Journal Club

1. Journal Club Alcohol, Other Drugs, and Health: Current Evidence July-August 2007 www.aodhealth.org

2. Featured Article Smoking, alcohol consumption, and Raynaud’s phenomenon in middle age Suter LG, et al. Am J Med. 2007;120(3):264–271. www.aodhealth.org

3. Study Objective To determine whether… • smoking and drinking are associated with Raynaud’s phenomenon www.aodhealth.org

4. Study Design • Data came from the community-based Framingham Heart Study Offspring Cohort. • Subjects included 1602 men and 1840 women who were white and had a mean age of about 62 years. • Researchers used a validated survey to classify Raynaud’s status. • Analyses were adjusted for key confounders (e.g., cardiovascular disease, body mass index). www.aodhealth.org

5. Assessing Validity of an Article About Harm • Are the results valid? • What are the results? • How can I apply the results to patient care? www.aodhealth.org

6. Are the Results Valid? • Did the investigators demonstrate similarity in all known determinants of outcomes? Did they adjust for differences in the analysis? • Were exposed patients equally likely to be identified in the two groups? • Were the outcomes measured in the same way in the groups being compared? • Was follow-up sufficiently complete? www.aodhealth.org

7. Did the investigators demonstrate similarity in all known determinants of outcomes? Did they adjust for differences in the analysis? • Subjects were excluded if they used occupational vibrational tools. • Most subjects were free of any connective tissue disease. • The following covariates associated with Raynaud’s or smoking and alcohol use were measured and adjusted for: • Age and Body Mass Index • Use of Antihypertensive Medications • Cardiovascular Disease • Menopausal and Hormonal Status • Antinuclear antibody (ANA) testing was not performed. www.aodhealth.org

8. Were exposed patients equally likely to be identified in the two groups? • All subjects received similar surveillance for the exposures of interest (smoking and drinking). www.aodhealth.org

9. Were the outcomes measured in the same way in the groups being compared? • All subjects received similar surveillance for the outcome of interest (Raynaud’s phenomenon). • The study was not blinded. • Thelarge number of variables and outcomes measured in this cohort makes bias due to lack of blinding unlikely. www.aodhealth.org

10. Was follow-up sufficiently complete? • Histories of the exposures and the outcome were measured simultaneously, precluding a cause-effect determination. • No information on the length of the exposures was presented. www.aodhealth.org

11. What are the Results? • How strong is the association between exposure and outcomes? • How precise is the estimate of the risk? www.aodhealth.org

12. What are the Results? • Approximately 6% of women and 4% of men had Raynaud’s phenomenon. • Regular smoking in the past 12 months, versus not smoking, was significantly associated with an increased risk of Raynaud’s in men (odds ratio [OR], 2.59) but not in women. • Moderate drinking, versus not drinking,* was significantly associated with a decreased risk in men (OR, 0.51) but not in women. *Not drinking is about <2 drinks per week; moderate drinking is ≥2 to ≤7 drinks per week for women and ≥2 to ≤14 drinks for men www.aodhealth.org

13. What are the Results? (cont.) • However, drinking red wine (≈1 glass or more per week), versus no red-wine drinking, appeared to… • lower risk for both men (OR, 0.30) and women (OR, 0.59). • Heavier drinking, versus not drinking, was associated with... • increased risk in women (OR, 1.69) but not in men. *Heavier drinking is >7 drinks per week for women and >14 drinks for men. www.aodhealth.org

14. How strong is the association between exposure and outcome? *There was no association between smoking and Raynaud’s among women in bivariate analyses; therefore, in multivariable analyses involving women, only drinking was included. www.aodhealth.org

15. How precise is the estimate of the risk? • The confidence intervals are fairly wide because of the low prevalence of the disorder among the general population. www.aodhealth.org

16. How Can I Apply the Results to Patient Care? • Were the study patients similar to the patients in my practice? • Was the duration of follow-up adequate? • What was the magnitude of the risk? • Should I attempt to stop the exposure? www.aodhealth.org

17. Were the study patients similar to the patients in my practice? • Subjects were white, in their early 60’s, and had a mean BMI close to 30. • 12%-13% currently smoked. • 31%-40% were abstinent from alcohol. • 14%-15% met criteria for heavy drinking. • 14%-32% had a history of cardiovascular disease. www.aodhealth.org

18. Was the duration of follow-up adequate? • Histories of the exposures and the outcome were assessed simultaneously. • The timing of the exposure in relation to the development of the outcome was not presented. www.aodhealth.org

19. What was the magnitude of the risk? • In men, the adjusted odds ratio for smoking (2.59) is substantial. • In men and women, the protective effect of moderate wine consumption (adjusted ORs, 0.3-0.6) is also notable. www.aodhealth.org

20. Should I attempt to stop the exposure? • According to these data, Raynaud’s can be added to the list of adverse effects of… • smoking in men and • heavier alcohol consumption in women. • Also, a lower risk of Raynaud’s can be added to the list of potential benefits of moderate wine consumption for both men and women. • However, this study does not support a role for alcohol consumption in general to decrease Raynaud’s risk. www.aodhealth.org