The health and health behaviors of people who do not drink alcohol

BACKGROUND: Compared to abstention, moderate drinking has been linked to better health, and heavy and hazardous drinking to increased morbidity and mortality. Many studies have failed to account for heterogeneity in health and drinking history among nondrinkers, however. If former drinkers quit in response to ill health, this could increase the risk in the nondrinker category and underestimate the effects of alcohol if illnesses leading to abstention are alcohol-related. In addition, health behaviors may vary with drinking status, affecting health outcomes often attributed to drinking. METHODS: Survey data were collected from a probability sample of a large health maintenance organization's membership. Regression analyses assess the relationship between drinking status (adjusting for covariates), mental and physical health and functioning, and health behaviors. RESULTS: Former drinkers and lifelong abstainers had worse health and functioning than current drinkers and, comparatively, former drinkers had worse health than lifelong abstainers. Former drinkers did not differ from light-to-moderate drinkers in regard to health behaviors (except for smoking), although lifelong abstainers and heavier drinkers were less likely to use preventive care or try to improve their health behaviors. CONCLUSIONS: Consistent with hypotheses that former drinkers may stop drinking because of poor health, former drinkers were less healthy than current drinkers and had slightly worse health than lifelong abstainers, compared to light-to-moderate drinkers. Former drinkers did not appear to be at risk because of poorer health behaviors (except smoking), but lifelong abstainers and heavier drinkers might benefit from outreach designed to increase use of preventive care and improve health behaviors.     

Clusters within a general adult population of alcohol abstainers

BACKGROUND: Our previous study found that alcohol abstainers use acute services more and preventative services less than safe level drinkers. The observed relationships between four categories of alcohol consumption and service use were J-shaped for acute services and inverted J-shaped for preventive services. The aim of this paper was to further investigate these relationships. METHODS: The design was a health and lifestyle survey of 41 000 randomly-sampled adults in SE England. The response rate was 60%. Distinctive subgroups within the alcohol abstainer group were investigated using cluster analysis, based on socio-demographic and health status variables. Odds ratios for services use for the abstainer clusters, and three alcohol consumption groups were estimated from a logistic regression model which included age, social class, ethnic group, employment status, household composition, whether the respondent was a carer, smoking habit, use of private health insurance, and health status. RESULTS: Two clusters were formed for both males and females. Cluster 1 comprised, on average, older, frailer, and more disabled people. Cluster 2 comprised younger, healthier people, a greater proportion of whom belonged to ethnic minority groups. Cluster 2 had similar rates of use of Accident & Emergency, GP, optician, and dental services compared with safe level drinkers. Cluster 1's rates differed from those of both Cluster 2 and safe level drinkers in almost all instances. CONCLUSIONS: The J- and inverted J-shaped relationships between alcohol consumption and service use are partly explained by a subgroup of abstainers who are older, of less good health, and who use hospital, clinic, and domiciliary healthcare services much more than safe level drinkers.     

Is moderate alcohol use related to wages? Evidence from four worksites

Moderate alcohol users (approximately two drinks per day on average) have recently been shown to have a lower risk of coronary heart disease relative to abstainers and heavy drinkers. Conversely, a few studies have found that alcoholism is associated with greater unemployment and lower earnings. But, little research has examined the differential effects of drinking levels on job compensation. We utilize a newly created database on employees at four worksites to test for a nonlinear relationship between alcohol use and wages. We also examine whether alcohol use affects wages indirectly through educational achievement, marital status, and poor health. Our findings suggest an inverse U-shaped relationship between alcohol consumption and wages with a peak at approximately 1.5 to 2.5 drinks per day on average. Thus, controlling for other variables and conditional on working, moderate alcohol users have higher wages than abstainers and heavy drinkers at these worksites. We also find evidence that alcohol use is related to wages through human capital variables.     

