Alcohol consumption and life insurance

28 Alcohol consumption and life insurance Dr. Kevin Somerville, MD Swiss Reinsurance Company Global Life & Health Underwriting, London Dr. sc. nat. Beatrice Baldinger Swiss Reinsurance Company Life & Health Products, Zürich Abstract Alcohol use is common. The culture of drinking differs substantially between societies and the mortality and morbidity risk depends upon the circumstances in which alcohol is taken as well as the quantity and pattern of consumption. There are two defined excess alcohol use syndromes, alcohol abuse (DSMIV)/harmful use (ICD10) and the more severe alcohol dependence (DSMIV and ICD10). The additional concept of hazardous drinking is frequently used to describe excessive alcohol use which is potentially injurious to health; in this the morbidity and mortality risks are increased but there is none of the physical, social or psychological effects associated with alcohol abuse/harmful use or dependence. Clinical and epidemiological studies show that the acute effects of alcohol excess (intoxication) are of particular importance in the young and that episodic heavy alcohol use (binge drinking) is more problematic than regular modest to high alcohol intake. Obtaining evidence about such a pattern of alcohol use is not straightforward and insurance application forms often do not ask. Alcohol intake is not without its benefits. The incidence of ischaemic heart disease (IHD) appears to be lowered by regular modest alcohol use and this is of particular relevance in high cardiovascular disease risk areas. This has an impact on critical illness risk assessment especially in older men where increased cancer and neuropsychiatric risk is offset, at least in part, by the lower IHD risk. Furthermore, modest alcohol intake is also used as part of social discourse and even business deals. Risk assessment needs to be placed in the context of the individual as well as society particularly as alcohol abuse/ dependence may be difficult to identify. However, once alcohol dependence has been diagnosed the mortality and morbidity risks are very high and only those with a well documented and sustained

29 recovery will be eligible for an offer of insurance. Introduction Alcohol use is widespread and common. Excessive alcohol use is regarded as a major health public hazard. The World Health Organisation (WHO) ranks harmful use of alcohol as the fifth leading risk factor for premature death and disability in the world. It estimated that worldwide in 2002 at least 2.3 million people died of alcohol-related causes (3.8% of global mortality) and that alcohol consumption caused 4.6% of the global burden of disease. The Institute for Alcohol studies in the UK estimates that the estimated social costs of alcohol are between 1% and 3% of GDP and for the European Union in 1998 are between $65 and $195 billion at 1990 prices, comparable to government expenditures on social security and welfare, and approximating to 25% of health service expenditure. The acute and chronic unwanted effects of high alcohol intake affect society, the family and the individual and these have been subdivided into: 1. Acute intoxication: accidents, suicide, inappropriate behaviour, family and social impact, and poor work performance. 2. Chronic excessive use: liver disease, neurological disorders, cardiomyopathy, family and social impact, unemployment, and poor work performance. In general, unintentional injuries associated with acute intoxication contribute most to alcohol-attributable mortality while neuropsychiatric disorders caused by chronic alcohol use contributed most to alcohol-attributable disease. The two defined clinical syndromes that reflect these problems are alcohol abuse/harmful use and alcohol dependence. Both the DSM IV and ICD 10 have similar definitions for alcohol dependence but the criteria for the less severe category of alcohol abuse (DSM IV) or harmful use (ICD 10) differ. The ICD10 category of harmful use is not specific to alcohol but is used for all psychoactive substances where use or excessive use causes harm. Broadly, alcohol dependence equates to the problems of chron-

