed per drinking day; (c) drinking frequency (cat-


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et al.

egorized as less than weekly, weekly non-daily, weekendonly, or daily drinkers); (d) drinking outside meals [cate-gorized as drinking at least 75% of the time with mealsor snacks, drinking at least 75% of the time withoutmeals or snacks, or having a mixed pattern (i.e. not fall-ing into either of the other two categories)]; (e) beveragepreference was defined as wine, beer or liquor if one ofthese beverages was drunk on at least 75% of all drink-ing occasions, otherwise it was categorized as mixed. A75% cut-point was used to categorize drinking outside ofmeals and beverage preference because it ensured rea-sonable sample sizes in all categories. Results, however,were consistent across a wide range of cut-points.Finally, frequency of intoxication was assessed by askingcurrent drinkers whether and how often, during the past30 days, they consumed enough alcohol to becomedrunk or very high, have slurred speech or becomeunsteady on their feet [29]. Because intoxication wasinfrequent (i.e. less than once a week), among currentdrinkers during the past 30 days, this variable wasdichotomized into two categories (i.e. intoxication versusno intoxication).

Statistical analysis

All analyses were conducted using the Statistical Packagefor Social Sciences (SPSS version 12.0). Descriptive anal-yses were performed across several categories of drinkingvariables. Among current drinkers, categorical variableswere created for both average volume (drinks per day)and intensity (drinks per drinking day) of alcohol con-sumption in the 30 days before the interview. Covariateswere selected based on their well-known associationswith both alcohol consumption and subjective health.They included age (years), education (years), BMI, race(non-white/white), marital status (married/not mar-ried), annual household income (

<

$30 000, $30 000–70 000,

>

$70 000), smoking status (never, former,current), self-reported history of CHD, hypertension,hypercholesterolemia and diabetes. Tests for interactionamong all drinking patterns and selected covariates werenot significant for subjective health outcomes.

We computed age-adjusted and fully adjusted one-way analyses of covariance (ANCOVA) by using sevencategorical measures of alcohol consumption as indepen-dent variables (drinking status, volume, intensity, patternin relation to frequency, intoxication, food consumptionand beverage type) and the two component summaries ofsubjective health (physical and mental health) as depen-dent variables, separately for women and men. Thegeneral linear model procedure was used to compareadjusted mean scores of physical and mental healthacross categories of alcohol drinking pattern and forpairwise comparisons rather than comparisons with aselected reference category. Findings for age-adjusted and

fully adjusted models were similar; consequently only thefully adjusted data are presented.

RESULTS

Participant characteristics according to drinking statusand current drinking patterns are shown in Tables 1 and2 for women and men, respectively. For drinking status,life-time abstainers of both genders were older than non-current and current drinkers and reported the highestprevalence of never smokers. Female life-time abstainerswere more likely to report CHD and hypertension, whilein men the highest prevalence of CHD, hypertension, anddiabetes was reported among non-current drinkers. Cur-rent drinkers of both genders reported, on average, thehighest level of education, while non-current drinkers ofboth genders reported, on average, the highest body massindex. Female and male current drinkers were also char-acterized by the highest prevalence of whites, marriedindividuals and participants in the two top annualincome categories (i.e. $30 000–70 000;

>

$70 000).For drinking pattern in relation to frequency, daily

drinkers of both genders were older and reported the low-est mean body mass index and the highest average vol-ume of alcohol consumption compared to other drinkers.Among women, the highest intensity of consumptionwas reported among weekend-only drinkers, whereas inmen the highest intensity of consumption was reportedamong daily drinkers. Daily drinkers of both genders alsoreported the highest prevalence of hypertensive individu-als. For drinking pattern in relation to food consumption,participants of both genders with a mixed pattern wereyounger and with a lower mean BMI than other drinkers;they were characterized as well by the highest averagelevels of both volume and intensity of alcohol consump-tion. Drinkers of both genders consuming alcohol mainlywithout food were less educated and reported a higherprevalence of non-white individuals and current smokersthan other drinkers. Women who consumed alcoholmainly without food reported the highest prevalence ofhypertension, whereas men who consumed alcoholmainly with food reported the highest prevalence of dia-betes. Finally, for beverage type, women and men whopreferred liquor drank at a higher intensity than partici-pants who preferred other alcoholic beverages; liquordrinkers of both genders also reported the highest preva-lence of non-white individuals, hypertension and diabe-tes compared to other drinkers.

