We’ve been told for some time now that drinking in moderation is good for your health. More recently (2014), in a scientific paper with the catchy title of “To Drink or Not to Drink,” a Dr. Rubin counseled his lifelong, nondrinking readers to “relax and take a drink a day, preferably with dinner.” So have most doctors decided that alcohol in moderation is really going to improve your health and enable you to live longer? Can we put alcohol alongside fruits, vegetables, vitamins, and minerals as contributors to our health and longevity? If so, then the health benefits of moderate drinking had better be pretty impressive, because a decision to start drinking alcoholic beverages carries some very measurable—and quite serious—risks.

The most serious risk

Let’s begin by considering the most serious problem with moderate drinking: the risk of become an immoderate drinker—an alcoholic. Most writers, when discussing the risks of moderate drinking, don’t include the risks assumed by all of those who drink. Because a person who begins to drink heavily is no longer a moderate drinker, he or she is dropped from the group whose health is being studied. This results in a serious underestimation of the risks of moderate alcohol consumption. It’s very important not to exclude from the study of moderate drinkers those who move on to abusing alcohol, for studies have shown that in the Caucasian population, 1 out of 12 moderate drinkers (8 percent) will become an alcoholic.

Perhaps a simple illustration will clarify the point. Picture if you will a man holding a six-shooter in each hand with the guns pointed at either side of his head. All six barrels of one gun are empty, while one of the six barrels of the other gun contains a bullet. If the man pulls one trigger at random with either his right hand or his left, he’s playing a two handed version of Russian roulette. Statistically, that’s how likely it is that a moderate drinker will become an alcoholic. And every expert, including Dr. Rubin, agrees that excessive consumption of alcohol is devastating to your health.

In the Native American population, the downside of light-to-moderate drinking is even worse. Twenty percent of Native American drinkers will become alcoholics! That’s the same as placing two bullets in one of the guns and one bullet in the second gun in our illustration!

So why is there any question about alcohol being harmful? Because, as I noted earlier, for some time now the popular press has claimed that “science shows” that alcohol in moderation will protect you from heart disease, stroke, and other unpleasant ways of dying. In other words, there’s supposed to be a health benefit to moderate drinking just as there’s a health benefit to eating fruits and vegetables.

What is the quality of the available evidence that supports this conclusion? Does science really demonstrate this?

Is the evidence reliable?

I try to keep informed about alcohol and its effect on health, both the scientific evidence and the views reported in the popular press. First, let me confirm that the popular press is reporting on a truly impressive amount of evidence. There are—if you can believe this—more than 2,500 scientific papers on the topic of alcohol in moderation and whether or not it correlates with living longer. There’s probably an equal number of articles in magazines and newspapers, although counting them is more difficult. Of the last 87 research reports that I read, 84 concluded that moderate drinkers are significantly less likely to die from heart disease and stroke, and two studies were inconclusive.

Before continuing, it will be helpful to note that although the amount of evidence is huge, it is of poor quality—because it cannot be otherwise. Virtually all of these papers are based on studies in which a large number of relatively healthy people are divided into two groups: light-to-moderate drinkers and ex-drinkers (those who have quit drinking entirely). These two groups are then studied 10 years, 15 years, or perhaps 20 years later to see what percentage of each group is still alive. How many of the light-to-moderate drinkers are still happily living their lives versus how many of the ex-drinkers (those who had already quit drinking years before at the time the study began) are still living contented lives. If a higher percentage of the ex-drinkers has died, then it is clear that moderate drinking and living longer are correlated—they go together.

This kind of research project is known as a prospective, observational study. The data it produces is considered by all researchers to be of poor scientific quality because there are so many other factors that can be influencing the outcome. (The technical way to say this is that many of the variables are uncontrolled.)

But if you think about it for a moment, better quality data is almost impossible to come by in studies on drinking, because the drinkers and the ex-drinkers are self-selected. For ethical and legal reasons a researcher cannot tell one research subject to start drinking, continue to drink, or stop drinking and stay that way for the next 10, 15, or 20 years! As a result, many other factors besides alcohol could influence how long that person lives.

In a more ideal set of circumstances, neither the investigators nor the participants would know who was getting alcohol and who was not. This is the so-called “double blind” setup. So even though the available data set is huge, the quality is poor—and there isn’t much that can be done about it. This makes the conclusions drawn from this data quite uncertain—and that includes the commonly drawn conclusion that drinking alcohol in moderation will, on average, help you to live longer.

An illustration

I’ll clarify the point with a hypothetical example of two schools. The students in school A are doing very well, and the students in school B are doing very poorly. It would be easy to conclude that the students in school A are doing well because they have better teachers than the students in school B.

But suppose we switch each school’s teachers to the other school (something we cannot do with our drinkers and ex-drinkers) and the students continue to perform as before. This would expose the logical fallacy of assuming that the skill of the teachers was the cause of the success of the students in school A and the lack of teaching skills in school B was the cause of those students’ failure.

