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Nondrinker Mortality Risk in the United States

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Abstract

The literature has shown that people who do not drink alcohol are at greater risk for death than light to moderate drinkers, yet the reasons for this remain largely unexplained. We examine whether variation in people’s reasons for nondrinking explains the increased mortality. Our data come from the 1988–2006 National Health Interview Survey Linked Mortality File (N = 41,076 individuals age 21 and above, of whom 10,421 died over the follow-up period). The results indicate that nondrinkers include several different groups that have unique mortality risks. Among abstainers and light drinkers the risk of mortality is the same as light drinkers for a subgroup who report that they do not drink because of their family upbringing, and moral/religious reasons. In contrast, the risk of mortality is higher than light drinkers for former drinkers who cite health problems or who report problematic drinking behaviors. Our findings address a notable gap in the literature and may inform social policies to reduce or prevent alcohol abuse, increase health, and lengthen life.

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Notes

  1. Underage drinking can contribute to increased risk of death through a number of specific causes including alcohol poisonings and external causes (accidents, suicides, and homicides), may set the stage for abuse in later years, and may impart additional mortality risks because it is illegal. Thus, we distinguish underage drinkers from those who are of legal drinking age.

  2. Some studies show that individuals underreport their drinking on surveys (Chikritzhs et al. 2009). Underreporting that is minor and that does not change the drinking category to which respondents are assigned will not affect our hazard ratios. But, if current drinkers report that they are abstainers, infrequent drinkers, or former drinkers, then the hazard ratios for nondrinkers will be biased.

  3. Separate analyses (not shown) that compare drinking quantity and drinking frequency as separate measures find similar results to those presented herein. Further, some studies have demonstrated that occasional binge drinking (usually defined as drinking 5 or more drinks on at least one occasion) is associated with higher risks of death, even among regular lower volume light drinkers (Chikritzhs et al. 2009). But controlling for binge drinking had a negligible effect on our results (not shown), which is consistent with findings from other studies (Fuller 2011; Mukamal et al. 2010). For parsimony and to follow standard practice, we do not show these additional models.

  4. We tested for but did not find improved model fit (based on the Bayesian Information Criterion) when including interactions between sex and the drinking/nondrinking statuses in the all-cause and cause-specific models. Because our results were substantively identical for men and women, we do not stratify our models by sex (for similar results, see Fuller 2011).

  5. Our results for those who were in good or better health at the time of the interview were similar to results for those who were free of activity limitations at the time of the interview (results not shown). We used SRH rather than activity limitation because SRH is a better global measure of health status (Jylhä 2011), and is consistent with other studies (Fuller 2011). The data also include information on whether the respondent ever had such health conditions as hypertension, heart disease, diabetes, diseases of the liver, cancer, or alcoholism (Adams and Hardy 1989). But these individual health conditions do not add any additional insight in our full models after we exclude those in fair or poor SRH. In addition, exercise may be associated with drinking and mortality, but the 1988 survey does not provide information on physical activity. However, the inclusion of BMI and SRH should capture some of the influence of exercise on mortality.

  6. Codes U01-U03 are preceded by an asterisk to indicate that they vary from the International Classification of Diseases because they include suicides and homicides due to acts of terrorism (Miniño et al. 2011).

  7. We use Cox proportional hazard models because they do not require us to make an assumption about the shape of the baseline hazard function. Separate tests (not shown) find that our drinking and nondrinking variables—our key predictors—meet the proportional hazards assumption. But control variables including black and other race, current smoking, widowed, never married, education, income, body mass, and Midwest region do not meet the proportional hazards assumption in our full model. As a result, the hazard ratios for those control variables represent the average effect of each covariate on mortality, across respondents’ age (Allison 1984). We follow the recommendation of the National Center for Health Statistics (2010) and adjust for the complex survey design employed by the NHIS, and include the sample weights to ensure our results are representative of the U.S. population. Separate analyses (not shown) that exclude the sample weights find results that are virtually identical to those shown herein.

