# Alcohol intake and total mortality in 142 960 individuals from the MORGAM Project: a population-based study

Augusto Di Castelnuovo, Simona Costanzo, Marialaura Bonaccio, Patrick Mcelduff, Allan Linneberg, Veikko Salomaa, Satu Männistö, Marie Moitry, Jean Ferrières, Jean Dallongeville, et al.

► To cite this version:

Augusto Di Castelnuovo, Simona Costanzo, Marialaura Bonaccio, Patrick Mcelduff, Allan Linneberg, et al.. Alcohol intake and total mortality in 142 960 individuals from the MORGAM Project: a population-based study. Addiction, 2022, 117 (2), pp.312-325. 10.1111/add.15593. hal-04177474

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# Alcohol intake and total mortality in 142 960 individuals from the MORGAM Project: a population-based study

Augusto Di Castelnuovo, Simona Costanzo, Marialaura Bonaccio, Patrick Mcelduff, Allan Linneberg, Veikko Salomaa, Satu Männistö, Marie Moitry, Jean Ferrières, Jean Dallongeville, et al.

► To cite this version:

Augusto Di Castelnuovo, Simona Costanzo, Marialaura Bonaccio, Patrick Mcelduff, Allan Linneberg, et al.. Alcohol intake and total mortality in 142 960 individuals from the MORGAM Project: a population-based study. Addiction, 2022, 117 (2), pp.312-325. 10.1111/add.15593. hal-04177474

HAL Id: hal-04177474

https://hal.science/hal-04177474v1

Submitted on 27 Feb 2024

HAL is a multi-disciplinary open access
archive for the deposit and dissemination of sci-
entific research documents, whether they are pub-
lished or not. The documents may come from
teaching and research institutions in France or
abroad, or from public or private research centers.

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destinée au dépôt et à la diffusion de documents
scientifiques de niveau recherche, publiés ou non,
émanant des établissements d'enseignement et de
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<figure><img src="image_1.png" /></figure>

Distributed under a Creative Commons Attribution 4.0 International License
<figure><img src="image_1.png" /></figure>

# Alcohol intake and total mortality in 142 960 individuals from the MORGAM Project: a population-based study

Augusto Di Castelnuovo¹ ID, Simona Costanzo² ID, Marialaura Bonaccio², Patrick McElduff³, Allan Linneberg⁴, Veikko Salomaa⁵, Satu Männistö⁵, Marie Moitry⁶, Jean Ferrières⁷, Jean Dallongeville⁸, Barbara Thorand⁹, Hermann Brenner¹⁰, Marco Ferrario¹¹, Giovanni Veronesi¹¹, Emanuela Pettenuzzo¹¹, Abdonas Tamosiunas¹², Inger Njølstad¹³, Wojciech Drygas¹⁴, Yuri Nikitin¹⁵, Stefan Söderberg¹⁶, Frank Kee¹⁷, Guido Grassi¹⁸, Dirk Westermann¹⁹, Benedikt Schrage¹⁹, Salim Dabboura¹⁹, Tanja Zeller¹⁹, Kari Kuulasmaa⁵, Stefan Blankenberg¹⁹, Maria Benedetta Donati², Giovanni de Gaetano² & Licia Iacoviello²,¹¹ ID

## ABSTRACT

**Aim** To test the association of alcohol consumption with total and cause-specific mortality risk. **Design** Prospective observational multi-centre population-based study. **Setting** Sixteen cohorts (15 from Europe) in the MONica Risk, Genetics, Archiving and Monograph (MORGAM) Project. **Participants** A total of 142 960 individuals (mean age 50 ± 13 years, 53.9% men). **Measurements** Average alcohol intake by food frequency questionnaire, total and cause-specific mortality. **Findings** In comparison with life-time abstainers, consumption of alcohol less than 10 g/day was associated with an average 11% [95% confidence interval (CI) = 7–14%] reduction in the risk of total mortality, while intake > 20 g/day was associated with a 13% (95% CI = 7–20%) increase in the risk of total mortality. Comparable findings were observed for cardiovascular (CV) deaths. With regard to cancer, drinking up to 10 g/day was not associated with either mortality risk reduction or increase, while alcohol intake > 20 g/day was associated with a 22% (95% CI = 10–35%) increased risk of mortality. The association of alcohol with fatal outcomes was similar in men and women, differed somewhat between countries and was more apparent in individuals preferring wine, suggesting that benefits may not be due to ethanol but other ingredients. Mediation analysis showed that high-density lipoprotein cholesterol explained 2.9 and 18.7% of the association between low alcohol intake and total as well as CV mortality, respectively. **Conclusions** In comparison with life-time abstainers, consuming less than one drink per day (nadir at 5 g/day) was associated with a reduced risk of total, cardiovascular and other causes mortality, except cancer. Intake of more than two drinks per day was associated with an increased risk of total, cardiovascular and especially cancer mortality.

**Keywords** Alcohol intake, cancer mortality, cardiovascular mortality, cohort study, HDL cholesterol, mortality.

Correspondence to: Licia Iacoviello, Department of Epidemiology and Prevention, IRCCS NEUROMED, Pozzilli (IS), Italy. Via dell'Elettronica 1, 86077 Pozzilli (Isernia), Italy. E-mail: licia.iacoviello@moli-sani.org

Submitted 19 July 2020; initial review completed 2 November 2020; final version accepted 26 May 2021

*Please see list of authors' affiliations at the end of the paper. †MORGAM Study Investigators.

## INTRODUCTION

Observational studies have reported that moderate alcohol drinkers live longer than both life-time abstainers and heavy drinkers [1–3]. In the absence of conclusions from randomized controlled trials [4] these findings have been scrutinized for confounding and bias [5, 6], and have been recently questioned [7–9]. The association of alcohol consumption with chronic diseases is complex, because of its distinct relationships with different chronic diseases, the potential for non-linear dose–response relationships, issues concerning setting, pattern of consumption, confounding, selection of the reference group and

the varied roles of different types of alcoholic beverages [10–13].

Previous studies examining single diseases at a time provided contrasting results, making it difficult to assess the full burden of alcohol consumption [8, 14, 15]. Specifically, a lower risk of cardiovascular (CV) events among moderate drinkers has been repeatedly observed [11, 14–18]; however, at the same time, heavy alcohol intake was associated with increased risk of some cancers and other disorders [8, 11, 19]. As a consequence, a consensus has emerged on the fact that heavy alcohol consumption has a definite detrimental effect [11]. However, the existence of a healthy non-zero level of alcohol
<figure><img src="image_2.png" /></figure>

# Alcohol intake and total mortality in 142 960 individuals from the MORGAM Project: a population-based study

Augusto Di Castelnuovo¹ ID, Simona Costanzo² ID, Marialaura Bonaccio², Patrick McElduff³,

Allan Linneberg⁴, Veikko Salomaa⁵, Satu Männistö⁵, Marie Moitry⁶, Jean Ferrières⁷,

Jean Dallongeville⁸, Barbara Thorand⁹, Hermann Brenner¹⁰, Marco Ferrario¹¹, Giovanni Veronesi¹¹,

Emanuela Pettenuzzo¹¹, Abdonas Tamosiunas¹², Inger Njølstad¹³, Wojciech Drygas¹⁴, Yuri Nikitin¹⁵,

Stefan Söderberg¹⁶, Frank Kee¹⁷, Guido Grassi¹⁸, Dirk Westermann¹⁹, Benedikt Schrage¹⁹,

Salim Dabboura¹⁹, Tanja Zeller¹⁹, Kari Kuulasmaa⁵, Stefan Blankenberg¹⁹, Maria Benedetta Donati²,

Giovanni de Gaetano² & Licia Iacoviello²,¹¹ ID

## ABSTRACT

**Aim** To test the association of alcohol consumption with total and cause-specific mortality risk. **Design** Prospective observational multi-centre population-based study. **Setting** Sixteen cohorts (15 from Europe) in the MONica Risk, Genetics, Archiving and Monograph (MORGAM) Project. **Participants** A total of 142 960 individuals (mean age 50 ± 13 years, 53.9% men). **Measurements** Average alcohol intake by food frequency questionnaire, total and cause-specific mortality.

**Findings** In comparison with life-time abstainers, consumption of alcohol less than 10 g/day was associated with an average 11% [95% confidence interval (CI) = 7–14%] reduction in the risk of total mortality, while intake > 20 g/day was associated with a 13% (95% CI = 7–20%) increase in the risk of total mortality. Comparable findings were observed for cardiovascular (CV) deaths. With regard to cancer, drinking up to 10 g/day was not associated with either mortality risk reduction or increase, while alcohol intake > 20 g/day was associated with a 22% (95% CI = 10–35%) increased risk of mortality. The association of alcohol with fatal outcomes was similar in men and women, differed somewhat between countries and was more apparent in individuals preferring wine, suggesting that benefits may not be due to ethanol but other ingredients. Mediation analysis showed that high-density lipoprotein cholesterol explained 2.9 and 18.7% of the association between low alcohol intake and total as well as CV mortality, respectively. **Conclusions** In comparison with life-time abstainers, consuming less than one drink per day (nadir at 5 g/day) was associated with a reduced risk of total, cardiovascular and other causes mortality, except cancer. Intake of more than two drinks per day was associated with an increased risk of total, cardiovascular and especially cancer mortality.

**Keywords** Alcohol intake, cancer mortality, cardiovascular mortality, cohort study, HDL cholesterol, mortality.

Correspondence to: Licia Iacoviello, Department of Epidemiology and Prevention, IRCCS NEUROMED, Pozzilli (IS), Italy. Via dell'Elettronica 1, 86077 Pozzilli (Isernia), Italy. E-mail: licia.iacoviello@moli-sani.org

Submitted 19 July 2020; initial review completed 2 November 2020; final version accepted 26 May 2021

*Please see list of authors' affiliations at the end of the paper. †MORGAM Study Investigators.

## INTRODUCTION

Observational studies have reported that moderate alcohol drinkers live longer than both life-time abstainers and heavy drinkers [1–3]. In the absence of conclusions from randomized controlled trials [4] these findings have been scrutinized for confounding and bias [5, 6], and have been recently questioned [7–9]. The association of alcohol consumption with chronic diseases is complex, because of its distinct relationships with different chronic diseases, the potential for non-linear dose–response relationships, issues concerning setting, pattern of consumption, confounding, selection of the reference group and

the varied roles of different types of alcoholic beverages [10–13].

Previous studies examining single diseases at a time provided contrasting results, making it difficult to assess the full burden of alcohol consumption [8, 14, 15]. Specifically, a lower risk of cardiovascular (CV) events among moderate drinkers has been repeatedly observed [11, 14–18]; however, at the same time, heavy alcohol intake was associated with increased risk of some cancers and other disorders [8, 11, 19]. As a consequence, a consensus has emerged on the fact that heavy alcohol consumption has a definite detrimental effect [11]. However, the existence of a healthy non-zero level of alcohol
<table><caption>**Table 1** General characteristics of the studied population according to alcohol intake.</caption><thead><tr><th rowspan="2">Baseline characteristics</th><th colspan="6">Alcohol intake categories</th></tr><tr><th>Former drinkers</th><th>Non-drinkers<sup>a</sup></th><th>Life-time abstainers</th><th>Light-moderate 0.1-10 g/day</th><th>Moderate 10.1-20 g/day</th><th>Heavy > 20 g/day</th></tr></thead><tbody><tr><td>Number of individuals (%)</td><td>5486 (3.8)</td><td>10 013 (7.0)</td><td>34 310 (24.0)</td><td>51 471 (36.0)</td><td>16 885 (11.8)</td><td>24 795 (17.3)</td></tr><tr><td>Alcohol intake, mean (SD), g/day</td><td>0</td><td>0</td><td>0</td><td>4.5 (2.7)</td><td>14.6 (2.7)</td><td>53.6 (54.6)</td></tr><tr><td>Men, %</td><td>52.5</td><td>36.2</td><td>35.4</td><td>50.1</td><td>68.5</td><td>85.1</td></tr><tr><td>Age at baseline examination, mean (SD), years</td><td>55 (11)</td><td>47 (12)</td><td>51 (13)</td><td>48 (13)</td><td>51 (13)</td><td>52 (11)</td></tr><tr><td>Daily smoker, %</td><td>22.4</td><td>21.6</td><td>24.6</td><td>29.9</td><td>34.2</td><td>37.4</td></tr><tr><td>Diabetes, %</td><td>11.3</td><td>5.0</td><td>5.9</td><td>3.7</td><td>4.3</td><td>4.8</td></tr><tr><td>Previous CVD, %</td><td>10.7</td><td>4.2</td><td>7.7</td><td>4.3</td><td>4.8</td><td>4.0</td></tr><tr><td>Hypertension, %</td><td>50.0</td><td>49.9</td><td>44.7</td><td>39.8</td><td>46.8</td><td>51.6</td></tr><tr><td>Body mass index, %</td><td>0.6</td><td>1.0</td><td>1.1</td><td>0.8</td><td>0.5</td><td>0.6</td></tr><tr><td></td><td>≤ 18.5 kg/m<sup>2</sup></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td></td><td>18.5-24.9 kg/m<sup>2</sup></td><td>32.3</td><td>40.3</td><td>37.3</td><td>41.9</td><td>32.4</td></tr><tr><td></td><td>25.0-29.9 kg/m<sup>2</sup></td><td>41.1</td><td>39.0</td><td>37.5</td><td>39.8</td><td>44.3</td></tr><tr><td></td><td>≥ 30 kg/m<sup>2</sup></td><td>26.1</td><td>19.7</td><td>24.2</td><td>17.6</td><td>17.5</td></tr><tr><td>Level of education, %</td><td>primary school only (or less)</td><td>30.8</td><td>59.3</td><td>34.2</td><td>19.6</td><td>29.0</td></tr><tr><td></td><td>Secondary school</td><td>49.9</td><td>20.5</td><td>35.1</td><td>33.3</td><td>35.8</td></tr><tr><td></td><td>Intermediate between secondary and university</td><td>10.4</td><td>14.8</td><td>18.9</td><td>24.9</td><td>17.1</td></tr><tr><td></td><td>University or college or equivalent</td><td>8.9</td><td>5.4</td><td>12.2</td><td>22.1</td><td>18.1</td><td>11.3</td></tr></tbody></table>

