Many studies don’t support the “any alcohol is bad” hypothesis.
By R. Curtis Ellison, MD, MS; and Creina Stockley, PhD, MBA
The risks of moderate alcohol consumption on health outcomes have been widely studied and debated for many years. Studies have considered the health impacts associated with alcohol consumption through a variety of approaches, ranging from exploring the effects on a single disease, to considering multiple health outcomes, to using all-cause mortality as an outcome. (All-cause mortality is death due to any disease, complication or hazardous exposure.)
The J Curve
Initial evidence in the 1970s showed a J-shaped relationship between alcohol consumption and all-cause mortality. In other words, at low levels of consumption, alcohol lowers the risk of all-cause mortality, whereas above some threshold, it increases the risk.
It is surprising that now, in 2023, with so many well-done, scientifically sound cohort studies and a huge number of basic science experiments supporting the protective effects of moderate wine consumption, there are persistent anti-alcohol statements and even suggestions that “no alcohol intake is safe.”
The cause of such sentiments is not known, but may relate to the fact that, for the first two-thirds of the 20th century, all research and medical reports on “alcohol“ focused only on alcohol abuse, and some scientists and officials remain reticent to admit any health effects of an alcohol-containing beverage. Further, some government officials continue to believe that we must “protect the public” — that we scientists must decide what the public should know about alcohol and health — and a “mixed message” (that a little is good for you but a lot is bad) will not be understood and will lead to increased abuse.
How do these anti-alcohol scientists create data to support their claims? There are a number of ways. Recommendations for moderate drinking should be focused on middle-aged and older men and postmenopausal women, who are at a life-stage when the so-called “diseases of ageing” generally first appear; in addition to cancer, these include coronary heart disease, ischemic stroke, diabetes and dementia.
Some anti-alcohol scientists tend to include in their analyses data on alcohol use in the young, long before the diseases of ageing appear. This means an increased risk of death from alcohol abuse (violence, drunk driving and other impulsive behavior, common in young people) is included in the analyses of older subjects and obscures the true relation in the latter.
Specific risks
The 2020 Global Burden of Disease study clearly showed that low to moderate drinking, pharmacologically considered to be approximately 1 to 2 drinks per day, does not increase risk of 22 selected health outcomes, and that coronary heart disease and ischemic stroke remain the leading causes of death worldwide. Instead of focusing on diet and lifestyle factors to reduce the risk of cardiovascular diseases, however, the focus by anti-alcohol scientists has firmly and fully turned to cancer in the past 15 years.
Current evidence, including that from the 2020 Global Burden of Disease, indicates that “truly moderate” drinking does not increase the risk of cancer per se. Alcohol consumption is only associated with an increased risk of certain, but not of all, cancers.
Multiple population studies have shown that the relationship between each cancer and alcohol differs. For example, there are stronger direct relationships in risk for cancers of the upper digestive tract from alcohol consumption but less strong direct relationships for cancers of the bowel and rectum, liver and breast. These are known as “alcohol-attributable cancers,” and analyses consistently suggest that the risk of each cancer is low and relatively non-significant from light to moderate alcohol consumption. Risk becomes significant, however, with heavier alcohol consumption. Amount, pattern and lifetime alcohol consumption all influence the risk of these alcohol-attributable cancers.
Highlighted in the recent international breast cancer awareness month, a woman’s risk of breast cancer will increase with each 10 g of daily alcohol consumption additive to that of other risk factors. Risk from alcohol appears most likely limited to those women who have a positive family history of breast cancer, such that the effect of alcohol consumption on the incidence of breast cancer appears mainly manifested in oestrogen receptor positive breast cancer.
Balanced data
In essence, the risk of the other age-related diseases and total mortality are all reduced when compared with the risk among non-drinkers, by an average of 11%. Especially, in essentially every epidemiologic study for the past few decades, it has been shown that the risk for cardiovascular diseases (coronary heart disease and ischemic stroke) and for diabetes are significantly and markedly lower among moderate drinkers than among abstainers (in effect, there is a U-shaped curve). This result persists when important potentially confounding factors (such as smoking and low socioeconomic factors) are taken into consideration.
Further, the anti-alcohol scientists often choose to exclude a large number of studies in their meta-analyses. It seems they select studies that reflect what they want their results to show, then exclude many studies that do not support their chosen result.
Another tactic is to exclude subjects with elevated levels of protective high-density cholesterol, those with diabetes and those with other factors that are mechanisms by which wine and alcohol protect against such diseases. Also, the pattern of drinking (for example, type of beverage, whether or not with food, regularly or in binges) is often ignored when calculating their results. It is clear from well-done analyses over many decades that truly moderate drinkers, especially those consuming wine with meals, have considerably lower risk of dying prematurely from the diseases of ageing.
Define the terms
Finally, the emphasis on terminology used by anti-alcohol scientists has also changed over the past three decades. Potential risk from alcohol consumption is highlighted rather than any potential benefits. The concept of risk needs some consideration, however, as risk is different from safety.
