Recommendations Regarding Drinking / Alcohol Policy

Recommendations Regarding Drinking / Alcohol Policy

Critique 038.  Effects of a large reduction in alcohol prices on mortality in Finland.

7 April 2011

Reference:  Herttua K, Mäkelä P, Martikainen P.  An evaluation of the impact of a large reduction in alcohol prices on alcohol-related and all-cause mortality: time series analysis of a population-based natural experiment.  Int J Epidemiol 2011;40:441-454; doi:10.1093/ije/dyp336.

Time series intervention analysis modeling was applied to the monthly aggregations of deaths in Finland for the period 1996–2006 to assess the impact of a reduction in alcohol prices in 2004.  The authors report that alcohol-related deaths increased in men aged 40–49 years, and in men and women aged 50–69 years: the mean rate of alcohol-related mortality increased by 17%, 14%, and 40%, respectively, which implies 2.5, 2.9 and 1.6 additional monthly deaths per 100,000 person-years following the price reduction.  In contrast to alcohol-related mortality, CVD and all-cause mortality decreased among men and women in the highest age category.  The changes were consistent with 19 and 25 fewer monthly deaths per 100,000 person-years for CVD and 42 and 69 fewer monthly deaths for all-cause mortality.

Forum members agreed that both potentially harmful and beneficial effects resulting from changes in alcohol intake should be considered when estimating population effects.  They were unsure whether all of the reported effects in the elderly should be attributed to changes in alcohol intake, as decreases in CVD and all-cause mortality rates were occurring prior to the change in alcohol intake.

Critique 032.  Comments on alcohol in newly released Dietary Guidelines for Americans, 2010. 9 February 2011


The United States has released new Dietary Guidelines for Amercans, 2010.  While the Key Recommendations regarding alcohol remain similar to those of earlier guidelines, there were some changes in the text that reflect increasing scientific data indicating potential health benefits of moderate drinking.  The key recommendation is as follows:

“If alcohol is consumed, it should be consumed in moderation—up to one drink per day for women and two drinks per day for men—and only by adults of legal drinking age.”

Within the main body of the guidelines, comments on alcohol include the following:

“The consumption of alcohol can have beneficial or harmful effects, depending on the amount consumed, age, and other characteristics of the person consuming the alcohol. Alcohol consumption may have beneficial effects when consumed in moderation. Strong evidence from observational studies has shown that moderate alcohol consumption is associated with a lower risk of cardiovascular disease. Moderate alcohol consumption also is associated with reduced risk of all-cause mortality among middle-aged and older adults and may help to keep cognitive function intact with age. However, it is not recommended that anyone begin drinking or drink more frequently on the basis of potential health benefits because moderate alcohol intake also is associated with increased risk of breast cancer, violence, drowning, and injuries from falls and motor vehicle crashes.”

Critique029.  Differing opinions on the message to the public regarding alcohol consumption. 16 January 2011


1.  Maurizio Ponz de Leon.  What should we advise about alcohol consumption?  Intern Emerg Med, DOI 10.1007/s11739-010-0487-1.

2.  Augusto Di Castelnuovo, Simona Costanzo, Maria Benedetta Donati, Licia Iacoviello, Giovanni de Gaetano. What should we advise about alcohol consumption?  Reply letter by A. Di Castelnuovo.  Intern Emerg Med, DOI 10.1007/s11739-010-0502-6.

3.  Ramon Estruch • Rosa Ma Lamuela-Raventos.  What should we advise about alcohol consumption: reply letter by R. Estruch.  Intern Emerg Med; DOI 10.1007/s11739-010-0503-5.

A Letter to the Editor entitled “What should we advise about alcohol consumption?” was recently published by Maurizio Ponz de Leon in Intern Emerg Med.1 Dr. de Leon argues that the message of health benefits of moderate drinking “seems to me hazardous and extremely dangerous to diffuse in the general population.”  His reasons included (1) many people may be unable to distinguish between low–moderate and high consumption of wine, beer or spirits, and alcohol metabolism may differ remarkably from one subject to another; (2) alcohol remains a frequent cause of car crash, and governments (in almost all western countries) try to convince or force people to abstain from drinking before driving; and (3) to consider alcohol as a medication whose consumption may contribute to improved health is another source of concern.  Dr. de Leon asks: “Are we truly at the point of prescribing alcohol consumption in order to reduce the risk of stroke and coronary damage?”  He concluded that “more studies are needed before we can give sensible recommendations on alcohol consumption to the general population.”

