GETTING
THE
FACTS
HEALTH ASPECTS
OF MODERATE
ALCOHOL
CONSUMPTION
RIGHT ON
Alcohol consumption is sometimes perceived as incompatible with a healthy lifestyle. In reality,
numerous scientific studies show that otherwise healthy adults who consume alcoholic beverages
in moderation may face a lower risk for a number of conditions, in particular age-related risks
such as coronary heart disease, ischemic stroke, diabetes and dementia.
1
2
3
4
Setting the scene:
definitions &
health aspects of
drinking
Beneficial health
aspects of moderate consumption
on major diseases
Alcohol
consumption and
certain “alcohol
related” diseases
Evidence in support
of balanced health
policies
KEY POINTS
Drinking patterns are of key relevance: regular moderate drinking (versus heavy episodic drinking)
has been shown to be associated with certain beneficial health effects. Public health policies
should not disregard the health effects of moderate consumption and should focus on alcohol
misuse and abuse.
• The effects of alcohol on consumers’ health are complex and consumption can have both positive and negative
consequences.
• Patterns of drinking are of key relevance; harmful consumption patterns are known to have adverse health
consequences.
• Health benefits and risks may vary between individuals and different drinking behaviours.
• Moderate alcohol use has been reported to be associated with a reduction in risk of circulatory system
diseases: the main cause of death in the EU.
• Circulatory system deaths, including heart diseases, are far more common than cancer deaths and specific
(clearly) alcohol related diseases in general: absolute and relative risks need to be considered.
• For healthy adults, moderate alcohol consumption may have beneficial effects on other health conditions.
• Independent studies conducted over 30 years indicate potential beneficial effects of moderate alcohol intake
on certain blood, brain, and heart-related diseases for otherwise healthy adults.
• Moderate drinking has not been shown to increase the risk of chronic liver disease.
• Overall chronic liver disease seems to be unrelated to per capita consumption.
• In 2010, it is reported that around 4% of all-cancer types are alcohol related and alcohol related cancer deaths
were responsible for 1.2% of all-cause mortality in the EU.
• Light drinkers appear to face a lower all-cancer mortality risk than abstainers and moderate drinkers seem to
have the same all-cancer mortality risk as abstainers.
• According to the majority of all-cause mortality risk studies, the all-cause mortality risk is significantly lower
for moderate drinkers compared to lifelong abstainers and excessive drinkers.
• Contemporary government recommended drinking guidelines appear to reflect the evidence on both adverse
& beneficial health effects of drinking.
• Public health policy measures should be targeted & culturally/contextually sensitive.
1
This document aims to provide a balanced perspective on benefits and
negative consequences of alcohol use on people’s health in pointing to
evidence that is often ignored in the public debate.
We encourage readers to review the vast body of literature regarding the
health effects of alcohol consumption.
Setting the scene:
definitions &
health aspects of
drinking
KEY
POINTS
1
• The effects of alcohol on consumers’ health are complex and consumption
can have both positive and negative consequences.
• Patterns of drinking are of key relevance.
• Some health benefits are associated with moderate drinking and certain
adverse health events are associated with heavy episodic and/or longer-term
heavy drinking.
Effects of alcohol consumption depend on
many factors
wide drinking guidelines that inform individual consumers
about health risks and benefits taking all alcohol related
diseases into account. An emerging consensus definition is
that moderate drinking refers to no more than 3 standard
drinks/day for healthy men (approx. 30g alcohol) and
no more than 2 standard drinks/day for healthy women
(approx. 20g alcohol). Additionally, 1 or 2 days of
abstinence per week are sometimes recommended,
despite unreliable supporting evidence. Moreover,
abstinence in particular circumstances is strongly
recommended, such as during pregnancy, under
medication, or underage.
• Patterns of consumption (e.g. frequency, quantity of
alcohol consumed, with or without food, time of the
day, place and social context);
• Age and gender (women should drink less due to their
typically lower weight and water-to-body-mass ratio);
• Body size and weight;
• Genes or genetic predisposition;
The objective of drinking guidelines is to convey a complex
issue in a simple way, so that people can make relatively
informed decisions.
• M ental & physical health status and medical
conditions.
The pattern of drinking is of key relevance, in particular
heavy episodic and long-term heavy drinking behaviours
need to be addressed from a health perspective, as
these drinking patterns increase the risk of acute and
chronic health conditions. On the other hand, moderate
drinking is associated with reduced risk of many chronic
diseases, such as cardiovascular disease (Graff-Iversen et
al 2013).
According to WHO, a standard drink refers to:
285 ml beer
— What are drinking patterns? —
30 ml spirits
120 ml wine
60 ml aperitif
Drinking patterns describe 3 important aspects of
drinking:
(1) WHO – individuals, the characteristics of those who drink;
(2) WHERE – drinking settings, or where drinking takes place, as
well as its role in everyday life and in a particular culture;
(3) HOW/WHY – drinking behaviours, or how people drink,
whether moderately or to extremes, over what time
period, and the activities that may accompany drinking.
According to a recent meta-analysis
‘consumption of alcohol, up to 4 drinks
per day in men and 2 drinks per day in
women, was inversely associated with
total mortality, maximum protection being
18% in women […] and 17% in men. […]
Our findings, while confirming the hazards
of excess drinking, indicate potential
windows of alcohol intake that may
confer a net beneficial effect of moderate
drinking, at least in terms of survival’ (Di
Castelnuovo et al 2006, p. 2437). Note that
other studies of a different design, such as
the Global Burden of Disease come to
different conclusions.
