American Journal of Epidemiology Vol. 158, No. 6 
Copyright © 2003 by the Johns Hopkins Bloomberg School of Public Health Printed in U.S.A. 
All rights reserved DOI: 10.1093/aje/kwg184 

Wine, Liquor, Beer, and Mortality 

Arthur L. Klatsky1,2, Gary D. Friedman2, Mary Anne Armstrong2, and Harald Kipp2 

1 Division of Cardiology, Department of Medicine, Kaiser Permanente Medical Center, Oakland, CA. 
2 Division of Research, Kaiser Permanente Medical Care Program, Oakland, CA. 

Received for publication July 11, 2002; accepted for publication March 25, 2003. 

A substantially increased risk for heavy drinkers and a slightly reduced risk for lighter drinkers results in the J-
shaped alcohol-mortality curve. Limited data suggest a more favorable mortality experience for drinkers of wine 
than for drinkers of liquor or beer. To examine these relations, the authors performed a cohort study of 
participants in a large Northern California prepaid health care program. Demographic and history data were 
collected from 128,934 adults undergoing health evaluations in 1978–1985, with subsequent death ascertained 
by an automated linkage system. Cox proportional hazards models with eight covariates were used to determine 
relative risk estimates according to total alcohol intake and days per week of drinking wine, wine types, beer, or 
liquor. The J-shaped alcohol-mortality relation was stable for 20 years. Independently, frequency of wine drinking 
was associated with lower mortality risk (p < 0.001) largely because of lower coronary disease risk. Similar risk 
reductions were associated with red wine, white wine, other types of wine, and combinations of wine types. Much 
of the lower risk associated with light drinking was related to wine drinking. The authors conclude that drinkers of 
any type of wine have a lower mortality risk than do beer or liquor drinkers, but it remains unclear whether this 
reduced risk is due to nonalcoholic wine ingredients, drinking pattern, or associated traits. 

alcohol drinking; alcoholic beverages; beer; mortality; risk; wine 

Abbreviations: CI, confidence interval; ICD-9, International Classification of Diseases, Ninth Revision. 

A balanced view of alcohol drinking and health should 
consider harmful and beneficial effects, amount of alcohol, 
beverage choice, and drinking patterns. Mortality has been 
studied as one specific global measure. Heavy drinking, 
defined as usual daily intake of three or more standard-sized 
drinks, carries excess mortality from cardiovascular and 
noncardiovascular causes (1–13), presumably due to both 
physiologic effects of alcohol and behavioral traits of heavy 
drinkers. It is unclear whether choice of wine, liquor, or beer 
plays a role in the adverse effects of heavy alcohol drinking, 
and relatively few studies have examined this aspect. 

Lighter drinking carries lower total mortality risk (1–16), 
largely because of lower coronary disease risk. Behavioral 
traits of light drinkers compared with those of abstainers 
probably also play some role in the lower risk for light 
drinkers. However, demonstration of plausible protective 
mechanisms of alcohol against coronary disease, including 
an effect via high density lipoprotein cholesterol and anti-

thrombotic actions (17–24), has resulted in widespread 
acceptance of a protective hypothesis (25–30). 

Interest in possible additional benefits of wine developed 
when international comparisons (31, 32) showed that 
persons in wine-drinking countries had a lower coronary 
disease mortality risk than persons in countries where the 
preponderant beverages were beer or liquor. Further support 
came from demonstration of potentially protective non-
alcohol antioxidant and antithrombotic compounds in wine, 
especially red wine (25, 33–35). Prospective population 
studies have provided no consensus that wine is more protective 
than liquor or beer against coronary disease (36–41). 

Limited data exist about beverage choice and total 
mortality. Danish studies show that wine drinkers, compared 
with beer or liquor drinkers, have lower risks of total 
mortality (42, 43), cancer (44), and stroke (45), and a French 
report indicates lower total and cardiovascular disease 
mortality (46). Attention to behavioral and other user trait 

Reprint requests to Dr. Arthur L. Klatsky, Kaiser Permanente Medical Center, 280 West McArthur Boulevard, Oakland, CA 94611 (e-mail: 
arthur.klatsky@kp.org). 

585 Am J Epidemiol 2003;158:585–595 


586 Klatsky et al. 

differences (36–50) has generally found more favorable 
health traits among wine drinkers. 

A Kaiser Permanente (Oakland, California) report of 
4,501 deaths in 1978–1988 among 128,934 persons (8) 
compared subsets (29 percent of deaths) of those who drank 
preponderantly wine, beer, or liquor (“preferrers”). Wine 
and beer preferrers had a nonsignificantly lower total 
mortality risk; the relative risk versus liquor preferrers was 

0.9 for each type (p > 0.05). Wine preferrers had a lower 
cardiovascular mortality risk (relative risk vs. liquor = 0.7, 
p = 0.01), but beer drinkers did not (relative risk vs. liquor = 
0.9, p = 0.2). With more data needed, here we present findings 
involving 10 additional follow-up years with a total of 
16,431 deaths. A more comprehensive analysis of the role of 
beverage choice is the major focus. 
MATERIALS AND METHODS 

Subjects and data 

The Institutional Review Board of the Kaiser Permanente 
Medical Care Program approved the study protocols. Baseline 
data were derived from 1978–1985 health examinations 
of 128,934 adults in San Francisco and Oakland, California. 
Voluntarily taken as a health appraisal, the examination 
included health measurements and queries about sociodemographic 
status, habits, and medical history (51). Usable data 
about alcohol were supplied by 79.8 percent of examinees. 
Persons not supplying data consisted largely of those taking 
the examination in the absence of the special alcohol questionnaire 
research clerk and those who declined (largely 
persons who were not fluent in English). 