Findings for the physical and mental health compo-nent summaries for women are displayed in Table 3.

Physical health

Overall, current drinkers reported better physical healthacross all drinking variables compared to life-time

Drinking pattern and subjective health

1269


Addiction,

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, 1265–1276

Tab

le 1

Ch

arac

teri

stic

s* o

f fe

mal

e pa

rtic

ipan

ts (

n

=

18

53

) by

drin

kin

g pa

tter

ns;

the

Wes

tern

New

Yor

k H

ealt

h S

tudy

, 19

95

–20

01

.

Vari

able

n

All

part

icip

ants

Cur

rent

dri

nker

s on

ly

Dri

nkin

g st

atus

Dri

nkin

g pa

tter

n in

rel

atio

n to

freq

uenc

yD

rink

ing

patt

ern

in r

elat

ion

to fo

odD

rink

ing

patt

ern

in r

elat

ion

to b

ever

age

type

Life

-tim

e

abst

aine

rs

27

8

Non

-cur

rent

drin

kers

46

7

Cur

rent

drin

kers

11

08

Less

tha

n

wee

kly

58

6

Wee

kly/

non-

daily

31

0

Onl

y

wee

kend

10

3

Dai

ly

10

9

Wit

h

food

65

3

Wit

hout

food

18

2

Mix

ed

patt

ern

27

3

Win

e

48

9

Bee

r

19

1

Liqu

or

21

3

Mix

ed

patt

ern

21

5

Mea

n (S

E)

Mea

n (S

E)

Mea

n (S

E)

Mea

n (S

E)

Age

(ye

ars)

61

.0 (

0.7

)

57

.7 (

0.5

)

56

.2 (

0.4

)

56

.2 (

0.5

)

54

.6 (

0.6

)

54

.9 (

1.1

)

62

.1 (

1.1

)

56

.8 (

0.5

)

57

.1 (

0.9

)

54

.1 (

0.7

)

57

.4 (

0.5

)

54

.1 (

0.8

)

56

.1 (

0.8

)5

5.4

(0

.8)

Edu

cati

on (

year

s)1

3.0

(0

.1)

12

.9 (

0.1

)

13

.8 (

0.1

)

13

.5 (

0.1

)

14

.2 (

0.1

)

14

.0 (

0.2

)

13

.4 (

0.2

)

13

.8 (

0.1

)1

3.1

(0

.2)

13

.9 (

0.1

)1

4.1

(0

.1)

13

.2 (

0.2

)

13

.3 (

0.2

)1

4.0

(0

.2)

BM

I (k

g/m

2

)2

9.4

(0

.4)

29

.8 (

0.3

)

27

.2 (

0.2

)

28

.1 (

0.2

)

26

.2 (

0.3

)2

7.6

(0

.5)

24

.9 (

0.5

)

27

.1 (

0.2

)

28

.5 (

0.4

)

26

.7 (

0.3

)2

6.5

(0

.2)

27

.1 (

0.4

)

28

.7 (

0.4

)

27

.5 (

0.4

)

Dri

nks

/day

––

0.6

(0

.02

)

0.1

(0

.03

)

0.9

(0

.04

)0

.5 (

0.0

7)

2.1

(0

.07

)

0.4

(0

.04

)

0.7

(0

.07

)

0.9

(0

.06

)

0.5

(0

.04

)0

.7 (

0.0

7)

0.6

(0

.06

)0

.6 (

0.0

6)

Dri

nks

/dri

nki

ng

day

––

1.9

(0

.05

)

1.7

(0

.09

)

1.9

(0

.1)

2.6

(0

.2)

2.1

(0

.2)

1.7

(0

.08

)

2.1

(0

.2)

2.2

(0

.1)

1.7

(0

.09

)

2.1

(0

.1)

2.4

(0

.1)

1.8

(0

.1)