Alcohol consumption, abstaining, health utility, and quality of life--a general population survey in Finland

AIMS: To examine the associations between alcohol consumption and utility-based health-related quality of life (HRQoL), subjective quality of life (QoL), self-rated health (SRH), and mental distress. METHODS: Representative general population survey in Finland, with 5871 persons aged 30-64 years. HRQoL was measured with two health utility instruments (15D and EQ-5D), QoL and SRH were measured with RATING scales, and mental distress with a General Health Questionnaire (GHQ-12). Past alcohol problems were diagnosed with a structured psychiatric interview known as the composite international diagnostic interview (CIDI). Alcohol consumption was examined with a self-report questionnaire. RESULTS: Negative associations between alcohol and well-being were observed on several measures for women consuming more than 173 g and men more than 229 g per week. Former drinkers scored worst on most measures, even in comparison to the highest drinking decile. For men, all statistically significant associations between moderate drinking and well-being disappeared when sociodemographic factors and former drinkers were controlled for. For women, moderate alcohol use associated with better SRH and EQ-5D as compared to abstainers. However, the possible health utility benefits associated with moderate alcohol consumption were of clinically insignificant magnitude. CONCLUSIONS: Failure to separate former drinkers and other abstainers produces a significant bias favoring moderate drinkers. As the possible health utility benefits of moderate alcohol use were clinically insignificant, it suffices to investigate mortality, when estimating the public health impact of moderate alcohol consumption using quality-adjusted life years.     

Moderate alcohol use and depression in young adults: findings from a national longitudinal study

OBJECTIVES: We examined the association between moderate alcohol use and depressive mood among young adults before and after adjustment for demographic, health, and socioeconomic factors that may act as confounders. METHODS: We analyzed 2 waves of interview data collected from 13892 young adults who participated in the National Longitudinal Study of Adolescent Health to compare frequency of depressive symptoms in moderate drinkers with frequency of symptoms in young adults in other alcohol use categories. RESULTS: With adjustment for health and socioeconomic factors, frequency of depressive symptoms were similar among moderate drinkers, lifetime and long-term abstainers, and heavy/heavier moderate drinkers but remained significantly higher among heavy drinkers. CONCLUSIONS: Moderate alcohol use may have no effect on depression in young adults relative to abstinence from alcohol use.     

The health benefits of moderate drinking revisited: alcohol use and self-reported health status

PURPOSE: To examine the association between alcohol use and self-reported health status. In particular, we sought to determine whether moderate drinkers are more likely to self-report above-average health status compared with other current drinkers, former drinkers, and lifetime abstainers. DESIGN: Cross-sectional survey. SETTING: Continental United States. SUBJECTS: The sample adult component of the 2002 U.S. National Health Interview Survey (n = 31,044), representative of the U.S. noninstitutionalized civilian household population. MEASURES: Dichotomous measure of above-average self-reported health status relative to all other health states. Several measures characterized alcohol use patterns (i.e., continuous and categorical measure of alcohol use, a proxy measure of problem drinking, former drinking, lifetime abstaining). Chronic health conditions and various demographic and lifestyle factors were included as covariates in all regression models. RESULTS: For both men and women, current moderate drinkers had the highest odds (OR = 1.27 for men, p < .01; OR = 2.03 for women, p < .01) of reporting above-average health status compared with other current drinkers, former drinkers, and lifetime abstainers. The odds dropped to 1.12 and 1.34, respectively, when all past-year drinkers were collapsed into a single group. CONCLUSION: Moderate alcohol consumption was associated with the highest odds of reporting above-average health status, even after controlling for chronic health conditions and demographic and lifestyle factors associated with health.     

Heavy drinking and health promotion activities

Empirical evidence suggests that individuals who consume relatively large amounts of alcohol are more likely to use expensive acute medical care and less likely to use preventive or ambulatory services than other individuals. The few studies that investigated the associations between heavy drinking and health promotion activities did not try to address omitted-variable biases that may confound the relationships. To fill this void in the literature, we examined the effects of heavy alcohol use on three health promotion activities (routine physical exam, flu shot, regular seatbelt use) using the US 2006 Behavioral Risk Factor Surveillance Survey. Although specification tests indicated that omitted variable bias was not present in the majority of the single-equation probit models, we cautiously interpret our findings as evidence of strong associations rather than causal effects. Among both men and women, heavy alcohol use is negatively and significantly associated with each of our three outcomes. These findings suggest that heavy drinkers may be investing less in health promotion activities relative to abstainers and other drinkers. Policy options to address the associated externalities may be warranted.     