Lifelong abstainers (n = 15,498) were defined as persons 
who reported no alcohol drinking during the past year and 
“never or almost never” drinking. Ex-drinkers (n = 4,194) 
were nondrinkers during the previous year who indicated 
prior drinking. Current drinkers reported usual amount as 
less than once per month (“special occasions only”), more 
than once per month but less than one drink per day, or daily 
number of drinks: one or two, three to five, six to eight, and 
nine or more. Size of “drinks” was not specified in this 
query. Drinkers received separate questions (47) about the 
number of days per week that they drank wine, liquor, or 
beer. Wine drinkers were asked to write in “type(s) of wine 
you usually drink,” leading to classification as red table wine 
only (n = 3,128), white table wine only (n = 10,762), both red 
and white table wine (n = 15,461), and “other specified” 
wine (fortified, champagne, rose, combinations) (n = 4,619) 
as well as wine drinkers who did not respond to the “type of 
wine” query (n = 33,388). Table 1 presents selected further 
details about the study population. 

Mortality ascertainment 

We followed subjects through December 1998 or known 
death by using an automated matching system (52) to ascertain 
death in California. We accepted primary International 
Classification of Diseases, Ninth Revision (ICD-9) death 
certificate codes, converting from International Classification of Diseases, Eighth Revision codes when necessary. We 

studied deaths from all causes, cardiovascular causes (ICD-9 
codes 390–459), noncardiovascular causes (all except ICD-9 
codes 390–459), cancer (ICD-9 codes 140–209), coronary 
disease (ICD-9 codes 410–414), respiratory conditions 
(ICD-9 codes 460–519), liver disease/cirrhosis (ICD-9 code 
571), and unnatural causes (ICD-9 codes 800–999). 
Presumption of complete follow-up yielded a calculated 
2,211,000 person-years, but estimates (52) suggest a sensitivity 
of 89 percent for the method used. 

Analytical methods 

We used Cox proportional hazards models determined by 
the PHREG procedure of Statistical Analysis System software, 
release 6.12 (SAS Institute, Inc., Cary, North Carolina). 
Covariates in multivariate models included age, sex, 
race, education (no college, some college, college graduate), 
marital status (now married, never married, formerly 
married), body mass index (weight (kg)/height (m)2), cigarette 
smoking (never, ex-smoker, <1 pack/day, ≥1 pack/day), 
and a composite of affirmative responses (any “yes”) to 12 
coronary disease risk or symptom items (47, 53). An indicator 
of drinking variability (47), constructed from queries 
about drinking on weekends versus weekdays, during the 
past day or week versus usual, and during the past year 
versus the past 10 years, was a covariate in some models. 

We studied total alcohol drinking categorically, with lifelong 
abstainers used as the referent for ex-drinkers and five 
drinking categories. Some models included four drinking 
categories, up to three or more drinks per day. Analyses of 
beverage choice excluded lifelong abstainers, ex-drinkers, 
and drinkers reporting drinking less than once per month. All 
analyses of beverage choice presented here were controlled 
for total alcohol intake by using as the referent for total 
alcohol persons reporting alcohol drinking more than 
monthly but less than one drink per day. In most models, 
choice of wine, liquor, and beer was a continuous variable 
derived from days per week for each type, with the following 
assigned values: never or almost never, 0.0; once per week or 
less, 0.5; 2–3 days per week, 2.5; 4–5 days per week, 4.5; 
and daily or almost daily, 6.5. The models for type of wine 
were identical except that wine days per week was categorized 
into subgroups. The beverage types and wine types in 
these analyses were modeled simultaneously. The number of 
days per week for the beverage types showed good correlation 
with the number of drinks per week of the types in a 
1984–1985 subset (47). 

For drinkers who drank more than once per month, we 
defined beverage preference as drinking one beverage type 
exclusively or on more days per week than either of the other 
two types (47). Drinkers without a preference reported two 
or three types with equal frequency. We studied total alcohol 
intake in these groups and for all persons who reported 
drinking wine, beer, or liquor 2 or more days per week. We 
also compared those who preferred wine, liquor, or beer with 
nonpreferrers. To further compare drinkers of the beverage 
types, we studied those who exclusively reported each type 
(i.e., drank none of the other two types). 

In this paper, we present results as relative risks with 95 
percent confidence intervals and associated p values. 

