Prevention and Treatment of Hypertension Study (PATHS): effects of an alcohol treatment program on blood pressure.

OBJECTIVE: To determine whether blood pressure is reduced for at least 6 months with an intervention to lower alcohol intake in moderate to heavy drinkers with above optimal to slightly elevated diastolic blood pressure, and whether reduction of alcohol intake can be maintained for 2 years. DESIGN: A randomized controlled trial. METHODS: Six hundred forty-one outpatient veterans with an average intake of 3 or more alcoholic drinks per day in the 6 months before entry into the study and with diastolic blood pressure 80 to 99 mm Hg were randomly assigned to a cognitive-behavioral alcohol reduction intervention program or a control observation group for 15 to 24 months. The goal of the intervention was the lower of 2 or fewer drinks daily or a 50% reduction in intake. A subgroup with hypertension was defined as having a diastolic blood pressure of 90 to 99 mm Hg, or 80 to 99 mm Hg if recently taking medication for hypertension. RESULTS: Reduction in average weekly self-reported alcohol intake was significantly greater (P<.001) at every assessment from 3 to 24 months in the intervention group vs the control group: levels declined from 432 g/wk at baseline by 202 g/wk in the intervention group and from 445 g/wk by 78 g/wk in the control group in the first 6 months, with similar reductions after 24 months. The intervention group had a 1.2/0.7-mm Hg greater reduction in blood pressure than the control group (for each, P = .17 and P = .18) for the 6-month primary end point; for the hypertensive stratum the difference was 0.9/0.7 mm Hg (for each, P = .58 and P = .44). CONCLUSIONS: The 1.3 drinks per day average difference between changes in self-reported alcohol intake observed in this trial produced only small nonsignificant effects on blood pressure. The results from the Prevention and Treatment of Hypertension Study (PATHS) do not provide strong support for reducing alcohol consumption in nondependent moderate drinkers as a sole method for the prevention or treatment of hypertension.

A method for estimating alcohol-related liver cirrhosis mortality in Japan.

In Japan, per capita alcohol consumption increased sharply during the post World War II period followed by an increase in cirrhosis mortality. The prevalence of alcoholic cirrhosis among hospitalized patients also increased, from 11% in 1969 to 18% in 1985. Despite an increase in the percentage of drinkers among young women, over 80% of women in Japan are still abstainers or light drinkers. Thus, female cirrhosis mortality rates can be used as a proxy measure of non-alcohol-related cirrhosis mortality rates to estimate alcohol-related cirrhosis deaths among Japanese men. Employing this method, we conclude that two-thirds of cirrhosis deaths among men between 24 and 85 years of age and half of all cirrhosis deaths were attributable to alcohol. Two factors are probably responsible for the differences in proportional morbidity and proportional mortality of alcohol-related cirrhosis: differences in survival rates between alcoholic and non-alcoholic cirrhosis patients and detection bias toward post-hepatic cirrhosis. The synergistic effect of alcohol on viral hepatitis may in part explain excess cirrhosis deaths among Japanese men.

Prevention and Treatment of Hypertension Study (PATHS). Rationale and design.

Alcohol consumption has been recognized as an important correlate of blood pressure in many epidemiologic studies, but few interventional studies have been conducted to examine the effect of a reduction in alcohol intake on blood pressure. Because these studies have usually included few subjects and been of short duration, the National Heart, Lung, and Blood Institute (NHLBI), the National Institute on Alcohol Abuse and Alcoholism (NIAAA), and the Veterans Affairs (VA) Cooperative Studies Program have initiated a randomized, controlled, multicenter trial to determine whether blood pressure and left ventricular mass are lowered over 6 months of alcohol moderation in non-dependent moderate to heavy drinkers (three or more drinks per day average but not alcohol dependent) with above-average normal (80 to 89 mm Hg) and mildly hypertensive (90 to 99 mm Hg) levels of diastolic blood pressure, and whether a reduction in alcohol intake can be maintained for 2 years. Eligible veterans are randomized to either an alcohol reduction intervention or a control observation group at seven clinical sites. The projected sample size is 580 participants. Alcohol intake is assessed by self-report using a retrospective diary (Chronological Drinking Record) and by various biochemical markers, including apolipoproteins, HDL cholesterol (and subfractions), and carbohydrate deficient transferrin, analyzed at a central laboratory. The alcohol intervention technique is a cognitive-behavioral program, the intensive phase of which consists of six counseling sessions over 3 months. Echocardiograms are obtained at baseline and 6 months after randomization. This trial has important implications for both the prevention and treatment of hypertension.

Drinking patterns among black and nonblack adolescents: results of a national survey.