Non-drinkers are individuals for which we failed to distinguish between teetotallers and former drinkers. Previous CVD means documented or self-reported history of myocardial infarction or stroke or unstable angina pectoris. CVD = cardiovascular disease; SD = standard deviation.
<table><caption>**Table 1** General characteristics of the studied population according to alcohol intake.</caption><thead><tr><th rowspan="2">Baseline characteristics</th><th colspan="6">Alcohol intake categories</th></tr><tr><th>Former drinkers</th><th>Non-drinkers<sup>a</sup></th><th>Life-time abstainers</th><th>Light-moderate 0.1-10 g/day</th><th>Moderate 10.1-20 g/day</th><th>Heavy > 20 g/day</th></tr></thead><tbody><tr><td>Number of individuals (%)</td><td>5486 (3.8)</td><td>10 013 (7.0)</td><td>34 310 (24.0)</td><td>51 471 (36.0)</td><td>16 885 (11.8)</td><td>24 795 (17.3)</td></tr><tr><td>Alcohol intake, mean (SD), g/day</td><td>0</td><td>0</td><td>0</td><td>4.5 (2.7)</td><td>14.6 (2.7)</td><td>53.6 (54.6)</td></tr><tr><td>Men, %</td><td>52.5</td><td>36.2</td><td>35.4</td><td>50.1</td><td>68.5</td><td>85.1</td></tr><tr><td>Age at baseline examination, mean (SD), years</td><td>55 (11)</td><td>47 (12)</td><td>51 (13)</td><td>48 (13)</td><td>51 (13)</td><td>52 (11)</td></tr><tr><td>Daily smoker, %</td><td>22.4</td><td>21.6</td><td>24.6</td><td>29.9</td><td>34.2</td><td>37.4</td></tr><tr><td>Diabetes, %</td><td>11.3</td><td>5.0</td><td>5.9</td><td>3.7</td><td>4.3</td><td>4.8</td></tr><tr><td>Previous CVD, %</td><td>10.7</td><td>4.2</td><td>7.7</td><td>4.3</td><td>4.8</td><td>4.0</td></tr><tr><td>Hypertension, %</td><td>50.0</td><td>49.9</td><td>44.7</td><td>39.8</td><td>46.8</td><td>51.6</td></tr><tr><td>Body mass index, %</td><td>0.6</td><td>1.0</td><td>1.1</td><td>0.8</td><td>0.5</td><td>0.6</td></tr><tr><td></td><td>≤ 18.5 kg/m<sup>2</sup></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td></td><td>18.5-24.9 kg/m<sup>2</sup></td><td>32.3</td><td>40.3</td><td>37.3</td><td>41.9</td><td>32.4</td></tr><tr><td></td><td>25.0-29.9 kg/m<sup>2</sup></td><td>41.1</td><td>39.0</td><td>37.5</td><td>39.8</td><td>44.3</td></tr><tr><td></td><td>≥ 30 kg/m<sup>2</sup></td><td>26.1</td><td>19.7</td><td>24.2</td><td>17.6</td><td>17.5</td></tr><tr><td>Level of education, %</td><td>primary school only (or less)</td><td>30.8</td><td>59.3</td><td>34.2</td><td>19.6</td><td>29.0</td></tr><tr><td></td><td>Secondary school</td><td>49.9</td><td>20.5</td><td>35.1</td><td>33.3</td><td>35.8</td></tr><tr><td></td><td>Intermediate between secondary and university</td><td>10.4</td><td>14.8</td><td>18.9</td><td>24.9</td><td>17.1</td></tr><tr><td></td><td>University or college or equivalent</td><td>8.9</td><td>5.4</td><td>12.2</td><td>22.1</td><td>18.1</td><td>11.3</td></tr></tbody></table>

Non-drinkers are individuals for which we failed to distinguish between teetotallers and former drinkers. Previous CVD means documented or self-reported history of myocardial infarction or stroke or unstable angina pectoris. CVD = cardiovascular disease; SD = standard deviation.
51 years [interquartile range (IQ) = 40–59 years]. The prevalence of men, smoking habit, hypertension, overweight and lower levels of education was higher in categories at increasing alcohol intake. The prevalence of history of CV disease or diabetes was higher in all three categories of non-alcohol consumers (Table 1).

## Risk of death

During a median follow-up time of 11.8 years (IQ = 6.8–16.1), 16 907 deaths occurred (during 1 801 926 person-years of observation). Of these, 5547 were from a CV cause, 5511 were cancer deaths and 5849 were classified from ‘other causes’.

Multivariable hazard ratios for mortality are reported in Table 2. In the fully adjusted model, in comparison with life-time abstainers, ex-drinkers and non-drinkers had a 19 and 13% higher risk of mortality, respectively; drinkers 0.1–10 g/day had an 11% (95% CI =7–14%) lower risk of death, whereas drinkers > 20 g/day had a 13% (7–20%) higher risk. Similar findings were observed for CV and ‘other causes’ deaths, whereas cancer mortality risk was higher in ex-drinkers, non-drinkers and in drinkers > 20 g/day (Table 2). Analogous results were observed after omission from the adjustment model of the factors that might be causally related to alcohol consumption (Table 2, Model 1) and after multiple imputations for missing data in all variables, including alcohol intake and history of cancer (Supporting information, Table S2).

Mortality risks according to drinking frequency are reported in Supporting information, Table S3. Irrespective of further adjustment for total alcohol intake, drinking on fewer than two occasions/week was associated with lower mortality for any cause but cancer. Drinking almost every day was associated with a 16% (1–33%) increase in the risk of cancer mortality, but this association disappeared [hazard ratio (HR) = 1.09; 95% CI = 0.94–1.26] when further adjusted for total alcohol intake.

Supporting information, Table S4 reports risks for alcohol after replacing ex-drinkers and non-drinkers with drinkers by use of multiple imputation. In comparison with life-time abstainers, light–moderate drinkers still had between an 8 and 18% lower total, cardiovascular and ‘other causes’ mortality, whereas heavy intake still was associated with an 8–20% higher risk for any type of mortality.

## Mediation analysis

High-density lipoprotein cholesterol (HDLc), C-reactive protein (CRP), troponin and N-terminal pro brain-type natriuretic peptide (NT-ProBNP) were associated with alcohol categories (adjusted for age, sex and cohort). Supporting information, Fig. S1 shows the percentage of variation, in comparison to life-time abstainers. HDLc increases with

alcohol intake, whereas CRP shows a J-shaped association. The percentage of the low intake effect mediated by HDLc was 2.9% (1.2–7.1%) for total and 18.7% (3.0–62.7%) for CV mortality, whereas the percentage of the heavy intake effect was 13.7% (6.4–27.0%) for ‘other causes’ deaths. No mediation role for CRP, troponin or NT-ProBNP was observed.

## Dose-response curves

The association with mortality of alcohol modelled as restricted-cubic splines is depicted in Fig. 1; former and non-drinkers were excluded and null intake served as the reference value. J-shaped curves were observed for total, CV and ‘other causes’ mortality (P-value for non-linearity < 0.0001), with the magnitude of the relative reduction ranging between 4 and 27% at nadir of 3–5 g/day and remaining lower than 1 up to 10–11 g/day (Fig. 1a,b,d); the relative risk becomes distinctly > 1 starting from 20 g/day, with the exception of CV mortality, for which the confidence intervals were somewhat wide (Fig. 1b). The association of alcohol with cancer mortality was null at low doses and became unequivocal at 15 g/day (Fig. 1c).

## Subgroup analyses

In Supporting information, Table S5 we show how the choice of the reference group impacts our findings. If the reference category includes ex-drinkers and/or non-drinkers, the association of light/moderate intake with lower mortality rises from 11 to 13–15%, the negative association with moderate intake rises to 5–7% and the positive association of high intake drops from 13 to 7–9%. Conversely, the choice of light/moderate drinkers as reference group exacerbates the risk for drinking categories.

A J-shaped relationship between alcohol and total mortality was confirmed in different cohorts grouped by geographical location (Fig. 2), with the exception of Australia (Fig. 2d), in which no association was observed. The magnitude of the association at nadir varied slightly, ranging from 14 to 24%, and was greater in cohorts from Italy/France (Fig. 2a). The nadir varied from 3 g/day in eastern Europe to 8 g/day in Italy/France. The volume at which the protection vanishes was also different across countries, from 7 g/day in eastern Europe to 40 g/day in Italy/France.

Figure 3 depicts hazard ratios for total mortality in different subgroups. The magnitude of the association of light–moderate intake was stronger in the younger age group and among individuals with BMI < 25 kg/m², whereas it was lacking in CV patients. The role of heavy intake was marginally higher in younger people and in smokers.

After exclusion of cohorts from Australia, France, Lithuania, Russia, Poland and Italy (Brianza and Pamela), in which history of cancer was missing, the association of
51 years [interquartile range (IQ) = 40–59 years]. The prevalence of men, smoking habit, hypertension, overweight and lower levels of education was higher in categories at increasing alcohol intake. The prevalence of history of CV disease or diabetes was higher in all three categories of non-alcohol consumers (Table 1).

## Risk of death

During a median follow-up time of 11.8 years (IQ = 6.8–16.1), 16 907 deaths occurred (during 1 801 926 person-years of observation). Of these, 5547 were from a CV cause, 5511 were cancer deaths and 5849 were classified from ‘other causes’.

Multivariable hazard ratios for mortality are reported in Table 2. In the fully adjusted model, in comparison with life-time abstainers, ex-drinkers and non-drinkers had a 19 and 13% higher risk of mortality, respectively; drinkers 0.1–10 g/day had an 11% (95% CI =7–14%) lower risk of death, whereas drinkers > 20 g/day had a 13% (7–20%) higher risk. Similar findings were observed for CV and ‘other causes’ deaths, whereas cancer mortality risk was higher in ex-drinkers, non-drinkers and in drinkers > 20 g/day (Table 2). Analogous results were observed after omission from the adjustment model of the factors that might be causally related to alcohol consumption (Table 2, Model 1) and after multiple imputations for missing data in all variables, including alcohol intake and history of cancer (Supporting information, Table S2).

Mortality risks according to drinking frequency are reported in Supporting information, Table S3. Irrespective of further adjustment for total alcohol intake, drinking on fewer than two occasions/week was associated with lower mortality for any cause but cancer. Drinking almost every day was associated with a 16% (1–33%) increase in the risk of cancer mortality, but this association disappeared [hazard ratio (HR) = 1.09; 95% CI = 0.94–1.26] when further adjusted for total alcohol intake.

Supporting information, Table S4 reports risks for alcohol after replacing ex-drinkers and non-drinkers with drinkers by use of multiple imputation. In comparison with life-time abstainers, light–moderate drinkers still had between an 8 and 18% lower total, cardiovascular and ‘other causes’ mortality, whereas heavy intake still was associated with an 8–20% higher risk for any type of mortality.

## Mediation analysis

High-density lipoprotein cholesterol (HDLc), C-reactive protein (CRP), troponin and N-terminal pro brain-type natriuretic peptide (NT-ProBNP) were associated with alcohol categories (adjusted for age, sex and cohort). Supporting information, Fig. S1 shows the percentage of variation, in comparison to life-time abstainers. HDLc increases with

alcohol intake, whereas CRP shows a J-shaped association. The percentage of the low intake effect mediated by HDLc was 2.9% (1.2–7.1%) for total and 18.7% (3.0–62.7%) for CV mortality, whereas the percentage of the heavy intake effect was 13.7% (6.4–27.0%) for ‘other causes’ deaths. No mediation role for CRP, troponin or NT-ProBNP was observed.

## Dose-response curves

The association with mortality of alcohol modelled as restricted-cubic splines is depicted in Fig. 1; former and non-drinkers were excluded and null intake served as the reference value. J-shaped curves were observed for total, CV and ‘other causes’ mortality (P-value for non-linearity < 0.0001), with the magnitude of the relative reduction ranging between 4 and 27% at nadir of 3–5 g/day and remaining lower than 1 up to 10–11 g/day (Fig. 1a,b,d); the relative risk becomes distinctly > 1 starting from 20 g/day, with the exception of CV mortality, for which the confidence intervals were somewhat wide (Fig. 1b). The association of alcohol with cancer mortality was null at low doses and became unequivocal at 15 g/day (Fig. 1c).

## Subgroup analyses

In Supporting information, Table S5 we show how the choice of the reference group impacts our findings. If the reference category includes ex-drinkers and/or non-drinkers, the association of light/moderate intake with lower mortality rises from 11 to 13–15%, the negative association with moderate intake rises to 5–7% and the positive association of high intake drops from 13 to 7–9%. Conversely, the choice of light/moderate drinkers as reference group exacerbates the risk for drinking categories.

A J-shaped relationship between alcohol and total mortality was confirmed in different cohorts grouped by geographical location (Fig. 2), with the exception of Australia (Fig. 2d), in which no association was observed. The magnitude of the association at nadir varied slightly, ranging from 14 to 24%, and was greater in cohorts from Italy/France (Fig. 2a). The nadir varied from 3 g/day in eastern Europe to 8 g/day in Italy/France. The volume at which the protection vanishes was also different across countries, from 7 g/day in eastern Europe to 40 g/day in Italy/France.

Figure 3 depicts hazard ratios for total mortality in different subgroups. The magnitude of the association of light–moderate intake was stronger in the younger age group and among individuals with BMI < 25 kg/m², whereas it was lacking in CV patients. The role of heavy intake was marginally higher in younger people and in smokers.

