Insurability of Former Drinkers

Hank George, FALU, CLU, FLMI

 

People stop consuming alcohol for a variety of reasons.

Some of those reasons – for example, joining a religious group where alcohol use is frowned upon or finally capitulating to nagging by a teetotaling spouse – have no insurability implications.

Then, there are the others…

Jürgen Rehm and his coworkers at the Centre for Addiction and Illness in Toronto make this observation regarding non-drinkers:

“There are at least 2 very distinct groups of abstainers – former drinkers, many of whom have given up drinking for health reasons; and long-term or even lifetime abstainers. For both groups, associations with health outcomes are different.”

Boston University epidemiologist R. Curtis Ellison affirms this conclusion, comment that:

“…almost all studies show a higher risk for CHD (as well as most other diseases and total mortality) for recognized ‘ex-drinkers.’ ”

 

Are former drinkers often cigarette smokers?

Numerous studies have shown that robust alcohol consumers are several times more likely to smoke than temperate consumers and lifetime nondrinkers.

Data from the British Regional Heart Study demonstrate that those who quit alcohol are ill-disposed to giving up their cigarettes:

 

Drinking Status % Current Smokers
Teetotalers 22%
Ex-drinkers 39%
Occasional drinkers 31%
Light drinkers 28%
Moderate drinkers 38%
Heavy drinkers 48%

 

We should expect a high prevalence of current tobacco use among applicants claiming to have quit drinking. [Wannamethee]

 

How do ex-drinkers compare to persons in other alcohol use categories in terms of medical impairments?

“…recent abstainers are more likely to have stopped because of medical concerns.”

Marc A Schuckit, MD
University of California-San Diego Medical School
Lancet
373(2009):492

Former imbibers are considerably more likely to have significant medical histories, as reflected by these findings from a German study: [Wellmann]

 

Alcohol Use Status
  Never Former Temperate Heavy
Heart attack 10% 9% 4% 2%
Stroke 2% 4% 1% 1%
Diabetes 5% 11% 5% 3%
Liver disease 6% 12% 3% 8%
Stomach disease 10% 16% 7% 6%

 

When gerontologists assessed the relative risks of underlying adversities in older age quitters, they discovered some interesting revelations. [Mukamal]

These individuals were distinguished from teetotalers and currently drinking elders by a number of disconcerting revelations, considering that ex-drinkers had:

The highest % of diabetics
The highest % with hypertension
The greatest prevalence of depression
The lowest average HDL-C readings
The highest mean fibrinogen levels

In addition, older age former alcohol aficionados are 3 times more likely to be disabled than teetotalers and have lower average cognitive scores than persons in all other alcohol use categories. [Lobo]

The foregoing evidence strongly suggests that many drinkers do indeed quit consuming alcohol because of illness.

 

Are former alcohol abusers more apt to continue manifesting unfavorable behaviors associated with ongoing alcohol abuse?

An investigation by experts in automotive medicine tells us that putative ex-drinkers have numerous risk-taking characteristics similar to those prevalent in current abusive drinkers: [Ryb]

 

Alcohol Abuse Status
  Never Former Current
Not using seat belts 48% 61% 94%
Speeding for thrills 5% 15% 18%
Single vehicle accidents 28% 35% 61%
Conviction for assault 9% 30% 36%

 

How do ex-drinkers fare in terms of mortality?

The first studies documenting that mortality based on alcohol consumption was U-shaped (higher in nondrinkers and heavy drinkers; lowest in temperate consumers) did not make a distinction between teetotalers and ex-drinkers. The result was that alcohol abstention appeared to be a high risk scenario. [Klatsky]

When these investigators redid their analyses by separating teetotalers from former drinkers, they found that all-cause mortality was indeed favorable in those who never took a drink…

…and all of the “abstainer” excess death risk fell squarely upon former users.

There have been numerous assessments of mortality sorted by alcohol use category over the intervening years.

Let’s look at some of the findings…

In a 2003 meta-analysis, Gmel and coworkers contrasted mortality in teetotalers to that of ex-users. They found that aggregate mortality was 44% higher in male former drinkers and 21% greater in their female peers.

Dutch epidemiologists followed 16,210 subjects, ages 45 to 70, for 5 years. They learned that mortality was 74% greater in ex-drinkers as compared to teetotalers, and both nonuser groups fared worse than moderate-to-heavy drinkers. [Friesema]

Similarly, researchers at the University of Texas Medical School discovered that mortality was 2-fold increased in current nonusers vs. temperate drinkers. Further analysis showed that all of that excess was clustered in the former drinker subset. [Holahan]

In a study encompassing over 14,000 adults, 5-year mortality was highest in subjects that went from moderate or heavy use to abstention. There was no increase in the risk of death for individuals than continued to consume 14 or more drinks each week. [Grønbek]

Bottom line?

Ex-drinkers have higher mortality than teetotalers, temperate drinkers and in some cases even heavy alcohol users.

The loss of the cardioprotective advantages incurred from alcohol consumption cannot explain these outcomes because for this to be true there would be no significant mortality difference in risk between former and never drinkers.

Hence, this survival disadvantage associated with discontinuing alcohol use is due to (a) underlying chronic disease and (b) ex-heavy drinkers retaining their other adverse health habits and risk-taking behaviors.

 

How can underwriters deal effectively with the insidious risk associated with quitting drinking?

When proposed insureds are asked about alcohol use and they disavow current consumption, ask them if they EVER used alcohol.

Then, if they affirm prior indulgence, question them further:

When did you quit drinking?

Why did you quit drinking?

Those that cite a specific date for the commencement of abstinence might also be asked what happened the day before!

If they quit within, say, the last 5 years…and/or medical, occupational, pharmaceutical, legal or driving record issues…it would be prudent to pursue further evidence of insurability.

One asset of particular utility in this context is the alcohol marker carbohydrate-deficient transferrin (CDT). If, indeed, they no longer consume alcohol, this test will surely be negative.

Attending physicians’ records will also be quite illuminating, especially in cases where substantial prior indulgence has (selectively) clouded their memory!

 

References

Ellison. Annals of Epidemiology. 18,Supplement(2007):1
Friesema. Journal of Epidemiology and Community Health. 61(2007):441
Gmel. European Journal of Epidemiology. 18(2007):631
Grønbek. Epidemiology. 15(2004):222
Holahan. Alcoholism: Clinical and Experimental Research. 34(2010):1961
Klatsky. American Journal of Cardiology. 98(2006):1063
Lobo. American Journal of Epidemiology. 172(2010):708
Mukamal. Journal of the American Geriatric Society. 54(2006):30
Rehm. American Journal of Epidemiology. 168(2008):866
Ryb. 49th Annual Proceedings, Association for the Advancement of Automotive
Medicine; September, 2005
Wannamethee. International Journal of Epidemiology. 26(1997):523
Wellmann. European Journal of Cardiovascular Prevention and Rehabilitation.
11(2004):48


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