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Wine, Liquor, Beer, and Mortality 587 

TABLE 1. Confirmed deaths through 1998 among 128,934 subjects studied to determine the associations 
of wine, liquor, and beer drinking with mortality, Northern California* 

Men Women 

All Deaths All Deaths 
(n = 56,926) (n = 9,102) (n = 72,008) (n = 7,329) 

No. % No. % No. % No. % 

Alcohol drinking 
Never 4,125 7.2 807 8.9 11,373 15.8 1,645 22.4 
Ex-drinker 2,390 4.2 674 7.4 1,804 2.5 317 4.3 
<1 drink/month 8,105 14.2 1,376 15.1 19,312 26.8 2,055 28.0 
>1 drink/month; <1 drink/day 21,264 37.4 2,623 28.8 26,631 37.0 1,819 24.8 
1–2 drinks/day 13,512 23.7 2,127 23.4 9,896 13.7 1,073 14.6 
3–5 drinks/day 5,905 10.5 1,122 12.3 2,523 3.5 350 4.8 
≥6 drinks/day 1,535 2.7 371 4.1 469 0.7 71 1.0 

Drink ≥2 days/week† 
Wine 14,383 25.3 2,019 22.2 15,209 21.1 1,077 14.7 
Liquor 13,279 23.3 2,812 30.9 8,080 11.2 1,231 16.8 
Beer 16,455 28.9 1,931 21.2 5,484 7.6 395 5.4 

Preference‡ 
Wine 6,562 11.5 898 9.9 10,965 15.2 677 9.2 
Liquor 5,249 9.2 1,415 15.5 3,933 5.5 792 10.8 
Beer 8,927 15.7 901 9.9 2,825 3.9 220 3.0 
None§ 21,478 37.7 3,029 33.2 10,786 14.9 1,624 22.2 

Exclusive type¶ 
Wine 841 1.5 172 1.9 2,686 3.7 206 2.8 
Liquor 874 1.5 332 3.6 909 1.3 259 3.5 
Beer 1,140 2.0 179 2.0 413 0.6 73 1.0 

* Some percentages do not total 100 because of rounding. 
† Without regard for amount of other beverage types. 
‡ For persons drinking more than once per month, indicates drinking the type at least 2 days per week and more 
often than either of the other types. 
§ Indicates reporting two or more types with equal frequency. 
¶ Indicates drinking the type ≥2 days/week and the other types “never or almost never.” 

RESULTS 

Relations of total alcohol intake to mortality 

The mean baseline age of the study population was 40.6 
years; of the 16,431 persons who later died, it was 60.8 years 
(mean age at death, 69.5 years). Multivariate data showed 
that heavy and ex-drinkers had an increased relative risk of 
total mortality (table 2), consistent in subgroups of race, age 
brackets, smoking, and interval to death (data not shown). 
Lighter drinkers had a lower relative risk of total mortality, 
which was more evident for women (p > 0.05 for men); this 
finding was otherwise fairly consistent in subgroups (data 
not shown). 

Of all 16,431 deaths, 62 percent (n = 10,150) were attributed 
to noncardiovascular causes, the three largest subsets 
being cancer (n = 4,878), respiratory conditions (n = 1,412), 
and unnatural causes (n = 949). Of 6,281 (38 percent of the 
total) deaths attributed to cardiovascular causes, about half 
(n = 3,049) were due to coronary disease. An increased relative 
risk for heavy drinkers came substantially from cancer, 

liver cirrhosis, respiratory conditions, and unnatural causes, 
with a slight contribution from cardiovascular causes. The 
increased relative risk for ex-drinkers was largely attributable 
to cancer, cirrhosis, respiratory conditions, and cardiovascular 
causes. Women who reported light drinking had a 
lower relative risk of death from coronary and respiratory 
disease. Male light drinkers had less of a reduction than 
women in the relative risk of coronary disease death, but the 
p value was 0.003 for one or two drinks per day, with consistency 
in race groups (data not shown). Male light drinkers 
had no reduced relative risk of respiratory death. 

Mortality from all causes in beverage choice groups 

For heavy drinkers, the increased total mortality risk was 
lower for those drinking beer 2 or more days per week than 
for those drinking either wine or liquor 2 or more days per 
week (table 3). Light drinkers who reported drinking either 
beer or wine 2 or more days per week, but not liquor, had a 
lower total mortality risk. The increased risk for heavy 

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588 Klatsky et al. 

TABLE 2. Adjusted risk of death† through 1998 for all persons from all causes and various diagnoses according to total alcohol 
intake compared with abstinence, Northern California 