Any sensible school district would consider the possibility that poor teaching skills contributed to the lower achievement of the students in school B, but they would also look for factors other than the skill of the teachers, including the students’ differing home environments, their educational achievement, and the standard of living of their parents.

Similarly, it’s easy to conclude at first glance that moderate drinking is the cause of the health benefits and increased life span that moderate drinkers enjoy. Many, perhaps most, observers have, in fact, done so, including the Dr. Rubin we’ve already heard from. However, other experts in the field are not so sure, and several of them have taken Dr. Rubin to task for his advice. They are convinced that he is premature in his recommendation.

And rightly so. Just because moderate drinkers live longer doesn’t mean that it’s the alcohol that extended their lives. Throughout the many years that the relationship between drinking and living longer has been studied, a key question has remained: “How is it possible to drink a toxin (a mild toxin, but a toxin nonetheless) and have this daily dose of a toxin help you to live longer?” It just doesn’t make sense; something else must be going on—but what is it?

A case study

A very recent study conducted by some researchers in New Zealand provides a plausible answer. It’s been known for at least ten years that moderate drinkers are both better educated and healthier than non-drinkers, and many researchers have suspected that this fact was contaminating the measurements of longevity. People who are richer and better educated are also healthier, and people who are healthier live longer. All researchers agree with these observations.

The New Zealand doctors investigated this relationship carefully. They even developed a very detailed questionnaire that took into account not only education level and income but also how much disposable income each participant had left over after paying for life’s necessities. From this they computed a quite sophisticated standard-of-living index that measured three things for each of the nearly 3,000 New Zealanders they studied: (1) how much alcohol he or she drank; (2) his or her state of health; and (3) the standard-of-living index that was just mentioned.

The results were enlightening, to say the least. The amount of alcohol consumed tracked the health status and the standard of living almost perfectly! That is to say, those who drank moderately had the highest standard of living and the best health status. Those who drank excessively and those who drank occasionally were less healthy and could maintain only a lower standard of living. The health status and the standard of living of the ex-drinkers—the group with the shortest lifespan—was the poorest of all of these groups.

While it has been claimed for almost two decades that alcohol in moderation might be responsible for better health and, therefore, also responsible for the longer lifespan enjoyed by drinkers, no one has ever claimed that a couple of drinks a day will increase your standard of living! Yet, as these researchers confirmed, light-to-moderate drinkers enjoy both better health and more wealth (more education, bigger homes, more leisure, etc.)

So now what of the alleged health benefits of moderate drinking? It’s easy enough to calculate how many years of productive life are lost by the 8 out of 100 drinkers who move on to become alcoholics. This group has been well studied, and the damage to their health is well documented. If there is no compensating benefit for the remaining 92 drinkers—if the supposed benefits are simply a reflection of the higher standard of living that moderate drinkers enjoy—then what? Well, we are left with a situation where there is severe life-shortening damage to 8 percent and no life-extending benefit to the remaining 92 percent! That is clearly not good. That, however, seems to be the situation as best we now understand it.

Is further, more definitive, research even possible? Well, in order to unequivocally determine whether moderate drinking contributes to health (it clearly is not going to improve the standard of living!), we would have to make the same switch that our hypothetical school board made. All the light-to-moderate drinkers would have to stop drinking for at least five years and all the heavy drinkers and occasional drinkers would have to drink moderately for the same period. At the same time, the former moderate drinkers would have to lower their lifestyle and the remaining groups would have to raise theirs! Then five years later the same survey would have to be repeated to determine which group was healthier.

Such a study is, of course, impossible.

Moderation versus abstinence

Let’s examine what we do know about alcohol: Whenever the cells or tissues of our bodies are exposed to even low concentrations of alcohol, the effects are, almost without exception, harmful. We also know that 8 out of every 100 light-to-moderate drinkers will become alcoholics. Thus, taking that first drink with the intention of drinking only moderately is like playing the two-gun version of Russian roulette. This is true because it’s generally impossible for a person to know before taking that first drink whether he or she will be among that 8 percent.

We’re left, then, with two significant questions. For those readers who do not yet drink, should you start to consume alcohol because of some possible health benefits that moderate drinking might confer? I will answer that question the same way nearly all other physicians would answer it (except, of course for Dr. Rubin): No! The research is telling us that in order to realize any supposed benefit in the length of your life from drinking, you would have to improve both your lifestyle and your health status at the same time as you took up drinking. As a physician and a researcher, I can assure you that if you do both of those things you can skip the alcohol, because your improved lifestyle and health status have now massively increased the chances that you will live long and prosper! Furthermore you will run no risk whatever of becoming an alcoholic—a member of that 8 percent who will experience a very short life span indeed.

Bottom line: Don’t drink alcohol, period. And if you’ve already started, stop taking into your body something that’s known to be toxic to your health.

Alcohol: Is Moderation OK?

by Dr. Brian Bull
  
From the September 2017 Signs