Background High average daily consumption of alcohol has been associated with elevated mortality risk, but more moderate consumption, relative to abstinence, has been associated with reduced mortality risk. However, average daily consumption can be complicated to assess, limiting its usefulness both in research and clinical practice. There are also concerns that average consumption fails to capture the risk associated with certain drinking patterns, such as heavy episodic drinking. The current study assessed mortality associated with drinking pattern, operationalized as the frequency of both heavy and non-heavy drinking occasions. Methods Data from the 1997 – 2001 administrations of the National Health Interview Survey (NHIS; n = 128 203) were paired with the current release of the NHIS Linked Mortality Files, which provided mortality follow-up data through the end of 2006. We estimated the impact of drinking pattern on all-cause mortality, operationalized as the frequency of heavy (5+ drinks) and non-heavy (less than 5 drinks) drinking occasions. Other covariates in the model included survey wave, sex, age, race/ethnicity, ratio of family income to poverty threshold, educational attainment, BMI and smoking status. Results Over a third of past-year drinkers reported heavy drinking. Mortality risk increased steadily as heavy drinking frequency increased; daily heavy drinkers exhibited an almost two-fold risk of death compared to abstainers (p < 0.001). Regular non-heavy drinking was associated with decreased mortality, similar to the “J-shaped curve” highlighted in past research on alcohol mortality; this potential protective effect peaked around 2 non-heavy occasions per week. Conclusions Any heavy drinking likely elevates mortality risk, and substantial health benefits could be realized by reducing heavy drinking occasions or limiting overall drinking. Heavy and non-heavy drinking frequency are valid targets for clinical screening and could be helpful in assessing risk and promoting less harmful drinking behavior.

Background The minimum legal drinking age (MLDA) of 21 has been associated with a number of benefits compared to lower MLDAs, including long-term effects, such as reduced risk for alcoholism in adulthood. However, no studies have examined whether MLDA during young adulthood is associated with mortality later in life. We examined whether individuals exposed to permissive MLDA (< 21) had higher risk of death from alcohol-related chronic disease compared to those exposed to the 21 MLDA. Because prior work suggests that MLDA affects college students differently, we also conducted conditional analyses based on ever having attended college. Methods Data from the 1990 through 2010 U.S. Multiple Cause of Death files were combined with data on the living population and analyzed. We included individuals who turned 18 during the years 1967 to 1990, the period during which MLDA varied across states. We examined records on death from several alcohol related chronic diseases, employing a quasi-experimental approach to control for unobserved state characteristics and stable time trends. Results Individuals who reported any college attendance did not exhibit significant associations between MLDA and mortality for the causes of death we examined. However, permissive MLDA for those who never attended college was associated with 6% higher odds for death from alcoholic liver disease, 8% higher odds for other liver disease, and 7% higher odds for lip/oral/pharynx cancers (OR = 1.06, 95% CI [1.02, 1.10]; OR = 1.08, 95% CI [1.02, 1.14]; OR = 1.07, 95% CI [1.03, 1.12], respectively). Conclusions The 21 MLDA likely protects against risk of death from alcohol-related chronic disease across the lifespan, at least for those who did not attend college. This is consistent with other work that shows that the long-term association between MLDA and alcohol-related outcomes is specific to those who did not attend college.