%%

%%

Non

-wh

ite

vers

us

wh

ite

15

.5

12

.2

4.4

5.5

3.2

4.9

1.8

4.0

9.3

2.2

3.3

6.3

8.5

1.4

Mar

ried

61

.2

57

.2

71

.3

70

.57

2.3

75

.76

8.8

72

.0

62

.1

76

.1

73

.46

6.5

68

.57

3.5

An

nu

al in

com

e

<

$3

0 0

00

53

.1

51

.5

29

.2

30

.0

24

.1

24

.2

44

.9

27

.2

47

.3

21

.5

30

.42

7.6

28

.82

8.4

$3

0 0

00

–70

00

04

0.2

36

.3

46

.15

1.0

41

.54

5.5

33

.7

47

.4

34

.3

51

.0

43

.25

2.3

46

.54

6.7

>

$7

0 0

00

6.7

12

.2

24

.7

19

.0

34

.4

30

.32

1.4

25

.4

18

.4

27

.5

26

.42

0.1

24

.72

4.9

Smok

ing

stat

us

Nev

er

74

.5

45

.4

44

.7

46

.64

5.1

43

.63

3.9

47

.0

34

.6

45

.94

9.7

31

.4

43

.7

46

.0

Form

er

19

.4

36

.0

40

.0

39

.63

9.7

35

.04

7.7

41

.5

40

.7

35

.7

41

.5

39

.3

38

.5

38

.6

Cu

rren

t

6.1

18

.6

15

.31

3.8

15

.22

1.4

18

.4

11

.5

24

.7

18

.48

.8

29

.3

17

.8

15

.4

CH

D†

10

.8

7.1

5.8

6.8

3.2

5.8

7.3

6.6

6.6

3.3

5.9

7.3

3.8

6.0

Hyp

erte

nsi

ve†

38

.8

35

.5

28

.1

29

.4

21

.6

32

.0

35

.8

27

.4

36

.3

23

.9

27

.62

6.2

35

.2

23

.7

Hyp

erch

oles

tero

lem

ic†

39

.63

8.3

33

.43

4.3

30

.03

5.0

36

.73

4.2

35

.72

9.8

33

.73

1.9

39

.03

6.1

Dia

beti

c†9

.4

10

.1

4.4

6.0

2.6

2.9

2.8

4.3

7.1

2.9

4.1

4.7

7.5

1.9

*Dat

a ar

e m

ean

val

ues

(st

anda

rd e

rror

, SE)

for

con

tin

uou

s va

riab

les,

per

cen

tage

val

ues

for

cate

gori

cal v

aria

bles

.

†

Perc

enta

ge r

epor

tin

g ye

s ar

e di

spla

yed

for

coro

nar

y h

eart

dis

ease

(C

HD

), h

yper

ten

sion

, hyp

erch

oles

tero

lem

ia a

nd

diab

etes

. Am

ong

sign

ifica

nt

diffe

ren

ces

in c

har

acte

rist

ics

betw

een

diff

eren

t ca

tego

ries

of

drin

kin

g pa

tter

ns

(

P

≤

0.0

5),

hig

hes

t va

lues

app

ear

in b

old,

low

est

in it

alic

s.


Addiction,

101

, 1265–1276

1270

Saverio Stranges

et al.

Tab

le 2

Ch

arac

teri

stic

s* o

f m

ale

part

icip

ants

(

n

=

17

33

) by

drin

kin

g pa

tter

ns;

the

Wes

tern

New

Yor

k H

ealt

h S

tudy

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Drinking pattern and subjective health 1271

© 2006 The Authors. Journal compilation © 2006 Society for the Study of Addiction Addiction, 101, 1265–1276

abstainers and non-current drinkers. Among currentdrinkers, no differences were found across different pat-terns of alcohol consumption with one exception: thosewho had less than one drink per drinking day reportedsignificantly worse physical health than those who hadeither one to 1.9 or three or more drinks per drinking day.

Mental health

Overall, non-current drinkers reported the poorest men-tal health across all drinking variables, although they didnot differ significantly from life-time abstainers. In addi-tion, daily drinkers reported significantly better mental

Table 3 Mean scores (standard errors) of the SF-36 component summaries* by drinking patterns; the Western New York HealthStudy, 1995–2001. Women, n = 1853.

