摘要：Objectives. We investigated Black–White differences in the association between average alcohol drinking patterns and all-cause mortality. Methods. We pooled nationally representative samples of 152 180 adults in the National Health Interview Survey from 1997 to 2002 with mortality follow-up through 2006. Usual drinking days per week and level of alcohol consumed per day were based on self-report. We used race- and gender-specific Cox proportional hazards regression analyses to adjust for physical activity, smoking status, and other potential confounders. Results. Over 9 years, 13 366 deaths occurred from all causes. For men, the lowest multivariable-adjusted hazard ratio (HR) for total mortality among drinkers was 0.81 among White men who consumed 1 to 2 drinks 3 to 7 days per week (compared with abstainers) and Black men who abstained. For women, the lowest mortality risk was among White women (HR = 0.71) consuming 1 drink per day 3 to 7 days per week and Black women (HR = 0.72) consuming 1 drink on 2 or fewer days per week. Conclusions. Risks and benefits of alcohol consumption in relation to mortality risk were dependent on race- and gender-specific drinking patterns. Alcohol consumption is associated with both harmful and beneficial health effects. For instance, alcohol intake at or above moderation is associated with increased breast cancer risk, liver disease, violence, drowning, and injuries from falls and motor vehicle crashes. 1 However, at moderate levels of consumption, alcohol is associated with a lower risk of type 2 diabetes and coronary heart disease 2 and with survival benefits among middle-aged and older adults. 3 Consuming alcohol in moderation may also help maintain cognitive function during the aging process. 4 Potential biological mechanisms by which moderate alcohol consumption may be beneficial to certain health outcomes such as coronary heart disease are thought to be through the direct effects of ethanol, which may increase high-density lipoprotein cholesterol in addition to being antiatherogenic, anti-inflammatory, antithrombotic, and an insulin-sensitizing agent. 5–9 Previous research has been conducted largely among US Whites or European populations, and whether alcohol in moderation yields comparable health and survival benefits among Blacks is unclear. Few previous studies have included a sufficient number of Black participants, 10–16 which may have contributed to the lack of power to investigate interactions of race with the alcohol–mortality or cardiovascular disease relationship. A prospective study of all-cause mortality using data from the first National Health and Nutrition Examination Survey did not find evidence of an inverse association among Blacks, 14 whereas a separate analysis in the same sample found a benefit for Whites. 17 An analysis of coronary heart disease incidence in the Atherosclerosis Risk in Communities Study also found a differential association by race among men, with a positive relationship between average alcohol intake and coronary heart disease risk for Blacks and an inverse relation for Whites. 10 Kerr et al. 18 found an inverse association for moderate alcohol consumption compared with lifetime abstainers only among Whites in the 1984 and 1995 National Alcohol Surveys. Last, in a prospective analysis of cardiovascular mortality using data from the National Health Interview Survey (NHIS), Mukamal et al. 13 reported significantly lower risk among light and moderate drinkers compared with abstainers among non-Hispanic Whites, but no significant benefit among the combined racial/ethnic minority populations. Although most studies have been conducted among Europeans or White Americans, some data have suggested that Blacks (men, in particular) do not experience the apparent cardioprotective effect of alcohol. 10,12,14,16 For instance, Fuchs et al. 11 found that low to moderate alcohol consumption increased risk of hypertension among 512 Black men in the CARDIA study. Polymorphisms in the gene that encodes one of the alcohol dehydrogenase isoforms (ADH1B) appear to confer different rates of ethanol metabolism and have a substantially different genotype distribution between Blacks and Whites. 19,20 Previous studies have found the alcohol-metabolizing ADH1B*3 functional polymorphism—found almost exclusively in populations with African ancestry and with a frequency of up to 33% —to be associated with a 70 to 80 times higher conversion rate of ethanol to acetaldehyde, reduced alcohol dependence, lower fetal alcohol syndrome rates, and increased liver cirrhosis risk. 20–24 However, Blacks are more likely to have health conditions (e.g., hypertension, type 2 diabetes, chronic kidney disease) that are exacerbated by heavy or episodic alcohol drinking. 25–27 The social and physical environmental contexts for drinking also influence patterns of drinking (e.g., bingeing) and the types of alcohol consumed, but context has been less studied in epidemiological studies of drinking and health across race. Investigators have raised the question of whether the cardioprotective effect of alcohol is real or confounded by varying lifestyle characteristics between drinkers and nondrinkers whereby moderate drinkers may be more affluent and have health behaviors that would reduce their mortality risk regardless of moderate alcohol consumption. 28,29 Moreover, the contrasting findings of previous research conducted mainly among White and Black men have also contributed to this concern. To address these issues, we investigated whether there were Black–White differences between both men and women from a large nationally representative survey in the relationship between alcohol consumption and all-cause mortality. We also explored differences in sociodemographic characteristics between Blacks and Whites to provide insights into the likelihood that social integration (the set of arrangements adopted by a society to accept new members) explains differences in apparent benefits. The extent to which moderate drinkers are more socially integrated than either abstainers or excessive drinkers may help explain whether moderate drinkers experience health benefits from alcohol consumption or whether they appear healthier because of indirect factors associated with being socially integrated, such as psychological and physical well-being enhanced through health behaviors (as one pathway) that affect health outcomes.
