Abstract: BACKGROUND & AIMS: Conflicting data exists on impact of alcohol use on risk of liver disease progression in patients with steatotic liver disease. We aim to evaluate the effect of longitudinal alcohol use on risk of cirrhosis among Veterans with steatotic liver disease. METHODS: U.S. Veterans with steatotic liver disease were identified from January 2010 to December 2022. Alcohol use was assessed using documented AUDIT-C scores and categorized as no alcohol (AUDIT-C = 0), low-risk alcohol use (AUDIT-C 1-2 for women and 1-3 for men), high-risk alcohol (AUDIT-C > 3 for women and > 4 for men). Incidence of cirrhosis was evaluated with competing risks Nelson-Aalen methods. Adjusted multivariable regression models evaluated risks of cirrhosis associated with baseline alcohol use and changes in alcohol use during follow up. RESULTS: 1,156,189 Veterans with steatotic liver disease were identified (54.2% no alcohol, 34.6% low-risk alcohol, 11.2% high-risk alcohol). Veterans with steatotic liver disease and high-risk alcohol have 43% higher incidence of cirrhosis compared to patients reporting no alcohol use. Compared to patients with baseline high-risk alcohol who reported no change in alcohol use, those who decreased their alcohol use during follow up experienced a 39% reduction in long-term risk of cirrhosis (HR 0.61, 95% CI 0.45-0.83, p< 0.01). CONCLUSIONS: One in nine Veterans with steatotic liver disease report concurrent high-risk alcohol use, which is associated with 43% greater risk of cirrhosis compared to no alcohol use. However, reducing alcohol use lowers risk of cirrhosis, emphasizing the importance of timely alcohol use assessment and early interventions to address high-risk alcohol use in steatotic liver disease.