SEARCHCROSS-SECTIONALpublic_health, epidemiology

cross-sectional·public_health, epidemiology, oncology, cardiology, endocrinology, gastroenterology, nutrition·PMC10030531

Alcohol consumption: context and association with mortality in Switzerland

European Journal of Nutrition · 5 authors, 4 centres

AI SUMMARY

FIDELITY 100%

POPULATIONSwiss adults aged 18-75 years from the menuCH national nutrition survey (n=2057) combined with Swiss mortality data 2015-2018

INTERVENTIONAlcohol consumption categorized into six groups: abstainer, safe_no (occasional), safe_during, safe_outside, heavy_during, heavy_outside mealtime drinking, based on EKAL thresholds (12 g/day women, 24 g/day men)

COMPARISONOccasional drinkers (safe_no) as reference group versus all other alcohol consumption categories

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TL;DR

This Swiss cross-sectional study linked alcohol consumption data from the menuCH survey (n=2057) with district-level mortality data to examine associations between amount and context of drinking and non-communicable disease mortality. Higher mortality rates were detected among drinkers versus non-drinkers for all-cancer (RR 1.01–1.07) and upper aero-digestive tract (UADT) cancer (RR 1.15–1.20), with outside mealtime drinking particularly linked to liver cancer, UADT cancer, and diabetes mortality. The findings support the absence of a safe alcohol consumption level and highlight risk groups and geographic districts that should be targeted by Swiss alcohol-prevention schemes.

Full summary

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## Background Non-communicable diseases (NCDs) are the leading cause of death globally, with alcohol consumption being a major modifiable risk factor. The International Agency for Research on Cancer classifies alcohol as a Group 1 carcinogen, with sufficient evidence for cancers of the oral cavity, pharynx, larynx, upper digestive tract, esophagus, colorectal, liver, bile duct, and breast. In Switzerland, 8.4% of all deaths among people aged 15-74 years in 2017 were attributable to alcohol. The Swiss Federal Commission for Alcohol Issues (EKAL) recommends a maximum daily intake of 12 g of pure alcohol for women and 24 g for men. Prior evidence suggested not only the amount but also the drinking context (during versus outside mealtime) may influence NCD risk, with outside mealtime drinking potentially more harmful.

## Methods This study combined three data sources at the Swiss district level: the cross-sectional menuCH National Nutrition Survey (2014-2015, n=2057), the Swiss population census (2015-2018), and Swiss mortality data (2015-2018). Participants were categorized into six alcohol consumption groups based on pure alcohol intake from two 24-hour dietary recalls and self-reported alcohol avoidance: abstainer, safe_no (occasional drinkers, reference group), safe_during, safe_outside, heavy_during, and heavy_outside. Heavy drinking was defined as exceeding EKAL thresholds. Outside mealtime drinking was defined per Sieri et al. (less than 10% of daily energy intake during the drinking occasion and at least 5 g pure alcohol).

Generalized linear regression models (negative binomial or Quasipoisson to handle over/underdispersion) were fitted, adjusting for sex, age, smoking, physical activity, BMI, education, and the Alternative Healthy Eating Index (AHEI, excluding alcohol component). Standardized mortality ratios (SMR) were calculated at the district level. Residuals were tested for spatial autocorrelation using global and local Moran's I statistics. Where significant spatial autocorrelation was detected, Integrated Nested Laplace Approximation (INLA) models were fitted with structured (Besag) and unstructured (iid) spatial components. Missing values were imputed using multivariate imputation by chained equations (MICE), with results pooled across 30 imputed datasets.

## Key Results The largest alcohol group was safe_no (n=678) and the smallest were outside mealtime groups (n=115 and n=117). Men consumed more alcohol than women, intake peaked on Saturdays, and only on Saturdays did both sexes exceed EKAL thresholds (men: 23.7 g during and 8.5 g outside mealtime; women: 11.1 g during and 3.4 g outside mealtime on average). Between 2015-2018, 84,959 all-cause deaths, 37,202 all-cancer deaths, 16,082 CVD deaths, and 2,360 UADT cancer deaths were recorded in Switzerland.

Compared with occasional drinkers, heavy during mealtime drinkers had significantly elevated all-cancer mortality (RR=1.05, 95% CI 1.00-1.10), breast cancer mortality (RR=1.10, 95% CI 1.00-1.21), and UADT cancer mortality (RR=1.19, 95% CI 1.09-1.31). Heavy outside mealtime drinkers had elevated UADT cancer (RR=1.20, 95% CI 1.00-1.43) and diabetes mortality (RR=1.35, 95% CI 1.07-1.71). Even safe during mealtime drinkers had increased all-cancer (RR=1.07, 95% CI 1.02-1.13) and UADT cancer (RR=1.15, 95% CI 1.04-1.26) mortality. Safe outside mealtime drinkers had elevated liver cancer mortality (RR=1.27, 95% CI 1.07-1.51). Notably, abstainers also showed increased all-cancer (RR=1.07, 95% CI 1.00-1.14) and UADT cancer (RR=1.21, 95% CI 1.07-1.37) mortality, possibly reflecting the heterogeneous composition of the abstainer group (potentially including former heavy drinkers or those abstaining due to illness).

