Background: Alcohol use is associated with increased blood pressure among adults with hypertension, but it is unknown whether some of the observed relationship is explained by mediating behaviors related to alcohol use.

Objective: We assess the potential indirect role of smoking, physical inactivity, unhealthy diet, and poor medication adherence on the association between alcohol use and blood pressure among Black and White men and women with hypertension.

Design: Adjusted repeated-measures analyses using generalized estimating equations and mediation analyses using inverse odds ratio weighting.

Participants: 1835 participants with hypertension based on ACC/AHA 2017 guidelines in three most recent follow-up exams of the longitudinal Coronary Artery Risk Development in Young Adults cohort study (2005-2016).

Main measures: Alcohol use was assessed using both self-reported average ethanol intake (drinks/day) and engagement in heavy episodic drinking (HED) in the past 30 days. Systolic and diastolic blood pressure (SBP, DBP) were measured by trained technicians (mmHg). Smoking, physical inactivity, and diet were self-reported and categorized according to American Heart Association criteria, and medication adherence was assessed using self-reported typical adherence to antihypertensive medications.

Key results: At baseline (2005-2006), 57.9% of participants were Black and 51.4% were women. Mean age (standard deviation) was 45.5 (3.6) years, mean SBP was 128.7 (15.5) mmHg, and mean DBP was 83.2 (10.1) mmHg. Each additional drink per day was significantly associated with higher SBP (β = 0.713 mmHg, 95% confidence interval (CI): 0.398, 1.028) and DBP (β = 0.398 mmHg, 95% CI: 0.160, 0.555), but there was no evidence of mediation by any of the behaviors. HED was not associated with blood pressure independent of average consumption.

Conclusions: These findings support the direct nature of the association of alcohol use with blood pressure and the utility of advising patients with hypertension to limit consumption in addition to other behavioral and pharmacological interventions.