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Several observational studies have found cardioprotective associations, while Mendelian randomization studies have found null or harmful effects of moderate drinking. Biases, including abstainer misclassification and sick-quitter effects, may obscure true associations. It is widely understood that former drinkers are often sick quitters. However, removal of former drinkers from analyses addresses bias in the abstainer group but fails to account for induced survivorship among current drinkers. This study sought to determine whether adjusting for biases altered the association between alcohol and CVD by comparing conventional models with those using (i) occasional drinkers as the reference group instead of lifetime abstainers and (ii) \u2018intention-to-treat\u2019 reallocation of former drinkers based on past drinking patterns.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods and results<\/jats:title>\n                    <jats:p>The Multi-Ethnic Study of Atherosclerosis is a prospective cohort study of 6814 participants aged 45\u201384 years between 2000 and 2002 without baseline CVD. A total of 6755 participants were included after excluding those with missing data. Alcohol consumption was self-reported and classified as lifetime abstainer, former, or current drinker [occasional (\u22641 drink\/week), light (2\u20137 drinks\/week), moderate (8\u201314 drinks\/week), heavy (&amp;gt;14 drinks\/week)]. Outcomes included coronary artery calcium (CAC; 0, 1\u2013100, 101\u2013300, and &amp;gt;300) and clinical events [myocardial infarction (MI), stroke, cardiovascular mortality, composite major adverse cardiovascular events (MACEs), and heart failure]. Of 6755 participants, 20.6% were lifetime abstainers, 24.1% former drinkers, and 55.3% current drinkers. Adjusting for biases altered the observed relationship between alcohol and CVD, showing increased harm with light drinking, decreased protection with moderate drinking, and a dose\u2013response relationship between alcohol and CAC, particularly CAC &amp;gt;300 in adjusted models. Protective associations between moderate drinking and MI [hazard ratio (HR): 0.64, 95% confidence interval (CI): 0.38\u20131.06] and cardiovascular mortality (HR: 0.81, 95% CI: 0.53\u20131.25) were attenuated and became non-significant. Light drinking shifted from null to increased risk for MI (HR: 1.46, 95% CI: 1.11\u20131.92), stroke (HR: 1.54, 95% CI: 1.17\u20132.03), MACE (HR: 1.33, 95% CI: 1.12\u20131.57), and heart failure (HR: 1.42, 95% CI: 1.10\u20131.84).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Associations between alcohol and CVD in observational studies are sensitive to methodologic variation. Results from models correcting for abstainer\/sick-quitter biases may help explain discrepant results from previous studies.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/eurjpc\/zwag201","type":"journal-article","created":{"date-parts":[[2026,5,9]],"date-time":"2026-05-09T11:42:10Z","timestamp":1778326930000},"page":"2788-2803","source":"Crossref","is-referenced-by-count":2,"title":["Reassessing alcohol consumption and cardiovascular disease by addressing bias in observational data: results from the multi-ethnic study of atherosclerosis"],"prefix":"10.1093","volume":"33","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9398-8358","authenticated-orcid":false,"given":"Shantanu","family":"Srivatsa","sequence":"first","affiliation":[{"name":"UNC Chapel Hill School of Medicine, University of North Carolina at Chapel Hill, 321 S Columbia St. , Chapel Hill, NC 27599, USA"},{"name":"University of North Carolina at Chapel Hill Department of Epidemiology, , 135 Dauer Drive, Chapel Hill, NC 27599 ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elizabeth K","family":"Farkouh","sequence":"additional","affiliation":[{"name":"Mayo Clinic Alix School of Medicine , Mayo Clinic, 200 First St. SW, Rochester, MN, USA55905"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5696-6803","authenticated-orcid":false,"given":"Tim","family":"Stockwell","sequence":"additional","affiliation":[{"name":"Canadian Institute for Substance Use Research, University of Victoria , 2300 McKenzie Ave, Victoria, BC V8N 5M8 ,","place":["Canada"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"James R","family":"Pike","sequence":"additional","affiliation":[{"name":"University of North Carolina at Chapel Hill Department of Epidemiology, , 135 Dauer Drive, Chapel Hill, NC 27599 ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"James M","family":"Clay","sequence":"additional","affiliation":[{"name":"Canadian Institute for Substance Use Research, University of Victoria , 2300 McKenzie Ave, Victoria, BC V8N 5M8 ,","place":["Canada"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9659-7096","authenticated-orcid":false,"given":"Ganga S","family":"Bey","sequence":"additional","affiliation":[{"name":"University of North Carolina at Chapel Hill Department of Epidemiology, , 135 Dauer Drive, Chapel Hill, NC 27599 ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Khurram","family":"Nasir","sequence":"additional","affiliation":[{"name":"DeBakey Heart and Vascular Center , Houston Methodist, 6565 Fannin St, Houston, TX 77030, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthew","family":"Budoff","sequence":"additional","affiliation":[{"name":"Department of Medicine, Lundquist Institute at Harbor\u2014UCLA , 1124 W Carson 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