The overall objective of this study was to identify factors that relate to the use of alcohol among black and nonblack students and that might serve to explain the lower prevalence of drinking among black students. Black students were shown to differ from nonblack students with respect to both demographic variables associated with social class and variables associated with exposure to and involvement with alcohol. Multivariate analyses, controlling for the effects of demographic status, yielded several predictors of the frequency and quantity of alcohol consumption. Among the major predictors of alcohol use were exposure to friends as drinking models, attitudes emphasizing the importance of social effects of alcohol, ease of access to alcohol, and behavior patterns of social transgressions and illicit drug use. While degree of religiosity and attainment of good school grades were inversely related to frequent and heavier use of alcohol among nonblack students, they were not related to patterns of alcohol use by black students. For the most part, however, there were more similarities than differences in the predictors of alcohol use among black and nonblack students. These findings suggest that environmental factors associated with the use of alcohol are similar for black and nonblack students. While the overall use of alcohol is lower among black students, the onset of drinking is grade-related but later in onset relative to nonblack drinkers. Despite the fact that the same predictors of drinking are common to both black and nonblack students, there is need to identify the environmental factors that delay exposure to a more extensive network of peer drinking models and access to alcohol. Comparisons between black and nonblack abstainers revealed that black abstainers reported lower proportions of school peers to be drinkers. This differential exposure to drinking models between black and nonblack abstainers may be implicated in the delay of onset of drinking among black students. A second factor that may be implicated in the delay of onset of drinking among black students related to differences in the perception of alcohol between blacks and nonblacks. Black abstainers, compared to nonblacks, viewed the personal effects of drinking as more important reasons for drinking. These reasons stress the use of alcohol as a coping mechanism to deal with personal stress and problems. Future studies need to address the status of these variables with regard to their implications in delaying the onset of drinking among black students.

The effects of order of questions on reported alcohol consumption.

This research note draws upon the US National Longitudinal Survey (NLS) of Labor Market Experience among youths aged 17-24 to report the effects of variation in the ordering of alcohol questions upon the prevalence of heavier drinking. A secondary analysis of the NLS indicated a substantial decrease in the prevalence of heavier drinking between 1984 and 1985 which is attributed to the order of presentation of two differently styled questions regarding heavier drinking.

The measurement of alcohol-related accidents.

This paper examines some of the major ethical and research issues associated with the measurement and recording of alcohol-related problems. Because self-reports of the history of the amount of alcohol ingested are sometimes unreliable, the assessment of the role of alcohol in casualties often relies on a variety of methods which are both diverse and interrelated. The unique measurement problems posed by the diversity of alcohol measures are reviewed and issues in selection and recording bias of alcohol's involvement in injury are discussed. A number of fundamental ethical and moral issues related to measurement are identified.

Stability and prevalence of drinking among young adults.

This data note draws upon the National Longitudinal Survey (NLS) of Labor Market Experience in Youth beginning at ages 17-24 to describe the stability and prevalence of alcohol use over a 6-year period up to ages 23-30. Approximately 70% of men and 58% of women maintained their drinking status throughout the study. The onset of current and heavier drinking decreased with increasing age while the offset of current and heavier drinking increased with increasing age. The absence of current drinking was unrelated to age for both men and women as was the presence of heavier drinking among men.

Comorbidity between DSM-IV alcohol use disorders and major depression: results of a national survey.

The purpose of this study was to describe detailed patterns of comorbidity between Diagnostic and Statistical Manual of Mental Disorders--Fourth Edition (DSM-IV) alcohol use disorders and major depression using a representative sample of the United States. Comorbidity rates and associations between DSM-IV alcohol use disorders and major depression were expressed as odds ratios with confidence intervals adjusted for the complex design characteristics of the NLAES. Comorbidity analyses were presented by sex, ethnicity and age for past year, prior to past year and lifetime diagnoses. Virtually all odds ratios were significantly greater than 1.0, demonstrating that comorbidity of alcohol use disorders and major depression is pervasive in the general population. The magnitude of the association remained stable across the three time frames but diagnostic and subgroup variations in comorbidity were noted. The association between alcohol dependence and major depression was greater than the association between abuse and major depression and the association between alcohol abuse and major depression was consistently greater for females and blacks, compared to their male and non-black counterparts. Implications of the results are discussed in terms of professional help seeking, the self-medication hypothesis, and differential social control theory.

Concurrent and simultaneous use of alcohol with cocaine: results of national survey.

The purpose of the present study was to determine the prevalence of the concurrent and simultaneous use of alcohol and cocaine in the general population and to examine differences in these rates between important sociodemographic subgroups. The results indicated that a sizable proportion of Americans were engaged in both substance use patterns. The population estimate for simultaneous use of both substances (i.e., simultaneously or on the same occasion) was approximately 4 million for the month preceding the interview, rising to approximately 9 million when the past year timeframe was considered. Corresponding figures for the concurrent use of alcohol and cocaine (i.e., use of both substances during the same time period) were approximately 5 million during the past month and 12 million during the past year. The extent of each substance use practice varied as a function of sociodemographic factors. Implications of these findings are discussed in terms of the need for age-sex-ethnic-specific prevention strategies. The need for future analytic epidemiologic research to determine the precise relationship between dose, frequency and duration of concurrent and simultaneous use and each adverse consequence is emphasized. The need for longitudinal research in the general population is also highlighted.