Alcohol consumption in a sample of Italian healthcare workers: A cross-sectional study

ABSTRACT

Since previous evidence suggested a risky alcohol consumption among healthcare workers (HCW), this study aimed to investigate the patterns of alcohol use in a sample of HCWs in Italy, through the Alcohol Use Disorders Identification Test Consumption (AUDIT-C). Overall, 639 HCWs participated in the study. 43.8% of them reported a score of 0 at AUDIT-C test. Drinkers were divided into “low-risk” and “at-/high-risk,” being respectively the 47.1% and 9.1% of the whole sample. There were significant differences between abstainers and drinkers, and between low-risk and at-/high-risk drinkers. In the multivariate logistic regression model, being younger, male, and physicians was associated with the profile of regular alcohol drinkers. A high risk AUDIT-C score was more likely in older and female HCWs. Briefly, this study confirmed the hypothesis of a risky level of drinking in HCWs. Educational preventive measures should be implemented to reduce alcohol consumption in this population.     

The association between alcohol consumption and health services utilization

The association between alcohol consumption patterns and the use of health services was examined in a cross-sectional survey of the general population of the Region of Madrid. Logistic regression analysis was used to determine the odds of moderate drinkers, excessive drinkers and non-drinkers to utilize health care services. Our findings indicate that moderate drinkers have a lower probability of utilizing health care services as compared to non-drinkers. Specifically, moderate drinkers showed a lower probability of utilizing both hospital (OR = 0.65 CI = 0.48-0.89) and ambulatory care (OR = 0.79 CI = 0.66-0.95) services. Furthermore, the frequency of use of ambulatory (OR = 0.79 CI = 0.64-0.95) and emergency care services (OR = 0.38 CI = 0.21-0.69) was also lower for moderate drinkers. Excessive drinkers also showed a tendency to use emergency care services less frequently (OR = 0.43 CI = 0.19-0.93). Both moderate and excessive drinking were also significantly associated with a shorter length of stay as compared to non-drinkers. The odds ratios are 0.41 (CI = 0.21-0.79) and 0.29 (CI = 0.19-0.39) respectively. Possible explanations of this "protective" effect of alcohol consumption, especially of moderate drinking, are discussed in relation to the diagnostic entities motivating the use of health care services.     

Alcohol exposure and health services utilization in older veterans

The objective of this study was to determine if increased alcohol exposure is associated with greater use of health services among older veterans. A total of 129 older veterans (> or =65 years old), receiving longitudinal care in a Veterans' Administration primary care clinic, were followed retrospectively for up to 42 months. Subjects were screened at baseline for problem drinking with the CAGE or the quantity-frequency questions from the Alcohol Use Disorders Identification Test (QF-AUDIT), and stratified by exposure into three categories: abstainers, social drinkers, and problem drinkers. Outcomes included total outpatient clinic visits, laboratory tests, radiologic and other technologic procedures, as well as acute care hospitalizations. For all subjects (N = 129), no association was found between alcohol exposure and use of any outpatient services. Among CAGE-screened (n = 62) abstainers, social drinkers, and problem drinkers, significant differences were found in the median number of laboratory tests (7.3 vs. 3.4 vs. 7.1, P = 0.004) and hospitalizations (0.3 vs. 0.0 vs. 0.3, P = 0.001) per patient year of follow-up. No exposure-outcome associations were present, however, among QF-AUDIT-screened subjects (n = 67). We were unable to demonstrate a consistent relationship between alcohol exposure and health services utilization. The effects of alcohol on older veterans' use of health services varied with the method used to measure alcohol exposure. Additional studies are needed to determine whether multiple, or possibly new, measures can more precisely define the health effects of alcohol in older populations.     