After exclusion of cohorts from Australia, France, Lithuania, Russia, Poland and Italy (Brianza and Pamela), in which history of cancer was missing, the association of
<table><caption>**Table 2** Hazard ratios for mortality, according to categories of alcohol intake.</caption><thead><tr><th colspan="7">Alcohol intake categories</th></tr><tr><th></th><th>Former drinkers</th><th>Non-drinkers<sup>a</sup></th><th>Life-time abstainers</th><th>Light-moderate 0.1-10 g/day</th><th>Moderate 10.1-20 g/day</th><th>Heavy > 20 g/day</th></tr></thead><tbody><tr><td>Number of individuals</td><td>5486</td><td>10 013</td><td>34 310</td><td>51 471</td><td>16 885</td><td>24 795</td></tr><tr><td>Person-year, years</td><td>57 893</td><td>204 659</td><td>401 755</td><td>690 658</td><td>189 365</td><td>257 596</td></tr><tr><td>Mortality for any causes (n = 16 907)</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Number of deaths</td><td>796</td><td>2412</td><td>4119</td><td>5473</td><td>1620</td><td>2487</td></tr><tr><td>Hazard ratio (1)</td><td>1.26</td><td>1.08</td><td>1</td><td>0.86</td><td>0.95</td><td>1.12</td></tr><tr><td>95% CI</td><td>1.16-1.36</td><td>1.01-1.14</td><td>Ref.</td><td>0.83-0.90</td><td>0.89-1.01</td><td>1.05-1.19</td></tr><tr><td>Hazard ratio (2)</td><td>1.19</td><td>1.13</td><td>1</td><td>0.89</td><td>0.98</td><td>1.13</td></tr><tr><td>95% CI</td><td>1.10-1.29</td><td>1.06-1.20</td><td>Ref.</td><td>0.86-0.93</td><td>0.92-1.05</td><td>1.07-1.20</td></tr><tr><td>Cardiovascular mortality (n = 5547)</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Number of deaths</td><td>250</td><td>989</td><td>1425</td><td>1762</td><td>484</td><td>637</td></tr><tr><td>Hazard ratio (1)</td><td>1.19</td><td>1.21</td><td>1</td><td>0.85</td><td>0.88</td><td>0.97</td></tr><tr><td>95% CI</td><td>1.03-1.37</td><td>1.09-1.33</td><td>Ref.</td><td>0.79-0.91</td><td>0.79-0.98</td><td>0.87-1.08</td></tr><tr><td>Hazard ratio (2)</td><td>1.08</td><td>1.30</td><td>1</td><td>0.90</td><td>0.94</td><td>0.99</td></tr><tr><td>95% CI</td><td>0.94-1.25</td><td>1.17-1.43</td><td>Ref.</td><td>0.83-0.97</td><td>0.84-1.05</td><td>0.88-1.10</td></tr><tr><td>Cancer mortality (n = 5511)</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Number of deaths</td><td>272</td><td>646</td><td>1230</td><td>1810</td><td>563</td><td>990</td></tr><tr><td>Hazard ratio (1)</td><td>1.35</td><td>1.11</td><td>1</td><td>0.99</td><td>1.03</td><td>1.21</td></tr><tr><td>95% CI</td><td>1.17-1.55</td><td>0.99-1.24</td><td>Ref.</td><td>0.92-1.07</td><td>0.93-1.15</td><td>1.09-1.33</td></tr><tr><td>Hazard ratio (2)</td><td>1.32</td><td>1.15</td><td>1</td><td>1.00</td><td>1.05</td><td>1.22</td></tr><tr><td>95% CI</td><td>1.14-1.51</td><td>1.02-1.29</td><td>Ref.</td><td>0.93-1.09</td><td>0.95-1.17</td><td>1.10-1.35</td></tr><tr><td>Mortality for other causes (n = 5849)</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Number of deaths</td><td>274</td><td>777</td><td>1464</td><td>1901</td><td>573</td><td>860</td></tr><tr><td>Hazard ratio (1)</td><td>1.24</td><td>0.92</td><td>1</td><td>0.78</td><td>0.95</td><td>1.20</td></tr><tr><td>95% CI</td><td>1.08-1.42</td><td>0.83-1.02</td><td>Ref.</td><td>0.73-0.84</td><td>0.86-1.06</td><td>1.09-1.33</td></tr><tr><td>Hazard ratio (2)</td><td>1.18</td><td>0.94</td><td>1</td><td>0.80</td><td>0.98</td><td>1.21</td></tr><tr><td>95% CI</td><td>1.03-1.35</td><td>0.85-1.05</td><td>Ref.</td><td>0.75-0.87</td><td>0.88-1.08</td><td>1.09-1.33</td></tr></tbody></table>

Non-drinkers are individuals for which we failed to distinguish between teetotallers and former drinkers. (1) Hazard ratio adjusted for age at baseline, sex, smoking, level of education and stratified by cohort; (2) further adjusted for hypertension, diabetes, history of myocardial infarction or stroke, history of cancer and categories of body mass index. CI = confidence interval.
<table><caption>**Table 2** Hazard ratios for mortality, according to categories of alcohol intake.</caption><thead><tr><th colspan="7">Alcohol intake categories</th></tr><tr><th></th><th>Former drinkers</th><th>Non-drinkers<sup>a</sup></th><th>Life-time abstainers</th><th>Light-moderate 0.1-10 g/day</th><th>Moderate 10.1-20 g/day</th><th>Heavy > 20 g/day</th></tr></thead><tbody><tr><td>Number of individuals</td><td>5486</td><td>10 013</td><td>34 310</td><td>51 471</td><td>16 885</td><td>24 795</td></tr><tr><td>Person-year, years</td><td>57 893</td><td>204 659</td><td>401 755</td><td>690 658</td><td>189 365</td><td>257 596</td></tr><tr><td>Mortality for any causes (n = 16 907)</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Number of deaths</td><td>796</td><td>2412</td><td>4119</td><td>5473</td><td>1620</td><td>2487</td></tr><tr><td>Hazard ratio (1)</td><td>1.26</td><td>1.08</td><td>1</td><td>0.86</td><td>0.95</td><td>1.12</td></tr><tr><td>95% CI</td><td>1.16-1.36</td><td>1.01-1.14</td><td>Ref.</td><td>0.83-0.90</td><td>0.89-1.01</td><td>1.05-1.19</td></tr><tr><td>Hazard ratio (2)</td><td>1.19</td><td>1.13</td><td>1</td><td>0.89</td><td>0.98</td><td>1.13</td></tr><tr><td>95% CI</td><td>1.10-1.29</td><td>1.06-1.20</td><td>Ref.</td><td>0.86-0.93</td><td>0.92-1.05</td><td>1.07-1.20</td></tr><tr><td>Cardiovascular mortality (n = 5547)</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Number of deaths</td><td>250</td><td>989</td><td>1425</td><td>1762</td><td>484</td><td>637</td></tr><tr><td>Hazard ratio (1)</td><td>1.19</td><td>1.21</td><td>1</td><td>0.85</td><td>0.88</td><td>0.97</td></tr><tr><td>95% CI</td><td>1.03-1.37</td><td>1.09-1.33</td><td>Ref.</td><td>0.79-0.91</td><td>0.79-0.98</td><td>0.87-1.08</td></tr><tr><td>Hazard ratio (2)</td><td>1.08</td><td>1.30</td><td>1</td><td>0.90</td><td>0.94</td><td>0.99</td></tr><tr><td>95% CI</td><td>0.94-1.25</td><td>1.17-1.43</td><td>Ref.</td><td>0.83-0.97</td><td>0.84-1.05</td><td>0.88-1.10</td></tr><tr><td>Cancer mortality (n = 5511)</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Number of deaths</td><td>272</td><td>646</td><td>1230</td><td>1810</td><td>563</td><td>990</td></tr><tr><td>Hazard ratio (1)</td><td>1.35</td><td>1.11</td><td>1</td><td>0.99</td><td>1.03</td><td>1.21</td></tr><tr><td>95% CI</td><td>1.17-1.55</td><td>0.99-1.24</td><td>Ref.</td><td>0.92-1.07</td><td>0.93-1.15</td><td>1.09-1.33</td></tr><tr><td>Hazard ratio (2)</td><td>1.32</td><td>1.15</td><td>1</td><td>1.00</td><td>1.05</td><td>1.22</td></tr><tr><td>95% CI</td><td>1.14-1.51</td><td>1.02-1.29</td><td>Ref.</td><td>0.93-1.09</td><td>0.95-1.17</td><td>1.10-1.35</td></tr><tr><td>Mortality for other causes (n = 5849)</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Number of deaths</td><td>274</td><td>777</td><td>1464</td><td>1901</td><td>573</td><td>860</td></tr><tr><td>Hazard ratio (1)</td><td>1.24</td><td>0.92</td><td>1</td><td>0.78</td><td>0.95</td><td>1.20</td></tr><tr><td>95% CI</td><td>1.08-1.42</td><td>0.83-1.02</td><td>Ref.</td><td>0.73-0.84</td><td>0.86-1.06</td><td>1.09-1.33</td></tr><tr><td>Hazard ratio (2)</td><td>1.18</td><td>0.94</td><td>1</td><td>0.80</td><td>0.98</td><td>1.21</td></tr><tr><td>95% CI</td><td>1.03-1.35</td><td>0.85-1.05</td><td>Ref.</td><td>0.75-0.87</td><td>0.88-1.08</td><td>1.09-1.33</td></tr></tbody></table>

Non-drinkers are individuals for which we failed to distinguish between teetotallers and former drinkers. (1) Hazard ratio adjusted for age at baseline, sex, smoking, level of education and stratified by cohort; (2) further adjusted for hypertension, diabetes, history of myocardial infarction or stroke, history of cancer and categories of body mass index. CI = confidence interval.
<figure><img src="image_2.png" /><figcaption>**Figure 1** Dose-response relationship between alcohol dosing and total (a), cardiovascular (b), cancer (c) and other-causes mortality (d). Alcohol intake was modelled as restricted cubic splines (3 knots at 5, 50 and 95% of the alcohol distribution). For these analyses, former drinkers and individuals for which we failed to distinguish between teetotallers and former drinkers were excluded; zero intake of alcohol was used as reference value. Full line is hazard ratio adjusted for age at baseline, sex, smoking, hypertension, diabetes, history of myocardial infarction or stroke, history of cancer, categories of body mass index (BMI) and level of education, and stratified by cohort. Dashed lines are 95% confidence intervals</figcaption></figure>

alcohol categories with mortality remained very similar (data not shown).

Subgroup analyses revealed that the association of light-moderate consumption with a reduced mortality risk was more apparent for individuals preferring wine or not having a beverage of preference (Table 3). Light-moderate intake was associated with a reduced risk of death for 'other causes' and was not associated with cancer mortality, irrespective of the type of beverage preferred. The detrimental effect of heavy intake was evident for individuals not having a preference and for beer or spirits drinkers.

Beverage preference was strongly dependent upon country. In Italy and France the preference for wine was very high (73.7%). Preference for beer was highest in northern Europe (28.1%) and that for spirits was highest in eastern Europe (56.5%) and very low in Italy/France (approximately 1.4%).

No difference was found between geographic locations in the association of specific types of beverage with mortality risk (Supporting information, Table S6).

DISCUSSION

In a large multi-country cohort, intake of > 20 g/day of ethanol was associated with a higher mortality risk (especially cancer-related), while light-moderate consumption (up to one drink per day) was associated with reduced risk of total, cardiovascular and 'other causes' mortality.

The observed higher risk over a certain amount is in line with a vast amount of literature [1–3, 5, 7–9, 15, 32]. Heavy drinking is associated with several adverse health effects. Although evidence from randomized clinical trials is lacking (very probably it will remain so for long time in the future), we can assert that alcohol intake above a certain volume is an unhealthy life-style to be firmly discouraged. Our data indicate that unsafe alcohol consumption is above 20 g/day of ethanol, nearly two drinks per day.

Conversely, 10–20 g/day intake of alcohol has a null association with mortality. Individuals who consume alcohol at these levels should be discouraged from increasing their consumption, but encouraged to reduce their consumption.
<figure><img src="image_3.png" /><figcaption>**Figure 1** Dose-response relationship between alcohol dosing and total (a), cardiovascular (b), cancer (c) and other-causes mortality (d). Alcohol intake was modelled as restricted cubic splines (3 knots at 5, 50 and 95% of the alcohol distribution). For these analyses, former drinkers and individuals for which we failed to distinguish between teetotallers and former drinkers were excluded; zero intake of alcohol was used as reference value. Full line is hazard ratio adjusted for age at baseline, sex, smoking, hypertension, diabetes, history of myocardial infarction or stroke, history of cancer, categories of body mass index (BMI) and level of education, and stratified by cohort. Dashed lines are 95% confidence intervals</figcaption></figure>

alcohol categories with mortality remained very similar (data not shown).

Subgroup analyses revealed that the association of light-moderate consumption with a reduced mortality risk was more apparent for individuals preferring wine or not having a beverage of preference (Table 3). Light-moderate intake was associated with a reduced risk of death for 'other causes' and was not associated with cancer mortality, irrespective of the type of beverage preferred. The detrimental effect of heavy intake was evident for individuals not having a preference and for beer or spirits drinkers.

Beverage preference was strongly dependent upon country. In Italy and France the preference for wine was very high (73.7%). Preference for beer was highest in northern Europe (28.1%) and that for spirits was highest in eastern Europe (56.5%) and very low in Italy/France (approximately 1.4%).

No difference was found between geographic locations in the association of specific types of beverage with mortality risk (Supporting information, Table S6).