30 ic use and alcohol abuse/harmful use to the acute effects of repeated overuse although there is considerable overlap. None of the definitions include the quantity of alcohol consumed as a guide or one of the essential criteria for diagnosis. The emphasis is upon the effects of alcohol use upon the health, performance and social network of the affected individual. Rehm et al (2004) provide a broad diagrammatic representation of the acute and chronic effects of alcohol consumption. However, the effects of alcohol consumption and its role in society are not universally deleterious; alcoholic beverages are ubiquitous and have a major role in social discourse as well as a cardioprotective effect in those at risk of ischaemic heart disease (IHD). How is alcohol consumption measured? Because there is a broad relationship between the pattern of alcohol use and the development of adverse effects, authorities have attempted to categorise both the acceptable and the potentially injurious levels of alcohol use in terms of the average drink or quantity of alcohol consumed. However, the social circumstances in which alcohol is used (taken with meals or standing at a bar, emphasis on drinking as distinct from emphasis on socialisation) appear to have a major modifying effect. The amount of alcohol consumed can be quantified by weight (grams) or by volume (litres of pure alcohol). However, this is not straightforward as the concentration of alcohol varies between and within drink classes (beer, wine, spirits); there is no easy linear relationship between the type of alcohol consumed along with the volume served with the quantity of alcohol consumed. The variation within typical different drink classes for a standardised serving is shown in the table (Table 1, P. 31). To compound the difficulty the average or standard drink volume varies between countries; this is frequently set by the average serving in the country concerned. No internationally recognised set of standards has been adopted. The table below shows the average or standard drink in a range of countries (Table 2, P. 31).

31 Table 1 Alcohol type Alcohol serving Metric measure Grams of alcohol Wine 1 glass 125 ml 8 12 Wine 1 bottle 750 ml 48 70 Mid strength beer 1 pint 587 ml 16 Spirits 1 measure (1/5 gill) 30 ml 8 10 Spirits 1 bottle 750 ml 200 250 Table 2 Country Alcohol measure Grams of alcohol United Kingdom, Ireland Unit 8 Netherlands Standard drink 9.9 Australia, Austria, Italy, New Zealand, Standard drink 10 Poland, Spain Finland Standard drink 11 Denmark, France, South Africa Standard drink 12 Canada Standard drink 13.6 USA, Portugal Standard drink 14 Japan (males) Standard drink 19.75 There are substantial differences between countries when average per capita consumption of alcohol is measured. In some predominantly Islamic countries the restricted availability of alcohol and the prevailing social and religious mores mean that alcohol intake is uncommon. Even in Europe the area that has the highest per capita alcohol intake in the world there are major inter-country differences ranging from Norway 4.4 l to Luxemburg at 11.9 l in 2002. However, particularly in Eastern European countries, a substantial amount of alcohol consumption is unrecorded. These differences bedevil observational studies of the effect of alcohol on acute

32 and chronic disease particularly as they usually rely upon self report; there are no randomised controlled trials! Broadly, those who abstain from alcohol are compared with those who use alcohol. There are inherent problems with such observational studies and questionnaires which include: 1. As noted above, different alcoholic beverages have variable concentrations of alcohol so quantification is difficult. 2. Studies use different standards of measurement of consumption such as blood alcohol concentration or estimates of the amount of alcohol consumed. The same term eg drink or unit can be used for different amounts of pure alcohol; authors are not always consistent. 3. Alcohol use is frequently assessed by very few questions; frequently the pattern of use is not measured despite binge drinking appearing to be particularly hazardous. Insurance companies use non-standardised questionnaires which ask about average intake over days or weeks. 4. Alcohol use may change over time. 5. Recall bias may occur amongst those questioned about their drinking hab- its. Asked to recall a typical day an interviewee is apt to state the intake on an atypical (low volume ) day. 6. The effect of alcohol could theoretically vary by beverage type eg does red wine have a greater beneficial effect on CVD than other types of alcoholic beverage? 7. Those who abstain belong to a heterogenous group which contains lifelong abstainers, reformed alcoholics, and those who have been advised to abstain for other health reasons (eg to avoid alcohol/pharmaceutical interactions). Few studies have attempted to correct for this unhealthy abstainer bias. 8. Societal differences in the type and quantity of alcohol consumed; cultural influences seem to modify whether alcohol related health & social problems occur. 9. Alcohol use may be associated with other potentially confounding factors. The most important of these are: a. Smoking: alcohol abuse/harmful use and alcohol dependence are strongly correlated with cigarette smoking and without accounting for smoking the morbidity and mortality risk estimates for alcohol will