Alcohol use beliefs and behaviors among high school students

Purpose: To identify specific alcohol use beliefs and behaviors among local high school students; to determine whether relationships exist between alcohol use and various sociodemographic and lifestyle behaviors; and to assist in the development and implementation of alcohol abuse prevention programs.Methods: This cross-sectional study involved the completion of a questionnaire by 1236 Grade 9–13 students (86% response rate) from 62 randomly selected classrooms in three Canadian urban schools. Data analyzed here are part of a larger lifestyle survey.Results: A total of 24% of students reported never having tasted alcohol, 22% have tasted alcohol but do not currently drink, 39% are current moderate drinkers, 11% are current heavy drinkers (five or more drinks on one occasion at least once a month), and 5% did not answer. Reasons stated most often for not drinking were “bad for health” and “upbringing,” while reasons stated most often for drinking were “enjoy it” and “to get in a party mood.” Student drinking patterns were significantly related to gender, ethnicity, grade, and the reported drinking habits of parents and friends. Older male adolescents who describe their ethnicity as Canadian are at higher risk for heavy drinking than students who are younger or female, or identify their ethnicity as European or Asian. Current heavy drinkers are at higher risk than other students for engaging in other high-risk behaviors such as drinking and driving, being a passenger in a car when the driver is intoxicated, and daily smoking.Conclusions: Heavy alcohol use in adolescents remains an important community health concern. Older self-described Canadian and Canadian-born male adolescents are at higher risk for heavy drinking. Current and heavy drinking rises significantly between Grades 9 and 12. Students who drink heavily are more likely to drink and drive, to smoke daily, and to have friends and parents who drink alcohol.     

Examining Australia's heaviest drinkers

Objective : This study examined the distribution of alcohol consumption in Australia, identifying the heaviest drinking 10% of the population and examining their sociodemographic characteristics and their alcohol consumption and purchasing practices. Methods : Data came from the 2016 National Drug Strategy Household Survey and the 2013 International Alcohol Control Study. The heaviest drinking 10% of the population identified based on estimates of annual alcohol consumption. Logistic regression was then used to assess the factors that distinguished these heaviest drinkers from the rest of the drinking population. Results : The heaviest drinking 10% of the population consumed 54.4% of all alcohol consumed. These heavy drinkers were more likely to be men and to live in regional and remote areas. They were more likely to drink cask wine and full‐strength beer and to purchase cheaper alcohol than other drinkers. Conclusions : Australian alcohol consumption is heavily skewed. Alcohol consumption practices appear to differentiate the heaviest drinkers from others more clearly than sociodemographic factors. Implications for public health : Public health interventions that reduce drinking among the heaviest 10% of drinkers in Australia have the potential to markedly reduce per‐capita consumption and reduce alcohol‐related harm. Interventions focused on cheap alcohol may be effective with these drinkers.     

Alcohol Storylines in Television Episodes: The Preventive Effect of Countering Epilogues

This experimental study assessed whether alcohol television storylines impact youth drinking attitudes and intentions and whether corrective epilogues can potentially moderate this impact. Television episodes were professionally produced to depict heavy drinking leading to either positive or negative consequences. The pro- and anti-alcohol episodes were shown alone or with an epilogue where a main character discussed the deleterious effects of excessive drinking. Attitudes toward drinkers and drinking intentions were measured subsequently, along with reactions to the episode and demographic data, among participants aged 14–17 using an online study. Exposure to the pro-alcohol episode was related to more positive attitudes toward drinkers. Including an epilogue after a pro-alcohol episode was related to more negative viewers’ attitudes toward drinkers and lower drinking intentions compared to a pro-alcohol episode with no epilogue. By contrast, including an epilogue after an anti-alcohol episode was unrelated to attitudes toward drinkers or drinking intentions. Viewing a single television episode with a pro-alcohol message may lead to more positive attitudes toward drinkers. The finding that a brief epilogue may reduce the impact of the pro-alcohol storyline suggests easily implemented preventive strategies to counter the adverse impact of substance use portrayals in entertainment programming.     

Relationship of alcohol consumption to diet: a population-based study in Hawaii

The relationship of alcohol use to diet was examined in 2272 male and 2337 female adults aged 45 y and older who provided a quantitative diet history during 1977-1979. Mean values for each dietary variable, adjusted for smoking, ethnicity, income, and education, were compared in each sex between abstainers and drinkers and by tertile of ethanol intake. Linear relationships with extent of drinking were also sought. Drinkers were found to be less obese than abstainers. Consumption of carbohydrate, vitamins, calcium, fruits, fruit juices, and raw vegetables was greater among abstainers whereas consumption of fat (particularly polyunsaturated fatty acids), cholesterol, zinc, meat, pickled vegetables, and dried fish was greater among drinkers. Because validations of dietary questionnaires have shown that alcohol consumption is more accurately recalled than food intake, the possibility of a residual confounding effect for these dietary variables should be considered in epidemiologic studies of alcohol and health.     

