It’s a simple question that physicians usually do not ask their patients: “When was your last drink?”

“If the patient says yesterday, you know the patient isn’t a casual drinker,” said Joe G. Zein, MD, PhD, a pulmonary and critical care physician with the Mayo Clinic in Phoenix.

If that noncasual drinker also has chronic obstructive pulmonary disease (COPD), they have a pulmonary system that takes a beating, not only from the damage incurred from the alcohol but also because these lungs are likely exposed to consistently inhaled cigarette smoke, the primary cause of COPD. It’s not a stretch: In general, most smokers drink, and a large amount of those with alcohol use disorder (AUD) smoke.

By not asking that question, physicians are missing out on a treatable disorder that, should the treatment be successful, can help reduce the impact of the COPD and that disease’s numerous possible comorbidities. “[AUD] is a treatable target,” he said. A few of those comorbidities: arthritis, cardiac conditions, hypertension.

Zein became aware of alcohol’s impact on COPD a few years ago. In a paper published in 2021, Zein and colleagues found that those with diagnosed COPD and documented AUD were more likely to present with respiratory failure in the emergency department, have a longer hospital stay, or are readmitted not long after.

More recent studies out of China and Spain showed that medical intervention (China) helped those with COPD and AUD, and that 15.6% of in-hospital deaths (Spain) were attributed to patients with COPD and AUD, with other comorbidities including pneumonia and COVID. The baseline figure of the in-hospital deaths was 7.46%.

In the Zein study, only 4% of the patients with COPD had documented AUD. In the Spanish study, 10.35% of 2.5 million COPD hospitalizations had documented AUD.

A coauthor of the Zein study was not surprised by the remarkable discrepancy between the two studies’ percentages of documented patients with AUD.

“That makes complete sense,” said Maeve Macmurdo, MD, a staff physician, Cleveland Clinic Respiratory Institute, Cleveland. “Doctors had to diagnose and chart it. We are not good at documenting; we don’t screen for AUD in hospital or clinical settings.” Ten percent is reasonable.

“We are not doing the screening consistently in the healthcare system as a whole.”

The Joint Pulmonary Beating

Alcohol — it likely doesn’t matter the type, Zein said — disrupts lung function. The cilia, the broom sweepers in the upper airways, become impaired, leaving open space for harmful infiltration, like pneumonia. And because alcohol also impairs the lung’s lower airways, the immune system is weakened. Heavy drinkers are highly susceptible to infections from that infiltration, like tuberculosis, respiratory syncytial virus infection, and community-acquired pneumonia. One study found that 10-20 g of alcohol per day raises the relative risk for pneumonia by 8%, with smoking not a factor.

“We know that alcoholism influences the immune system, so those with AUD and liver disease are more prone to having worse outcomes with pneumonia,” Zein said.

If smoking is a factor, the risk for pneumonia increases, especially with patients with COPD who are prescribed inhaled corticosteroids, Zein said. “So with COPD, with pneumonia, they are likely to have worse outcomes if they drink.”

Considering that refractory asthma is included with emphysema and chronic bronchitis under the COPD umbrella, the following August 2025 study is worth a mention. Researchers followed 201 patients for 12 years after their diagnosis of adult-onset asthma. Those who were in the heavy-drinking category had significant lung function loss; the median annual forced vital capacity drop was -30 mL; the forced expiratory volume in 1 second was -26 mL. The drop for nonheavy drinkers was -5 mL and -17 mL, respectively.

Profiling Patients With COPD

Macmurdo said the 2021 paper came about because the researchers were interested in COPD and asthma-related readmissions. The patients’ AUD diagnoses were included in the databases they reviewed. “We looked at AUD, and [found] it increases the severity of illness.” Hence, AUD became a treatable target.

Other reasons exist as to why heavy drinkers with COPD have poorer outcomes than their lighter or nondrinking counterparts, she said. It’s because of the patient’s behavior.

“In those that drink heavily, they miss [taking] medication and are at an increased risk of swallowing badly; [drinking] can impact [health outcomes] in multiple ways,” she said, including patients missing pulmonary rehabilitation appointments.

It is the primary care physicians (PCPs) who are in a better spot to help these patients, these experts said. PCPs, in time, can build trust, said Macmurdo.

“In the hospital we can’t because we are meeting the patient for the first time.”

Plus, she added, quitting these addictive behaviors will go better if there is a plan and a care partner to support the patient.

But drinking might not be the first thing to bring up when meeting the patient, she said. Maybe discuss exposures in the workplace. “PCPs need to take a holistic approach for people with respiratory illness,” she said.

A holistic approach can uncover what the person does for a living, how much education the person has had, and his socioeconomic circumstances. Those with COPD tend to be primarily older individuals who mostly live in small towns, who do not have graduate degrees, and who likely have worked in places that create particles that, when inhaled, inflame and narrow airways. In 2021, West Virginia had the highest prevalence rate of COPD of any state, at 11.8. Alabama, Arkansas, and Mississippi weren’t too far behind. Hawaii, Utah, and Maryland were the lowest.

COPD, said Zein, is probably less of a problem for society in general. But for individual patients it is still a big problem. “The essence of this [2021] paper…is we can do more.”