Alcohol consumption has been causally related to more than 60 disease categories in the International Statistical Classification of Diseases and Related Health Problems
, Tenth Revision (1
), and most of these associations depend on the volume of alcohol consumed, often measured as average volume per day. Although the dose-response associations for the different outcome categories are different (3
), they all share the problem of finding the appropriate control group for the effect of volume of drinking. Many early publications based the dose-response curves on using current abstainers as a comparison group (4
This procedure has been heavily criticized, most influentially in the area of cardiovascular epidemiology and with respect to the cardioprotective benefits (5
), but of course the argument brought forward applies equally to other dose-response associations. The core of the criticism is based on the heterogeneity of abstainers as a control group: there are at least 2 very distinct groups of abstainers—former drinkers, many of whom had given up drinking for health reasons; and long-term or even lifetime abstainers (6
). For both groups, associations with health outcomes are different. For example, in a recent series of meta-analyses on alcohol consumption and all-cause mortality, Gmel et al. (7
) found that the mortality risk for former drinkers compared with lifetime abstainers was 44% higher for women (95% confidence interval: 28, 61) and 21% higher for men (95% confidence interval: 10, 32). Thus, former drinkers had a higher mortality risk than lifetime abstainers, and both had a higher risk than light drinkers, who benefitted from the cardioprotective effect of alcohol on ischemic disease.
As a reason for the higher risk for former drinkers, the “sick-quitter” hypothesis has been proposed: many people stop consuming alcohol because of health reasons (5; refer to the Discussion section below). Regarding morbidity, Lown et al. (8
) found that 52% of lifetime drinkers now abstaining who reported prior loss of control of drinking (i.e., alcohol dependence) indicated health harms categorized as involving “internal organs” versus only 2.5% of current abstainers who never had loss-of-control symptoms (P
< 0.0001), an indication of the inclusion, among quitters, of many with serious health conditions.
On the basis of these considerations, lifetime abstainers have often been recommended as the control group in alcohol epidemiology (9
). However, what do we know about the stability and validity of this group? Previous research indicates that there may be substantial inconsistency in self-reports of lifetime abstention. An analysis considering 2 measurements 10 years apart in the First National Health and Nutrition Examination Survey found that 45% of men and 33% of women who reported never having at least 12 drinks in 1 year at time 2 had reported drinking at time 1, although 68% of these subjects reported very light drinking consistent with the question asked (10
). In a British longitudinal study with 5 measurements over the ages of 16–45 years, more than half of those reporting never drinking at age 45 years had reported at least some drinking in the past (11
). This study also found that many of those who reported being occasional-only drinkers had reported drinking more regularly in previous assessments.
The present article provides further insight into lifetime abstention using baseline and 2 follow-ups of a nationally representative alcohol survey in the United States. Specifically, the following 5 questions will be answered: 1) What is the measurement error for self-reported lifetime abstention? 2) What had been the previous drinking status of people who erroneously reported lifetime abstention in the second follow-up? 3) What was the chance of starting to drink for people reporting lifetime abstention at baseline? 4) How different were people who consistently reported lifetime abstention compared with the rest of the population? and 5) What is the potential impact of misclassification on alcohol-attributable mortality?