The de Leon editorial has prompted considerable response from other scientists, including further Letters to the Editor of the journal by Di Castelnuovo, Costanzo, Donati, Iacoviello, and de Gaetano,2 and by Estruch and Lamuela-Raventos.3 In addition, the original editorial has stimulated considerable debate among members of the International Scientific Forum on Alcohol Research.  Among key arguments presented by the Forum members, all experts in scientific research on alcohol, are that messages to the public should not be “paternalistic” (we will tell you what is best for you since you are not smart enough to understand the facts), and that guidelines must always be based on sound, balanced scientific data rather than on uninformed opinion.  Forum members emphasized that there are certain people who should not drink at all (including former abusers of drugs or alcohol, people with certain medical conditions, children and adolescents, and people with religious or moral proscriptions against alcohol), and there can never be a general recommendation for everybody to consume alcohol.  On the other hand, physicians should not withhold from their patients and the public scientifically sound and balanced data on alcohol and health.  And the data are extremely strong supporting a role for moderate alcohol intake, for appropriate adults, for the reduction in risk of coronary artery disease and other diseases of ageing.

Several Forum members pointed out that it was unfortunate that the journal had chosen to publish the original letter that castigates alcohol from an author with good scientific credentials, but little to no apparent research expertise in the subject of alcohol and health.  Many Forum members disagreed with the statement of de Leon that “Many people may be unable to distinguish between low–moderate and high consumption of wine, beer or spirits.”  A leading scientist dealing with this subject for decades, Dr. Arthur Klatsky, has written: “Most people know very well what the difference is between light to moderate drinking and binge or excessive drinking.  While some patients may rationalize their heavy drinking because of its purported health effects, I have yet to find someone who had developed alcohol abuse because of messages about the health effects of moderate drinking.”  Medical practitioners, in his view, “have a ‘solemn duty’ to tell the truth about alcohol consumption, as they understand it, to all of their patients.”

While pointing out that certain individuals will not benefit from the consumption of alcohol (and it should definitely not be encouraged in people with former abuse or other contraindications to alcohol use), several Forum members believed that it would be unethical for physicians to withhold from middle-aged or elderly subjects at risk of cardiovascular disease information on the potential benefits of light-to-moderate drinking.

Critique 011. A Review of the Proposed New US Dietary Guidelines. 14 July 2010

Reference:  The draft of the proposed new Dietary Guidelines is available at

Members of our International Scientific Forum on Alcohol Research have submitted a detailed review of the draft recently circulated by the United States Department of Agriculture for proposed new US Dietary Guidelines for 2010.  In general, Forum members were very pleased with the alcohol recommendations in the proposal, finding them interesting, balanced, and accurate.  Many commented that, rather than just focusing on warnings against heavy drinking, the new Guidelines appear to take into account the large amount of recent epidemiologic and experimental data that support many potential beneficial health effects of moderate drinking.

Among specific recommendations from the Forum were the following:

■          A stronger statement is needed of the effects of light-to-moderate drinking on total mortality, in that recent prospective studies show a considerably lower of risk of death for moderate drinkers.

■          Additional emphasis is needed on the reduced risk of developing diabetes for moderate drinkers, and the much lower risk of cardiovascular disease among diabetics who consume some alcohol.

■          Further information should be presented on the consistent scientific data showing that women who drink moderately are at reduced, not increased, risk of weight gain in adult life.

There were a number of topics not discussed in the draft Guidelines that members of the Forum thought deserved consideration for inclusion.

■          Recent reports have consistently shown that among people who have already had a myocardial infarction or other cardiovascular event, moderate drinking is associated with a reduced risk of further cardiovascular events and death.