Variable n

Fully adjusted†

Physical health Mental health

Drinking statusLife-time abstainers (A) 278 47.3C (0.5) 52.6 (0.5)Non-current drinkers (B) 467 46.6C (0.4) 51.6C (0.4)Current drinkers (C) 1108 48.6A,B (0.3) 52.8B (0.3)

Drinks per dayLife-time abstainers (A) 278 47.3 (0.5) 52.6 (0.5)Non-current drinkers (B) 467 46.6C,D,E,F (0.4) 51.6C (0.4)< 1 drink (C) 904 48.6B (0.3) 52.8B (0.3)1–1.9 drinks (D) 133 48.6B (0.8) 52.8 (0.7)2–2.9 drinks (E) 54 48.9B (1.2) 53.1 (1.2)≥ 3 drinks (F) 17 51.2B (2.1) 50.7 (2.1)

Drinks per drinking dayLife-time abstainers (A) 278 47.3D,F (0.5) 52.6 (0.5)Non-current drinkers (B) 467 46.6D,E,F (0.4) 51.6C (0.4)< 1 drink (C) 322 47.6D,F (0.5) 53.4B (0.5)1–1.9 drinks (D) 451 49.0A,B,C (0.4) 52.5 (0.4)2–2.9 drinks (E) 208 48.7B (0.6) 52.6 (0.6)≥ 3 drinks (F) 127 49.8A,B,C (0.8) 52.3 (0.8)

Pattern in relation to frequencyLife-time abstainers (A) 278 47.3C,D (0.5) 52.6F (0.5)Non-current drinkers (B) 467 46.6C,D (0.4) 51.6E,F (0.4)Less than weekly drinkers (C) 586 48.7A,B (0.4) 52.2F (0.3)Weekly/non-daily drinkers (D) 310 48.8A,B (0.5) 52.7F (0.5)Weekend-only drinkers (E) 103 48.4 (0.9) 54.0B (0.8)Daily drinkers (F) 109 48.2 (0.9) 54.8A,B,C,D (0.8)

Pattern in relation to intoxicationLife-time abstainers (A) 278 47.3D (0.5) 52.6C (0.5)Non-current drinkers (B) 467 46.6D (0.4) 51.6C,D (0.4)Intoxication (C) 40 48.7 (1.4) 46.1A,B,D (1.3)No intoxication (D) 1068 48.7A,B (0.3) 53.0B,C (0.3)

Pattern in relation to foodLife-time abstainers (A) 278 47.3C (0.5) 52.6 (0.5)Non-current drinkers (B) 467 46.6C,D,E (0.4) 51.6C,E (0.4)With food (C) 653 48.7A,B (0.3) 52.8B (0.3)Without food (D) 182 48.2B (0.7) 52.1 (0.6)Mixed pattern (E) 273 48.7B (0.5) 53.0B (0.5)

Pattern in relation to beverage typeLife-time abstainers (A) 278 47.3C (0.5) 52.6 (0.5)Non-current drinkers (B) 467 46.6C,D,E,F (0.4) 51.6D,F (0.4)Wine (C) 489 48.8A,B (0.4) 52.2D,F (0.4)Beer (D) 191 48.8B (0.6) 53.8B,C,E (0.6)Liquor (E) 213 48.0B (0.6) 52.1D,F (0.6)Mixed pattern (F) 215 48.8B (0.6) 53.8B,C,E (0.6)

*Higher scores indicate better health and functioning. †Adjusted for age, education, body mass index, race, marital status, annual household income,smoking status, self-reported history of coronary heart disease (CHD), hypertension, hypercholesterolemia and diabetes. The superscript notations for theadjusted mean scores indicate the significant contrast (P ≤ 0.05) between that group and the specific category indicated by the capital letter.


1272 Saverio Stranges et al.

health compared to life-time abstainers, less than weeklydrinkers and weekly but not daily drinkers. Furthermore,current drinkers who experienced at least one episode ofintoxication in the past 30 days reported significantlyworse mental health compared to life-time abstainers,non-current drinkers and all other current drinkers.

Finally, current drinkers who preferred beer or mixedbeverage types reported significantly better mentalhealth compared to current drinkers who preferred wineor liquor.

Findings for the physical and mental health compo-nent summaries for men are displayed in Table 4.

