Alcohol and chronic diseases: complex relations. Guillemont J. Conference on Cardiovascular Diseases (Madrid: Ministry of Health and Social Policy; 2010).

1. Alcohol and chronic diseases:
complex relations
Juliette Guillemont, Alcohol Programme Coordinator
National Institute for Prevention and Health Education
(Inpes, France)
Conference on cardiovascular diseases
Madrid, 18 February 2010

2. 2
• Alcohol and cancer
• Alcohol and CVD
• Alcohol and chronic diseases in public
health policies

3. 3
Alcohol and cancer: the fruit of
collective expertise (1/2)
• WHO International Agency for Research on
Cancer (IARC) monographs:
– 1988: Alcohol drinking
– 1999: Acetaldehyde
– 2007: Ethanol in alcoholic beverages
• World Cancer Research Fund (WCRF) and
American Institute for Cancer Research
(IARC):
– 1st report on food, nutrition and the prevention of
cancer in 1997
– 2nd report in 2007

4. 4
Alcohol and cancer: the fruit of
collective expertise (2/2)
• IARC (Monograph n°96, to be published)
– Alcoholic beverages and ethanol in alcoholic
beverages are carcinogenic to humans (Group 1)
– Causal link between alcohol consumption and the
occurrence of malignant tumours of the oral cavity,
pharynx, larynx, oesophagus, liver, colorectum, and
female breast
• WCRF/AICR:
– Increase of the risk of several cancers: UADT
(mouth, pharynx, larynx, oesophagus), colon-
rectum, breast, liver
– No threshold observed
– No significant difference depending on the type of
drink

5. 5
Alcohol and CVD: what we
know about harmful effects
• Alcohol:
– raises blood pressure and increases the risk of
hypertension in a dose dependent manner
– increases the risk of haemorrhagic stroke
• Episodic heavy drinking:
– is an important risk factor for both ischaemic and
haemorrhagic stroke
– increases the risk of heart arrhythmias and of
sudden coronary death
Anderson & Baumberg, 2006

6. 6
Alcohol and hypertension
Relative risks of hypertension by alcohol intake
(Corrao et al., 1999 in Anderson & Baumberg, 2006)

7. 8
Alcohol and coronary heart
disease (1/2)
• J curve:
– Alcohol in low doses (< 20g/day) reduces the risk of
coronary heart disease
– High doses increase the risk
• Plausible biochemical basis:
– Alcohol consumption raises levels of HDL cholesterol,
which removes fatty deposits in blood vessels
– Moderate alcohol intake favourably affects blood
clotting profiles
– Independant of beverage type
Anderson & Baumberg, 2006

8. 9
Alcohol and coronary heart
disease (2/2)
Dose response relationship between reported alcohol consumption
and the relative risk of CHD obtained by pooling 28 higher quality
cohort studies (Corrao et al., 2000 in Anderson & Baumberg, 2006)

9. 10
Alcohol and coronary heart disease
Alternative explanations
• Abstainers include people who have reduced
or stopped drinking, due to ageing and ill
health
– Error-free studies find no significant protection
• Unhealthier lifestyle in abstainers
– Diet, physical activity, smoking
– Education, income, mental health etc.
Anderson & Baumberg, 2006

10. 11
Alcohol and coronary heart disease
Alternative explanations
Risk of death from CHD according to reference groups
Stockwell et al., 2007
Type of study Number OR
p
Men ≤ 44 g/day All studies together 32 0.845 < 0.0001
Lifelong abstainers + ex-drinkers + occasional drinkers 24 0.792 < 0.0001
Lifelong abstainers + ex-drinkers 6 0.892 NS
Lifelong abstainers 2 1.11 NS
Women ≤ 24 g/day All studies together 13 0.792 < 0.0001
Lifelong abstainers + ex-drinkers + occasional drinkers 9 0.888 < 0.02
Lifelong abstainers + ex-drinkers 3 0.749 < 0.05
Lifelong abstainers 1 0.779 NS

