Sober October?

Has the time come to re-examine our love–hate relationship with drinking? A recent episode of the New York Times podcast The Daily[1] got me thinking about how we talk to patients, and ourselves, about alcohol.

The general teaching when I was in medical school was that alcohol was a good thing . . . in moderation. The term French paradox was coined after evidence suggested that drinking red wine was responsible for a reduction in heart disease in some European countries.[2] In 1991, after 60 Minutes aired a story on the research, sales of red wine in the United States increased 40%.[3,4]

Research eventually also found health benefits in beer and other drinks.[5,6] Alcohol was credited with lower rates of ischemic heart disease[7] and ischemic stroke,[8] theoretically due to benefits to cholesterol profile, endothelial inflammation, and coagulation factors.[7-9]

A meta-analysis in Archives of Internal Medicine (2006) demonstrated that death from all-cause mortality was lowest with moderate drinking. The article’s now infamous J-shaped curve compared various quantities of alcohol consumption to “abstainers” and concluded that one to two drinks per day for women and two to four for men was a healthy range.[9] Cheers to salubrious spirits!

Let’s be honest: wasn’t that what everyone wanted to hear anyway? How wonderfully convenient to have one of our most beloved rituals supported by science. But why weren’t we talking more about the negative effects of alcohol? Addiction, increased risk of cancers, cirrhosis, and death from accidents? Publication bias, you say? Don’t be a buzzkill.

More recently, new evidence has changed the narrative. Published in January 2023, Canada’s Guidance on Alcohol and Health: Final Report by the Canadian Centre on Substance Use and Addiction contains what are likely the strictest drinking guidelines of any country.[2,10]

Compared with 2012 guidelines, which suggested that women could consume up to two drinks (27 g) daily and men up to three drinks (40 g) daily, the 2023 update dramatically cut consumption recommendations. The current message is, unequivocally, that no amount of alcohol is good for your health and that men and women are to consume a maximum of zero to two drinks (27 g) per week.[10]

Professor Tim Stockwell, a psychologist and alcohol researcher from Victoria, conducted a number of meta-analyses, including data that were foundational in Canada’s most recent guidelines on alcohol.[11,12] In his April 2024 address to the Royal College of Physicians of Edinburgh, Professor Stockwell dove into some of the nuances, assumptions, and misinterpretations in past research that led to overly generous estimates of alcohol’s benefits. Among them are that data were mainly restricted to white populations in high-income countries and that the maximum doses for benefit were very low, around one to three drinks per week. He also suggested we give sober second thought to some of the improbable benefits of alcohol reported in older studies—reduced asthma, deafness, common colds, liver disease, and falls in the elderly, and improved infant development.[2]

The crux of the issue, however, appears to be how older studies categorized “abstainers” versus “moderate drinkers.” A closer look at study subjects reveals that “abstainers” had higher baseline risks and unfavorable socioeconomic factors and included sick quitters, which systematically biased nondrinkers to ill health.

If we now accept that drinking can harm our health and shorten our lives, how will this impact our behavior? Alcohol is a ubiquitous social lubricant, and it can be hard to avoid.

What do you think—is it time to raise a mocktail and toast Sober October? Or do you plan to keep calm and pour on?
—Caitlin Dunne, MD, FRCSC

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References

1.    Kitroeff N, Dominus, S. How bad is drinking for you, really? The Daily. 5 July 2024. Accessed 1 August 2024. www.nytimes.com/2024/07/05/podcasts/the-daily/alcohol-health-risks.html.

2.    Stockwell T. Health benefits of drinking moderately: Too good to be true? YouTube. 17 April 2024. Accessed 1 August 2024. www.youtube.com/watch?v=_5o3MyFF6Pg.

3.    Chang KJ, Liz Thach MW, Olsen J. Wine and health perceptions: Exploring the impact of gender, age and ethnicity on consumer perceptions of wine and health. Wine Econ Policy. 2016;5:105-113.

4.    Prial FJ. Wine talk. The New York Times. 25 December 1991. Accessed 1 August 2024. www.nytimes.com/1991/12/25/garden/wine-talk-425591.html.

5.    Keil U, Chambless LE, Döring A, et al. The relation of alcohol intake to coronary heart disease and all-cause mortality in a beer-drinking population. Epidemiology 1997;8:150-156.

6.    Arranz S, Chiva-Blanch G, Valderas-Martínez P, et al. Wine, beer, alcohol and polyphenols on cardiovascular disease and cancer. Nutrients 2012;4:759-781.

7.    Rimm EB, Klatsky A, Grobbee D, Stampfer MJ. Review of moderate alcohol consumption and reduced risk of coronary heart disease: Is the effect due to beer, wine, or spirits. BMJ 1996;312:731-736.

8.    Reynolds K, Lewis B, Nolen JD, et al. Alcohol consumption and risk of stroke: A meta-analysis. JAMA 2003;289:579-588. Erratum in: JAMA 2003;289:2798.

9.    Di Castelnuovo A, Costanzo S, Bagnardi V, et al. Alcohol dosing and total mortality in men and women: An updated meta-analysis of 34 prospective studies. Arch Intern Med 2006;166:2437-2445.

10.    Paradis C, Butt P, Shield K, et al. Canada’s guidance on alcohol and health: Final report. Ottawa, ON: Canadian Centre on Substance Use and Addiction, 2023. www.ccsa.ca/canadas-guidance-alcohol-and-health-final-report.

11.    Zhao J, Stockwell T, Roemer A, et al. Alcohol consumption and mortality from coronary heart disease: An updated meta-analysis of cohort studies. J Stud Alcohol Drugs 2017;78:375-386.

12.    Zhao J, Stockwell T, Naimi T, et al. Association between daily alcohol intake and risk of all-cause mortality: A systematic review and meta-analyses. JAMA Netw Open 2023;6:e236185. Erratum in: JAMA Netw Open 2023;6:e2315283.