33 be inflated. b. Social class: alcohol consumption especially moderate alcohol intake is more common amongst the middle classes. c. Diet: This influences both average intake and pattern of alcohol use (Breslow et al, 2006). d. Cardiovascular risk factors: blood pressure is higher in those who take excessive amounts of alcohol. A different and sometimes lowered prevalence of other associated cardiovascular risk factors such as obesity, diabetes mellitus, and physical activity can also act as confounding factors, ie it is these rather than the alcohol intake that are directly responsible for the ill health (Naimi et al, 2005). 10. The poor reliability of the diagnosis of the alcohol abuse (DSMIV) and harmful use (ICD10) syndromes; this correlates with the poor reliability of the current risk stratification systems. Alcohol: beneficial and harmful effects Moderate alcohol use has been shown to have beneficial effects on many cardiovascular diseases although some of this may be artifactual, a result of poor recognition of and control for important confounding factors (Jackson R et al, 2005). In part this is because alcohol use appears to be associated with a lower prevalence of important cardiovascular risk factors such as obesity, diabetes mellitus, physical activity although hypertension is more common (Naimi et al, 2005). However, studies in many countries, some of which have controlled for the unhealthy alcohol abstainer effect, have consistently shown that modest alcohol use reduces cardiovascular mortality. By contrast, the association of alcohol excess with acute and chronic problems such as accidents, suicide, psychosis, various types of cancer, liver disease, pancreatitis, cardiomyopathy, and brain disorders is well documented and of major public health and societal concern. Rehm et al (2004) produced an outline of the protective and adverse effects of alcohol. What are the safe levels of alcohol intake? Research comparing countries in North America and Europe has produced a classic subdivision into wet and dry

34 cultures. In the former, alcohol is integrated into daily life, in particular wine at meal times, and abstinence is uncommon. In the latter, access to alcohol is less integrated, use of alcohol is more frequently associated with excess and intoxication, and beer rather than wine is the beverage of choice. However, this distinction is disappearing with harmonisation of drinking patterns within Europe apart from the recent notable exception of Eastern Europe where excessive alcohol intake has become a major social problem. This phenomenon is occurring to a lesser extent within the remnants of the dry culture in Northern European countries such as the UK and Ireland. Other measures of alcohol use to average daily intake such as the pattern of drinking especially binge drinking and the frequency of drunkenness have also been introduced into some national guidelines. In dry cultures binge drinking is more common, beer and spirits predominate, and the risk to the population per unit of alcohol appears greater (Rehm, 2001). or desirable levels of consumption based upon grams of alcohol have been produced. Published risk level recommendations by the amount of alcohol consumed include the following: World Health Organisation (WHO, 2000): Criteria for risk of consumption on a single drinking day WHO recommend that this be used for comparative research purposes only Category Males Females Low Risk 1 to 40g 1 to 20g Medium Risk 41 to 60g 21 to 40g High Risk 61 to 100g 41 to 60g Very High Risk 101+g 61+g The number of standard drinks corresponding to these thresholds varies (see above). In both the academic literature and publications issued by a number of government agencies in many countries safe

35 The WHO criteria appear to be based upon a paper by Rehm et al in the International Journal of Epidemiology in 1999. This group have published extensively on the subject of alcohol risk, their criteria are as follows: Category Males Females Abstention and very light drinking Low Risk Hazardous drinking Harmful drinking 0 2.5 g pure ethanol per day 0 2.5 g pure ethanol per day 2.6 to 40g 2.6 to 20g 40.1 to 60g 60g 20.1 to 40g 40g Hazardous drinking is regarded as putting the user at risk for adverse effects whereas harmful drinking is associated with physical, mental or social damage and conforms more closely to the alcohol abuse/harmful use syndromes defined by DSM IV and WHO respectively. Harmful/ hazardous drinking Males 50 g, 7 days per week or 70 g, 4-6 days per week or 120 g, 2 3 days per week Binge drinking 70 g no more than 1 day per week Heavy drinking Moderate drinking 50 g usually Less than those above Females 30 g, 4 days per week or 50 g, 2 3 days per week or 60 g, 2 days per week 50 g no more than 1 day per week 30 g usually Less than those above Makkai & McAllister (Australia), 1998 produced a set of recommendations which include binge drinking and also took the pattern of drinking into account:

36 The National Institute on Alcohol Abuse and Alcoholism (NIAAA), USA, has adopted the following guidelines: Heavy drinking: Males ( 65 years) Females or males ( 65 years) 5 drinks (60 g) in one day or 14 drinks (168 g) in one week ie an average of 2 drinks (24 g) per day 4 drinks (48 g) in one day or 8 drinks (96 g) in one week ie an average of 1.2 drinks (14 g) per day In the United Kingdom the recommended safe limits are 3 4 units (24 32 g) per day for a man and 2 3 units (16 24 g) per day for a woman. In summary, there are substantial differences to recommendations about safe limits of alcohol intake in the approach taken by governments and pub- lic health bodies and no clear relationship between the pattern or volume of alcohol consumed and the diagnosis of the alcohol syndromes. Screening for alcohol abuse Alcohol questionnaires The NIAAA recommends either a single screening question: How many times in the past year have you had 5 or more drinks (4 or more for a woman) on a single occasion or the more comprehensive AUDIT screening questionnaire before asking further questions about pattern of alcohol use or symptoms indicating abuse or dependence. The AUDIT (Alcohol Use Disorder Identification Test) produced by WHO in 1989 has ten questions about the quantity as well as pattern and experience of alcohol use. Two supplementary questions are asked about alcohol related injury (self or others) and advice to cut-down alcohol intake. While it has reasonable sensitivity and specificity for the detection of hazardous drinking or alcohol abuse, it is predominantly used in research settings or in specialty clinics rather than as a population screening

37 tool. A simpler more practical form of the AUDIT using 3 questions (AUDIT- C) has been produced and preliminary studies suggest that there is little loss of utility but it has not been well studied. These questions are How often did you have a drink containing alcohol in the past year? How many drinks did you have on a typical day when you were drinking in the past year? How often did you have 6 or more drinks on one occasion in the past year? A short questionnaire alternative is the CAGE questionnaire; an acronym based upon the 4 questions asked: Have you ever felt the need to Cut down on drinking? Have you ever felt Annoyed by criticism of your drinking? Have you ever had Guilty feelings about your drinking? Do you ever take a morning Eye opener (a drink first thing in the morning to steady your nerves or get rid of a hangover)? Although commendably short, it has been criticized as lacking sensitivity. The unsatisfactory role of and difficul- ty with questionnaire based screening is apparent from the number of screening instruments available with a wide variety of title or acronyms: MAST; TWEAK, T-ACE, CRAFFT However, insurance application forms which typically contain just one question about average alcohol intake have not been formally studied as to their sensitivity or specificity. The positive and negative predictive value of screening questionnaires depends upon the prevalence of hazardous drinking and alcohol abuse/ dependence in the population being asked and information about this in turn mostly comes from the questionnaires themselves. Evidence that should raise the suspicion of an alcohol problem include convictions for drunk driving, martial breakdown, job loss or frequent absenteeism, arrest by the police for an alcohol related offence, repeated falls with or without fracture, and physical problems which raise the possibility of alcohol excess. These last include such as pancreatitis or cardiac problems including paroxysmal atrial fibrillation.

38 As screening tests in insurance applicants routine blood tests have a very low yield and in a population at low risk of alcohol abuse the potential for a high false positive rate. However, these can be useful if there is a feature suspicious for excessive alcohol use in the past or current history. Routine laboratory tests which increase the likelihood of an alcohol problem include unexplained macrocystosis, a high HDL cholesterol, elevated triglycerides and elevated liver function tests, in particular the gamma glutamyl transpeptidase (GGT). While all of these tests are non-specific, in a context where alcohol abuse has been considered they help to raise or lower the possibility. In the past GGT has been discounted as a major mortality risk factor but recent research from insurance laboratories in the USA suggest that it is a better mortality marker than ALT or AST; some of this could be related to alcohol abuse increasing the level of the enzyme. Alcohol markers such as carbohydrate deficient transferrin (CDT) and haemoglobin acetaldehyde (HAA) are extensively used as reflex tests for heavy alcohol use by insurance applicants in North America. The sensitivity of CDT for alcohol problems is about 70% and the false positive rate is about 15% which is not good enough for a population of low prior probability of alcohol abuse. The performance of the HAA is not as good as the CDT but the latter is a better reflex screening test than GGT or HDL cholesterol. Chronic Effects of alcohol There are numerous summaries of the relative risks for individual diseases in the clinical literature for given levels of alcohol intake. That of Corrao et al (1999) is widely quoted; these authors also produced a follow up report in 2004 where their database was extended to publications up until 1998. The table below gives a summary of the relative risks (RRs) for IHD, stroke and various cancers for various levels of average alcohol intake estimated from the 1999 Corrao report by Britton & McPherson (2001) for average alcohol intake up to 50 grams per day. The full list of Corrao et al (1999 & 2004) estimates is too extensive to be reproduced in this paper.