Relative risk for each drinking category† 
Deaths (no.) 
Ex-drinker <1 drink/month 
>1 drink/month; 
<1 drink/day 1–2 drinks/day 3–5 drinks/day ≥6 drinks/day 
All causes 16,431 1.2** 1.0 0.9** 0.9** 1.1 1.4** 
Men 9,102 1.3** 1.1 0.9 0.9 1.1 1.5** 
Women 7,329 1.2** 0.9† 0.8** 0.9* 1.1 1.6** 
Noncardiovascular causes 10,150 1.3** 1.0 0.9 1.0 1.2** 1.6** 
Men 5,651 1.3* 1.0 1.0 1.0 1.1* 1.5** 
Women 4,499 1.3** 1.0 0.9 1.0 1.2† 1.9** 
Cardiovascular causes 6,281 1.1† 1.0 0.8** 0.8** 0.9† 1.1 
Men 3,451 1.3* 1.2† 1.0 0.9 0.9 1.3† 
Women 2,830 1.0 0.9 0.7** 0.8** 0.9 1.1 
Coronary disease 3,054 1.2 1.0 0.8** 0.7** 0.8* 1.0 
Men 1,855 1.3† 1.1 0.9 0.8* 0.8 1.1 
Women 1,199 1.1 0.9 0.6** 0.6** 0.8 0.8 
Cancer 4,878 1.4** 1.1 1.1 1.1 1.3** 1.4** 
Men 2,536 1.4* 1.2† 1.1 1.1 1.3* 1.4* 
Women 2,342 1.4* 1.0 1.0 1.1 1.3* 1.7* 
Cirrhosis 232 3.4* 0.9 1.2 2.7* 6.9** 14.9** 
Men 146 1.7 0.7 0.5 1.3 3.3* 8.3** 
Women 86 6.5* 1.2 2.5 4.7* 14.2** 15.2** 
Respiratory conditions 1,412 1.4† 0.9 0.8† 0.9 1.3† 1.7* 
Men 754 1.8** 1.1 0.9 1.0 1.7* 2.2** 
Women 658 0.9 0.8 0.7† 0.8 1.0 0.9 
Unnatural causes 949 1.1 1.1 1.1 1.1 1.4† 2.2** 
Men 625 1.0 0.9 1.0 1.0 1.3 1.8† 
Women 324 1.3 1.3 1.2 1.4 1.2 5.0** 

* p < 0.01; ** p < 0.001. 
† Computed by using Cox proportional hazards models controlled for age, sex, race, body mass index, education, marital status, smoking, and a coronary 
disease risk/symptoms variable; referent, lifelong abstainers. 
drinking was lower in preponderant (“preferrers”) and exclusive 
wine drinkers than in corresponding liquor and beer 
subsets. Only two deaths occurred in heavy, exclusive wine 
drinkers, limiting data interpretation. 

Frequency of beverage choice and risk of death 

Independent of total alcohol intake, wine drinking 
frequency was associated with lower risk of total mortality 
and several other endpoints, most notably coronary disease 
and respiratory deaths (table 4). Respiratory death results 
were similar for influenza/pneumonia (ICD-9 codes 480– 
487, n = 664) and chronic respiratory conditions (ICD-9 
codes 490–496, n = 532) (data not shown). Only a slightly 
lower risk of cancer was associated with wine drinking 
frequency, and deaths from cirrhosis and unnatural causes 
were not inversely related to wine drinking frequency. 
Frequency of liquor drinking was independently related to 
higher cirrhosis risk, and beer drinking frequency was 
weakly related to increased noncardiovascular risk among 
women. 

The relative risks shown in this paper represent risks per 
days per week. We also performed analyses with beverage 

types entered as categories of days per week. When the analyses 
were conducted in this way, the relative risks of coronary 
disease mortality for categories of wine drinking 
frequency were 0.94 (p = 0.3) for less than once per week, 

0.84 (p = 0.04) for 2–3 days per week, 0.77 (p = 0.04) for 
4–5 days per week, and 0.67 (p < 0.001) for daily or almost 
daily. For coronary disease mortality in men, the relative risk 
for drinking wine daily or almost daily was 0.78 (p = 0.02); 
for women, it was 0.48 (p < 0.001). For all persons, the relative 
risk of coronary disease mortality for daily or almost 
daily drinking of liquor was 0.99 (p = 0.9); for beer, it was 
0.92 (p = 0.4). 
The variability index was independently related to risk of 
death (data not shown). However, its introduction into the 
model had little effect on the relations of beverage type to 
risk of death (data not shown). 

The lower risk of death for wine drinkers was consistent in 
subsets of age, smoking, education, and death date. This 
paper presents details for smoking and death date subsets. 
For total mortality, the relative risks for wine drinking per 
day per week were 0.97 (95 percent confidence interval (CI): 
0.95, 0.99) for never smokers, 0.96 (95 percent CI: 0.94, 
0.98) for ex-smokers, and 0.96 (95 percent CI: 0.95, 0.98) for 

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Wine, Liquor, Beer, and Mortality 589 

TABLE 3. Adjusted risk of death† through 1998 from all causes in various beverage choice groups 
according to total alcohol intake compared with abstinence, Northern California 

Relative risk for each drinking category‡ 
Group‡ Deaths (no.) 
<1 drink/day 1–2 drinks/day 3–5 drinks/day ≥6 drinks/day 
Drink wine ≥2 days/week 3,096 0.8*** 0.8*** 0.9 1.3** 
Drink liquor ≥2 days/week 4,043 0.9 0.9 1.1 1.4*** 
Drink beer ≥2 days/week 2,326 0.7** 0.7*** 0.7* 0.9 
Prefer wine 1,575 0.8*** 0.8*** 0.9 1.2 
Prefer liquor 2,207 0.9* 0.9 1.1* 1.5*** 
Prefer beer 1,121 0.9* 1.0 1.2** 1.7*** 
Have no preference 4,653 0.9*** 0.9*** 1.0 1.3*** 
Drink wine exclusively 378 0.8* 0.8*** 1.0 0.5 
Drink liquor exclusively 591 0.9 1.0 1.2 1.8*** 
Drink beer exclusively 252 0.9 1.2 1.3 2.0*** 