Safety is related to a level of risk and a level of risk is inherent to almost every activity. The level of risk is analysed by combining estimates of likelihood and consequences. Acceptability of a risk is primarily subjective and is generally viewed relative to other risks. Risk seems greater when put in terms of relative risk. A 100% increase in risk may seem enormous, but if the risk began as 1 in 100 people, the risk is increased to 2 in 100. To some people, this will seem like a large increase in risk but to others, it will not. Some risk, therefore, needs to be accepted in our lives otherwise living is impossible such as that of riding a bike or driving a motor vehicle.
Moderation is key
Instead of being villainized in 2023, moderate alcohol consumption should continue to be considered as integral to a healthy diet and lifestyle. Indeed, as discussed at October’s Lifestyle, Diet, Wine and Health International Scientific Congress in Spain, the overwhelming body of observational scientific data, as well as an immense number of experimental studies, support the contention that, for most middle-aged and older men and women who choose to do so, the regular consumption of small amounts of an alcoholic beverage can be considered as one of four or five additive components of a “healthy lifestyle.”
Moderate alcohol consumption has been repeatedly shown to be associated with a lower risk of cardiovascular diseases and of total mortality, where the recent US Nurses’ Health Study and the Health Professionals Follow-up Study concluded there is “important evidence” that maintaining healthy behaviors should be recommended to individuals through mid-life to late adulthood as well as at young ages.
A critical assessment of more than 270 published scientific studies since 2009 on the effects of alcohol consumption on human health is available on the website of the International Scientific Forum on Alcohol Research. The forum consists of an international group of more than 30 invited physicians and scientists, each a specialist in their field and committed to balanced and well-researched analysis regarding alcohol and health.
Recommended reading
Brien, S.E., Ronksley, P.E., Turner, B.J., et al. (2011). Effect of alcohol consumption on biological markers associated with risk of coronary heart disease: systematic review and meta-analysis of interventional studies. British Medical Journal, 342, d636. https://doi.org/10.1136/bmj.d636
Bryazka, D., Reitsma, M.B., Griswold, M.G., et al. (2022). Population-level risks of alcohol consumption by amount, geography, age, sex, and year: a systematic analysis for the Global Burden of Disease Study 2020. Lancet (London, England), 400(10347), 185–235. https://doi.org/10.1016/S0140-6736(22)00847-9.
Colpani ,V., Baena, C.P., Jaspers, L., et al. (2018) Lifestyle factors, cardiovascular disease and all-cause mortality in middle-aged and elderly women: a systematic review and meta-analysis. European Journal of Epidemiology, pre-publication. https://doi.org/10.1007/s10654-018-0374-z
Di Castelnuovo, A., Costanzo, S., Bonaccio, M., et al. (2022). Alcohol intake and total mortality in 142 960 individuals from the MORGAM Project: a population-based study. Addiction (Abingdon, England), 117(2), 312–325. https://doi.org/10.1111/ADD.15593
Li, X., Hur, J., Cao, Y. et al. Moderate alcohol consumption, types of beverages and drinking pattern with cardiometabolic biomarkers in three cohorts of US men and women. Eur J Epidemiol (2023). https://doi.org/10.1007/s10654-023-01053-w
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Curtis Ellison, MD, MS, is a physician/epidemiologist with training in internal medicine, cardiology and epidemiology. A graduate of Davidson College, the Medical University of South Carolina and Harvard School of Public Health, he served on the faculty of Harvard University, Georgetown University and the University of Massachusetts Medical School before spending the past three decades as professor of medicine at Boston University School of Medicine. He also spent several decades as a senior investigator at the Framingham Heart Study.
Ellison’s interest in recent decades has focused on the effects on health of the moderate consumption of wine and other alcoholic beverages. With Helena Conibear, who directs Alcohol in Moderation based in Dorchester, Devon, UK, he was a founder and is the current chairman of the International Scientific Forum on Alcohol Research. The forum consists of a group of more than 45 scientists from around the world who work in the field and voluntarily prepare and publish on the forum website (www.alcoholresearchforum.org), critical reviews of emerging scientific articles on wine, alcohol and health.
Creina S. Stockley Ph.D., MBA, has 30 years of experience in the alcohol and health arena, and was based at the Australian Wine Research Institute from 1991 to 2018. Her academic background is clinical pharmacology and physiology, and she has also been associated with public health projects via the Faculty of Medicine, Nursing and Health Sciences at Flinders University. She is currently an independent consultant as well as an adjunct senior lecturer in the School of Agriculture, Food and Wine at the University of Adelaide and co-director of the International Forum on Alcohol Research (ISFAR). In 1997, she was appointed the Australian government representative on the Health and Safety Commission of the Organisation International de la Vigne et du Vin (OIV) and served as president of the Commission IV Safety and Health, being awarded the Knight of the Order of Agricultural Merit (France) in 2015 and, more recently, the OIV Merit Award.
Stockley has been actively involved in the preparation of Australian and international alcohol policy, alcohol drinking guidelines and alcohol warning labelling, as well as actively being involved in pharmacokinetic/dynamic/therapeutic research projects on a range of health, nutrition and safety related issues to alcohol consumption. Recently, these have included the potential allergenicity of wine and the effects of wine and wine-derived phenolic compounds on cardiovascular diseases, cognitive function and certain cancers.