39 Alcohol consumption Disorder None 1 10 g/day* 10 20 g/day 20 30 g/day 30 40 g/day 40 50 g/day IHD men 1 (referent) 0.832 0.778 0.768 0.775 0.793 IHD women 1 0.857 0.853 0.896 0.962 1.047 Colon cancer 1 1.067 1.215 1.384 1.575 1.794 Breast cancer 1 1.039 1.122 1.211 1.308 1.412 Haemorrhagic 1 1.078 1.252 1.455 1.690 1.964 stroke *Midpoint in each category used to calculate relative risks. Taken from Britton A and McPherson K 2001 and based upon Corrao et al, 1999 The relative risk estimates given by Corrao et al, 2004, include measures up to 100g of alcohol per day: RR and 95% CI compared to non-drinkers 25g/day 50g/day 100 g/day RR 95%CI RR 95%CI RR 95%CI Colon 1.05 1.01 1.09 1.1 1.03 1.18 1.21 1.05 1.39 Rectum 1.09 1.09 1.12 1.19 1.14 1.24 1.42 1.30 1.55 Liver 1.19 1.12 1.27 1.4 1.24 1.56 1.81 1.50 2.19 Breast 1.25 1.20 1.29 1.55 1.44 1.67 2.41 2.07 2.80 IHD 0.81 0.79 0.83 0.87 0.84 0.90 1.13 1.06 1.21 Ischaemic 0.9 0.75 1.07 1.17 0.97 1.44 4.37 2.28 8.37 stroke Haemorrhagic 1.19 0.97-1.49 1.82 1.46 2.28 4.7 3.35 6.59 stroke Cirrhosis 2.9 2.71-3.09 7.13 6.35 8.00 26.52 22.26 31.6 An extensive overview on chronic alcohol use and individual diseases was included in the original article. The full version can be obtained from the authors.

40 Summary of the acute adverse effects of alcohol: There is a substantial and verified increase in the risk of trauma and traumatic death and disability as a result of heavy drinking and there is some evidence that even modest intakes reduce reaction times and increase in motor vehicle accident rates. Drowning, sudden cardiac death and dysrhythmia are more common after episodic heavy drinking especially if on a background of low average use of alcohol. However in many cultures, episodes of heavy drinking are common especially in young adults which reduces the discriminatory power of this phenomenon. It is only when alcohol intake either as a high daily intake or a pattern of binge drinking, affects the individual s health and social discourse including the ability to work satisfactorily that an alcohol related problem can be identified. Alcohol syndromes and all cause mortality Insurance studies Alcohol abuse and liver enzymes: results of an intercompany study of mortality (Cliff Titcomb) JIM 2001; 33: 277 289 This is a pooled study of 82262 (after exclusions; 131'394 were originally considered) policies issued between 1989 and 1995 with exposure until the 1997 anniversary. Maximum exposure was 8 years; average 2.5 3 years. The Medical Insurance Bureau (MIB) database was searched for one of 4 diagnostic codes: alcohol use significant to health and longevity; adverse driving record or multiple moving violations; abnormal transaminases; and abnormal GGT. As exposure in females was low (9.5% of claims) the analysis was restricted to males. Because the numbers of those with both abnormal LFTs, and alcohol and/or driving problems were low an analysis of individuals with both was not carried out (it is likely that most of these had been declined an offer of insurance). The basis for expected mortality was the 1990 95 Basic Table (BT). For those men with a rating of either abnormal alcohol use or driving problems (and normal LFTs), a standard rating was associated with a mortality ratio (MR) of 217, a substandard 175- there was no age gradient. Mortality ratios were highest when the face amount was less than $50,000 and in smokers:

41 Smoker status: Actual deaths Expected Deaths MR Unknown 46 15 307% Non- 72 47 153% Smoker Smoker 83 25 332% Total 201 87 231% Although not stated BT 1990-95 had a smoker/non-smoker split so that the expected deaths recorded above are unlikely to be based upon aggregate mortality data. The MIB codes do not correlate absolutely with either of the clinically defined alcohol syndromes but the cases above represent a combination of alcohol abuse and alcohol dependence. Titcomb commented that the observed high MRs with low face amount and smoking probably represented behavioural and socio-economic factors; in addition those with larger sums assured were more likely to be medically scrutinised. These data suggest that the risk in non-smokers is substantially lower than in smokers. Unfortunately there is no age stratification for the alcohol syndromes; but there is an age breakdown for the entire group (abnormal LFTs and alcohol). There was no clear reduction in the MR with increasing age. This may represent a differential pattern of alcohol associated mortality with acute intoxication predisposing to accidental death in the young and chronic alcohol abuse/dependence causing physical and mental disorders in older people. Single Medical Impairment Study (SMIS) and Multiple Medical Impairment Study (MMIS), 1983 Unfortunately there is no smoker / nonsmoker stratification in this dataset and as female exposure to major alcohol misuse is about 4% of the whole, only MR for males were reported. For those rated standard the MR was 208%; for substandard lives the MR was 243%. Alcohol misuse was defined as persons who misused alcohol by regular heavy use, but who are not obvious or admitted alcoholics. A small number of dry former alcoholics were included. The importance of confounding by smoking is suggested by the MRs of 149 and 197 for heart/circulatory disease in the SMIS and MMIS respectively.

42 A trend to reducing MR with age was observed in both studies: Issue age SMIS MMIS 15 29 272% 533% 30 39 282% 380% 40 49 234% 288% 50 59 216% 240% 60 69 147% 206% A further analysis of the SMIS with weighting the combined standard & substandard policies in the ratio of 4 to 1 to reflect the proportions of the insurance issued showed MRs for all durations and ages of 226% in males and 334% in females (Medical Risks: abstract 327). Issue age Males Females 15 39 258% 254% 40 49 228% 280% 50 59 205% 632% 60 69 148% % Total 226 334 Summary insurance studies: The studies are heterogenous and not well defined. Risk estimates vary from no increase to a modest increase in the mortality ratio. Smoking is a confounder which has been poorly controlled for. Clinical studies: Alcohol dependence and alcohol abuse/ harmful use (alcoholism) and mortality have not been extensively studied. The one exception is the alcohol dependent admitted to hospital. Alcohol dependence Although individual studies do not have large numbers of patients these studies show that alcoholics abstaining from alcohol have a lower mortality than those who relapse or continue to drink. All of these studies show a high mortality rate amongst alcoholics. For example Gerdner & Berglund (1997) showed an 8.5 year cumulative mortality of 76% (annualised mortality of 32 per mille) in male alcoholics (average age 41 years) who were treated as inpatients. None of those who abstained from alcohol died during follow up. A similar finding of improved outcomes in treated male alcoholics abstaining (stable abstainers) from alcohol comes from the VA Center in San Diego (Bullock et al, 1992). Stable abstainers had similar 11 year mortality (HR 1.25) as a cohort of age & race matched men from the general population whereas relapsers had a significant mortality ratio of 5.