DISCUSSION

In a large multi-country cohort, intake of > 20 g/day of ethanol was associated with a higher mortality risk (especially cancer-related), while light-moderate consumption (up to one drink per day) was associated with reduced risk of total, cardiovascular and 'other causes' mortality.

The observed higher risk over a certain amount is in line with a vast amount of literature [1–3, 5, 7–9, 15, 32]. Heavy drinking is associated with several adverse health effects. Although evidence from randomized clinical trials is lacking (very probably it will remain so for long time in the future), we can assert that alcohol intake above a certain volume is an unhealthy life-style to be firmly discouraged. Our data indicate that unsafe alcohol consumption is above 20 g/day of ethanol, nearly two drinks per day.

Conversely, 10–20 g/day intake of alcohol has a null association with mortality. Individuals who consume alcohol at these levels should be discouraged from increasing their consumption, but encouraged to reduce their consumption.
<figure><img src="image_3.png" /><figcaption>**Figure 2** Dose-response relationship between alcohol dosing and total mortality in different cohorts grouped by geographical location. See Fig. 1 for the remainder</figcaption></figure>

In comparison with life-time abstainers, individuals who consumed up to one drink a day have a 7–15% reduced risk of total mortality. The nadir of the association was observed at 5 g/day, a finding in agreement with a previous large meta-analysis [1]. The association was null for cancer deaths. These conclusions are in accord with a large amount of literature [1–3, 15, 32], but are not fully in line with the conclusions proposed by the Global Burden of Disease (GBD) study 2016 [8], suggesting that no level of alcohol consumption improves health. However, it is noteworthy that the GBD authors did not consider total mortality as an outcome; rather, they combined 23 relative-risk curves for as many different outcomes in a single dose-response curve; some of us have previously questioned the way in which the curves were combined [23].

An average consumption of 5 g/day corresponds to nearly three drinks per week; accordingly, we found that drinking up to 2 days per week is the only habit associated with a reduction in mortality (but not for cancer).

Epidemiological research findings should be only one input for making appropriate recommendations for individuals. For example, individuals with strong family history of alcohol use disorder or who take interacting medications may be best advised to abstain from alcohol.

Alcohol consumption seems to modify several vascular and biochemical factors that have potentially different health effects. Specifically, an increase in HDLc levels, decrease in platelet aggregation and changes in fibrinogen and fibrinolysis are thought to represent some mechanisms by which alcohol could reduce cardiovascular risk. Indeed, we observed that the inclusion of HDLc in risk models attenuated the inverse association between light-moderate intake and total and CV mortality while strengthening the association between heavy consumption and mortality, in line with other studies [7]. However, concern persists regarding whether HDLc is in the causal pathway to cardiovascular disease (medications to raise it have not succeeded) [33]. We also tested the role of a panel of biomarkers as potential mediators of alcohol action via different pathways—for example, regulation of inflammation, but failed to observe any role in mediating either the positive or the negative effect of alcohol.

## The importance of the reference category

The ‘sick quitter’ hypothesis suggests that the inclusion of individuals who quit drinking alcohol because of health problems leads to an exaggeration of the poor health
<figure><img src="image_4.png" /><figcaption>**Figure 2** Dose-response relationship between alcohol dosing and total mortality in different cohorts grouped by geographical location. See Fig. 1 for the remainder</figcaption></figure>

In comparison with life-time abstainers, individuals who consumed up to one drink a day have a 7–15% reduced risk of total mortality. The nadir of the association was observed at 5 g/day, a finding in agreement with a previous large meta-analysis [1]. The association was null for cancer deaths. These conclusions are in accord with a large amount of literature [1–3, 15, 32], but are not fully in line with the conclusions proposed by the Global Burden of Disease (GBD) study 2016 [8], suggesting that no level of alcohol consumption improves health. However, it is noteworthy that the GBD authors did not consider total mortality as an outcome; rather, they combined 23 relative-risk curves for as many different outcomes in a single dose-response curve; some of us have previously questioned the way in which the curves were combined [23].

An average consumption of 5 g/day corresponds to nearly three drinks per week; accordingly, we found that drinking up to 2 days per week is the only habit associated with a reduction in mortality (but not for cancer).

Epidemiological research findings should be only one input for making appropriate recommendations for individuals. For example, individuals with strong family history of alcohol use disorder or who take interacting medications may be best advised to abstain from alcohol.

Alcohol consumption seems to modify several vascular and biochemical factors that have potentially different health effects. Specifically, an increase in HDLc levels, decrease in platelet aggregation and changes in fibrinogen and fibrinolysis are thought to represent some mechanisms by which alcohol could reduce cardiovascular risk. Indeed, we observed that the inclusion of HDLc in risk models attenuated the inverse association between light-moderate intake and total and CV mortality while strengthening the association between heavy consumption and mortality, in line with other studies [7]. However, concern persists regarding whether HDLc is in the causal pathway to cardiovascular disease (medications to raise it have not succeeded) [33]. We also tested the role of a panel of biomarkers as potential mediators of alcohol action via different pathways—for example, regulation of inflammation, but failed to observe any role in mediating either the positive or the negative effect of alcohol.

## The importance of the reference category

The ‘sick quitter’ hypothesis suggests that the inclusion of individuals who quit drinking alcohol because of health problems leads to an exaggeration of the poor health
<figure><img src="image_4.png" /><figcaption>**Figure 3** Hazard ratio for total mortality and 95% CI (adjusted as in Table 2) for alcohol intake 0.1–10 g/day (left) and for alcohol intake > 20 g/day (right) in comparison with life-time teetotallers, in subgroups with different risk factors; P-values are for the differences among hazard ratios across levels of the risk factor</figcaption></figure>

profiles of non-drinkers [11, 34, 35]. Our data indicate that ex-drinkers have a poor health profile. The inclusion of ex-drinkers in the reference group induced non-negligible overestimation in the protective effect of light-moderate intake and also led to underestimation of the risk associated with heavy consumption. Our findings reveal the bias induced by combining life-time abstainers with former drinkers, and confirm that ex-drinkers must be excluded from the reference group [1]. Several investigators have even argued that ex-drinkers should be assigned to a drinking category based possibly on their previous alcohol consumption patterns [36]. We were not able to recover the prior levels of consumption of our ex-drinkers; however, we replaced them with drinkers by the use of multiple imputation and found very similar results to the main analyses with ex-drinkers as a sole group. Some worries remain, however, in using life-time abstainers as a reference group; life-time abstainers might be different in many ways from drinkers for reasons independent of alcohol consumption. As an example, young life-time abstainers already show health disparities with their drinking peers before any positive or negative effects of alcohol become relevant [37]. Wood et al. [7] chose moderate drinkers as reference group. As a consequence, their findings strengthened the risk for higher intake and put abstainers at higher risk, a result

we replicated here when moderate drinkers were used as the reference group. We recognize that the communication of health policy messages may vary according to the choice of reference group and its interpretation [21].

## Subgroup analyses

In our study, J-shaped association curves of alcohol intake with mortality were observed for all European countries. The magnitude, nadir and persistence of the association varied somewhat, with stronger values observed in Italy and France. This finding may be explained by the different patterns of alcohol consumption across countries [12, 16, 32, 38]. In Mediterranean countries alcohol is typically consumed during main meals, a pattern that has been recognized as a healthy habit [11, 39] and largely in the form of wine, whereas in non-Mediterranean countries alcohol is not usually consumed during meals; the preferred alcoholic beverage is not wine, and the practice of binge drinking, that is unequivocally an unhealthy habit [11, 40], is more frequent.

Accordingly, we found that intake of alcohol in moderation was associated more apparently with a reduced mortality risk in individuals preferring wine. This finding is in agreement with ample literature suggesting
<figure><img src="image_5.png" /><figcaption>**Figure 3** Hazard ratio for total mortality and 95% CI (adjusted as in Table 2) for alcohol intake 0.1–10 g/day (left) and for alcohol intake > 20 g/day (right) in comparison with life-time teetotallers, in subgroups with different risk factors; P-values are for the differences among hazard ratios across levels of the risk factor</figcaption></figure>

profiles of non-drinkers [11, 34, 35]. Our data indicate that ex-drinkers have a poor health profile. The inclusion of ex-drinkers in the reference group induced non-negligible overestimation in the protective effect of light–moderate intake and also led to underestimation of the risk associated with heavy consumption. Our findings reveal the bias induced by combining life-time abstainers with former drinkers, and confirm that ex-drinkers must be excluded from the reference group [1]. Several investigators have even argued that ex-drinkers should be assigned to a drinking category based possibly on their previous alcohol consumption patterns [36]. We were not able to recover the prior levels of consumption of our ex-drinkers; however, we replaced them with drinkers by the use of multiple imputation and found very similar results to the main analyses with ex-drinkers as a sole group. Some worries remain, however, in using life-time abstainers as a reference group; life-time abstainers might be different in many ways from drinkers for reasons independent of alcohol consumption. As an example, young life-time abstainers already show health disparities with their drinking peers before any positive or negative effects of alcohol become relevant [37]. Wood et al. [7] chose moderate drinkers as reference group. As a consequence, their findings strengthened the risk for higher intake and put abstainers at higher risk, a result

we replicated here when moderate drinkers were used as the reference group. We recognize that the communication of health policy messages may vary according to the choice of reference group and its interpretation [21].

## Subgroup analyses

In our study, J-shaped association curves of alcohol intake with mortality were observed for all European countries. The magnitude, nadir and persistence of the association varied somewhat, with stronger values observed in Italy and France. This finding may be explained by the different patterns of alcohol consumption across countries [12, 16, 32, 38]. In Mediterranean countries alcohol is typically consumed during main meals, a pattern that has been recognized as a healthy habit [11, 39] and largely in the form of wine, whereas in non-Mediterranean countries alcohol is not usually consumed during meals; the preferred alcoholic beverage is not wine, and the practice of binge drinking, that is unequivocally an unhealthy habit [11, 40], is more frequent.