Occupation and alcohol-related causes of death.

The purpose of the present investigation is to determine if various alcohol-related causes of death are associated with similar occupational groups. The California Occupational Mortality Study data set (1979-1981) provided information on primary occupation and deaths from cirrhosis, digestive cancers, injury, suicide and homicide. Age-adjusted mortality rates were calculated along with 95% confidence intervals. Findings indicate that farming/forestry/fishing personnel and handlers/equipment cleaners/helpers/labourers seem to be at risk of dying from alcohol-related causes. Due to the various methodological issues discussed, these findings need to be interpreted with caution.

Screening for major depression among alcoholics: an application of receiver operating characteristic analysis.

When comparing several screening tests designed to detect the same disease, methodological problems arise in determining which is most accurate. We have previously demonstrated that receiver operating characteristic (ROC) methodology can provide a set of statistical procedures which allow for objective comparisons of screening tests. In this report, ROC methodology is brought to a different substantive area: the detection of clinical depression among treated alcoholics. In a sample of hospitalized alcoholics, we compared the accuracies of several commonly used screening tests for depressive disorders, as well as comparing each of these with a screening test for anxiety disorders. No test offered a statistically significant advantage over any other, and all did poorly in detecting clinically diagnosed major depression. The performance of the screening tests was worst when the non-depressed comparison group included subjects with remitted disorder, but was still poor when the comparison group did not include such potentially 'noisy' subjects. Factors contributing to the difficulty of screening for clinical depression are discussed, as well as suggestions for improvements in future screening efforts.

Screening for current drug use disorders in alcoholics: an application of receiver operating characteristic analysis.

The major objectives of the present study were 2-fold: (1) to demonstrate the superiority of receiver operating characteristic (ROC) methodology in the comparison of screening tests that yield continuous values; and (2) to identify the best screening indicator of current drug use disorders in alcoholics. We evaluated the ability of the screening tests to detect drug use disorder (DUD) according to the research diagnostic criteria. Results showed that the language of addiction - drug version and the reasons for drug use (RDU) screening tests offered excellent detectability for current DUD. The accuracy of both tests was reduced as the result of broadening the clinical spectrum in the comparative group. Implications of these findings to the neglected topic of clinical and co-morbid spectrums in screening test evaluation is presented. Issues surrounding the use of psychiatric diagnoses as standards, assessment of efficacy, the role of screening in defining subthreshold disorder, and the use of biochemical screening as an adjunct to the questionnaire approach are also discussed.

The relative validity of a chronological drinking record.

The results of chronological and a daily drinking record are compared. The chronological record was completed by interviewers who probed for information on all drinking episodes during the last week. The daily record covered only the last day and was completed by the respondent without interviewer assistance. Because of the recency of the information, the daily record was expected to yield the more valid results, but this hypothesis was not supported by the findings. Total alcohol consumption reported by the chronological method was significantly higher because men, but not women, reported fewer drinking episodes with the daily record for the same period. Daily recording may have placed too heavy a burden on the most frequent drinkers, most of whom were men.

The Alcohol Use Disorder and Associated Disabilities Interview schedule (AUDADIS): reliability of alcohol and drug modules in a general population sample.

Using a representative sample of the general population, the test-retest reliability of the alcohol and drug modules of the Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS) was examined. The AUDADIS showed good to excellent reliability for measures of alcohol consumption and use of sedatives, tranquilizers, amphetamines, opioids (other than heroin), cannabis and cocaine. Equally good reliability was demonstrated for diagnoses of alcohol, cannabis, cocaine and heroin abuse or harmful use and dependence defined in terms of the International Classification of Diseases-Tenth Revision (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders-Third Edition-Revised (DSM-III-R) and Fourth Edition (DSM-IV). Results are discussed in terms of the need for future research on the psychometric properties of the AUDADIS in clinical and general population samples.

Alcoholic beverage type, recall period effects and functional disability: evidence from the 1983 NHIS.