Table 4 Mean scores (standard errors) of the SF-36 component summaries* by drinking patterns; the Western New York HealthStudy, 1995–2001. Men, n = 1733.

Variable n

Fully adjusted†

Physical health Mental health

Drinking statusLife-time abstainers (A) 73 48.3 (0.9) 53.5 (0.9)Non-current drinkers (B) 417 47.7C (0.4) 52.7C (0.4)Current drinkers (C) 1243 49.4B (0.2) 54.3B (0.2)

Drinks per dayLife-time abstainers (A) 73 48.3E (0.9) 53.5 (0.9)Non-current drinkers (B) 417 47.7C,D,E (0.4) 52.7C,D,E,F (0.4)< 1 drink (C) 773 49.4B (0.3) 54.1B (0.3)1–1.9 drinks (D) 233 49.4B (0.5) 54.4B (0.5)2–2.9 drinks (E) 97 51.0A,B,F (0.8) 55.2B (0.8)≥ 3 drinks (F) 140 48.2E (0.7) 55.1B (0.6)

Drinks per drinking dayLife-time abstainers (A) 73 48.3 (0.9) 53.5 (0.9)Non-current drinkers (B) 417 47.7C,D,E,F (0.4) 52.7D,E,F (0.4)< 1 drink (C) 150 49.8B (0.7) 53.9 (0.6)1–1.9 drinks (D) 436 49.5B (0.4) 54.0B (0.4)2–2.9 drinks (E) 287 49.7B (0.5) 54.2B (0.5)≥ 3 drinks (F) 370 48.9B (0.4) 55.0B (0.4)

Pattern in relation to frequencyLife-time abstainers (A) 73 48.3 (0.9) 53.5 (0.9)Non-current drinkers (B) 417 47.7C,D,E,F (0.4) 52.7C,D,E,F (0.4)Less than weekly drinkers (C) 463 49.1B (0.4) 54.1B (0.4)Weekly/non-daily drinkers (D) 467 49.2B (0.4) 54.1B (0.4)Weekend-only drinkers (E) 95 50.6B (0.8) 54.8B (0.8)Daily drinkers (F) 218 50.1B (0.5) 55.3B (0.5)

Pattern in relation to intoxicationLife-time abstainers (A) 73 48.3 (0.9) 53.5 (0.9)Non-current drinkers (B) 417 47.7D (0.4) 52.7D (0.4)Intoxication (C) 94 47.7D (0.8) 53.2 (0.8)No intoxication (D) 1149 49.5B,C (0.2) 54.4B (0.2)

Pattern in relation to foodLife-time abstainers (A) 73 48.3 (0.9) 53.5 (0.9)Non-current drinkers (B) 417 47.7C,D,E (0.4) 52.7C,D,E (0.4)With food (C) 563 49.6B (0.3) 54.4B (0.3)Without food (D) 257 49.2B (0.5) 53.9B (0.5)Mixed pattern (E) 423 49.3B (0.4) 54.5B (0.4)

Pattern in relation to beverage typeLife-time abstainers (A) 73 48.3 (0.9) 53.5 (0.9)Non-current drinkers (B) 417 47.7C,D,F (0.4) 52.7D,E,F (0.4)Wine (C) 216 50.1B,E (0.5) 53.7 (0.5)Beer (D) 544 49.1B,F (0.4) 54.8B (0.3)Liquor (E) 187 48.2C,F (0.6) 54.1B (0.6)Mixed pattern (F) 296 50.3B,D,E (0.5) 54.1B (0.4)

*Higher scores indicate better health and functioning. †Adjusted for age, education, body mass index, race, marital status, annual household income,smoking status, self-reported history of coronary heart disease (CHD), hypertension, hypercholesterolemia and diabetes. The superscript notations for theadjusted mean scores indicate the significant contrast (P ≤ 0.05) between that group and the specific category indicated by the capital letter.



Physical health

Overall, non-current drinkers reported the poorest phys-ical health across all drinking variables, although theydid not differ significantly from life-time abstainers. Inaddition, current drinkers who consumed two to 2.9drinks per day reported significantly better physicalhealth compared to life-time abstainers and currentdrinkers of three or more drinks per day. Furthermore,current drinkers who experienced at least one episode ofintoxication in the past 30 days reported significantlyworse physical health compared to all other currentdrinkers. Finally, current drinkers who preferred liquorreported significantly worse physical health compared tocurrent drinkers who preferred wine or mixed beveragetypes.