Accordingly, we found that intake of alcohol in moderation was associated more apparently with a reduced mortality risk in individuals preferring wine. This finding is in agreement with ample literature suggesting
<table><caption>Table 3 Hazard ratios for mortality, in subgroups with different alcoholic preferences.</caption><thead><tr><th></th><th></th><th>Life-time abstainers</th><th>Light-moderate 0.1-10 g/day</th><th>Moderate 10.1-20 g/day</th><th>Heavy > 20 g/day</th></tr></thead><tbody><tr><td>No preferences</td><td></td><td>34 310</td><td>16 009</td><td>48 36</td><td>56 38</td></tr><tr><td>Mortality for any causes</td><td>Hazard ratio</td><td>1</td><td>0.85</td><td>0.92</td><td>1.22</td></tr><tr><td></td><td>95% CI</td><td>Ref.</td><td>0.80-0.91</td><td>0.83-1.01</td><td>1.11-1.34</td></tr><tr><td>Cardiovascular mortality</td><td>Hazard ratio</td><td>1</td><td>0.84</td><td>0.92</td><td>1.01</td></tr><tr><td></td><td>95% CI</td><td>Ref.</td><td>0.75-0.95</td><td>0.77-1.10</td><td>0.84-1.20</td></tr><tr><td>Cancer mortality</td><td>Hazard ratio</td><td>1</td><td>0.99</td><td>0.94</td><td>1.23</td></tr><tr><td></td><td>95% CI</td><td>Ref.</td><td>0.88-1.11</td><td>0.78-1.12</td><td>1.05-1.44</td></tr><tr><td>Other causes</td><td>Hazard ratio</td><td>1</td><td>0.75</td><td>0.90</td><td>1.43</td></tr><tr><td></td><td>95% CI</td><td>Ref.</td><td>0.67-0.84</td><td>0.76-1.06</td><td>1.24-1.66</td></tr><tr><td>Wine preferred (≥ 70%)</td><td></td><td>34 310</td><td>13 919</td><td>65 88</td><td>10 855</td></tr><tr><td>Mortality for any causes</td><td>Hazard ratio</td><td>1</td><td>0.87</td><td>0.81</td><td>0.85</td></tr><tr><td></td><td>95% CI</td><td>Ref.</td><td>0.81-0.93</td><td>0.71-0.91</td><td>0.76-0.95</td></tr><tr><td>Cardiovascular mortality</td><td>Hazard ratio</td><td>1</td><td>0.84</td><td>0.84</td><td>0.69</td></tr><tr><td></td><td>95% CI</td><td>Ref.</td><td>0.74-0.96</td><td>0.66-1.05</td><td>0.54-0.89</td></tr><tr><td>Cancer mortality</td><td>Hazard ratio</td><td>1</td><td>1.00</td><td>0.88</td><td>1.04</td></tr><tr><td></td><td>95% CI</td><td>Ref.</td><td>0.89-1.13</td><td>0.72-1.06</td><td>0.88-1.13</td></tr><tr><td>Other causes</td><td>Hazard ratio</td><td>1</td><td>0.77</td><td>0.74</td><td>0.79</td></tr><tr><td></td><td>95% CI</td><td>Ref.</td><td>0.68-0.87</td><td>0.60-0.91</td><td>0.60-0.91</td></tr><tr><td>Beer preferred (≥ 70%)</td><td></td><td>34 310</td><td>10 938</td><td>26 80</td><td>29 07</td></tr><tr><td>Mortality for any causes</td><td>Hazard ratio</td><td>1</td><td>0.96</td><td>1.20</td><td>1.39</td></tr><tr><td></td><td>95% CI</td><td>Ref.</td><td>0.90-1.03</td><td>1.06-1.34</td><td>1.25-1.55</td></tr><tr><td>Cardiovascular mortality</td><td>Hazard ratio</td><td>1</td><td>0.98</td><td>1.14</td><td>1.35</td></tr><tr><td></td><td>95% CI</td><td>Ref.</td><td>0.87-1.11</td><td>0.92-1.41</td><td>1.11-1.64</td></tr><tr><td>Cancer mortality</td><td>Hazard ratio</td><td>1</td><td>1.02</td><td>1.26</td><td>1.44</td></tr><tr><td></td><td>95% CI</td><td>Ref.</td><td>0.90-1.16</td><td>1.03-1.54</td><td>1.21-1.71</td></tr><tr><td>Other causes</td><td>Hazard ratio</td><td>1</td><td>0.89</td><td>1.21</td><td>1.40</td></tr><tr><td></td><td>95% CI</td><td>Ref.</td><td>0.79-1.01</td><td>0.99-1.47</td><td>1.17-1.68</td></tr><tr><td>Spirits preferred (≥ 70%)</td><td></td><td>34 310</td><td>81 35</td><td>19 59</td><td>17 20</td></tr><tr><td>Mortality for any causes</td><td>Hazard ratio</td><td>1</td><td>0.94</td><td>1.15</td><td>1.23</td></tr><tr><td></td><td>95% CI</td><td>Ref.</td><td>0.88-1.00</td><td>1.03-1.29</td><td>1.09-1.38</td></tr><tr><td>Cardiovascular mortality</td><td>Hazard ratio</td><td>1</td><td>0.98</td><td>0.98</td><td>1.18</td></tr><tr><td></td><td>95% CI</td><td>Ref.</td><td>0.87-1.09</td><td>0.80-1.19</td><td>0.97-1.44</td></tr></tbody><tfoot><tr><td colspan="6" style="text-align: right;">(Continues)</td></tr></tfoot></table>
<table><caption>Table 3 Hazard ratios for mortality, in subgroups with different alcoholic preferences.</caption><thead><tr><th></th><th></th><th>Life-time abstainers</th><th>Light-moderate 0.1-10 g/day</th><th>Moderate 10.1-20 g/day</th><th>Heavy > 20 g/day</th></tr></thead><tbody><tr><td>No preferences</td><td></td><td>34 310</td><td>16 009</td><td>48 36</td><td>56 38</td></tr><tr><td>Mortality for any causes</td><td>Hazard ratio</td><td>1</td><td>0.85</td><td>0.92</td><td>1.22</td></tr><tr><td></td><td>95% CI</td><td>Ref.</td><td>0.80-0.91</td><td>0.83-1.01</td><td>1.11-1.34</td></tr><tr><td>Cardiovascular mortality</td><td>Hazard ratio</td><td>1</td><td>0.84</td><td>0.92</td><td>1.01</td></tr><tr><td></td><td>95% CI</td><td>Ref.</td><td>0.75-0.95</td><td>0.77-1.10</td><td>0.84-1.20</td></tr><tr><td>Cancer mortality</td><td>Hazard ratio</td><td>1</td><td>0.99</td><td>0.94</td><td>1.23</td></tr><tr><td></td><td>95% CI</td><td>Ref.</td><td>0.88-1.11</td><td>0.78-1.12</td><td>1.05-1.44</td></tr><tr><td>Other causes</td><td>Hazard ratio</td><td>1</td><td>0.75</td><td>0.90</td><td>1.43</td></tr><tr><td></td><td>95% CI</td><td>Ref.</td><td>0.67-0.84</td><td>0.76-1.06</td><td>1.24-1.66</td></tr><tr><td>Wine preferred (≥ 70%)</td><td></td><td>34 310</td><td>13 919</td><td>65 88</td><td>10 855</td></tr><tr><td>Mortality for any causes</td><td>Hazard ratio</td><td>1</td><td>0.87</td><td>0.81</td><td>0.85</td></tr><tr><td></td><td>95% CI</td><td>Ref.</td><td>0.81-0.93</td><td>0.71-0.91</td><td>0.76-0.95</td></tr><tr><td>Cardiovascular mortality</td><td>Hazard ratio</td><td>1</td><td>0.84</td><td>0.84</td><td>0.69</td></tr><tr><td></td><td>95% CI</td><td>Ref.</td><td>0.74-0.96</td><td>0.66-1.05</td><td>0.54-0.89</td></tr><tr><td>Cancer mortality</td><td>Hazard ratio</td><td>1</td><td>1.00</td><td>0.88</td><td>1.04</td></tr><tr><td></td><td>95% CI</td><td>Ref.</td><td>0.89-1.13</td><td>0.72-1.06</td><td>0.88-1.13</td></tr><tr><td>Other causes</td><td>Hazard ratio</td><td>1</td><td>0.77</td><td>0.74</td><td>0.79</td></tr><tr><td></td><td>95% CI</td><td>Ref.</td><td>0.68-0.87</td><td>0.60-0.91</td><td>0.60-0.91</td></tr><tr><td>Beer preferred (≥ 70%)</td><td></td><td>34 310</td><td>10 938</td><td>26 80</td><td>29 07</td></tr><tr><td>Mortality for any causes</td><td>Hazard ratio</td><td>1</td><td>0.96</td><td>1.20</td><td>1.39</td></tr><tr><td></td><td>95% CI</td><td>Ref.</td><td>0.90-1.03</td><td>1.06-1.34</td><td>1.25-1.55</td></tr><tr><td>Cardiovascular mortality</td><td>Hazard ratio</td><td>1</td><td>0.98</td><td>1.14</td><td>1.35</td></tr><tr><td></td><td>95% CI</td><td>Ref.</td><td>0.87-1.11</td><td>0.92-1.41</td><td>1.11-1.64</td></tr><tr><td>Cancer mortality</td><td>Hazard ratio</td><td>1</td><td>1.02</td><td>1.26</td><td>1.44</td></tr><tr><td></td><td>95% CI</td><td>Ref.</td><td>0.90-1.16</td><td>1.03-1.54</td><td>1.21-1.71</td></tr><tr><td>Other causes</td><td>Hazard ratio</td><td>1</td><td>0.89</td><td>1.21</td><td>1.40</td></tr><tr><td></td><td>95% CI</td><td>Ref.</td><td>0.79-1.01</td><td>0.99-1.47</td><td>1.17-1.68</td></tr><tr><td>Spirits preferred (≥ 70%)</td><td></td><td>34 310</td><td>81 35</td><td>19 59</td><td>17 20</td></tr><tr><td>Mortality for any causes</td><td>Hazard ratio</td><td>1</td><td>0.94</td><td>1.15</td><td>1.23</td></tr><tr><td></td><td>95% CI</td><td>Ref.</td><td>0.88-1.00</td><td>1.03-1.29</td><td>1.09-1.38</td></tr><tr><td>Cardiovascular mortality</td><td>Hazard ratio</td><td>1</td><td>0.98</td><td>0.98</td><td>1.18</td></tr><tr><td></td><td>95% CI</td><td>Ref.</td><td>0.87-1.09</td><td>0.80-1.19</td><td>0.97-1.44</td></tr></tbody><tfoot><tr><td colspan="6" style="text-align: right;">(Continues)</td></tr></tfoot></table>
<table><caption>Table 3. (Continued)</caption><thead><tr><th></th><th></th><th>Life-time abstainers</th><th>Light-moderate 0.1-10 g/day</th><th>Moderate 10.1-20 g/day</th><th>Heavy > 20 g/day</th></tr></thead><tbody><tr><td rowspan="2">Cancer mortality</td><td>Hazard ratio</td><td>1</td><td>1.03</td><td>1.35</td><td>1.18</td></tr><tr><td>95% CI</td><td>Ref.</td><td>0.91-1.16</td><td>1.11-1.66</td><td>0.94-1.47</td></tr><tr><td rowspan="2">Other causes</td><td>Hazard ratio</td><td>1</td><td>0.84</td><td>1.17</td><td>1.32</td></tr><tr><td>95% CI</td><td>Ref.</td><td>0.75-0.93</td><td>0.97-1.41</td><td>1.09-1.59</td></tr></tbody></table>

Hazard ratio adjusted for age at baseline, sex, smoking, hypertension, diabetes, history of myocardial infarction or stroke, history of cancer, categories of body mass index and level of education and stratified by cohort; n = 6967 drinkers for which type of alcoholic beverage preferred was missing information have been eliminated in this analysis. CI = confidence interval.

that non-alcoholic components of wine may contribute to its health benefits [41–44].

## Strengths and limitations

This study has a number of strengths. It is based on a large multi-national sample size of individuals followed-up during several years for hard end-points such as death. Measurements among cohorts have been harmonized. Assessment of alcohol drinking was based both on volume, frequency and pattern of consumption. Non-linear association was evaluated by splines modelling. Ex-drinkers were excluded from the reference group or re-added to drinkers using multiple imputation. Missing values have been dealt with multiple imputation. Mediation analysis of how a large panel of biomarkers could explain the alcohol association with mortality has been provided. Sensitivity analyses, including by type of alcoholic beverages, have been conducted.

We also acknowledge several study limitations. First, these findings did not derive from pre-registered analyses and the analyses should be considered exploratory. Alcohol consumption information was self-reported and was based on a single baseline ascertainment, although this is common in large population-based studies. Self-reporting can lead to the possibility of misclassification of exposure. Under-reporting by heavier drinkers is frequent [45]: the inclusion of ‘real’ heavier drinkers in ‘apparently’ lower intake categories may falsely lower the threshold for apparent harm. Other potential limitations include misclassification of former drinkers as never drinkers, not modelling heavy episodic drinking and the observational nature of the study, which cannot fully rule out residual confounding and confounding by unmeasured factors. Selection biases might also distort the relationship between alcohol intake and health [13]; however, self-selection bias related to an individual’s alcohol consumption and study participation was negligible in our study because selection of individuals in the MORGAM cohorts was unrelated to alcohol intake [27, 28]. Several limitations of conventional epidemiological studies on alcohol might be overcome by genetic studies based on Mendelian randomization, which indicates that alcohol intake has no clear causal association either with myocardial infarction [9] or cancer [46]. However, use of the Mendelian randomization approach for studying alcohol has been questioned [47]. The cohorts included in our analysis were older than the age at which alcohol-related outcomes usually occur. However, we reported that the magnitude of the association of light/moderate intake with mortality was stronger in younger age groups, and the magnitude of the association of heavy intake was marginally higher in these younger people. Thus, we suppose that both positive and negative effects of alcohol would be more evident if our cohorts were
<table><caption>Table 3. (Continued)</caption><thead><tr><th></th><th></th><th>Life-time abstainers</th><th>Light-moderate 0.1-10 g/day</th><th>Moderate 10.1-20 g/day</th><th>Heavy > 20 g/day</th></tr></thead><tbody><tr><td rowspan="2">Cancer mortality</td><td>Hazard ratio</td><td>1</td><td>1.03</td><td>1.35</td><td>1.18</td></tr><tr><td>95% CI</td><td>Ref.</td><td>0.91-1.16</td><td>1.11-1.66</td><td>0.94-1.47</td></tr><tr><td rowspan="2">Other causes</td><td>Hazard ratio</td><td>1</td><td>0.84</td><td>1.17</td><td>1.32</td></tr><tr><td>95% CI</td><td>Ref.</td><td>0.75-0.93</td><td>0.97-1.41</td><td>1.09-1.59</td></tr></tbody></table>

Hazard ratio adjusted for age at baseline, sex, smoking, hypertension, diabetes, history of myocardial infarction or stroke, history of cancer, categories of body mass index and level of education and stratified by cohort; n = 6967 drinkers for which type of alcoholic beverage preferred was missing information have been eliminated in this analysis. CI = confidence interval.

that non-alcoholic components of wine may contribute to its health benefits [41–44].

## Strengths and limitations

This study has a number of strengths. It is based on a large multi-national sample size of individuals followed-up during several years for hard end-points such as death. Measurements among cohorts have been harmonized. Assessment of alcohol drinking was based both on volume, frequency and pattern of consumption. Non-linear association was evaluated by splines modelling. Ex-drinkers were excluded from the reference group or re-added to drinkers using multiple imputation. Missing values have been dealt with multiple imputation. Mediation analysis of how a large panel of biomarkers could explain the alcohol association with mortality has been provided. Sensitivity analyses, including by type of alcoholic beverages, have been conducted.

We also acknowledge several study limitations. First, these findings did not derive from pre-registered analyses and the analyses should be considered exploratory. Alcohol consumption information was self-reported and was based on a single baseline ascertainment, although this is common in large population-based studies. Self-reporting can lead to the possibility of misclassification of exposure. Under-reporting by heavier drinkers is frequent [45]: the inclusion of ‘real’ heavier drinkers in ‘apparently’ lower intake categories may falsely lower the threshold for apparent harm. Other potential limitations include misclassification of former drinkers as never drinkers, not modelling heavy episodic drinking and the observational nature of the study, which cannot fully rule out residual confounding and confounding by unmeasured factors. Selection biases might also distort the relationship between alcohol intake and health [13]; however, self-selection bias related to an individual’s alcohol consumption and study participation was negligible in our study because selection of individuals in the MORGAM cohorts was unrelated to alcohol intake [27, 28]. Several limitations of conventional epidemiological studies on alcohol might be overcome by genetic studies based on Mendelian randomization, which indicates that alcohol intake has no clear causal association either with myocardial infarction [9] or cancer [46]. However, use of the Mendelian randomization approach for studying alcohol has been questioned [47]. The cohorts included in our analysis were older than the age at which alcohol-related outcomes usually occur. However, we reported that the magnitude of the association of light/moderate intake with mortality was stronger in younger age groups, and the magnitude of the association of heavy intake was marginally higher in these younger people. Thus, we suppose that both positive and negative effects of alcohol would be more evident if our cohorts were
younger. Studies showing that alcohol consumption is as-
sociated with a reduced risk of cardiovascular death have
been criticized, as disease-specific longitudinal studies
might not take into account competing risks from other
alcohol-linked causes of death, thus resulting in a survival
bias [48]. This bias could have potentially occurred in our
study among older heavy drinkers in regard to cardiovas-
cular deaths. However, our main findings are focused upon
light drinking and total mortality, so they are unlikely to
have been influenced by a survival bias. A non-negligible
percentage of non-drinkers had missing data regarding
drinking habits, so we failed to distinguish them from ex-
drinkers and life-time abstainers; to avoid the bias of
counting ex-drinkers as abstainers, we did not include
'non-drinkers' in the group of life-time abstainers. There
was some missing data for covariates, and we tried to deal
with this issue by performing several multiple imputation
analyses. History of cancer was not ascertained in some co-
horts; however, we conducted a sensitivity analysis exclud-
ing these cohorts and conclusions did not change. Finally,
because of missing values, mediation analysis (with the ex-
ception of HDLc) could only be performed on a small
subsample.