11. 12
What about the French paradox?
• The French paradox was born in 1981
• France vs. Nordic countries:
– Lower coronary heart mortality
– Similar levels of saturated fat intake
• Proposed explanation: high wine
consumption

12. 13
What about the French paradox?
Alternative explanations
• Underestimate of coronary heart disease
– Coronary heart death in MONICA study >> national
statistics
– No French specificity: rates of coronary events in
French regions are similar to those in regions of
other countries but of similar latitude (North-South
gradient)
• Misestimate of lipid intake
– MONICA study: eating habits in France are healthier
than in Nordic countries

13. 14
What about the French paradox?
Alternative explanations
Mean standard rates of coronary events and coronary deaths in
MONICA and coronary deaths according to national satistics in 8
countries (men 35-64; 1985-1994). Source: MONICA
Coronary mortality
Coronary events
national
(MONICA)
MONICA
statistics
UK (Belfast + Glasgow)
736
322
306
Finland (Kuopio + Karelia + Turku)
701
329
319
Belgium (Ghent + Charleroi)
417
199
117
Germany (Augsburg + Bremen + East)
339
174
139
France (Lille + Strasbourg + Toulouse)
274
134
74
Italy (Brianza + Friuli)
266
112
101
Switzerland (Vaud/Fribourg + Ticino)
261
91
89
Spain (Barcelona)
210
76
63

14. 17
Disease burden
attributable to alcohol
Deaths attributable to alcohol consumption in the world in 2002
(WHO, 2007)
% of deaths as a proportion of the
Number of deaths (thousands) deaths attributable to the disease
Disease category
categories listed
Males Females Total Males Females Total
Deaths caused
Maternal and perinatal conditions (low birth
weight) 1 1 3 0,1 0,3
0,1
Cancer 361 105 466 18,7 25,0
19,8
Diabetes mellitus 0 1 1 0,0 0,2
0,0
Neuropsychiatric disorders 106 25 130 5,5 5,9
5,5
Cardiovascular diseases 452 77 528 23,3 18,2
22,4
Cirrhosis of the liver 293 77 370 15,2 18,2
15,7
Unintentional injuries 501 96 597 25,9 22,7
25,3
Intentional injuries 220 40 260 11,4 9,6
11,1
Total “detrimental effects” attributable to alcohol 1 934 421 2 355 100,0 100,0
100,0
Deaths prevented
Diabetes mellitus -8 -5 -12 7,7 3,5 5,3
Cardiovascular diseases -90 -130 -220 92,3 96,5 94,7
Total “beneficial effects" attributable to alcohol -98 -135 -232 100,0 100,0 100,0
All alcohol-attributable net deaths 1 836 287 2 123 100,0 100,0 100,0
All deaths 29 891 27 138 57 029
Net deaths attributable to alcohol as a
percentage of all deaths 6,1% 1,1% 3,7%

15. 18
Who would like to take
care of their heart with a
carcinogenic product?

16. 19
Chronic diseases in
French public health policies
• Action plan to enhance quality of life in
patients with chronic diseases
• Action plans for specific chronic diseases:
cancer, Alzheimer disease, rare diseases etc.
• No specific strategy for CVD:
– Actions plans on CVD determinants: nutrition &
physical activity, addictions etc.
– Generate less fear than other diseases?
– Alleged low level of cardiovascular mortality

17. 20
Alcohol in
French public health policies
• Alcohol is addressed in various action plans:
– Prevention and treatment of addictions
– Government plan against drug and drug addiction
– Youth health
– Cancer
– National Nutrition & Health Programme
• No comprehensive strategy on alcohol but 2
objectives:
– To decrease mean alcohol consumption
– To decrease the incidence of hazardous and harmful
drinking

18. Effectiveness of alcohol policies
Adapted from Babor et al., 2003