In recent years scientists have debated how much alcohol is safe for the average person to drink. There’s no question that too much is unhealthy, but what counts as too much is still being debated.
Experts in alcohol-related diseases don’t want to stop people from having fun, but they often come down on the side of “less is better” and any alcohol at all carries some risk. Others, mostly those who focus on population-level data for their research, say there’s still a benefit to moderate drinking.
It comes down to how much risk you are willing to take for that Budweiser, glass of red wine, or gin and tonic.
“If you’re OK with being potentially at risk, then you responsibly drink a small amount of alcohol,” said breast cancer oncologist Dr. Marleen Meyers, of NYU Langone Health.
“If you’re 100% risk averse, then you don’t smoke, you don’t drink, you don’t go in the sun, you keep your body weight down, exercise, eat well,” she continued. “It’s an individual choice.”
On the flip side, there is some social benefit to relaxing and having a drink – as long as people can control their consumption, said Eric Rimm, an epidemiologist at the Harvard T.H. Chan School of Public Health.
“To have people feel scared and deny them that drink, I think we’re doing them a disservice by freaking everybody out,” he said.
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What’s the scientific debate?
It’s not possible for studies to determine what level of alcohol is unambiguously safe. It wouldn’t be realistic or ethical to randomly assign one group of people to drink regularly for decades and another group to abstain.
Also, many factors impact why someone might drink heavily, moderately or not at all, which might also lead them toward or away from other healthy lifestyle factors. That makes it hard to figure out whether it’s alcohol or lifestyle or some combination that contributes to their well-being.
Researchers are left with studies modestly flawed in different ways and new data that contradicts older findings.
Rimm’s work revolves around analyzing such data. He helped write the USDA Dietary Guidelines for Americans, which recommends that for those who choose to drink, men consume no more than two drinks a day on any drinking day and women no more than one.
He remains convinced, based on 40 years of research, that level is fine – and even healthy.
Yes, people will likely get more benefit from an hour of exercise than a glass of wine, but alcohol will somewhat reduce the risk of blood clots and improve glucose control, he said. That’s why you bleed more if you nick yourself shaving the morning after having a drink or two.
That’s also why he thinks it’s probably better to drink small amounts five nights a week rather than just more on weekends – because it will keep alcohol’s benefits consistent in the bloodstream.
George Koob, who directs the National Institute on Alcohol Abuse and Alcoholism, also stands by the American guidelines, though he notes they are currently under review. More and more studies, he said, show that drinking even a small amount increases the risk for cancer, and 5% of cancers are causes by alcohol.
In January, the Canadian government issued new guidelines, encouraging people to cut their drinking. Health risks from drinking are “low” for people who have two drinks or less per week; “moderate” for those who consume between three and six drinks per week; and “increasingly high” for those who drink seven or more per week, according to the new guidelines.
Binge drinking is also dangerous, the report concluded: “Consuming more than two standard drinks per drinking occasion is associated with an increased risk of harms to self and others, including injuries and violence.”
Specialists in liver disease, oncology and cardiology, among others, argue there’s no totally safe level of alcohol.
“Any benefit that you see from heart disease and diabetes, it’s weighed by the increased risk of cancer,” said Dr. Brian Lee, a liver specialist at the Keck School of Medicine of the University of Southern California. “There’s no alcohol that can improve your health and probably any alcohol use is harmful.”
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Heavy drinking is unhealthy for everyone
All the experts agree that heavy drinking – more than one drink a day for women and two for men – presents serious health risks.
“The problem that we haven’t recognized is what is the excessive amounts of alcohol that definitely leads to problems,” Koob said. (His organization offers a Treatment Navigator to help people with drinking problems.)
Heavy drinking can cause all sorts of health problems, including liver disease, some types of cancer, heart attack, stroke and an increased risk of accidents such as falls and car crashes. Some evidence suggests alcohol can exacerbate the effects of dementia, Koob said.
In Massachusetts alcohol accounted for 1 in 20 deaths – roughly 3,000 in 2019.
Heavy drinking also costs the public money, David Jernigan, a Boston University School of Public Health professor of health law, policy and management, recently told Massachusetts legislators. In 2010, the most recent data available, problem drinking cost the state government $345 per person, he said, while alcohol taxes generated only $11.
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Medications and psychotherapy can help people with alcohol use disorder remain sober for the two to five years needed to dramatically reduce the risk of relapse, said Dr. David Streem, a psychiatrist and medical director of the Cleveland Clinic’s Alcohol and Drug Recovery Center.