Mental health

Overall, non-current drinkers reported the poorest men-tal health across all drinking variables, although they didnot differ significantly from life-time abstainers. No sig-nificant differences were found between life-time abstain-ers and current drinkers or across categories of currentdrinkers.

DISCUSSION

In this population-based study, we examined gender-specific associations of several patterns of alcohol con-sumption with subjective health as assessed by the twocomponent summaries of the SF-36 questionnaire. Wesummarize the findings below. First, non-current drink-ers of both genders consistently reported poorer physicaland mental health than either life-time abstainers orcurrent drinkers. Secondly, no consistent differences insubjective health were demonstrated between life-timeabstainers and current drinkers. The only exception wasin women, with life-time abstainers reporting signifi-cantly poorer physical health compared to currentdrinkers. Finally, among current drinkers, aspects ofdrinking pattern differentially affected the subjectivehealth of women and men. Specifically, in women, dailydrinking, beer and mixed beverage consumption wereassociated with better mental health, as was avoidingintoxication. In men, moderate alcohol consumption(two to 2.9 drinks per day), wine and mixed beverageconsumption, and avoiding intoxication were all associ-ated with better physical health. Overall, of the four bev-erage types, current drinkers who preferred liquorreported poorer subjective health than other drinkers;no consistent associations were found for drinking out-side of meals.

The current study encompassed several patterns ofalcohol consumption including previously unstudied

patterns (e.g. drinking outside of meals) in relation tosubjective health. In addition, for subjective healthassessment we used the SF-36 physical and mentalhealth component summaries, which have received littleattention in previous research. We also analyzed the rela-tionship between the selected alcohol drinking patternsand the SF-36 individual scales, but we did not find anyconsistent associations (data not shown).

Our findings further confirm the notion that non-current (or former) drinkers have to be considered as aseparate category from life-time abstainers in researchon the health consequences of alcohol consumption[22,23]. Importantly, although neither former drinkersnor life-time abstainers currently consume alcohol, theformer category may include subjects who no longerdrink because of pre-existing diseases, which confoundsthe relationship between health status and alcohol con-sumption. In the current study, non-current drinkers ofboth genders reported consistently poorer physical andmental health than either life-time abstainers or currentdrinkers. This finding is inconsistent with previous cross-sectional studies. For example, Poikolainen and col-leagues did not find a significant difference in the risk of‘suboptimal’ versus ‘good’ subjective health between life-time abstainers and former drinkers [18]. However, intheir study subjective health was assessed using a singlequestion rather than multiple scales, which constrainstheir measurement of subjective health. In a more recentstudy on a Dutch cohort, former drinkers on averagereported an intermediate, but not significantly different,position between current drinkers and abstainers on theSF-36 subscales, except for significantly better mentalhealth than abstainers [20]. However, in their study thescores on the SF-36 subscales were dichotomized, thusagain constraining their measurement of subjectivehealth.

In the current study, no consistent differences werefound between life-time abstainers and current drink-ers across patterns of alcohol consumption. In particu-lar, moderate alcohol consumption was not consistentlyassociated with better subjective health than life-timeabstention. These findings from a large communitysample of women and men extend recent researchbased on a selected cohort of middle-aged men of thehighest social class in Finland, which demonstrated nohealth disadvantages, over the long term, from absten-tion as opposed to moderate consumption of alcohol[30].

The current study also demonstrated gender differ-ences for the two components of subjective health. Spe-cifically, among women some aspects of drinking patternwere differently associated with mental health. Amongmen, we did not find consistent differences in the effectsof alcohol drinking pattern on mental health across



categories of current drinkers; however, some aspects ofdrinking pattern were differently associated with physicalhealth. These findings are consistent with previousresearch that has recognized the significance of psycho-logical and social factors on the alcohol-related behaviorsof women, but not men [31,32].

