Slate.com | Aug. 14, 1998
FIRST, to prevent any misunderstanding, the warning: Alcohol, when abused, is vicious, dangerous stuff. Each year about 100,000 Americans die alcohol-related deaths. No one should drink and drive or drink to excess. Some people--teen-agers, people on contraindicated medications, pregnant women, and those who have trouble controlling their consumption--should avoid alcohol, period. And all that you know already.
Here is what you may not know--or may know only fuzzily. For most people of middle age and beyond, one drink a day helps prevent heart disease and makes you less likely to die prematurely. After one or (for men) two drinks, bad effects swamp the good--dosage is everything! But on average the positive cardiovascular effect of moderate drinking is not small, and it is not in dispute. Epidemiologists figure that if all Americans became teetotalers tomorrow, about 80,000 more people might die each year of heart disease. So there are lives on both sides of the equation.
One of those lives might, just as an example, belong to my father. He is 69, has mild hypertension (controlled with medication) and, but for the rare social occasion, doesn't drink. He has read some news reports suggesting moderate alcohol use may yield benefits, but his doctor has never mentioned such benefits, and my father has never given a thought to changing his drinking habits. And, in the standard view of public health officialdom, that is as it should be: People should not be encouraged to drink, even in moderation, and alcohol should not be linked with better health.
The trouble is that moderate drinking is linked with better health. We don't know exactly why; some evidence suggests alcohol--of whatever sort, by the way, not just red wine--stimulates "good" (HDL, for high density lipoprotein) cholesterol and may help prevent blood clotting. But we do know the effects: On average, if you're over about 40, a drink a day will reduce your chances of heart trouble.
"Besides the association between smoking and lung cancer, I think this is the most consistent association I've seen in the literature," says Eric Rimm, a Harvard epidemiologist. Research has shown heart benefits consistently since the 1970s with, Rimm guesses, 70 or 80 studies of 30 to 35 countries by now. Not surprisingly, he has a drink on most days.
ALCOHOL also causes harm, of course. It can increase chances of breast cancer, cirrhosis, accidents, and so on. Heart disease, however, is an enormous cause of death; improve those odds, and the net effect is significantly to the good. Last December, the New England Journal of Medicine reported the results of the biggest and probably best mortality study yet conducted, one that followed almost half a million people over nine years. It found that, after netting out all causes of death, moderate drinkers over 30 were 20 percent less likely than nondrinkers to die prematurely.
But there are a lot of people like my father out there: uninformed or vaguely informed or not thinking about it. In 1995, a free market advocacy group called the Competitive Enterprise Institute commissioned a survey asking people whether they believed "that scientific evidence exists showing that moderate consumption of alcohol, approximately one or two drinks per day, may reduce the risk of heart disease for many people." Only 42 percent of those who responded said they did, and a majority of those believed, wrongly, that the potential benefits come only from wine.
The evidence on alcohol and health is now more than 20 years old--so why the confusion? Two groups have a stake in getting the word out, but one of them, the alcohol industry, is effectively forbidden to do so. Every bottle of alcohol carries a government warning label, and the Bureau of Alcohol, Tobacco and Firearms has never permitted ads or labels to carry any health claims, even mild ones. (For more on rejected health claims, click here.)
Given that the government restricts health claims even for innocuous foods such as orange juice and eggs, it's reasonable to decide that booze merchants are the wrong people to entrust with public education about drinking. That leaves only one other constituency for getting the word out: the public health community. Its approach, however, might charitably be called cautious--or, less charitably, embarrassed mumbling.
For example, the authors of the aforementioned New England Journal study characterized their finding of a 20 percent mortality reduction as "slight." The accompanying editorial called it "small." I phoned Michael J. Thun, one of the study's authors and an epidemiologist with the American Cancer Society, and asked him whether a 20 percent mortality reduction is indeed small in the world of epidemiology. "It's a sizable benefit in terms of prolonged survival," he said. Why not say so? "Messages about alcohol don't come out the way you say them when they're broadcast," he replied. "There's been a very long history in society of problems with alcohol."
The British health authorities, in their 1995 guidelines ("Sensible Drinking"), say that people who drink very little or not at all and are in an age group at high risk for heart disease should "consider the possibility that light drinking might benefit their health." But American authorities balk even at such a modest suggestion.
AND so the U.S. official nutritional guidelines say just this about potential benefits: "Current evidence suggests that moderate drinking is associated with a lower risk for coronary heart disease in some individuals." They then go on to recite a litany of risks (for the text, click here). Similarly, the American Heart Association's official recommendation advises, "If you drink, do so in moderation." It goes on to say heart disease is lower in moderate drinkers but then warns of other dangers and cautions against "guidelines to the general public" that encourage drinking (for the full text, click here). See for yourself, but I think the message most people would get from both sources is "Drinking isn't all bad, but eschew it anyway."
I asked Ronald Krauss--a doctor who, as the immediate past chairman of the American Heart Association's nutrition committee, helped write that statement--whether it was aggressive enough. "We don't have much leeway around that 'one or two drinks a day,' " he said, and what isn't known is whether encouraging moderate drinking will also encourage excessive drinking.
The public health people understandably dread creating more drunks, more broken marriages, more crime, more car wrecks. "When somebody calls you up saying, 'You're putting out a message to people to drink, and my daughter just got killed last night because of some drunk,' that's the other side of the equation," Thun says. "There are substantial numbers of people out there who are looking for justification to drink more than they should."
A real worry. But there are lives, again, on both sides of the equation. The question, then, is what would happen if the public health folks ran a campaign saying, for example, "Just One Drink" or "Drink a Little--Not a Lot." Would people's drinking habits improve, or would we create a nation of drunks--or what? The answer is: Nobody knows. What is surprising, given the public health community's usual eagerness to save lives, is that no one is trying to find out. It is simply assumed that too many people will do the wrong thing.
"People have a very hard time with complicated messages," says Thun. No doubt some people do. But is it really so hard to understand that a glass a day may help save your life if you're of middle age or beyond, but that more than that is dangerous? Presumably an avoidable heart attack is equally tragic whether the cause is too much alcohol or too little. To continue today's policy of muttering and changing the subject verges perilously on saying not just that too much alcohol is bad for you but that ignorance is good for you.