Full length articleAge of first drunkenness and risks for all-cause mortality: A 27-year follow-up from the epidemiologic catchment area study
Introduction
Harmful drinking of alcoholic beverages (hereinafter, alcohol) is one of the most prevalent behavioral health problems in the world. Estimated to contribute to over 2.7 million deaths annually (Whiteford et al., 2013), the alcohol-mortality prediction often has a J-shape, with lower death rates for lighter drinking subgroups, relative to non-drinkers, and with excess mortality risk along a gradient toward heavier drinking and among subgroups with alcohol use disorders (AUD); (Mattisson et al., 2011, Ojesjö et al., 1998, Vaillant, 2003). In recent meta-analytic work that strengthens earlier summaries (Harris and Barraclough, 1998), a total of 81 observational studies with 221,683 observed deaths among 853,722 people suggested that the mortality rate among AUD cases might be an estimated three times greater than the non-AUD mortality rate (Roerecke and Rehm, 2013). Multiple background characteristic and associated covariates are thought to play a role in elevated AUD-related mortality rates. Especially prominent are acute consequences of AUD-related impairments and injury deaths (Vinson et al., 2003), and chronic health effects of drinking, such as cardiovascular diseases and cancers (French, 1971, Rehm et al., 2003, Rehm et al., 2009), as well as more occult pathways such as drinking-associated increased absorption of heavy metals (Hu et al., 2014, Newton et al., 1992).
Early onset of drinking and drunkenness also may be implicated, since they are associated with AUD and alcohol-related health behaviors such as smoking, fighting, unplanned and unprotected sex, and low academic performance (Dawson et al., 2008, Grant et al., 2001, Hingson et al., 2003, Hingson et al., 2006, Kuntsche et al., 2013, Thomas et al., 2000). While most literature in the field focused on early onset of drinking, emerging evidence suggested that the association between early age of alcohol initiation and AUD does not reflect a causal relationship (Ystrom et al., 2014). Kuntsche et al. (2016) suggested to shift the focus of alcohol research away from infrequenct, low-quantity drinking towards more detrimental drinking patterns.
For the present investigation, we wondered whether early age of first drunkenness (e.g., drinking enough to get drunk at <15 years) might modulate AUD-associated excess mortality risk, given observed links from early drunkenness and later AUD, and from AUD and excess mortality (Spiegler, 1993). Accordingly, we hypothesize that mortality rates will be greater for the subgroup with early-onset drunkenness, as compared with others, and we investigated whether this predictive relationship varied by AUD status. For new empirical estimates, we constructed a prospective cohort research design, and yoked drinking characteristics of participants in the United States National Institute of Mental Health Epidemiologic Catchment Area (US, NIMH, ECA) study, 1981-83, with the US death records through 2007. In addition, an exploratory mediation analysis was conducted to estimate possible effects of AUD in a causal pathway thought to link age of first drunkenness with occurrence of death. Of methodological note are two pertinent facts: (1) the ECA assessments assessed age of first drunkenness but not age of first drink, and (2) we have aggregated ‘never drinkers’ with the subgroup of drinkers who never got drunk. We note that detrimental drinking patterns such as drunkenness might be more appropriate predictors of death and other alcohol-related health consequences (Dawson et al., 2008, Kuntsche et al., 2016), but we return to this issue of age of first drink versus age of the first drunken episode in our discussion section, as well as the aggregation of ‘never drinkers’ with ‘never drunk’ individuals.
Section snippets
Study population
The ECA study was designed in the late 1970s as a multi-site National Institute of Mental Health collaboration with five participating university-based research teams (Yale University, Johns Hopkins University, Washington University, Duke University, and University of California at Los Angeles), with probability sample surveys of nearby community residents initiated site-by-site in the early 1980s (Eaton WW, 1985). The California site did not retain identifiers required for NDI linkages, but it
Results
Table 1 is a display of characteristics of the 14,848 adult study participants at baseline interview by age at first drunkenness. In aggregate, 60 percent were female and 27.1% self-designated as ‘Black’. A total of 9089 adults (61.2%) said they had been drunk, with most of them first getting drunk at or after age 15 (86.6%). Irrespective of age at the 1st drunken episode, most who had gotten drunk were between 18 and 44 years of age at the time of the baseline interview in the early 1980s.
Discussion
In this study, we found that drunkenness, earlier than mid-adolescence, or later than mid-adolescence, is a predictor of excess mortality, even among drinkers who did not qualify as alcohol use disorder cases at baseline assessment. The estimated effect of early-onset drunkenness (before age 15 years) was numerically larger than the estimated effect of later-onset drunkenness, but the 95% confidence intervals for these estimates showed considerable overlap. Our exploratory mediation analyses
Conclusion
In this prospective cohort study of a probability sample of adult community respondents recruited from four US cities in the early 1980s, a baseline history of lifetime drunkenness predicted excess mortality, with marginally higher rates for subgroups of drinkers whose first episode of being drunk occurred before age 15. In addition, exploratory mediational analyses are suggestive of a possibility that an indirect mediational pathway, via AUD, might be substantively more important for the
Role of funding source
Funding for this study was provided by the National Institute on Drug Abuse (grants R01 DA026652, T32 DA021129, T32 DA035167, and K01 DA015799)
Contributors
Dr. Hu conducted analyses. Dr. Hu and Dr. Cottler wrote the initial draft of the manuscript. All co-authors gave input on statistical analyses, interpretation of results, and contributed to and approved the final manuscript.
Conflict of interest
No conflict of interest.
Human participant protection
The study was approved by the institutional review boards of the University of Florida and the Johns Hopkins Bloomberg School of Public Health. Michigan State University and Duke University Medical Center participations were judged exempt.
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