■          More emphasis in the Guidelines should be put on the pattern of drinking (regular moderate rather than occasional binge drinking) and also on the much lower blood alcohol levels after drinking when the beverage is consumed with food, rather than on an empty stomach.

■          It was also suggested to the Guidelines Committee that the beneficial effects on cardiovascular risk of polyphenols and other substances in wine and certain beers, in addition to alcohol, be discussed more adequately.

There were also some suggestions from THE FORUM regarding future research needs in the field.

■          The Forum strongly supports the need for further research on the risks and benefits of light-to-moderate alcohol consumption, rather than focusing research only on alcohol abuse.

■          The Forum proposed emphasis on future research dealing with targeting recommendations for groups of people according to age, gender, other behaviors, etc., although there was some disagreement among Forum members as to whether or not moderate drinking has strong health effects in the young and not just in middle-aged and older adults.

■          The Forum considers moderate drinking, unless contraindicated by certain conditions (e.g, former abuse, some types of severe liver disease), to be an important aspect of a healthy lifestyle.  It should be a complement, not an alternative, to other lifestyle factors such as not smoking, getting exercise, eating a healthy diet, and avoiding obesity.

Critique 010. Should moderate alcohol consumption be advised following a heart attack? 30 June 2010

Reference:  Carter MD, Lee JH, Buchanan DM, Peterson ED, Tang F, Reid KJ, Spertus JA, Valtos J, O’Keefe JH.  Comparison of outcomes among moderate alcohol drinkers before acute myocardial infarction to effect of continued versus discontinuing alcohol intake after the infarct.  Am J Cardiol 2010 (Published early online).

There has been considerable recent interest in the effects of alcohol consumption following an acute myocardial infarction (AMI).  In an observational study among 325 subjects who were moderate drinkers prior to an AMI, 84% continued to drink and 16% quit.  While most of the outcome measures showed no statistically significant effects between the two groups of patients, all outcomes showed a tendency towards better physical and mental health outcomes for persistent drinkers in comparison with those who quit drinking.

A key problem with this analysis, and with all observational epidemiologic studies on this topic, is that the reason that some subjects stopped drinking after having an AMI, while others continued to drink, is not known.  Even though adjustments were made for many known related factors, there is always the possibility that subjects who stopped drinking were “sicker” in many ways than those who persisted in their alcohol consumption.

It may well require a randomized trial, in which some subjects having an AMI are randomly advised to continue to drink and others advised to stop drinking, to be able to determine reliably the effects on the clinical course of the persistence of alcohol intake following an AMI.

Critique 009 Should moderate alcohol consumption be advised for its health effects?

25 June 2010

Reference:  Clinical Crossroads: Conferences with patients and doctors.  A 42-year-old man considering whether to drink alcohol for his health.  Kenneth J. Mukamal, MD, MPH, Discussant.  JAMA 2010;303:2065-2073. (doi:10.1001/jama.2010.550)

A report from a conference that took place at the Medicine Grand Rounds at Beth Israel Deaconess Medical Center, Boston, Massachusetts, on January 15, 2009 has recently been published in the Journal of the American Medical Association, JAMA.  It provides a discussion by an epidemiologist with a broad knowledge in the field in response to a theoretical question, as from a middle-aged patient, as to the advisability of consuming some alcohol “for his health.”

The paper provides an excellent discussion of a theoretical question about drinking and health.  It focuses on the potential risks and benefits associated with moderate drinking for a middle-aged male patient.  Most members of the International Scientific Forum on Alcohol Research were pleased with the discussion of the topic.  It was noted how uncommon it is that such knowledgeable, detailed, and mostly objective data appear in the mainstream medical literature.  It was thought to be “readable, informative and thoughtful.”

The Forum critique points out a number of topics that were covered incompletely in the paper, including inadequate information on the importance of the pattern of drinking: moderate regular consumption versus binge drinking.  Further, there was a notable lack of information on the beneficial effects on many pathophysiologic processes of polyphenols and other non-alcohol substances present in wine and certain other foods and beverages.  Overall, it was believed that the paper provided important information for physicians who may be discussing alcohol consumption with their patients.