CONCLUSIONS

With the known limitations of any observational study, al-
cohol consumption appears to be differently associated
with total or cause-specific mortality depending upon the
average in daily volume consumed. At excessive consump-
tion levels (higher than two drinks per day), an excess of
mortality risk is evident. At intermediate consumption
(one to two drinks per day), the protection against CV dis-
eases and the risk of dying from other disease appears to be
balanced. At light—moderate but non-null intake (less than
one drink per day), the balance is in favour of total, cardio-
vascular and ‘other cause’ mortality risk reduction, with
no apparent increased cancer mortality risk. Thus, in our
study any beneficial effect of light—moderate alcohol con-
sumption on total mortality occurred at lower levels than
those generally indicated in several guidelines.

Declaration of interests

S.C. and A.D.C. were the principal investigator and the co-
applicant, respectively, of a study supported by a research
grant from ERAB (the European Foundation for Alcohol
Research; id. EA1767, completed in January 2020), out-
side the submitted work. A.D.C. reports personal fees as
member of the Organizing Committee for the 7th European
Beer and Health Symposium (2014), Beer and Health Ini-
tiative (The Dutch Beer Institute foundation—The Brewers
of Europe), outside the submitted work. S.C. reports per-
sonal fees as member of the Organizing Committee and

speaker for the 9th European Beer and Health Symposium
(Bruxelles 2019) and for given lecture at the 13th
European Nutrition Conference | FENS 2019 (Dublin),
sponsored by the Beer and Health Initiative (The Dutch
Beer Institute foundation—The Brewers of Europe),
outside the submitted work. G.d.G. is a member of the Inter-
national Scientific Forum on Alcohol Research (http://
alcoholresearchforum.org), an independent organization
of scientists that prepares critiques of emerging research re-
ports on alcohol and health. The members of the Forum do-
nate their time and effort to the review of papers and
receive no financial support for their contributions to cri-
tiques. The Forum itself receives no support from any orga-
nization or company in the alcoholic beverage industry.
However, whether the support for individual members is
from governmental agencies, universities, private founda-
tions or other groups, none of these organizations has any
input into the conclusions presented in the critiques pub-
lished on the forum web-site. A detailed disclosure state-
ment signed by each member of the forum is available at:
http://alcoholresearchforum.org/disclosure-statement. G.
d.G. was also previously a consultant to the Web Newsletter
of Assobirra, the Italian Association of the Beer and Malt
Industries (until 2019) and is a corresponding member of
the non-profit Accademia Italiana della Vite e del Vino; G.
d.G. reports personal fees for a lecture at the 8th European
Beer and Health Symposium (2017), Beer and Health Ini-
tiative (The Dutch Beer Institute Foundation—The Brewers
of Europe), outside the submitted work. V.S. was supported
by the Finnish Foundation for Cardiovascular Research and
has received honoraria from Novo Nordisk and Sanofi and
travel support from Novo Nordisk. V.S. also has ongoing re-
search collaboration with Bayer Ltd (all unrelated to the
present study). S.S. was supported by the Swedish Heart–
Lung Foundation, the County Council of Västerbotten
(ALF. VLL-548791) and Umeå University, and reports
speakers’ honoraria from Actelion Pharmaceuticals Ltd
and from Astra Zeneca Ltd (unrelated to the present study).
J.F. reports lectures fees from Amgen, MSD, Sanofi and
Servier. B.S. is funded by the German Research Foundation.

Acknowledgements

The MORGAM Project received funding from Medical Re-
search Council London grant G0601463 (80983) and
European Union FP7 project BiomarCaRE (HEALTH-
F2-2011-278 913). The activities of the MORGAM Data
Centre have also been sustained by recent funding from
European Union FP 7 project CHANCES (HEALTH-
F3-2010-242 244). The present analysis was partially
supported by the Ministero della Salute, Italy, Bando
Ricerca Finalizzata 2018 RF-2018-12 367 074 and by
the Associazione Italiana per la Ricerca sul Cancro
AIRC “5xMILLE”, Italy, bando n. 12237. The funders
had no role in study design, data collection and
younger. Studies showing that alcohol consumption is as-
sociated with a reduced risk of cardiovascular death have
been criticized, as disease-specific longitudinal studies
might not take into account competing risks from other
alcohol-linked causes of death, thus resulting in a survival
bias [48]. This bias could have potentially occurred in our
study among older heavy drinkers in regard to cardiovas-
cular deaths. However, our main findings are focused upon
light drinking and total mortality, so they are unlikely to
have been influenced by a survival bias. A non-negligible
percentage of non-drinkers had missing data regarding
drinking habits, so we failed to distinguish them from ex-
drinkers and life-time abstainers; to avoid the bias of
counting ex-drinkers as abstainers, we did not include
'non-drinkers' in the group of life-time abstainers. There
was some missing data for covariates, and we tried to deal
with this issue by performing several multiple imputation
analyses. History of cancer was not ascertained in some co-
horts; however, we conducted a sensitivity analysis exclud-
ing these cohorts and conclusions did not change. Finally,
because of missing values, mediation analysis (with the ex-
ception of HDLc) could only be performed on a small
subsample.

CONCLUSIONS

With the known limitations of any observational study, al-
cohol consumption appears to be differently associated
with total or cause-specific mortality depending upon the
average in daily volume consumed. At excessive consump-
tion levels (higher than two drinks per day), an excess of
mortality risk is evident. At intermediate consumption
(one to two drinks per day), the protection against CV dis-
eases and the risk of dying from other disease appears to be
balanced. At light—moderate but non-null intake (less than
one drink per day), the balance is in favour of total, cardio-
vascular and ‘other cause’ mortality risk reduction, with
no apparent increased cancer mortality risk. Thus, in our
study any beneficial effect of light—moderate alcohol con-
sumption on total mortality occurred at lower levels than
those generally indicated in several guidelines.

Declaration of interests

S.C. and A.D.C. were the principal investigator and the co-
applicant, respectively, of a study supported by a research
grant from ERAB (the European Foundation for Alcohol
Research; id. EA1767, completed in January 2020), out-
side the submitted work. A.D.C. reports personal fees as
member of the Organizing Committee for the 7th European
Beer and Health Symposium (2014), Beer and Health Ini-
tiative (The Dutch Beer Institute foundation—The Brewers
of Europe), outside the submitted work. S.C. reports per-
sonal fees as member of the Organizing Committee and

speaker for the 9th European Beer and Health Symposium
(Bruxelles 2019) and for given lecture at the 13th
European Nutrition Conference | FENS 2019 (Dublin),
sponsored by the Beer and Health Initiative (The Dutch
Beer Institute foundation—The Brewers of Europe),
outside the submitted work. G.d.G. is a member of the Inter-
national Scientific Forum on Alcohol Research (http://
alcoholresearchforum.org), an independent organization
of scientists that prepares critiques of emerging research re-
ports on alcohol and health. The members of the Forum do-
nate their time and effort to the review of papers and
receive no financial support for their contributions to cri-
tiques. The Forum itself receives no support from any orga-
nization or company in the alcoholic beverage industry.
However, whether the support for individual members is
from governmental agencies, universities, private founda-
tions or other groups, none of these organizations has any
input into the conclusions presented in the critiques pub-
lished on the forum web-site. A detailed disclosure state-
ment signed by each member of the forum is available at:
http://alcoholresearchforum.org/disclosure-statement. G.
d.G. was also previously a consultant to the Web Newsletter
of Assobirra, the Italian Association of the Beer and Malt
Industries (until 2019) and is a corresponding member of
the non-profit Accademia Italiana della Vite e del Vino; G.
d.G. reports personal fees for a lecture at the 8th European
Beer and Health Symposium (2017), Beer and Health Ini-
tiative (The Dutch Beer Institute Foundation—The Brewers
of Europe), outside the submitted work. V.S. was supported
by the Finnish Foundation for Cardiovascular Research and
has received honoraria from Novo Nordisk and Sanofi and
travel support from Novo Nordisk. V.S. also has ongoing re-
search collaboration with Bayer Ltd (all unrelated to the
present study). S.S. was supported by the Swedish Heart–
Lung Foundation, the County Council of Västerbotten
(ALF. VLL-548791) and Umeå University, and reports
speakers’ honoraria from Actelion Pharmaceuticals Ltd
and from Astra Zeneca Ltd (unrelated to the present study).
J.F. reports lectures fees from Amgen, MSD, Sanofi and
Servier. B.S. is funded by the German Research Foundation.

Acknowledgements

The MORGAM Project received funding from Medical Re-
search Council London grant G0601463 (80983) and
European Union FP7 project BiomarCaRE (HEALTH-
F2-2011-278 913). The activities of the MORGAM Data
Centre have also been sustained by recent funding from
European Union FP 7 project CHANCES (HEALTH-
F3-2010-242 244). The present analysis was partially
supported by the Ministero della Salute, Italy, Bando
Ricerca Finalizzata 2018 RF-2018-12 367 074 and by
the Associazione Italiana per la Ricerca sul Cancro
AIRC “5xMILLE”, Italy, bando n. 12237. The funders
had no role in study design, data collection and
analysis, decision to publish or preparation of the manuscript. A.D.C. affirms that the manuscript is an honest, accurate, and transparent account of the study being reported, and no important aspect of the study has been omitted. Open Access Funding provided by Universita degli Studi dell'Insubria within the CRUI-CARE Agreement. [Correction added on 19 May 2022, after first online publication: CRUI funding statement has been added.]

Open Access Funding provided by Universita degli Studi dell'Insubria within the CRUI-CARE Agreement.

## Author contributions

**Augusto Di Castelnuovo:** Conceptualization; formal analysis; supervision. **Simona Costanzo:** Data curation; methodology; validation. **Marialaura Bonaccio:** Conceptualization; data curation. **Patrick McElduff:** Data curation; supervision. **Allan Linneberg:** Data curation; supervision. **Veikko Salomaa:** Data curation; supervision. **Satu Männistö:** Data curation. **Maria Moitry:** Data curation; supervision. **Jean Ferrières:** Data curation; supervision. **Jean Dallongeville:** Data curation; supervision. **Barbara Thorand:** Supervision. **Hermann Brenner:** Data curation; supervision. **Marco Ferrario:** Data curation; supervision. **Giovanni Veronesi:** Formal analysis; methodology; supervision. **Emanuela Pettenuzzo:** Data curation. **Abdonas Tamosiunas:** Data curation; supervision. **Inger Njølstad:** Supervision. **Wojciech Drygas:** Data curation; supervision. **Yuri Nikitin:** Data curation; supervision. **Stefan Söderberg:** Data curation; supervision. **Frank Kee:** Data curation; supervision. **Guido Grassi:** Data curation; supervision. **Dirk Westermann:** Data curation; supervision. **Benedikt Schrage:** Conceptualization; data curation; supervision. **Salim Dabboura:** Data curation; supervision. **Tania Zeller:** Data curation; methodology; supervision. **Kari Kuulasmaa:** Conceptualization; data curation; funding acquisition; methodology; project administration; supervision. **Stefan Blankenberg:** Conceptualization; data curation; funding acquisition; project administration; supervision. **Maria Benedetta Donati:** Conceptualization; data curation; funding acquisition; supervision. **Giovanni de Gaetano:** Conceptualization; methodology; supervision. **Licia Iacoviello:** Conceptualization; supervision.

## Author's affiliations

Mediteranea Cardiocentro, Napoli, Italy,¹ Department of Epidemiology and Prevention, IRCCS Neuromed, Pozzilli, Italy,² University of Newcastle & Hunter Medical Research Institute, Australia,³ Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark,⁴ Finnish Institute for Health and Welfare, Helsinki, Finland,⁵ Department of Public Health, University Hospital of Strasbourg and Department of Epidemiology and Public Health, University of Strasbourg, France,⁶ Department of Cardiology and INSERM UMR 1295,

Toulouse University Hospital, Toulouse, France,⁷ University of Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille, France,⁸ Helmholtz Zentrum München, German Research Center for Environmental Health, Institute of Epidemiology, Neuherberg, Germany,⁹ Division of Clinical Epidemiology and Aging Research and Division of Preventive Oncology, German Cancer Research Center, Heidelberg, Germany,¹⁰ Research Center in Epidemiology and Preventive Medicine (EPIMED), Department of Medicine and Surgery, University of Insubria, Varese, Italy,¹¹ Lithuanian University of Health Sciences, Kaunas, Lithuania,¹² Department of community Medicine, University of Tromsø - the Arctic University of Norway, Norway,¹³ Department of Epidemiology CVD Prevention and Health Promotion, National Institute of Cardiology, Warsaw, Poland,¹⁴ The Institute of Internal and Preventive Medicine, Novosibirsk, Russia,¹⁵ Department of Public Health and Clinical Medicine, and Heart Centre, Umeå University, Sweden,¹⁶ Centre for Public Health, Queens University of Belfast, Belfast, Northern Ireland,¹⁷ Clinica Medica, Università Milano-Bicocca, Milano, Italy¹⁸ and
Clinic of General and Interventional Cardiology, University Heart & Vascular Center Hamburg, Germany, and German Center for cardiovascular research, Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany¹⁹

## References

1. Di Castelnuovo A., Costanzo S., Bagnardi V., Donati M. B., Iacoviello L., de Gaetano G. Alcohol dosing and total mortality in men and women: an updated meta-analysis of 34 prospective studies. *Arch Intern Med* 2006; **166**: 2437–45.