Beverage companies and others are recognizing the need to provide alcohol alternatives, selling mocktails and opening dry bars, Koob said. There’s Dry January, Sober October and even a section in the Green Bay Packers’ Lambeau Field for those who want to avoid alcohol.
“I see a shift to people wanting to engage with alcohol in a healthier way,” he said.
One drink a day?
Dr. Henry R. Kranzler directs the Center for Studies of Addiction at the University of Pennsylvania’s Perelman School of Medicine. He is also a wine lover.
His research suggests that drinking more than about one drink a day – for both men and women – is associated with lower white and gray matter in the brain. In other words, people who drink much more than that may have cognitive problems.
“The more you drink, the more health risk you incur,” he said. “Low levels, like a drink a day on average or less, is probably not meaningfully increasing your risk.”
Kranzler keeps his own red wine consumption below this. “I drink three or four times a week and I have one or one-and-a-half glasses of wine. I’m not concerned that’s adversely affecting my health.”
One drink per day increases the risk for heart attack, stroke and death by about 10% to 20%, but Dr. Stanley Hazen, who specializes in preventive cardiovascular medicine at the Cleveland Clinic, thinks it’s the sweet spot for the heart. Two drinks increase the danger.
“By three drinks, you’re at more than double the risk,” he said. “That’s the same magnitude as having diabetes.”
The role of genetics
Alcohol has been part of human life likely at least since people started cultivating crops, said Dr. Victor Karpyak, a psychiatrist who studies the genetics of alcoholism at the Mayo Clinic in Rochester, Minnesota.
Still, some people are more sensitive to alcohol’s effects than others. “Rather than trying to apply a one-size-fits-all approach, we need to consider a more personalized point of view,” he said.
Between 15% and 25% of white people carry a genetic risk for alcohol abuse, showing a greater response to alcohol, Streem said. Less than 5% of Black Americans have the same genetic mutation.
People of Asian descent often carry a gene that protects against alcoholism by causing the person to flush or feel sick with the first few sips. They lack a protein that normally breaks down a toxic breakdown product of alcohol, Kranzler said.
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For someone with an alcohol use problem, the only safe level of drinking is none, Streem said. Someone with a family history of alcohol use disorder also should avoid all alcohol.
“We know there’s a lot of genetic risk that is carried from one generation to the next, even if you only have one parent or one side of the family that has significant substance use history,” he said.
Men whose fathers had a drinking problem are at highest risk and shouldn’t drink at all. “Once you have a genetic proclivity to develop the disorder, there’s only one missing piece and that’s exposure to the substance,” Streem said.
Compared to men, women are more likely to avoid alcohol entirely or drink less. But women who do drink excessively develop more medical problems, Karpyak’s review of contemporary research has found.
Still, genetic makeup contributes about 50% to 60% of vulnerability to alcohol use disorder, Karpyak said, with environmental factors making up the balance.
How to find the ‘right’ amount for you
A “safe” level of alcohol is going to be different for everyone, depending on their personal risks and tolerance.
A woman who consumes the same amount of alcohol as a man likely will have a higher blood alcohol concentration, Kranzler said. That’s because women tend to be lighter than men and tend to have lower lean body mass, which determines how alcohol is distributed in the body and its concentration in the brain.
People also tend to have less lean body as they age, so an older person will reach a high blood alcohol concentration faster than a young one, he said.
Drinkers also develop tolerance, so a person who consumes alcohol regularly will be less impacted by that first drink than a teetotaler, Kranzler said.
Starting to drink at a young age also increases risk for drinking problems later on, as does being exposed to marijuana before age 14.
It’s important for parents to explain this risk to young adolescents, especially those with a family history of alcohol problems. Just as some kids can’t eat peanuts because of allergies, others shouldn’t drink or use marijuana at an early age because they are already at higher risk than their friends, Streem said.
For her patients and those at high risk for breast cancer, Meyers recommends no drinking at all.
“We would never say to a patient ‘one cigarette occasionally is OK.’ It’s the same with alcohol,” she said. “The advice I would give to anyone who has cancer or wants to reduce the risk of cancer is to drink as sparingly as possible.”
Unfortunately, Meyers said, medicine is not yet to the point where a doctor can identify each person’s individual risk.
There will always be people who live to 100 eating bacon, drinking whiskey and smoking every day. But it’s not possible to identify those lucky few early in life. Until then, she said, the only guidance people have is from population-level data suggesting “what you can do to bring your odds down.”
Contact Karen Weintraub at firstname.lastname@example.org.
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