title: Alcohol consumption and cardiovascular disease, cancer, injury, admission to hospital, and mortality: a prospective cohort study.
abstract: BACKGROUND
  Alcohol consumption is proposed to be the third most important modifiable risk factor for death and disability. However, alcohol consumption has been associated with both benefits and harms, and previous studies were mostly done in high-income countries. We investigated associations between alcohol consumption and outcomes in a prospective cohort of countries at different economic levels in five continents.
  
  
  METHODS
  We included information from 12 countries participating in the Prospective Urban Rural Epidemiological (PURE) study, a prospective cohort study of individuals aged 35-70 years. We used Cox proportional hazards regression to study associations with mortality (n=2723), cardiovascular disease (n=2742), myocardial infarction (n=979), stroke (n=817), alcohol-related cancer (n=764), injury (n=824), admission to hospital (n=8786), and for a composite of these outcomes (n=11,963).
  
  
  RESULTS
  We included 114,970 adults, of whom 12,904 (11%) were from high-income countries (HICs), 24,408 (21%) were from upper-middle-income countries (UMICs), 48,845 (43%) were from lower-middle-income countries (LMICs), and 28,813 (25%) were from low-income countries (LICs). Median follow-up was 4.3 years (IQR 3.0-6.0). Current drinking was reported by 36,030 (31%) individuals, and was associated with reduced myocardial infarction (hazard ratio [HR] 0.76 [95% CI 0.63-0.93]), but increased alcohol-related cancers (HR 1.51 [1.22-1.89]) and injury (HR 1.29 [1.04-1.61]). High intake was associated with increased mortality (HR 1.31 [1.04-1.66]). Compared with never drinkers, we identified significantly reduced hazards for the composite outcome for current drinkers in HICs and UMICs (HR 0.84 [0.77-0.92]), but not in LMICs and LICs, for which we identified no reductions in this outcome (HR 1.07 [0.95-1.21]; pinteraction<0.0001).
  
  
  CONCLUSIONS
  Current alcohol consumption had differing associations by clinical outcome, and differing associations by income region. However, we identified sufficient commonalities to support global health strategies and national initiatives to reduce harmful alcohol use.
  
  
  BACKGROUND
  Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, GlaxoSmithKline, Novartis, King Pharma, and national or local organisations in participating countries.
authors.affiliation: Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Health Research Board Clinical Research Facility Galway, National University of Ireland Galway, Galway, Ireland. Electronic address: andrew.smyth@phri.ca.
authors.forename: Andrew
authors.initials: A
authors.lastname: Smyth
authors.affiliation: Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.
authors.forename: Koon K
authors.initials: KK
authors.lastname: Teo
authors.affiliation: Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.
authors.forename: Sumathy
authors.initials: S
authors.lastname: Rangarajan
authors.affiliation: Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Health Research Board Clinical Research Facility Galway, National University of Ireland Galway, Galway, Ireland.
authors.forename: Martin
authors.initials: M
authors.lastname: O'Donnell
authors.affiliation: Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.
authors.forename: Xiaohe
authors.initials: X
authors.lastname: Zhang
authors.affiliation: Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.
authors.forename: Punam
authors.initials: P
authors.lastname: Rana
authors.affiliation: Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.
authors.forename: Darryl P
authors.initials: DP
authors.lastname: Leong
authors.affiliation: Institut Universitaire de Cardiologie et de Pneumologic de Quebec, Universitaire Laval, Quebec City, QC, Canada.
authors.forename: Gilles
authors.initials: G
authors.lastname: Dagenais
authors.affiliation: Facultad de Medicina, Universidad de La Frontera, Manuel Montt, Chile.
authors.forename: Pamela
authors.initials: P
authors.lastname: Seron
authors.affiliation: Sahlgrenska University Hospital and Östra Hospital, Diagnosvägen, Göteburg, Sweden.
authors.forename: Annika
authors.initials: A
authors.lastname: Rosengren
authors.affiliation: Hypertension in Africa Research Team (HART) and MRC Research Unit on Hypertension and Cardiovascular Disease, North-West University, Potchefstroom, South Africa.
authors.forename: Aletta E
authors.initials: AE
authors.lastname: Schutte
authors.affiliation: Research Insitute, Fundacion Oftalmologica de Santander, Medical School, University of Santander, Floridablanca, Bucaramanga, Colombia.
authors.forename: Patricio
authors.initials: P
authors.lastname: Lopez-Jaramillo
authors.affiliation: Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey.
authors.forename: Ayetkin
authors.initials: A
authors.lastname: Oguz
authors.affiliation: Physiology Department, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe.
authors.forename: Jephat
authors.initials: J
authors.lastname: Chifamba
authors.affiliation: Estudios Clínicos Latinoamérica, Rosario, Argentina.
authors.forename: Rafael
authors.initials: R
authors.lastname: Diaz
authors.affiliation: Faculty of Health Sciences, Simon Fraser University, Vancouver, BC, Canada.
authors.forename: Scott
authors.initials: S
authors.lastname: Lear
authors.affiliation: Dante Pazzanese Institute of Cardiology, São Paulo, Brazil.
authors.forename: Alvaro
authors.initials: A
authors.lastname: Avezum
authors.affiliation: Postgraduate Institute of Medical Education and Research, School of Public Health, Chandigarh, India.
authors.forename: Rajesh
authors.initials: R
authors.lastname: Kumar
authors.affiliation: Madras Diabetes Research Foundation, Madras, India.
authors.forename: Viswanathan
authors.initials: V
authors.lastname: Mohan
authors.affiliation: Department of Internal Medicine, Wroclaw Medical University & 4th Military Hospital in Wroclaw, Wroclaw, Poland.
authors.forename: Andrzej
authors.initials: A
authors.lastname: Szuba
authors.affiliation: National Center for Cardiovascular Diseases, Cardiovascular Academy of Medical Sciences, Beijing, China.
authors.forename: Li
authors.initials: L
authors.lastname: Wei
authors.affiliation: National Center for Cardiovascular Diseases, Cardiovascular Academy of Medical Sciences, Beijing, China.
authors.forename: Wang
authors.initials: W
authors.lastname: Yang
authors.affiliation: National Center for Cardiovascular Diseases, Cardiovascular Academy of Medical Sciences, Beijing, China.
authors.forename: Bo
authors.initials: B
authors.lastname: Jian
authors.affiliation: European Centre on Health of Societies in Transition, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Martin
authors.initials: M
authors.lastname: McKee
authors.affiliation: Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.
authors.forename: Salim
authors.initials: S
authors.lastname: Yusuf
mesh_terms: D000328:Adult; D000368:Aged; D000428:Alcohol Drinking / Q000453:epidemiology*; D002318:Cardiovascular Diseases / Q000453:epidemiology*; D015331:Cohort Studies; D019049:Developed Countries; D003906:Developing Countries; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000453:epidemiology*; D016016:Proportional Hazards Models; D014947:Wounds and Injuries / Q000453:epidemiology*