* p < 0.05; ** p < 0.01; *** p < 0.001. 
† For persons drinking more than once per month; computed by using Cox proportional hazards models 
controlled for age, sex, race, body mass index, education, marital status, smoking, and a coronary disease risk/ 
symptoms variable; referent, lifelong abstainers. 
‡ Refer to the Materials and Methods section of the text and the footnotes to table 1 for definitions. Each row 
represents a separate analysis, with lifelong abstainers as the referent for the total drinking amounts. 
current smokers (p < 0.001 for all three subsets). For death 
date subsets, the relative risks were 0.95 (95 percent CI: 
0.93, 0.96) for deaths in 1978–1988, 0.96 (95 percent CI: 
0.94, 0.98) for deaths in 1989–1993, and 0.96 (95 percent CI: 
0.94, 0.98) for deaths in 1993–1998 (p < 0.001 for all three 
subsets). A lower risk related to wine was not observed for 
African Americans and Asian Americans (data not shown), 
who drank wine less often than Whites did. Among Whites, 
African Americans, and Asian Americans, the proportions 
reporting wine drinking at least 2 days per week were 23.4 
percent, 10.1 percent, and 8.9 percent, respectively. In 
contrast, in 38 total mortality subset analyses for liquor or 
beer frequency, only one subset (ex-smokers) showed a 
borderline decreased risk (data not shown). 

On the basis of the responses of 12,600 subjects in 1974– 
1975 to a supplemental query about the number of drinks 
they consumed per day of each beverage type (47), we estimated 
that beverage preferrers consumed, on average, 80–90 
percent of their drinks as the preferred beverage. Data 
showed less risk for wine preferrers, especially of cardiovascular 
deaths, and a higher risk of noncardiovascular death for 
liquor preferrers. When nonpreferrers were used as the 
referent and we controlled for total alcohol intake, the relative 
risks of noncardiovascular death for preferrers were 0.89 
(95 percent CI: 0.82, 0.95) for wine (p < 0.001), 1.08 (95 
percent CI: 1.01, 1.16) for liquor (p = 0.02), and 1.05 (95 
percent CI: 0.97, 1.14) for beer. For cardiovascular death, the 
corresponding relative risks were 0.78 (95 percent CI: 0.70, 
0.86) for wine (p < 0.001), 1.02 (95 percent CI: 0.93, 1.12) 
for liquor, and 1.02 (95 percent CI: 0.90, 1.16) for beer. For 
coronary disease deaths, the relative risks were 0.72 for wine 
preferrers (p < 0.001), 0.79 for men (p = 0.007), and 0.62 for 
women (p < 0.001). 

There were 693 deaths among persons reporting drinking 
any wine but no liquor or beer, 601 deaths among those who 

reported drinking any liquor but no beer or wine, and 414 
deaths among those reporting drinking any beer but no wine 
or liquor. Comparing these groups for total mortality risk in 
multivariate analyses showed the following relative risks: 
wine versus liquor, 0.82 (95 percent CI: 0.73, 0.92; p < 
0.001); wine versus beer, 0.83 (95 percent CI: 0.73, 0.97; p = 
0.02); and beer versus liquor, 0.98 (95 percent CI: 0.97, 
1.11). This apparent lower risk for wine drinkers was due 
primarily to the data on women; for example, comparing the 
wine drinkers with the liquor and beer drinkers combined 
yielded the following relative risks for wine versus liquor/ 
beer: men, 0.93 (95 percent CI: 0.81, 1.08); women, 0.74 (95 
percent CI: 0.64, 0.86; p < 0.001). 

Type of wine 

Almost identical reductions in risk were associated with 
drinking either red or white table wine exclusively, both red 
and white table wine, or “other” wine (table 5). Of the wine 
groups, men constituted 61 percent of the red only, 41 
percent of the white only, 52 percent of the red and white, 
58 percent of the other specified, and 49 percent of the 
unspecified. 

Covariate relations 

As an indication of comparability with established predictors 
of coronary disease, a few examples of the relative risks 
for total mortality follow: male versus female, 1.6 (95 
percent CI: 1.6, 1.7); African-American versus White, 1.2 
(95 percent CI: 1.1, 1.2); Asian-American versus White, 0.8 
(95 percent CI: 0.7, 0.9); college graduate versus no college, 

0.8 (95 percent CI: 0.7, 0.8); smoking one or more packs of 
cigarettes per day versus having never smoked, 2.3 (95 
percent CI: 2.2, 2.4); not married versus married, 1.1 (95 
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590 Klatsky et al. 