43 Alcohol abuse Unfortunately, mortality associated with the recently defined syndrome of alcohol abuse/harmful use has not been well studied. In general, clinical studies tend to be based upon average alcohol use rather than the clinical syndromes of alcohol abuse/dependence. Useful reviews of all cause mortality and levels of alcohol use have been carried out by the Australian Institute of Health and Welfare (Single at al, 1999), and by Rehm et al (2003). In addition, White et al, 2002, modelled alcohol consumption and mortality for both sexes by age. A longitudinal study of male doctors in the UK compared lifelong abstainers with quitters (ie controlled for stopping alcohol because of illness which might confound the all cause mortality and disease specific mortality rates) (Doll et al, 2005) and is worth considering as are a mathematical modelling study (Bagnardi et al, 2004), a report from the cancer prevention study in the USA (Thun et al, 1997), There are few studies which investigate the pattern of alcohol intake, intermittent vs binge drinking vs sustained excessive use. An extension of the Whitehall II cohort study (Brit- ton & Marmot, 2004) investigated the pattern of use as did a report from the US National Alcohol survey (Rehm et al, 2001). Mortality Studies based upon the volume of Alcohol Consumption While there is considerable heterogeneity between the studies there is consensus that the all cause mortality risk curve is J shaped in most populations and that the nadir of the J is lowest in populations where the cardiovascular risk is high so that any protective effect of alcohol is higher in men and in older individuals. Episodic heavy drinking despite a low or modest background intake of alcohol also increases the mortality risk. Summary of the clinical mortality studies These are heterogenous but show limited increases in risk up to an intake of 60 g per day in males and 40 g per day in females. Heavy episodic drinking appears to as, if not much more, important than average intake especially in the young with high accident rate and

44 A paper from the same authors showed that the probability of receiving a disability pension and sickness absence in young men is directly related to criminal behaviour and drink driving convica significant increase in mortality which is independent of the average daily consumption. How much of this is already included in the baseline pricing is uncertain but a substantial amount of such risk taking behaviour is. Disability There are few formal studies of levels of alcohol intake and disability rates. Both the alcohol syndromes are defined in disability terms so that the presence of these equates to a diagnosis of disability. Upmark et al (1999) found that increasing levels of alcohol intake were associated with higher rates of disability pension uptake and more days off work. Their study was based upon data from the Stockholm Health of the Population Study and used 3 different measures of alcohol habits: usual alcohol consumption, consumption during the previous week, and answers to the four CAGE questions on problem drinking. Information from the health survey and data from a subsequent health examination were related to information from the National Swedish Social Insurance Board for the year 1984 and the years 1986 to 1991 concerning sick leave and disability pensioning. The study population was aged 20 to 52 years in 1984 and comprised 985 women and 870 men fulfilling the criteria for inclusion out of 6217 subjects aged 18 years and over randomly drawn. In both sexes, a consistent pattern of increased sickness absence was seen for high alcohol consumers and for those with indications of problem drinking. In most comparisons, a clearly increased relative risk, although not always statistically significant, for an average of at least 60 sick days per year or for a disability pension during follow up was found. In multivariate analysis, controlling for age, socioeconomic group, smoking habits, and self reported health, a small reduction in the relative risks was found, suggesting that these factors could explain only a small part of the relative risks. The risks for abstainers were higher than for low and moderate consumers.

45 tions. In bivariate regression analysis, drink driving implied a relative risk (RR) of a disability pension/high sickness absence of 3.4 (95% CI: 2.8 4.1), and criminality a RR of 3.6 (95% CI: 3.1 4.1). In multivariate logistic regression analysis, controlling for psychosocial factors from conscription and for criminality, drink driving remained a strong predictor (RR 2.1, 95% CI: 1.7 2.7) (Upmark et al, 1999). Conclusion The risk associated with alcohol excess is complex, heterogenous and difficult to quantify. Alcohol use is almost ubiquitous and in some cultures heavy episodic drinking (binge drinking) is common. Furthermore there are social benefits as well as health benefits such as a lower incidence of IHD so that the background levels of risk are impor- tant. However excessive use of alcohol is an important cause or mortality and morbidity. The syndrome of alcohol dependence is now well established but the disorder may go unrecognised. Using self reported alcohol intake can be unreliable and the diagnosis of alcohol abuse/harmful use is often one of inference. However, despite these difficulties broad conclusions about the risks associated with alcohol excess can be made. The choice of comparator is of interest. Traditionally the reference group has been abstainers but except in some societies abstention from alcohol is uncommon and the nadir of mortality and morbidity risk is about to 10 g alcohol per day especially if the incidence of cardiovascular disease is high. Abstainers are not representative of the insured or general population.

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