2. Jayasekara H., English D. R., Room R., MacInnis R. J. Alcohol consumption over time and risk of death: a systematic review and meta-analysis. *Am J Epidemiol* 2014; **179**: 1049–59.

3. Wang C., Xue H., Wang Q., Hao Y., Li D., Gu D., et al. Effect of drinking on all-cause mortality in women compared with men: a meta-analysis. *J Womens Health* 2014; **23**: 373–81.

4. Mukamal K. J., Clowry C. M., Murray M. M., Hendriks H. F. J., Rimm E. B., Sink K. M., et al. Moderate alcohol consumption and chronic disease: the case for a long-term trial. *Alcohol Clin Exp Res* 2016; **40**: 2283–91.

5. Stockwell T., Zhao J., Panwar S., Roemer A., Naimi T., Chikritzhats T. Do 'moderate' drinkers have reduced mortality risk? A systematic review and meta-analysis of alcohol consumption and all-cause mortality. *J Stud Alcohol Drugs* 2016; **77**: 185–98.

6. Naimi T. S., Brown D. W., Brewer R. D., Giles W. H., Mensah G., Serdula M. K., et al. Cardiovascular risk factors and founders among nondrinking and moderate-drinking U.S. adults. *Am J Prev Med* 2005; **28**: 369–73.

7. Wood A. M., Kaptoge S., Butterworth A. S., Willeit P., Warnakula S., Bolton T., et al. Risk thresholds for alcohol consumption: combined analysis of individual-participant data for 599 912 current drinkers in 83 prospective studies. *Lancet* 2018; **391**: 1513–23.

8. Global Burden of Disease (GBD) 2016 Alcohol Collaborators Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the global burden of disease study 2016. *Lancet* 2018 Sep 22; **392**: 1015–35.

9. Millwood I. Y., Walters R. G., Mei X. W., Guo Y., Yang L., Bian Z., et al. Conventional and genetic evidence on alcohol and vascular disease aetiology: a prospective study of 500 000 men and women in China. *Lancet* 2019 May 4; **393**: 1831–42.

10. Rehm J., Gmel G. E. Sr., Gmel G., Hasan O. S. M., Imtiaz S., Popova S., et al. The relationship between different dimensions of alcohol use and the burden of disease—an update. *Addiction* 2017; **112**: 968–1001.

11. Poli A., Marangoni F., Avogaro A., Barba G., Bellentani S., Bucci M., et al. Moderate alcohol use and health: a consensus document. *Nutr Metab Cardiovasc Dis* 2013; **23**: 487–504.
analysis, decision to publish or preparation of the
manuscript. A.D.C. affirms that the manuscript is an
honest, accurate, and transparent account of the study
being reported, and no important aspect of the study
has been omitted. Open Access Funding provided by
Università degli Studi dell'Insubria within the CRUI-
CARE Agreement. [Correction added on 19 May 2022,
after first online publication: CRUI funding statement
has been added.]

Open Access Funding provided by Universita degli Studi
dell'Insubria within the CRUI-CARE Agreement.

Author contributions

Augusto Di Castelnuovo: Conceptualization; formal analysis; supervision. Simona Costanzo: Data curation; methodology; validation. Marialaura Bonaccio: Conceptualization; data curation. Patrick McElduff: Data curation; supervision. Allan Linneberg: Data curation; supervision. Veikko Salomaa: Data curation; supervision. Satu Männistö: Data curation. Maria Moitry: Data curation; supervision. Jean Ferrières: Data curation; supervision. Jean Dallongeville: Data curation; supervision. Barbara Thorand: Supervision. Hermann Brenner: Data curation; supervision. Marco Ferrario: Data curation; supervision. Giovanni Veronesi: Formal analysis; methodology; supervision. Emanuelo Pettenuzzo: Data curation. Abdonas Tamosiunas: Data curation; supervision. Inger Njølstad: Supervision. Wojciech Drygas: Data curation; supervision. Yuri Nikitin: Data curation; supervision. Stefan Söderberg: Data curation; supervision. Frank Kee: Data curation; supervision. Guido Grassi: Data curation; supervision. Dirk Westermann: Data curation; supervision. Benedikt Schrage: Conceptualization; data curation; supervision. Salim Dabboura: Data curation; supervision. Tania Zeller: Data curation; methodology; supervision. Kari Kuulasmaa: Conceptualization; data curation; funding acquisition; methodology; project administration; supervision. Stefan Blankenberg: Conceptualization; data curation; funding acquisition; project administration; supervision. Maria Benedetta Donati: Conceptualization; data curation; funding acquisition; supervision. Giovanni de Gaetano: Conceptualization; methodology; supervision. Licia Iacoviello: Conceptualization; supervision.

Author's affiliations

Mediterranea Cardiocentro, Napoli, Italy,¹ Department of Epidemiology and Prevention, IRCCS Neuromed, Pozzilli, Italy,² University of Newcastle & Hunter Medical Research Institute, Australia,³ Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark,⁴ Finnish Institute for Health and Welfare, Helsinki, Finland,⁵ Department of Public Health, University Hospital of Strasbourg and Department of Epidemiology and Public Health, University of Strasbourg, France,⁶ Department of Cardiology and INSERM UMR 1295,

Toulouse University Hospital, Toulouse, France,⁷ University of Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille, France,⁸ Helmholtz Zentrum München, German Research Center for Environmental Health, Institute of Epidemiology, Neuherberg, Germany,⁹ Division of Clinical Epidemiology and Aging Research and Division of Preventive Oncology, German Cancer Research Center, Heidelberg, Germany,¹⁰ Research Center in Epidemiology and Preventive Medicine (EPIMED), Department of Medicine and Surgery, University of Insubria, Varese, Italy,¹¹ Lithuanian University of Health Sciences, Kaunas, Lithuania,¹² Department of community Medicine, University of Tromsø - the Arctic University of Norway, Norway,¹³ Department of Epidemiology CVD Prevention and Health Promotion, National Institute of Cardiology, Warsaw, Poland,¹⁴ The Institute of Internal and Preventive Medicine, Novosibirsk, Russia,¹⁵ Department of Public Health and Clinical Medicine, and Heart Centre, Umeå University, Sweden,¹⁶ Centre for Public Health, Queens University of Belfast, Belfast, Northern Ireland,¹⁷ Clinica Medica, Università Milano-Bicocca, Milano, Italy¹⁸ and
Clinic of General and Interventional Cardiology, University Heart & Vascular Center Hamburg, Germany, and German Center for cardiovascular research, Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany¹⁹

References

1. Di Castelnuovo A., Costanzo S., Bagnardi V., Donati M. B., Iacoviello L., de Gaetano G. Alcohol dosing and total mortality in men and women: an updated meta-analysis of 34 prospective studies. *Arch Intern Med* 2006; **166**: 2437–45.

2. Jayasekara H., English D. R., Room R., MacInnis R. J. Alcohol consumption over time and risk of death: a systematic review and meta-analysis. *Am J Epidemiol* 2014; **179**: 1049–59.

3. Wang C., Xue H., Wang Q., Hao Y., Li D., Gu D., et al. Effect of drinking on all-cause mortality in women compared with men: a meta-analysis. *J Womens Health* 2014; **23**: 373–81.

4. Mukamal K. J., Clowry C. M., Murray M. M., Hendriks H. F. J., Rimm E. B., Sink K. M., et al. Moderate alcohol consumption and chronic disease: the case for a long-term trial. *Alcohol Clin Exp Res* 2016; **40**: 2283–91.

5. Stockwell T., Zhao J., Panwar S., Roemer A., Naimi T., Chikritzhats T. Do 'moderate' drinkers have reduced mortality risk? A systematic review and meta-analysis of alcohol consumption and all-cause mortality. *J Stud Alcohol Drugs* 2016; **77**: 185–98.

6. Naimi T. S., Brown D. W., Brewer R. D., Giles W. H., Mensah G., Serdula M. K., et al. Cardiovascular risk factors and founders among nondrinking and moderate-drinking U.S. adults. *Am J Prev Med* 2005; **28**: 369–73.

7. Wood A. M., Kaptoge S., Butterworth A. S., Willeit P., Warnakula S., Bolton T., et al. Risk thresholds for alcohol consumption: combined analysis of individual-participant data for 599 912 current drinkers in 83 prospective studies. *Lancet* 2018; **391**: 1513–23.

8. Global Burden of Disease (GBD) 2016 Alcohol Collaborators Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the global burden of disease study 2016. *Lancet* 2018 Sep 22; **392**: 1015–35.

9. Millwood I. Y., Walters R. G., Mei X. W., Guo Y., Yang L., Bian Z., et al. Conventional and genetic evidence on alcohol and vascular disease aetiology: a prospective study of 500 000 men and women in China. *Lancet* 2019 May 4; **393**: 1831–42.

10. Rehm J., Gmel G. E. Sr., Gmel G., Hasan O. S. M., Imtiaz S., Popova S., et al. The relationship between different dimensions of alcohol use and the burden of disease—an update. *Addiction* 2017; **112**: 968–1001.

11. Poli A., Marangoni F., Avogaro A., Barba G., Bellentani S., Bucci M., et al. Moderate alcohol use and health: a consensus document. *Nutr Metab Cardiovasc Dis* 2013; **23**: 487–504.
12. Mukamal K. J., Conigrave K. M., Mittleman M. A., Camargo C. A., Stampfer M. J., Willett W. C., et al. Roles of drinking pattern and type of alcohol consumed in coronary heart disease in men. *N Engl J Med* 2003; **348**: 109–18.

13. Naimi T. S., Stockwell T., Zhao J., Xuan Z., Dangardt E., Saitz R., et al. Selection biases in observational studies affect associations between 'moderate' alcohol consumption and mortality. *Addiction* 2017; **112**: 207–14.

14. Bell S., Daskalopoulou M., Rapsomaniki E., George J., Britton A., Bobak M., et al. Association between clinically recorded alcohol consumption and initial presentation of 12 cardiovascular diseases: population based cohort study using linked health records. *BMJ* 2017; **356**: j909.

15. Xi B., Veeranki S. P., Zhao M., Ma C., Yan Y., Mi J. Relationship of alcohol consumption to all-cause, cardiovascular, and cancer-related mortality in U.S. adults. *J Am Coll Cardiol* 2017; **70**: 913–22.

16. Roerecke M., Rehm J. Alcohol consumption, drinking patterns, and ischemic heart disease: a narrative review of meta-analyses and a systematic review and meta-analysis of the impact of heavy drinking occasions on risk for moderate drinkers. *BMC Med* 2014; **12**: 182.

17. Costanzo S., Di Castelnuovo A., Donati M. B., Iacoviello L., de Gaetano G. Wine, beer or spirit drinking in relation to fatal and non-fatal cardiovascular events: a meta-analysis. *Eur J Epidemiol* 2011; **26**: 833–50.

18. Di Castelnuovo A., Costanzo S., Bonaccio M., Rago L., De Curtis A., Persichillo M., et al. Moderate alcohol consumption is associated with lower risk for heart failure but not atrial fibrillation. *JACC Heart Fail* 2017; **5**: 837–44.

19. Corrao G., Bagnardi V., Zambon A., La Vecchia C. A meta-analysis of alcohol consumption and the risk of 15 diseases. *Prev Med* 2004; **38**: 613–9.

20. Connor J., Hall W. Thresholds for safer alcohol use might need lowering. *Lancet* 2018; **391**: 1460–1.

21. Astrup A., Costanzo S., de Gaetano G. Risk thresholds for alcohol consumption. *Lancet* 2018; **392**: 2165–6.

22. de Gaetano G., Costanzo S. Alcohol and health: praise of the J curves. *J Am Coll Cardiol* 2017; **70**: 923–5.

23. Di Castelnuovo A. E., Costanzo S., de Gaetano G. Alcohol and the global burden of disease. *Lancet* 2019; **393**: 2389.

24. Barrett-Connor E., de Gaetano G., Djoussé L., Ellison R. C., Estruch R., Finkel H., et al. Comments on moderate alcohol consumption and mortality. *J Stud Alcohol Drugs* 2016; **77**: 834–6.

25. Sluik D., Jankovic N., Hughes M., O'Doherty M. G., Schötker B., Drygas W., et al. Alcoholic beverage preference and diabetes incidence across Europe: the consortium on health and ageing network of cohorts in Europe and the United States (CHANCES) project. *Eur J Clin Nutr* 2017; **71**: 659–68.

26. Evans A., Salomaa V., Kulathinal S., Asplund K., Cambien E., Ferrario M., et al. MORGAM (an international pooling of cardiovascular cohorts). *Int J Epidemiol* 2005; **34**: 21–7.

27. Kulathinal S., Niemela M., Niiranen T., Saarela O., Palosaari T., Tapanainen H., et al. Contributors from participating Centres, for the MORGAM project. Description of MORGAM Cohorts MORGAM Project. Available at: http://www.thl.fi/publications/morgam/manual/contents.htm (accessed 15 July 2019).

28. MORGAM Project. MORGAM Manual. MORGAM Project e-publications [internet] 2001–; (1). URN:NBN:fife20041529. Available at: https://thl.fi/publications/morgam/manual/contents.htm (accessed 15 July 2019).

29. Zeller T., Hughes M., Tuovinen T., Schillert A., Conrads-Frank A., den Ruijter H., et al. BiomarCaRE: rationale and design of the European BiomarCaRE project including 300,000 participants from 13 European countries. *Eur J Epidemiol* 2014; **29**: 777–90.

30. Tunstall-Pedoe H., Kuulasmaa K., Amouyel P., Arveiler D., Rajakangas A. M., Pajak A. Myocardial infarction and coronary deaths in the World Health Organization MONICA project. Registration procedures, event rates, and case-fatality rates in 38 populations from 21 countries in four continents. *Circulation* 1994; **90**: 583–612.

31. Nevo D., Liao X., Spiegelman D. Estimation and inference for the mediation proportion. *Int J Biostat* 2017; **13**: j-ijb.

32. Saito E., Inoue M., Sawada N., Charvat H., Shimazu T., Yamaji T., et al. Impact of alcohol intake and drinking patterns on mortality from all causes and major causes of death in a Japanese population. *J Epidemiol* 2018; **28**: 140–8.

33. Wright R. S. Recent clinical trials evaluating benefit of drug therapy for modification of HDL cholesterol. *Curr Opin Cardiol* 2013; **28**: 389–98.

34. Shaper A. G., Wannamethee G., Walker M. Alcohol and mortality in British men: explaining the U-shaped curve. *Lancet* 1988; **2**: 1267–73.

35. Costanzo S., de Gaetano G., Di Castelnuovo A., Djoussé L., Poli A., Van Velden D. P. Moderate alcohol consumption and lower total mortality risk: justified doubts or established facts? *Nutr Metab Cardiovasc Dis* 2019; **29**: 1003–8.

36. Liang W., Chikritzhs T. The association between alcohol exposure and self-reported health status: the effect of separating former and current drinkers. *PLOS ONE* 2013; **8**: e55881.

37. Ng Fat L., Shelton N. Associations between self-reported illness and non-drinking in young adults. *Addiction* 2012; **107**: 1612–20.

38. Shield K. D., Gmel G., Gmel G., Mäkelä P., Probst C., Room R., et al. Life-time risk of mortality due to different levels of alcohol consumption in seven European countries: implications for low-risk drinking guidelines. *Addiction* 2017; **112**: 1535–44.

39. Schrieks I. C., Stafleu A., Kallen V. L., Grootjen M., Witkamp R. E., Hendriks H. F. The biphasic effects of moderate alcohol consumption with a meal on ambiance-induced mood and autonomic nervous system balance: a randomized crossover trial. *PLOS ONE* 2014; **9**: e86199.

40. Kuntsche E., Kuntsche S., Thrul J., Gmel G. Binge drinking: health impact, prevalence, correlates and interventions. *Psychol Health* 2017; **32**: 976–1017.

41. Di Castelnuovo A., Costanzo S., di Giuseppe R., de Gaetano G., Iacoviello L. Alcohol consumption and cardiovascular risk: mechanisms of action and epidemiologic perspectives. *Future Cardiol* 2009; **5**: 467–77.

42. Fragopoulou E., Choleva M., Antonopoulou S., Demopoulos C. A. Wine and its metabolic effects. A comprehensive review of clinical trials. *Metabolism* 2018; **83**: 102–19.

43. Klatsky A. L., Friedman G. D., Armstrong M. A., Kipp H. Wine, liquor, beer, and mortality. *Am J Epidemiol* 2003; **158**: 585–95.

44. Estruch R., Sacanella E., Badia E., Antúnez E., Nicolás J. M., Fernández-Solá J., et al. Different effects of red wine and gin consumption on inflammatory biomarkers of atherosclerosis: a prospective randomized crossover trial. Effects of wine on inflammatory markers. *Atherosclerosis* 2004; **175**: 117–23.

45. Klatsky A. L., Udaltsova N., Li Y., Baer D., Nicole Tran H., Friedman G. D. Moderate alcohol intake and cancer: the role of underreporting. *Cancer Causes Control* 2014; **25**: 693–9.
12. Mukamal K. J., Conigrave K. M., Mittleman M. A., Camargo C. A., Stampfer M. J., Willett W. C., et al. Roles of drinking pattern and type of alcohol consumed in coronary heart disease in men. *N Engl J Med* 2003; **348**: 109–18.

13. Naimi T. S., Stockwell T., Zhao J., Xuan Z., Dangardt E., Saitz R., et al. Selection biases in observational studies affect associations between 'moderate' alcohol consumption and mortality. *Addiction* 2017; **112**: 207–14.

14. Bell S., Daskalopoulou M., Rapsomaniki E., George J., Britton A., Bobak M., et al. Association between clinically recorded alcohol consumption and initial presentation of 12 cardiovascular diseases: population based cohort study using linked health records. *BMJ* 2017; **356**: j909.

15. Xi B., Veeranki S. P., Zhao M., Ma C., Yan Y., Mi J. Relationship of alcohol consumption to all-cause, cardiovascular, and cancer-related mortality in U.S. adults. *J Am Coll Cardiol* 2017; **70**: 913–22.

16. Roerecke M., Rehm J. Alcohol consumption, drinking patterns, and ischemic heart disease: a narrative review of meta-analyses and a systematic review and meta-analysis of the impact of heavy drinking occasions on risk for moderate drinkers. *BMC Med* 2014; **12**: 182.

17. Costanzo S., Di Castelnuovo A., Donati M. B., Iacoviello L., de Gaetano G. Wine, beer or spirit drinking in relation to fatal and non-fatal cardiovascular events: a meta-analysis. *Eur J Epidemiol* 2011; **26**: 833–50.

18. Di Castelnuovo A., Costanzo S., Bonaccio M., Rago L., De Curtis A., Persichillo M., et al. Moderate alcohol consumption is associated with lower risk for heart failure but not atrial fibrillation. *JACC Heart Fail* 2017; **5**: 837–44.

19. Corrao G., Bagnardi V., Zambon A., La Vecchia C. A meta-analysis of alcohol consumption and the risk of 15 diseases. *Prev Med* 2004; **38**: 613–9.

20. Connor J., Hall W. Thresholds for safer alcohol use might need lowering. *Lancet* 2018; **391**: 1460–1.

21. Astrup A., Costanzo S., de Gaetano G. Risk thresholds for alcohol consumption. *Lancet* 2018; **392**: 2165–6.

22. de Gaetano G., Costanzo S. Alcohol and health: praise of the J curves. *J Am Coll Cardiol* 2017; **70**: 923–5.

23. Di Castelnuovo A. E., Costanzo S., de Gaetano G. Alcohol and the global burden of disease. *Lancet* 2019; **393**: 2389.

24. Barrett-Connor E., de Gaetano G., Djoussé L., Ellison R. C., Estruch R., Finkel H., et al. Comments on moderate alcohol consumption and mortality. *J Stud Alcohol Drugs* 2016; **77**: 834–6.

25. Sluik D., Jankovic N., Hughes M., O'Doherty M. G., Schötker B., Drygas W., et al. Alcoholic beverage preference and diabetes incidence across Europe: the consortium on health and ageing network of cohorts in Europe and the United States (CHANCES) project. *Eur J Clin Nutr* 2017; **71**: 659–68.

26. Evans A., Salomaa V., Kulathinal S., Asplund K., Cambien E., Ferrario M., et al. MORGAM (an international pooling of cardiovascular cohorts). *Int J Epidemiol* 2005; **34**: 21–7.

27. Kulathinal S., Niemela M., Niiranen T., Saarela O., Palosaari T., Tapanainen H., et al. Contributors from participating Centres, for the MORGAM project. Description of MORGAM Cohorts MORGAM Project. Available at: http://www.thl.fi/publications/morgam/manual/contents.htm (accessed 15 July 2019).

28. MORGAM Project. MORGAM Manual. MORGAM Project e-publications [internet] 2001–; (1). URN:NBN:fife20041529. Available at: https://thl.fi/publications/morgam/manual/contents.htm (accessed 15 July 2019).

29. Zeller T., Hughes M., Tuovinen T., Schillert A., Conrads-Frank A., den Ruijter H., et al. BiomarCaRE: rationale and design of the European BiomarCaRE project including 300,000 participants from 13 European countries. *Eur J Epidemiol* 2014; **29**: 777–90.

30. Tunstall-Pedoe H., Kuulasmaa K., Amouyel P., Arveiler D., Rajakangas A. M., Pajak A. Myocardial infarction and coronary deaths in the World Health Organization MONICA project. Registration procedures, event rates, and case-fatality rates in 38 populations from 21 countries in four continents. *Circulation* 1994; **90**: 583–612.

31. Nevo D., Liao X., Spiegelman D. Estimation and inference for the mediation proportion. *Int J Biostat* 2017; **13**: j-ijb.

32. Saito E., Inoue M., Sawada N., Charvat H., Shimazu T., Yamaji T., et al. Impact of alcohol intake and drinking patterns on mortality from all causes and major causes of death in a Japanese population. *J Epidemiol* 2018; **28**: 140–8.

33. Wright R. S. Recent clinical trials evaluating benefit of drug therapy for modification of HDL cholesterol. *Curr Opin Cardiol* 2013; **28**: 389–98.

34. Shaper A. G., Wannamethee G., Walker M. Alcohol and mortality in British men: explaining the U-shaped curve. *Lancet* 1988; **2**: 1267–73.

35. Costanzo S., de Gaetano G., Di Castelnuovo A., Djoussé L., Poli A., Van Velden D. P. Moderate alcohol consumption and lower total mortality risk: justified doubts or established facts? *Nutr Metab Cardiovasc Dis* 2019; **29**: 1003–8.

36. Liang W., Chikritzhs T. The association between alcohol exposure and self-reported health status: the effect of separating former and current drinkers. *PLOS ONE* 2013; **8**: e55881.

37. Ng Fat L., Shelton N. Associations between self-reported illness and non-drinking in young adults. *Addiction* 2012; **107**: 1612–20.

38. Shield K. D., Gmel G., Gmel G., Mäkelä P., Probst C., Room R., et al. Life-time risk of mortality due to different levels of alcohol consumption in seven European countries: implications for low-risk drinking guidelines. *Addiction* 2017; **112**: 1535–44.

39. Schrieks I. C., Stafleu A., Kallen V. L., Grootjen M., Witkamp R. E., Hendriks H. F. The biphasic effects of moderate alcohol consumption with a meal on ambiance-induced mood and autonomic nervous system balance: a randomized crossover trial. *PLOS ONE* 2014; **9**: e86199.

40. Kuntsche E., Kuntsche S., Thrul J., Gmel G. Binge drinking: health impact, prevalence, correlates and interventions. *Psychol Health* 2017; **32**: 976–1017.

41. Di Castelnuovo A., Costanzo S., di Giuseppe R., de Gaetano G., Iacoviello L. Alcohol consumption and cardiovascular risk: mechanisms of action and epidemiologic perspectives. *Future Cardiol* 2009; **5**: 467–77.

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## Supporting Information

Additional supporting information may be found online in the Supporting Information section at the end of the article.

**Table S1** Characteristics of the cohort studies.

**Table S2** Hazard ratios for total mortality according to different alcoholic preferences after multiple imputation for missing data in all variables, including alcohol intake

and history of cancer (total number of individual *n* = 154 920, deaths for any causes *n* = 19 139).

**Table S3** Hazard ratios for mortality, according to categories of frequency of alcohol intake.

**Table S4** Hazard ratios for mortality, according to categories of alcohol intake after replacing former drinkers and non-drinkers back in with drinkers by using of multiple imputation.

**Table S5** Hazard ratios for total mortality using different reference categories.

**Table S6** Hazard ratios for total mortality according to different alcoholic preferences and geographical location.

**Figure S1** Percentage of variation respect to life-time abstainers for different categories of alcohol intake. Error bars are 95% confidence intervals. CRP means C-reactive protein and NT-ProBNP means N-terminal pro brain-type na-triuretic peptide. CRP, troponin and NT-ProBNP were log transformed before analysis. P for association with alcohol categories <0.01 for each biomarker, adjusted for age, sex and cohort. Sample sizes were: *N* = 116 756 for HDLc; *N* = 42 109 for CRP; *N* = 43 497 for troponin and *N* = 40 301 for NT-ProBNP.
46. Larsson S. C., Carter P., Kar S., Vithayathil M., Mason A. M., Michaëlsson K., *et al*. Smoking, alcohol consumption, and cancer: a mendelian randomisation study in UK biobank and international genetic consortia participants. *PLOS Med* 2020; **17**: e1003178.

47. Mukamal K. J., Stampfer M. J., Rimm E. B. Genetic instrumental variable analysis: time to call mendelian randomization what it is. The example of alcohol and cardiovascular disease. *Eur J Epidemiol* 2020; **35**: 93–7.

48. Stockwell T., Chikritzhs T. Commentary: another serious challenge to the hypothesis that moderate drinking is good for health? *Int J Epidemiol* 2013; **42**: 1792–4.

## Supporting Information

Additional supporting information may be found online in the Supporting Information section at the end of the article.

**Table S1** Characteristics of the cohort studies.

**Table S2** Hazard ratios for total mortality according to different alcoholic preferences after multiple imputation for missing data in all variables, including alcohol intake

and history of cancer (total number of individual $n = 154 920$, deaths for any causes $n = 19 139$).

**Table S3** Hazard ratios for mortality, according to categories of frequency of alcohol intake.

**Table S4** Hazard ratios for mortality, according to categories of alcohol intake after replacing former drinkers and non-drinkers back in with drinkers by using of multiple imputation.

**Table S5** Hazard ratios for total mortality using different reference categories.

**Table S6** Hazard ratios for total mortality according to different alcoholic preferences and geographical location.

**Figure S1** Percentage of variation respect to life-time abstainers for different categories of alcohol intake. Error bars are 95% confidence intervals. CRP means C-reactive protein and NT-ProBNP means N-terminal pro brain-type na-triuretic peptide. CRP, troponin and NT-ProBNP were log transformed before analysis. P for association with alcohol categories <0.01 for each biomarker, adjusted for age, sex and cohort. Sample sizes were: $N = 116 756$ for HDLC; $N = 42 109$ for CRP; $N = 43 497$ for troponin and $N = 40 301$ for NT-ProBNP.