TABLE 4. Adjusted risk of death† through 1998 for selected diagnoses per day per week of wine, liquor, 
and beer intake, Northern California 

Group (no. of deaths in drinkers drinking >once/month) Wine Liquor Beer 
All causes (n = 11,542) 0.96*** 1.01 1.01 
Men (n = 6,772) 0.96*** 1.00 1.00 
Women (n = 4,770) 0.95*** 1.00 1.04** 
Noncardiovascular causes (n = 7,306) 0.97*** 1.01 1.00 
Men (n = 4,307) 0.98** 1.01 0.99 
Women (n = 2,999) 0.96*** 1.01 1.04* 
All cardiovascular causes (n = 4,236) 0.95*** 1.00 1.00 
Men (n = 2,465) 0.96*** 0.99 1.00 
Women (n = 1,771) 0.94*** 1.00 1.02 
Coronary disease (n = 2,025) 0.94*** 1.00 0.98 
Men (n = 1,305) 0.96** 0.99 0.98 
Women (n = 720) 0.90*** 1.02 0.95 
Cancer (n = 3,453) 0.98* 1.00 0.99 
Men (n = 1,888) 0.99 1.01 0.99 
Women (n = 1,565) 0.96* 1.00 1.03 
Cirrhosis (n = 191) 0.99 1.10** 1.02 
Men (n = 124) 0.95 1.10* 1.01 
Women (n = 67) 1.05 1.10 1.08 
Respiratory conditions (n = 990) 0.94*** 0.98 1.00 
Men (n = 550) 0.95* 0.98 1.00 
Women (n = 440) 0.93* 0.97 1.01 
Unnatural causes (n = 718) 0.97 1.03 1.05* 
Men (n = 508) 0.97 1.02 1.04 
Women (n = 210) 0.98 1.07 1.09 

* p < 0.05 but ≥ 0.01; ** p < 0.01 but ≥ 0.001; *** p < 0.001. 
† For persons drinking more than once per month; controlled for age, sex, race, education, marital status, 
smoking, body mass index, and total alcohol intake. 
percent CI: 1.1, 1.2); and body mass index (per kg/m2), 1.01 
(95 percent CI: 1.00, 1.01) (all p values < 0.001). 

Beverage choice and coronary disease death 

Lower risk at lighter drinking levels was present for most 
groups drinking any of the three beverage types 2 or more 
days per week, as preferrers, or exclusively (table 6). This 
reduction was greatest for wine and smallest for liquor. 
Small numbers of exclusive drinkers resulted in several 
unstable estimates. 

DISCUSSION 

Wine drinking and risk 

The major finding in these data was the independent relation 
of wine drinking frequency to lower total mortality risk. 
This interpretation was buttressed by consistency in most 
population subsets. Perhaps most convincing was the lower 
risk associated with wine drinking frequency at each of three 
total drinking levels (less than one, one or two, and three or 
more drinks per day). The reduction in wine-related risk was 

clearest for deaths attributed to coronary disease and respiratory 
causes. 

Problems of interpretation and confounding 

Since any independent effect of wine on mortality is likely 
to be additional to the role of alcohol, interpretive problems 
are substantial. Although data from populations that drink 
preponderantly wine (e.g., Mediterranean countries) show a 
lower risk of coronary disease death than do data from other 
countries (31, 32), these studies lacked information about 
individuals and thus were inadequately controlled for major 
confounders. International differences in coding criteria may 
also play a role, since the Mediterranean countries do not 
enjoy greater overall longevity than other developed countries 
(32). Prospective cohort studies using data about individuals 
have shown statistically significant inverse relations 
of light drinking to coronary disease for beer (2, 8, 37), 
liquor (16, 37), and wine (36, 37, 42, 43, 46) and tend to 
show inverse, nonsignificant relations for all beverage types 
(38, 39). 

Persons in Northern California who drink preponderantly 
wine are more often women, college graduates, nonsmokers, 

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Wine, Liquor, Beer, and Mortality 591 

TABLE 5. Adjusted risk of death† through 1998 for selected diagnoses per day per week of intake of wine 
types, Northern California 

Wine type (no. of deaths) 

Red only White only Red and white Other specified Unspecified 
(n = 355) (n = 808) (n = 1,635) (n = 572) (n = 3,556) 
All causes 0.97** 0.96*** 0.97*** 0.98* 0.97*** 
Men 0.97** 0.99 0.97** 0.99 0.97*** 
Women 0.98* 0.94*** 0.96*** 0.96* 0.96* 
All cardiovascular causes 0.94** 0.95** 0.96** 0.98 0.96*** 
Men 0.94* 0.95* 0.98 0.99 0.96** 
Women 0.97 0.93* 0.92*** 0.95 0.95* 
All noncardiovascular causes 0.98 0.97 0.97*** 0.98 0.97** 
Men 0.99 1.00 0.97** 0.99 0.98* 
Women 0.98 0.94** 0.96* 0.96 0.97* 
Coronary disease 0.94* 0.95* 0.98 0.94* 0.93*** 
Men 0.95 0.98 1.00 0.95 0.94** 
Women 0.93 0.89* 0.92* 0.91 0.92* 