At-risk drinking among patients making routine primary care visits

BACKGROUND: Addressing non-alcoholic, at-risk patterns of alcohol consumption that are associated with increased morbidity and mortality is an important health care priority. OBJECTIVE: The objective was to describe the prevalence and characteristics of at-risk drinkers in a population-based sample of adults with routine primary care visits. Methods: Three thousand four hundred thirty-nine patients with advance appointments in 23 primary care practices completed a health survey prior to their visit. At-risk drinking was defined as consuming an average of two or more drinks per day (chronic drinking), or two or more occasions of consuming five or more drinks in the past month (binge drinking), or, in the past month, one or more occasion of driving after consuming three or more drinks (drinking and driving). RESULTS: Prevalence was: 11% at-risk drinking; 63% light to moderate drinking; 26% abstinence. Abstainers differed from alcohol users on demographics (older, fewer Caucasian, lower income, more unemployed), other health behaviors (less exercise, lower rates of smoking, and marijuana and cocaine use), and family history of alcohol problems (lower). Abstainers also reported poorer physical and psychological health. Compared to light to moderate drinkers, at-risk drinkers were more likely to be male, unmarried, and to use other substances (tobacco, marijuana, and cocaine). Among at-risk drinkers, those with two or more risk factors were more likely male, consumed more alcohol per week, had higher AUDIT scores and were more motivated to change their drinking. Among those with only one risk factor, binge drinkers reported high rates of tobacco and marijuana use, relatively poor perceived health, and the highest proportion of negative consequences from drinking. CONCLUSIONS: At least 1 in 10 patients making routine primary care visits have drinking practices that place them at risk for negative consequences from drinking. Three drinking patterns that can be used to define at-risk drinking are relatively distinct.     

Prospective study of alcohol consumption and metabolic syndrome

BACKGROUND: Alcohol consumption is related to the prevalent metabolic syndrome. Few studies have evaluated the effects of alcohol consumption on the development of metabolic syndrome. OBJECTIVE: We examined the association between alcohol consumption and incident metabolic syndrome. DESIGN: This was a prospective cohort study of 3833 male and female Koreans aged 40-69 y and free of the metabolic syndrome at baseline. Information on alcohol consumption was obtained periodically from interviewer-administered questionnaires. Incident cases of the metabolic syndrome were identified by biennial health examinations during 4 y of follow-up between 2003 and 2006. RESULTS: Compared with nondrinkers, the multivariate relative risk [RR (95% CI)] of the metabolic syndrome for very light drinkers consuming 0.1 to 5 g of alcohol per day (g/d) was 1.06 (0.71, 1.58), that for light drinkers consuming 5.1 to 15 g/d was 1.13 (0.69, 1.83), that for moderate drinkers consuming 15.1 to 30 g/d was 1.25 (0.75, 2.09), and that for heavy drinkers consuming >30 g/d was 1.63 (1.02, 2.62). All individual components of the metabolic syndrome were significantly associated with heavy drinking, particularly among heavy liquor drinkers. CONCLUSIONS: Heavy drinking, in particular among liquor drinkers, is associated with an increased risk of the metabolic syndrome by influencing its components. Further data are warranted to clarify the association between drinking minimal alcohol and the metabolic syndrome as well as the beverage-specific association for drinking beer or wine.     

A community study of alcohol consumption and dietary habits in middle-aged Italian women

This population-based study examines whether dietary intake in middle-aged Italian women is influenced by alcohol drinking habits. The 499 participants were interviewed using a dietary history questionnaire designed to investigate alcohol consumption. Mean intake of total and non-alcohol energy increased progressively within categories of increasing alcohol consumption (less than 5, 5-19, 20-39, 40+ g/day). Mean body weight and Quetelet index (kg/m2), however, decreased with increasing alcohol consumption. Once the disparities in energy intake were reduced by computing intake densities, the data suggest that moderate and heavy drinkers have dietary habits similar to those of abstainers or light drinkers. These findings were confirmed by multiple linear regression analyses in which the confounding effects of age, place of residence, occupation, and Quetelet index were taken into account. Increasing alcohol consumption appeared associated only with a modest decrease in the intake of fibre, beta-carotene, and vitamin C. These findings do not support the hypothesis that the observed protection from coronary artery disease among moderate drinkers is related to a chronic reduction in the intake of carbohydrates and fat, at least in middle-aged women.     

