Benefits of Moderate Drinking Over Abstinence

The US public health establishment buries overwhelming evidence that abstinence is a cause of heart disease and early death. People deserve to know that alcohol gives most of us a higher life expectancy—even if consumed above recommended limits.

Evidence that abstinence from alcohol is a cause of heart disease and early death is irrefutable—yet this is almost unmentionable in the United States. Even as health bodies like the CDC and Dietary Guidelines for Americans (prepared by Health and Human Services) now recognize the decisive benefits from moderate drinking, each such announcement is met by an onslaught of opposition and criticism, and is always at risk of being reversed. (1)

Noting that even drinking at non-pathological levels above recommended moderate limits gives you a better chance of a longer life than abstaining draws louder protests still. Yet that’s exactly what the evidence tells us.

Driven by the cultural residue of Temperance, most Americans still view drinking as unhealthy; many call alcohol toxic. Yet, despite drinking far less than many European nations, Americans have significantly worse health outcomes than heavier-drinking countries. (For example, despite being heavily out-drunk by the English, we have almost exactly twice their levels of diabetes, cancer and heart disease.)

Alcohol is that happy combination: a pleasurable substance that also conveys health benefits. Those benefits are greatest if you drink moderately. But even drinking more than is “perfectly” recommended, without displaying clinical symptoms of problem drinking or alcohol dependence (and these are not subtle), is generally better for you than drinking nothing.

After David Letterman underwent quintuple bypass surgery in 2000, he had Bryant Gumbel on his show. Letterman exercises maniacally, is resultingly skinny and long ago gave up cigars and alcohol. Confronting the slightly doughy Gumbel, Letterman bemoaned, “How come I do everything healthy and you smoke cigars and drink and I end up on the surgery table?”

The real mystery is why an intelligent man receiving the best healthcare advice money can buy thinks that not drinking makes it less likely he will succumb to coronary artery disease (which also includes strokes and dementia).

Someone else who required bypass surgery (although I don’t know his drinking habits) was Larry King, who underwent the procedure in 1987 following a heart attack. In 2007, King hosted a two-hour PBS special, The Hidden Epidemic: Heart Disease in America, about the pioneering Framingham Heart Study. King led a panel of five experts in a discussion of diet, sex, exercise, smoking—just about everything that people do that impacts the health of their hearts. Everything, that is, except that beverage alcohol conveys heart health advantages, and that abstinence from alcohol is among the major risk factors for heart disease.

Not discussing the beneficial impact of alcohol on heart disease has been a systematic policy of the US public health establishment, one example of which is the Framingham Study. The National Institutes of Health, which funded the Framingham research, forbad Harvard epidemiologist Carl Seltzer from publishing this finding, he later revealed. Why? NIH’s reasoning, published in a 1972 memo, still pervades American thinking:

“The encouragement of undertaking drinking with the implication of prevention of coronary heart disease would be scientifically misleading and socially undesirable in view of the major health problem of alcoholism that already exists in the country.”(2)

Flash forward to 2011, when the 2010 Dietary Guidelines for Americans were finally released by the Department of Agriculture and HHS. One reason for their delayed publication was the uproar raised by public health organizations to the Guidelines’ alcohol committee’s report of “strong evidence” that moderate drinking prevents heart disease, and the “moderate evidence” that it prevents dementia. Such battles are old hat: Similar campaigns against mentioning alcohol’s health benefits are mounted every five years when the Guidelines threaten to include them, starting with South Carolina Senator and teetotaler Strom Thurmond’s strenuous objections to the 1995 edition.

Epidemiological study after study (that is, research tracing drinkers, their consumption, and their life outcomes) produces consistent findings—there are now hundreds of such studies. But whenever any sort of research can be teased out to suggest drinking is bad for you, it will be put on full display to confuse the picture.

Thus, when people with a gene associated with less alcohol consumption (including less binge drinking), as well as other effects, were found to have better outcomes, this highly indirect evidence—as opposed to research measuring actual drinking and heart disease—was cited to prove “alcohol does not benefit the heart.”

Given the multitude of studies of the effects of alcohol on mortality (since heart disease is the leading killer of men and women, drinking reduces overall mortality significantly), meta-analyses combining the results of the best-designed such studies can be generated. In 2006, the Archives of Internal Medicine, an American Medical Association journal, published an analysis based on 34 well-designed prospective studies—that is, research which follows subjects for years, even decades. This meta-analysis, incorporating a million subjects, found that “1 to 2 drinks per day for women and 2 to 4 drinks per day for men are inversely associated with total mortality.”