* p < 0.05 but ≥ 0.01; ** p < 0.01 but ≥ 0.001; *** p < 0.001. 
† For persons drinking more than once per month; controlled for age, sex, race, education, marital status, 
smoking, body mass index, total alcohol intake, and days/week of liquor and beer drinking. Refer to the Materials 
and Methods section of the text for definitions of wine types. 
and temperate drinkers, characteristics even more than did consumers of other beverage types. Since drinking 
pronounced in persons drinking wine exclusively (47). In pattern probably has a role in health effects (38, 43, 58–60), 
Denmark, wine drinking is associated with better percep-the usual pattern of ingesting wine slowly with food may be 
tions of overall health (49), higher socioeconomic status and important. In this context, a recent report that beer drinkers 
intelligence quotients (50), and intake of a “healthy” diet are more likely than wine drinkers to progress to heavier 
(high in fruits, vegetables, fish, salads, and olive oil) (48). drinking is both interesting and potentially important (61). In 
Higher socioeconomic status is associated with good health, a comprehensive review of possible benefits of wine addiand 
healthy habits tend to be clustered in the same person tional to those of alcohol (62), the conclusion was reached 
(54–56). A report on University of North Carolina alumni that confounding is a likely factor. We agree that uncon


(57) showed that wine drinkers had healthier lifestyle habits trolled traits in our analyses (e.g., dietary, exercise) were 
TABLE 6. Adjusted risk of death† through 1998 from coronary disease in beverage choice groups 
according to total alcohol intake compared with abstainers, Northern California 

Relative risk for each drinking category 
Group (no. of coronary disease deaths)‡ >1 drink/month; 
<1 drink/day 1–2 drinks/day 3–5 drinks/day ≥6 drinks/day 
Drink wine ≥2 days/week (n = 480) 0.7*** 0.6*** 0.6*** 0.8 
Drink liquor ≥2 days/week (n = 686) 0.8* 0.8** 0.8 1.0 
Drink beer ≥2 days/week (n = 329) 0.7* 0.7*** 0.7* 0.9 
Prefer wine (n = 235) 0.6*** 0.5*** 0.6** 1.1 
Prefer liquor (n = 383) 0.7** 0.8* 0.9 1.0 
Prefer beer (n = 140) 0.6** 0.6*** 0.8 1.0 
Have no preference (n = 831) 0.7 0.6** 1.0 1.1 
Drink wine exclusively (n = 109) 0.5** 0.4*** 0.9 0.7 
Drink liquor exclusively (n = 186) 0.5* 1.0 1.0 1.6 
Drink beer exclusively (n = 62) 0.3* 0.7 0.8 1.1 

* p < 0.05; ** p < 0.01; *** p < 0.001. 
† Computed by using Cox proportional hazards models controlled for age, sex, race, body mass index, 
education, marital status, smoking, and coronary disease risk/symptoms variable; referent, lifelong abstainers. 
‡ Refer to the Materials and Methods section of the text and the footnotes to table 1 for definitions. 
Am J Epidemiol 2003;158:585–595 


592 Klatsky et al. 

probably more favorable to wine drinkers, making some of 
the apparent additional benefit of wine due to residual 
confounding. 

Protective wine ingredients 

Antioxidant and antithrombotic substances, mostly in red 
wine and potentially beneficial against atherothrombotic 
disease and cancer, have been extensively detailed in 
reviews (35, 38, 41). The hypothesis that these substances 
protect against coronary disease is appealing, since oxidative 
modification of low density lipoprotein cholesterol is 
involved in the development of atherosclerotic plaques. 
Antioxidant compounds may well be antiatherogenic, yet 
prospective clinical trials of antioxidant supplements are 
inconclusive (63–65). Since, in our data, all wine types 
seemed equally protective, nonalcoholic factors responsible 
for the lower risk among wine drinkers would have to be 
present in both red and white wine. 

Heavy drinking and beverage choice 

Some aspects of these data suggest attenuation of 
increased risk for heavier wine drinkers compared with 
heavier liquor or beer drinkers. For example, wine drinking 
frequency showed less relation to cirrhosis risk than liquor or 
beer drinking did. Attenuation of increased risk in heavy 
drinkers preferring or exclusively drinking wine must be 
interpreted in light of the probability that confounding by 
“healthy” traits becomes progressively more likely in these 
groups (47). Of 71,600 persons drinking any beverage type 2 
or more days per week, 52 percent were preferrers, but only 
10 percent were exclusive drinkers of one beverage type. 
Liquor drinkers are most likely and wine drinkers least likely 
to consume larger-than-standard drinks (47), another factor 
probably important in the risk for chronic heavy drinkers. 

The risk of alcoholic liver cirrhosis is related primarily to 
lifetime alcohol intake (66). In countries with preponderant 
wine drinking, most heavy drinkers drink the prevalent 
beverage, resulting in reports of other wine-induced disorders, 
including hypertension (67), cardiomyopathy (68, 69), 
and peripheral neuropathy (70). It is thus clear that heavy 
chronic wine drinking carries substantial risks. 