To replicate a Canada Health Survey (CHS) study that found beer drinking was associated with lower morbidity, National Health Interview Survey (NHIS) data for 19,462 persons were used to examine associations between functional disability and beverage specific ethanol consumption. A functional disability index consisting of morbidity and symptom coping events reported for 2 weeks prior to the NHIS interview was constructed. Alcohol consumption was reported for the same period as disability (coincident recall), or for the 2 weeks prior to the respondent's last drink during the past year (antecedent recall). The analysis controlled for confounders using direct standardization and multiple logistic regression. The results of this investigation were not consistent with the CHS study. Former drinkers and antecedent recall drinkers reported greater disability rates than either non-drinkers or coincident recall drinkers. Antecedent recall drinkers exhibiting a preference for beer and wine were, respectively, 40 and 80 percent more likely to be disabled than non-drinkers. Further, this study found no evidence of a protective effect among any subgroup of drinkers. The finding of a significant interaction between alcohol consumption and alcohol recall period suggests that epidemiologic studies should give greater attention to the classification of drinker groups by proximity of alcohol consumption.

Time series analysis of alcohol consumption and suicide mortality in the United States, 1934-1987.

OBJECTIVE: The objective is to analyze time series data on per capita alcohol consumption and suicide mortality between 1934 and 1987. Specifically, the aim is to test the hypothesis that increases in per capita consumption are associated with increases in suicide mortality overall and in gender and age subgroups. This study also examines whether the effect of per capita consumption on subsequent rates of suicide is influenced by other aggregate factors, particularly unemployment rates, per capita income and divorce rates. METHOD: This analysis examines the temporal structure of suicide mortality, alcohol consumption and covariate time series data in the United States, 1934-1987, using the Box-Jenkins method. RESULTS: Bivariate associations between alcohol consumption and suicide rates were not significant. However, when unemployment was included in the model, increases in per capita alcohol consumption were significantly related to increases in suicide overall, for men and women, and for the young (under age 40) and middle-aged (40 to 59 years), but not for those over age 60. CONCLUSIONS: The use in modeling of other known covariates of suicide rates, particularly unemployment, affects the magnitude of the relationship between alcohol consumption and suicide. Consistent with other studies, unemployment was significantly related to suicide and was shown to confound the relationship between alcohol and suicide. The effects of changes in alcohol consumption on changes in suicide rates differ by gender and age group, which demonstrates that focusing on the total population alone can mask divergent effects that can cancel each other out when subgroups are combined.

National study of the demography of adolescent drinking practices in 1980.

According to a national survey, adolescent drinking patterns appear to have remained relatively stable in the last half decade. Among those aged 16-18, 73% are drinkers; drinking and drunkenness continue to be age- and sex-graded phenomena.

Alcohol-related problems of children of heavy-drinking parents.

Alcohol-related problems that are experienced by sons and daughters of heavy-drinking parents (either father or mother) are examined using data from a 1978 household sample of employed adults in metropolitan Detroit. Adult children with heavy-drinking parents were found to have a higher percentage of dependent problem drinking than those without heavy-drinking parents. Also, adult children with low status (blue-collar) occupations were found to have a higher percentage of dependent problem drinking than those with high status (white-collar) occupations. Although it was not possible to disentangle the genetic processes from the social processes in this study, the results support the hypothesis that having both heavy-drinking parents and low occupational status places sons and daughters at elevated risk for alcohol-related problems. Implications for future epidemiological studies are discussed.

Psychosocial factors in adolescent drinking contexts.

A number of environmental and personality characteristics of adolescent students and their relationship to types of drinking contexts were examined using a series of canonical correlation analyses. The strongest relationship was defined by the perceived normative support for drinking, which accounted for 55% of the variance in the drinking context items for males (58% among females). Positive functions of drinking, personal attitudes and values, and environmental contexts were also associated with drinking context items but accounted for smaller proportions of the variance. The contribution of important environmental, personality and drinking context variables to each canonical relationship is discussed. Consistency of studies relevant to the major finding is reviewed and possible bases for discrepancies are explored. Further studies relating to antecedent networks of access to various drinking contexts are identified as areas deserving more intensive and extensive research efforts.

Cirrhosis mortality and occupation.

Cirrhosis, the ninth leading cause of death in the United States, has been associated with abusive alcohol consumption patterns. Since the workplace serves as a major exposure variable for alcohol consumption over a significant portion of the lifecourse, and since heavy drinking has been shown to differ by type of occupation, this study examines the relationship between type of occupation and cirrhosis mortality. The California Occupational Mortality Study data set (1979 to 1981) provided the information on primary occupation and liver cirrhosis mortality. Crude and sex-specific mortality rates were calculated based on information from a 20% sample of the 1980 California census (included in the data set). Ninety-five percent confidence intervals were calculated around all rates to determine if any were significantly different from rates for the entire state. The findings uphold the view that an association exists between occupation and cirrhosis mortality. The highest mortality rates were found among persons with blue-collar type jobs (e.g., construction laborers and machinists) or jobs where alcohol was easily available (e.g., bartenders and waitresses). Future research needs to specify the factors associated with occupation that may promote the chronic heavy drinking that leads to cirrhosis.