Effect of moderate alcohol consumption on liver enzymes increases with increasing body mass index

BACKGROUND: Although both ethanol consumption and overweight alter the activities of hepatic enzymes in circulation, the differentiation of an alcohol or nonalcohol basis for such changes remains problematic. The magnitude of alterations occurring among moderate drinkers has remained obscure. OBJECTIVE: We examined the links between moderate ethanol consumption, body mass index (BMI; in kg/m(2)), and liver enzymes. DESIGN: Serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), and gamma-glutamyltransferase (GGT) were recorded from 2,164 apparently healthy participants (1,028 men, 1,136 women) reporting either no alcohol (abstainers) or <40 g ethanol consumption per day (moderate drinkers). The study population was further classified according to BMI as follows: <19 (underweight), > or =19 and <25 (normal weight), > or =25 and <30 (overweight), and > or =30 (obese). RESULTS: Serum ALT (P < 0.05) and GGT (P < 0.001) but not AST (P = 0.805) activities in moderate drinkers were higher than those in abstainers. For all enzymes, a significant main effect was observed of increasing BMI, which was more striking in moderate drinkers than in abstainers. Tests of between-subjects effects indicated significant interactions with sex and drinking status, although not with sex and BMI. CONCLUSIONS: The effect of moderate alcohol consumption on liver enzymes increases with increasing BMI. These findings should be considered in the clinical assessment of overweight alcohol consumers and in the definition of normal ranges for liver enzymes. These results may also help to develop new approaches for examining patients with fatty liver induced by either ethanol or adiposity.     

Cardiovascular risk factors and confounders among nondrinking and moderate-drinking U.S. adults

BACKGROUND: Studies suggest that moderate drinkers have lower cardiovascular disease (CVD) mortality than nondrinkers and heavy drinkers, but there have been no randomized trials on this topic. Although most observational studies control for major cardiac risk factors, CVD is independently associated with other factors that could explain the CVD benefits ascribed to moderate drinking. METHODS: Data from the 2003 Behavioral Risk Factor Surveillance System, a population-based telephone survey of U.S. adults, was used to assess the prevalence of CVD risk factors and potential confounders among moderate drinkers and nondrinkers. Moderate drinkers were defined as men who drank an average of two drinks per day or fewer, or women who drank one drink or fewer per day. RESULTS: After adjusting for age and gender, nondrinkers were more likely to have characteristics associated with increased CVD mortality in terms of demographic factors, social factors, behavioral factors, access to health care, and health-related conditions. Of the 30 CVD-associated factors or groups of factors that we assessed, 27 (90%) were significantly more prevalent among nondrinkers. Among factors with multiple categories (e.g., body weight), those in higher-risk groups were progressively more likely to be nondrinkers. Removing those with poor health status or a history of CVD did not affect the results. CONCLUSIONS: These findings suggest that some or all of the apparent protective effect of moderate alcohol consumption on CVD may be due to residual or unmeasured confounding. Given their limitations, nonrandomized studies about the health effects of moderate drinking should be interpreted with caution, particularly since excessive alcohol consumption is a leading health hazard in the United States.     

Making sense of drinking: the role of techniques of neutralisation and counter‐neutralisation in negotiating alcohol consumption

This article contributes to the understanding of how students neutralise potential feelings of guilt and stigmatisation regarding their alcohol consumption. We report findings from two qualitative studies with students at a UK university. The aim of the research was to uncover the range and ways in which neutralisation and counter‐neutralisation techniques are used by drinkers and abstainers/near‐abstainers in managing their alcohol position. Study 1 consisted of five focus groups with heavy drinkers and Study 2 comprised nine one‐to‐one interviews with abstainers and near‐abstainers. Analysis highlights the importance of alcohol consumption in students’ lifestyles, but also the potential identity conflicts experienced by all drinkers, regardless of the amount consumed. Heavy drinkers primarily employ neutralisation techniques as a means to rationalise the negative impacts of their actions, whereas abstainers and near‐abstainers mainly use counter‐neutralisation techniques as a means to reinforce their commitment to lifestyles which run counter to mainstream student life expectations. However, regardless of the amount of alcohol consumed, all participants employed neutralising and counter‐neutralising arguments in some social situations. The article discusses the usefulness of neutralisation theory to account for the adoption of risky health behaviours, such as excessive alcohol consumption, and the potential implications for public health interventions.