  8. Although the labels we devise for the latent class categories are ultimately arbitrary, we sought to describe the underlying orientations that might drive the patterns of reasons for nondrinking that emerge in our LCA categories.

  9. Cause-specific analyses (not shown) for the full sample find similar results as those in Table 3 that include only those in good or better health. Models that use the full sample find more statistically significant results, both due to the larger sample size and because health may mediate the relationship between drinking status and mortality. However, the reduced risk for cancer mortality for family prosocial abstainers in Table 3 is not significant in the full sample.

  10. We cannot parse out whether drinking and smoking are independent, which is what the hazard model assumes, or whether drinking precipitates or sustains smoking (see Kozlowski and Ferrence 1990). The mortality risk for current drinkers declines with controls for smoking (compare Models 1 and 2 in Table 2), which suggests that the mortality risk of current drinkers, including light drinkers, is overstated (if smoking and drinking are independent). On the other hand, if smoking triggers or encourages drinking, then controls for smoking may underestimate the true mortality effect of drinking. Notably, Table 1 shows that the highest rates of former smoking are among former drinkers, suggesting that adults may quit smoking and drinking at the same time or for similar reasons.

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Acknowledgments

We thank the Eunice Kennedy Shriver NICHD-funded University of Colorado Population Center (grant R24 HD066613) for administrative and computing support; the National Center for Health Statistics (NCHS) for collecting the data and making the linked files available to the research public; and the anonymous reviewers for helpful comments and suggestions. Earlier versions of this manuscript were presented at the 2012 Population Association of America annual meetings in San Francisco, California, May 3–5, and to the Rice University Department of Sociology and Kinder Institute for Urban Research, and the University of Houston Center for Drug and Social Policy Research, September 21, 2011. The content of this manuscript is solely the responsibility of the authors and does not necessarily represent the official views of NIH, NICHD, or NCHS.

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Authors and Affiliations

  1. Department of Sociology and Population Program, IBS, University of Colorado Boulder, 483 UCB, Boulder, CO, 80309-0483, USA

    Richard G. Rogers, Elizabeth M. Lawrence & Robert Kemp

  2. Department of Health and Behavioral Sciences, University of Colorado Denver, Denver, CO, USA

    Patrick M. Krueger & Richard Miech

  3. Department of Sociology, University of Colorado Denver, Denver, CO, USA

    Patrick M. Krueger

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  1. Richard G. Rogers
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Correspondence to Richard G. Rogers.

Appendix

Appendix

Response categories for any reason and primary reason for abstention, lifetime infrequency, or not having drank 12 drinks in the last year

Based on the previous responses, interviewers handed abstainers and infrequent drinkers a card before asking the reasons for not drinking (or not drinking very much, or not drinking in the previous year). First, the interviewer stated, “Please look at this list and tell me, what are your reasons for not drinking/not drinking very much/not drinking since (previous year)?” Once the interviewer obtained all of the responses, s/he asked “Of the reasons you have just told me, which of these is your MOST IMPORTANT reason for not drinking/not drinking very much/not drinking since previous year?” The reasons are listed verbatim below.

  1. 1.

    Don’t socialize very much

  2. 2.

    Don’t care for it or dislike it

  3. 3.

    Am an alcoholic

  4. 4.

    Thought I might become an alcoholic

  5. 5.

    Had problems with my drinking

  6. 6.

    Have a responsibility to my family

  7. 7.

    Family member an alcoholic or problem drinker

  8. 8.

    Medical or health reasons

  9. 9.

    Religious or moral reasons

  10. 10.

    Brought up not to drink

  11. 11.

    Makes me sick

  12. 12.

    Can’t control my drinking

  13. 13.

    Costs too much or can’t afford it

  14. 14.

    Dieting or too fattening

  15. 15.

    Other

  16. 16.

    DK

Source: NCHS 1989.

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Rogers, R.G., Krueger, P.M., Miech, R. et al. Nondrinker Mortality Risk in the United States. Popul Res Policy Rev 32, 325–352 (2013). https://doi.org/10.1007/s11113-013-9268-7

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