So the more you drink—up to two drinks a day for woman, and four for men—the less likely you are to die! You may have heard that before, and you may have heard it doubted. But the consensus of the science is overwhelming: It is true.

Although I dispute many of the caveats offered against the life-saving benefits of alcohol, I will endorse two. First, these outcome data do not apply to women with the “breast-cancer gene” mutations (BRCA 1 or 2) or a first-degree (mother, sister) relation who has had breast cancer, for whom alcohol consumption is far riskier. Second, drinking 10 drinks Friday and Saturday nights does not convey the benefits of two or three drinks daily, even though your weekly totals would be the same: Frequent, heavy binge drinking is unhealthy. But then you knew that already, didn’t you? If you don’t distinguish binge drinking from daily moderate drinking, that would be due to Americans’ addiction-phobia, which causes them to interpret any daily drinking as addictive.

The global summary of alcohol’s benefits raises a key question: How much do you have to drink regularly before you become as likely to die as an abstainer? We’ll see below.

First, let’s address some typical objections to these findings. Of course, abstainers may not drink because they are already ill. Thus the meta-analysis relied on studies that eliminated subjects who are abstaining due to illness, or else contrast drinkers with lifetime abstainers. Additionally, objectors note, drinkers showing such longevity may be wine-sniffling, upper-middle-class professionals (virtually no study has ever found that the type of alcohol consumed impacts these results), people who exercise, eat right and don’t smoke. To counter this argument, researchers from the prestigious Harvard Health Professionals Study published a paper which found that even men with four healthy life factors (diet, weight, non-smoking, exercise) had one-third to one-half the risk of suffering a heart attack if they had 1-2 drinks daily, relative to comparable men in each category who abstained.

Now let’s turn quickly to four special topics—biological mechanisms; cognitive benefits of drinking; the resveratrol myth; and the answer to our key question: If you drink just a little too much alcohol, doesn’t your death rate shoot up way over that of abstainers? (This is the so-called “J–shaped curve.”)

Biological mechanisms. The Research Society on Alcoholism—as its name suggests, not a group predisposed to say good things about alcohol—published a review in 2008 concluding “A considerable body of epidemiology associates moderate alcohol consumption with significantly reduced risks of coronary heart disease and, albeit currently a less robust relationship, cerebrovascular (ischemic) stroke.” It went further, reviewing a range of biological “evidence that moderate alcohol levels can exert direct neuroprotective actions.”

Cognitive benefits. The RSA review also noted: “In over half of nearly 45 reports since the early 1990s, significantly reduced risks of cognitive loss or dementia in moderate, nonbinge consumers of alcohol (wine, beer, liquor) have been observed.” (3) This finding has been affirmed numerous times, for example in this article based on the Whitehall Study, the British equivalent of Framingham. (Predictably, this result will be confused with headlines like the following widely publicized finding: “Problem drinking in middle age doubles the risk of memory loss in later life.” You see the bait-and-switch, right?)  And, even in the Whitehall study, in which “The authors concluded that for middle-aged subjects, increasing levels of alcohol consumption were associated with better function regarding some aspects of cognition,” the researchers cautioned, “it is not proposed that these findings be used to encourage increased alcohol consumption.” What about encouraging moderate alcohol consumption?

Resveratrol. Don’t get me started on resveratrol, a supplement based on an antioxidant found in the skin of red grapes which, in early studies done in test tubes and with animals, was proposed to account for the heart-healthy benefits of wine. I identified this claim as bullshit from the start. It was simply a way to avoid recognizing that alcohol is good for you by claiming instead that alcohol’s benefits are due to some other ingredient. I was thus beside myself when research conducted at Johns Hopkins finding that resveratrol has no significant impact on lifespan or heart disease, led to nonsequitur headlines like this one: “Sorry! Red Wine isn’t good for you after all.” (It was never red wine to start with, but beverage alcohol!)

The J-shaped curve. The chief way in which drinking is discouraged is by claiming that, if you drink an iota too much, you are doomed. This is the so-called J–shaped curve, where abstainers have worse outcomes than the nadir for deaths at some low level of drinking, but then supposedly shoot up exponentially for those who drink more. This curve does not exist in nature. Studies that have found it tend to be of small subgroups of drinkers. But in the largest epidemiological surveys the drinking curve struggles gradually to make it up to a “U.”