Global Moran's I revealed significant spatial autocorrelation for all-cancer mortality (observed=0.144, expected=-0.014, p=0.035). The INLA model identified three districts with significantly decreased all-cancer mortality (Uster RR=0.91, Hinwil RR=0.91, Meilen RR=0.89) and four districts with significantly increased mortality (canton Neuchâtel RR=1.12, Jura Bernois RR=1.13, Seeland RR=1.14, Biel RR=1.18).

## Clinical Implications The findings support the conclusion that no safe level of alcohol consumption exists, with consistent direction of effect across all mortality outcomes even when statistical significance was not reached. Drinking context matters: outside mealtime drinking was particularly associated with liver cancer, UADT cancer, and diabetes mortality. The elevated mortality among abstainers likely reflects a heterogeneous reference group rather than a true protective effect of occasional drinking, an important methodological consideration for clinical interpretation. Specific risk groups identified include men, younger outside mealtime drinkers, current smokers, and those with higher BMI and education levels. The geographic clustering of cancer mortality in cantons Neuchâtel and Bern (increased) versus Zurich districts (decreased) suggests that regional (diet) culture, socioeconomic factors, and urbanization warrant further investigation and should inform targeted alcohol-prevention strategies. These results can guide the development of future Swiss alcohol-prevention schemes aimed at reducing the substantial burden of avoidable alcohol-attributable deaths.

PICO

PPOPULATION

Swiss adults aged 18-75 years from the menuCH national nutrition survey (n=2057) combined with Swiss mortality data 2015-2018

IINTERVENTION

Alcohol consumption categorized into six groups: abstainer, safe_no (occasional), safe_during, safe_outside, heavy_during, heavy_outside mealtime drinking, based on EKAL thresholds (12 g/day women, 24 g/day men)

OOUTCOME

All-cause, cardiovascular, all-cancer, colorectal, liver, UADT, breast cancer mortality, and diabetes mortality at the district level

STUDY TYPE

cross-sectional

SPECIALTY

public_health

SUMMARISED BY

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FIDELITY CHECK

100% · A

ORIGINAL PAPER

PMC10030531

Alcohol consumption: context and association with mortality in Switzerland

European Journal of Nutrition

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ABSTRACT

Abstract Purpose Non-communicable diseases generate the largest number of avoidable deaths often caused by risk factors such as alcohol, smoking, and unhealthy diets. Our study investigates the association between amount and context of alcohol consumption and mortality from major non-communicable diseases in Switzerland. Methods Generalized linear regression models were fitted on data of the cross-sectional population-based National Nutrition Survey menuCH (2014–2015, n = 2057). Mortality rates based on the Swiss mortality data (2015–2018) were modeled by the alcohol consumption group considering the amount and context (i.e., during or outside mealtime) of alcohol consumption and potential confounders. The models were checked for spatial autocorrelation using Moran’s I statistic. Integrated nested Laplace approximation (INLA) models were fitted when evidence for missing spatial information was found. Results Higher mortality rates were detected among drinkers compared to non-drinkers for all-cancer (rate ratio (RR) ranging from 1.01 to 1.07) and upper aero-digestive tract cancer (RR ranging from 1.15 to 1.20) mortality. Global Moran’s I statistic revealed spatial autocorrelation at the Swiss district level for all-cancer mortality. An INLA model led to the identification of three districts with a significant decrease and four districts with a significant increase in all-cancer mortality. Conclusion Significant associations of alcohol consumption with all-cancer and upper aero-digestive tract cancer mortality were detected. Our study results indicate the need for further studies to improve the next alcohol-prevention scheme and to lower the number of avoidable deaths in Switzerland. Supplementary Information The online version contains supplementary material available at 10.1007/s00394-022-03073-w. Keywords: Alcohol consumption, Non-communicable disease mortality, menuCH study, Spatial analysis

CITATION EXPORT

Flurina Suter, Giulia Pestoni, Janice Sych et al.. Alcohol consumption: context and association with mortality in Switzerland. European Journal of Nutrition. (2022). https://doi.org/10.1007/s00394-022-03073-w

AUTHORS

5 · 4 CENTRES

Flurina Suter, Giulia Pestoni, Janice Sych, Sabine Rohrmann, Julia Braun

1Division of Chronic Disease Epidemiology, Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland
2Nutrition Group, Health Department, Swiss Distance University of Applied Sciences, Zurich, Switzerland
3Institute of Food and Beverage Innovation, ZHAW School of Life Sciences and Facility Management, Waedenswil, Switzerland
4Divisions of Epidemiology and Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland