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Mental health conditions may confer additional risk. Therefore, we aimed to determine whether alcohol misuse increases cardiometabolic risk among firefighters and whether mental health conditions modify these relationships.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>Deidentified data from firefighters (<jats:italic>N<\/jats:italic>\u2009=\u20092405; 95.8% males, 38\u2009\u00b1\u20099\u2009years, 29.6\u2009\u00b1\u20094.6\u2009kg\/m<jats:sup>2<\/jats:sup>) included demographics, Alcohol Use Disorders Identification Test (AUDIT) and AUDIT\u2010C scores, mental health screening scores, anthropometrics, metabolic panel, and cardiorespiratory testing results. Differences in cardiometabolic parameters between firefighters with low AUDIT\u2010C (&lt;3 [females] or &lt;4 [males]; no or low\u2010risk alcohol use) or high AUDIT\u2010C (\u22653 [females] or \u22654 [males]; hazardous alcohol use) were determined and odds ratios for clinical risk factors were calculated. Posttraumatic stress disorder (PTSD), insomnia, depression, and anxiety were assessed as moderators.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Firefighters with high AUDIT\u2010C had significantly (<jats:italic>p<\/jats:italic>\u2009&lt;\u20090.05) higher total cholesterol (TC), high\u2010density lipoprotein (HDL\u2010C), and systolic blood pressure (SBP) and diastolic blood pressure (DBP) and lower hemoglobin A1C (HbA1c) than those with low AUDIT\u2010C. In unadjusted and\/or adjusted analyses, those with high AUDIT\u2010C had increased risk for overweight\/obesity, hypercholesterolemia, and prehypertension\/hypertension, and decreased risk for low HDL and elevated HbA1c. There were inverse moderation effects by posttraumatic stress disorder (PTSD), depression, and anxiety on relationships between AUDIT\u2010C score and BP. Insomnia (directly) and anxiety (inversely) moderated relationships between AUDIT\u2010C score and circulating lipids.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>Firefighters with high AUDIT\u2010C have differential cardiometabolic risk, with specific relationships altered by mental health status. Whether higher HDL and lower HbA1c with high AUDIT\u2010C in firefighters is protective long\u2010term remains to be explored. Overall, these results underscore the need for alcohol screening and intervention to maintain cardiometabolic health and long\u2010term occupational readiness among firefighters.<\/jats:p><\/jats:sec>","DOI":"10.1111\/acer.15517","type":"journal-article","created":{"date-parts":[[2025,1,3]],"date-time":"2025-01-03T03:03:43Z","timestamp":1735873423000},"page":"392-406","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Hazardous alcohol use and cardiometabolic risk among firefighters"],"prefix":"10.1111","volume":"49","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1865-1971","authenticated-orcid":false,"given":"Danielle E.","family":"Levitt","sequence":"first","affiliation":[{"name":"Metabolic Health and Muscle Physiology Laboratory, Department of Kinesiology &amp; Sport Management Texas Tech University  Lubbock Texas USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kealey J.","family":"Wohlgemuth","sequence":"additional","affiliation":[{"name":"Neuromuscular and Occupational Performance Laboratory, Department of Kinesiology &amp; Sport Management Texas Tech University  Lubbock Texas USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Emilie F.","family":"Burnham","sequence":"additional","affiliation":[{"name":"Front Line Mobile Health  Georgetown Texas USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0000-6870-1485","authenticated-orcid":false,"given":"Michael J.","family":"Conner","sequence":"additional","affiliation":[{"name":"Front Line Mobile Health  Georgetown Texas USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"J. 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