In the largest prospective study ever conducted for alcohol, involving nearly a half million subjects, sponsored by the American Cancer Society (need I say, an organization not regarded as an alcohol industry stooge), Michael Thun (famed for his anti-smoking investigations) and colleagues examined all causes of death related to drinking among middle-age and elderly subjects. As in all such similar studies, this research is the best available to us other than controlled, randomized studies—it follows people forward in time and statistically controls for all identifiable confounding variables. Here is Thun et al.’s summary of their findings:

“The overall death rates were lowest among men and women reporting about one drink daily. Mortality from all causes increased with heavier drinking, particularly among adults under age 60 with lower risk of cardiovascular disease.”

This seems to say, “Never have more than a drink a day—or you’re doomed!”

But the value of this study’s huge number of subjects is that it is possible to reliably identify death rates during follow-up for people drinking up to six or more drinks daily. For all levels of drinking, including the highest one, for both men and women, death rates did not reach those for abstainers. How would you describe the shape displayed above? It is not a J.  (This group is mainly heavier, but nonetheless normal—along with some pathological—drinkers, middle-age and older.)

While we’re at it, let’s do some more headline-hunting. Time magazine published an article titled “Why Do Heavy Drinkers Outlive Nondrinkers?” while one in the Daily Mail was headlined “Heavy Drinking Kills You Quicker than Smoking.” So why the difference? It’s no surprise to learn that the study on which the Daily Mail article was based was titled, “Excess Mortality of Alcohol-Dependent Individuals. . . ,” while the research referred to in Time identified heavy drinkers as those who had 21 or more drinks per week. You see by now, I hope, our tendency to compare a clinical sample of apples with a group of robust-drinking oranges.

Alcohol is that happy combination: a pleasurable substance that also conveys health benefits. Those benefits are greatest if you drink moderately. But even drinking more than is “perfectly” recommended, without displaying clinical symptoms of problem drinking or alcohol dependence (and these are not subtle), is generally better for you than drinking nothing.

I hasten to add that any human being has the right to drink or abstain, for brief or longer periods, for any reason, personal or social. I never tell my clinical clients that they should try moderate drinking. What I tell clients who wish to attempt such a goal is that it can be done—and to pay close attention to whether they are in fact achieving this goal.

But I don’t shy away from letting people know that drinking is among a list of health behaviors. We don’t all exercise as much as we should, or eat the best diets, and perhaps we may not drink, yet many of us still live long, healthy lives. But this is one piece of information you should have on which to base your decision-making—not something to be squirreled away by public health advocates for their own delectation (for the record, I can’t think of a public health professional I have known who doesn’t drink).

If you still ask why I, an addiction/public health specialist, feel it necessary to point out alcohol’s benefits, recall some facts reviewed here:

* Well-informed Americans are often remarkably ignorant about the benefits of moderate drinking and think that abstinence is better for them.

* The US is not a heavy-drinking nation, yet its health outcomes are poor compared with other economically-advanced nations.

* The worst drinking pattern is frequent binge-drinking, yet many Americans engage in such drinking (certainly young Americans), while thinking daily-but-moderate drinking is a sign of addiction.

* In treatment and prevention, the American abstinence/just-say-no fixation can lead to tenuous, unrealistic efforts to abstain, efforts at which people frequently fail, only to engage in the highest-risk forms of binge consumption.

A society best handles its available intoxicants by regarding them calmly and rationally, and by understanding that people have the capacity (and the responsibility) to consume them in sensible, even life-enhancing ways. As formerly illegal drugs are decriminalized, as new “designer” substances are regularly introduced, as performance-enhancing drugs and quite powerful psychiatric drugs are more and more commonly used, there is really no other option for navigating substance use in the 21st century.

Human beings have grown up alongside alcohol: Beverage alcohol has been found at the site of every early center of civilization. The more alcohol a society consumes, the fewer alcohol-related problems and alcohol-related deaths (including cirrhosis) it has, since these societies, such as those in Southern Europe, integrate drinking with social life. And alcohol conveys health benefits. If you cannot drink (or believe that you cannot), you probably increase your likelihood of early death. If so, I am truly sorry for you.

(1)The author was one of the first researchers to review the life-protective effects of alcohol, in 1993, in the American Journal of Public Health.

(2) C. Seltzer, Journal of Clinical Epidemiology 1997 50: 627-629.

(3) Archie Brodsky and the author pointed this cognitive benefit out in a 2000 article in the journal Alcohol and Drug Dependence.

Dr. Stanton Peele, recognized as one of the world's leading addiction experts, developed the Life Process Program after decades of research, writing, and treatment about and for people with addictions. Dr. Peele is the author of 14 books. His work has been published in leading professional journals and popular publications around the globe.