The relation of heavy drinking to coronary disease is 
incompletely resolved (27, 39). Studies of coronary disease 
mortality have generally shown a U-curve relation to total 
alcohol intake (27), with heavy drinkers at higher risk than 
lighter drinkers and, in some studies, abstainers. Some 
studies of nonfatal coronary disease fail to show an upturn in 
risk with heavy drinking. Questions arise about misattribution 
of some deaths to coronary disease (27). Beverage 
choice for heavy drinkers, via drinking pattern, size of 
drinks, or risk trait differences, could play a selective role in 
apparent coronary disease mortality. In particular, a binge 
pattern among some beer drinkers, with associated deaths 
from cardiac rhythm disturbances, might account for the 
disparity between this report of coronary disease mortality 
and our report (36) that both wine and beer drinking carried 
a lower risk of nonfatal coronary events. 

Total alcohol intake and mortality 

The J-shaped alcohol-mortality relation was stable for 20 
years in this cohort. With longer follow-up, there was more 
apparent protection for women regarding coronary disease 
and total mortality. Thus, the magnitude of the sex disparity 
among light drinkers increased. This finding is not readily 
explained by known sex differences in potential mechanisms 
for alcohol’s benefit, such as increased high density lipoprotein 
cholesterol levels, antithrombotic effects, endothelial 
effects, or decreased insulin resistance (23–25, 41). Equivalent 
alcohol doses do result in higher average blood alcohol 
levels in women than in men because of women’s smaller 
size, larger body fat proportion, and reduced gastric metabolism 
of ethanol (27, 41). More benefit from lighter drinking 
and more harm from heavy drinking might ensue. Drinking 
pattern is another probable factor, since men, on average, 
binge drink more than women (27, 41, 69). If wine is associated 
with extra benefit, the fact that women in this study 
were more likely to drink preponderantly wine may also be a 
factor. 

We previously attributed apparent protection from lighter 
drinking against deaths from respiratory conditions to probable 
less-overt or -occult coronary disease (8). It is also 
possible that light drinking and wine drinking in particular are 
directly protective against death from pneumonia and chronic 
respiratory conditions, but mechanisms were not evident to us. 

Is lower risk due entirely to wine? 

In some respects, our findings are in general agreement 
with those from Danish and French studies that suggest a 
benefit primarily from wine (42–46). However, our study 
shows that each beverage type apparently protects against 
coronary disease mortality (table 6). Previous studies and 
evidence that protective mechanisms are related to ethyl 
alcohol mitigate against the hypothesis that only wine offers 
coronary disease protection (27, 37, 38). Epidemiologic data 
from beer-drinking populations (2, 11) are especially 
convincing. Yet, the unexpected strength and consistency in 
our data showing an apparent additional benefit from wine 
raises the likelihood of a causal association. 

Limitations 

Determination of habits only at baseline is a limitation, but 
drinking amount and beverage preference were relatively 
stable in this population (37, 71). Additionally, relations of 
beverage choice to mortality risk were as strong in the last 5 
years as for those who died earlier. It is possible that wine 
drinkers might be more likely than liquor or beer drinkers to 
persist with their drinking as they become older. A second 
limitation is our lack of data about wine type for more than 
50 percent of wine drinkers and about the proportions of red 
and white wine consumed by persons reporting both types. 
However, persons in “red only” and “white only” categories 
represent clearly defined groups that showed quite similar 
mortality risks. A third limitation is the already mentioned 
inability to control for some traits with probable relations to 
beverage choice and/or mortality risk. There was also prob-

Am J Epidemiol 2003;158:585–595 


Wine, Liquor, Beer, and Mortality 593 

able residual confounding for controlled variables; for 
example, control for packs per day of cigarette smoking does 
not fully measure the effective dose of harmful components. 

A fourth limitation is ascertainment of deaths only in California. 
However, while previous pilot studies indicate that 7– 
17 percent of current or former health care plan members die 
outside of California (52), we do not believe that these findings 
are likely to reflect bias related to alcohol drinking or 
beverage choice. Excluding the known dead, we examined 
proportions of persons remaining in the health plan in 1998 
as a plausible marker for continued residence in California, 
with the following results: entire cohort, 56.1 percent; 
drinkers of wine 2 or more days per week, 55.7 percent; and 
preferrers of wine; 56.6 percent. A fifth limitation was our 
lack of control for drink size, known in this population to be, 
on average, largest for liquor drinkers and smallest for wine 
drinkers (47). Thus, “moderate” liquor drinkers might 
include a larger proportion of heavier drinkers than exists 
among “moderate” wine drinkers. Finally, like all reported 
studies of alcoholic beverage choice and mortality, this study 
was observational. Only a controlled clinical trial can 
account completely for all confounders. 

Conclusions 

Frequency of wine drinking but not of liquor or beer 
drinking was independently related to lower mortality risk, 
especially for coronary disease and respiratory deaths. Red, 
white, and other types of wine had similar relations to lower 
risk. Associated traits and/or drinking patterns among wine 
drinkers and/or a specific benefit from wine may be 
involved. 

ACKNOWLEDGMENTS 

This work was supported by grants from the Alcoholic 
Beverage Medical Research Foundation of Baltimore, Maryland; 
the National Institute of Alcoholism and Alcohol 
Abuse (1 RO1 AA 10830-01); and the Wine Institute of San 
Francisco, California. 

The authors thank Cynthia Landy for assistance with data 
collection and Sally McBride Allen and Teresa Klask for 
technical assistance. 

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