The effects of some aspects of alcohol drinking patternon subjective health that were found in the current studywarrant further discussion. With regard to drinkingfrequency, we found that daily drinking, especially inwomen, was associated with better mental health thanother drinking frequency categories. Because femaledaily drinkers did not differ significantly in drinkingintensity from other drinkers, it is possible that the bene-ficial effect associated with daily drinking on mentalhealth is due, at least in women, to a frequent moderateconsumption of alcohol, as opposed to a pattern of epi-sodic heavy drinking that presents well-known acute andlong-term health risks [33]. The cross-sectional design ofthe current study prevents us from establishing causalrelationships, thus we cannot rule out the possibility thatindividuals who perceive their health as ‘good’ may tendto drink more frequently or that their daily drinking maybe part of a healthy life-style.

Complementary to the last result, in the currentstudy a pattern of intoxication was associated withpoorer mental health in women, and poorer physicalhealth in men. This finding is consistent with accumu-lating evidence demonstrating the detrimental effects ofepisodic heavy drinking on both objective and subjec-tive health outcomes, even in individuals who regularlyconsume a light to moderate volume of alcohol. Forexample, a number of studies suggest that binge drink-ing may counteract the cardioprotective effects of regu-lar, moderate alcohol consumption, thereby increasingthe risk of cardiovascular and total mortality [4–6].Recent findings have also demonstrated that a patternof episodic heavy drinking is associated with poorerhealth status and poorer health-related quality of life[2,3].

For drinking pattern in relation to food consumption,current drinkers consuming alcohol mainly without foodwere associated generally with lower scores of physicaland mental health compared to current drinkers con-suming alcohol mainly with food or with a mixed pat-tern. However, no significant associations were found fordrinking outside meals when analyses were fully adjustedfor potential confounders. Thus, we cannot rule out thepossibility that drinking alcohol with or without foodmay represent a marker of life-style profile and health-related behaviors, which may itself be the link to protec-tive and detrimental health effects [34].

For predominant beverage consumption, we foundthat participants consuming more than one type of

alcoholic beverages (i.e. wine, beer and liquor) generallyreported higher health status scores than single beveragedrinkers, while current drinkers who preferred liquorgenerally reported poorer subjective health than otherdrinkers. While these findings are not consistent withprevious studies showing beneficial effects of specificalcoholic beverages on subjective health [11,12] theyare, however, consistent with more recent investigationsand the current belief that the protective and detrimentaleffects of alcohol consumption on health are linked toethanol per se, rather than to beverage preference[10,13,35]. In other words, beverage preferences arelinked differentially across countries with other socio-demographic and behavioral variables, thus representinga marker of life-style profile, and yielding a limited possi-bility of discriminating their specific effects from othereffects [36].

Some limitations of the current study deserve men-tion. First, the cross-sectional design does not allow forestablishing causality with respect to the observed asso-ciations. Given the nature of subjective health, we cannotdisregard the likelihood that self-perceptions of healthmay lead to different drinking habits, and not vice versa.Secondly, the suboptimal participation rate (59.5%) mayleave the possibility for selection bias and restrict the gen-eralizability of these findings to the general population.However, our participation rate reflects the overall partic-ipation rate of similar studies conducted in the UnitedStates that require a visit to a clinical center and a com-plex examination and interview [37,38]. The strengths ofthis study include the extensive measurement of patternsof alcohol use, the inclusion of several covariates knownto be related to either alcohol consumption or subjectivehealth, the large community-wide sample and the use ofthe SF-36, which is a well-validated instrument used inover 4000 studies.

In conclusion, the present study emphasizes theimportance of incorporating more comprehensiveassessments of alcohol consumption and further investi-gating possible gender differences in epidemiologicalresearch on the health consequences of alcohol con-sumption. We found that aspects of drinking patternwere associated differentially with the two main compo-nents of subjective health (i.e. physical and mental), andthat this association was gender-specific. In particular,this study confirms that a pattern of intoxication is asso-ciated with poorer health outcomes compared to regu-lar, moderate alcohol consumption. Future researchshould attempt to identify the causal links between pat-terns of alcohol consumption and subjective health. Inaddition, the differential associations between drinkingpattern and mental health for women and betweendrinking pattern and physical health for men warrantfurther consideration.



Acknowledgements

This study was supported in part by grant no. 5 P50AA09802 from the National Institute on Alcohol Abuseand Alcoholism.

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Alcohol drinking pattern and subjective health in a population-based study

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