Definition of safe/low-risk/moderate
drinking
Since so many individually differing factors represent
important elements when talking about alcohol
consumption and health, it is difficult to provide population-
2
1
A number of independent studies also report that moderate
drinkers may benefit psychologically, e.g. feelings of
pleasure, happiness or stress relief (Arntzen et al, 2010).
For instance, Chan et al (2009) conclude: ‘regular alcohol
consumption is associated with increased quality of life in
older men and women’ (p. 294).
Goldberg et al (1999) find that ‘compared with
abstainers, moderate drinkers exhibit improved mental
status characterized by decreased stress and depression,
lower absenteeism from work, and decreased incidence
of dementia (including Alzheimer’s disease)’ (p. 505).
Very recently, Valencia et al (2013, p. 703) conclude:
‘Alcohol drinkers, including those with heavy drinking,
reported better physical HRQL [health related quality of
life] than non-drinkers’.
— The consequences of alcohol misuse —
The term binge/heavy episodic drinking generally refers
to the consumption of 5 or more standard alcohol units/
drinks in one sitting (usually defined as drinking in excess
of 50g/60g of pure alcohol), which increases the risk of
acute consequences, such as alcohol related falls or, if
combined with driving, road traffic accidents.
“”
The emerging
consensus definition
for low-risk drinking
is 2 and 3 drinks
per day for healthy
women and men
respectively.
Longer-term heavy drinking is associated with alcohol
related chronic diseases, such as alcoholic liver disease.
Such drinking habits can also enhance negative
psychological states and lead to mental and behavioural
disorders including anxiety, depression, insomnia and
sexual dysfunction (mental and behavioural disorders due
to the use of alcohol were responsible for 0.4% of all-cause
mortality in the EU in 2010 according to Eurostat data).
Therefore heavy episodic & longer-term heavy drinking
behaviours (alcohol abuse more generally) are of public
concern and should be avoided or at least reduced.
3
Beneficial health
aspects of
moderate
consumption on
major diseases
KEY
POINTS
2
• Moderate alcohol use has been reported to reduce the risk of circulatory
system diseases: the main cause of death in the EU.
• Circulatory system deaths, including heart diseases, are far more common
than cancer deaths and specific (clearly) alcohol related diseases in general:
absolute and relative risks need to be considered.
• For healthy adults, moderate alcohol consumption may have beneficial
effects on other health conditions.
• Independent studies conducted over 30 years indicate potential beneficial
effects of moderate alcohol intake on blood, brain, and heart-related
diseases for otherwise healthy adults.
The health benefits of moderate consumption
on EU’s top mortality causes: absolute vs.
relative risks
Heart diseases represent 55% of the circulatory system diseases
- base shows that the risk of heart diseases is
and a large evidence
reduced by alcohol intake, especially by moderate consumption.
On the other hand, around 4% of all cancer deaths appear
to be alcohol related. For the US, Nelson et al (2013) find:
‘Alcohol consumption resulted in an estimated 18,200 to
21,300 cancer deaths, or 3.2% to 3.7% of all US cancer
deaths’ (p. 641). Next to the frequency of a disease, it is
important from a public health perspective to distinguish
between absolute and relative risks to identify the right
objectives and tools. In the case of alcohol, moderate
consumption generates a large risk reduction of a frequent
disease (heart diseases).
In 2010, 39% (1,898,416 people in absolute terms) of all
deaths (4,852,998) in the EU were caused by diseases of
the circulatory system, including blood, heart and brain
diseases: the main cause of death in the EU (see Eurostat).
That is to say, more than the entire population of Estonia
and Luxembourg combined passes away each year due
to diseases of the circulatory system. Indeed, a US study,
which ‘serves as the National Institutes of Health’s formal
position paper on the health risks and potential benefits of
moderate alcohol use’ and which focuses solely on coronary
heart disease finds that ‘if all current consumers of alcohol
abstained from drinking, another ≈ 80,000 CHD [coronary
heart disease] deaths would occur each year’ (Gunzerath
et al 2004, p. 829).
“”
A small risk
reduction of a frequent
disease may offset a
large risk increase of a
very rare disease.
If one assumes the lowest percentage (about 10% across
studies) of ischaemic and other heart diseases deaths
(1,050,543 deaths in absolute terms in the EU in 2010) saved
due to alcohol consumption in the EU, then if people totally
abstained from drinking, more than 100,000 ischaemic and
other heart disease deaths would occur each year in the EU.
Britton & McPherson (2001) hold that ‘there are
approximately 2% fewer deaths annually in England and
Wales than would be expected in a non-drinking
population’ (p. 383).
The 2 major causes of all-cause mortality in the EU (Eurostat)
100
Other causes
of deaths
90
80
35%
70
.
Diseases of
the circulatory
system
60
50
40
39.1%
30
Cancers
20
10
25.9%
0
2010
4
2
The beneficial effect of moderate alcohol
consumption for healthy adults on other
diseases: two cases
Studies also report that drinkers and in particular moderate
drinkers have a lower dementia and Alzheimer risk of
around 30% compared to abstainers (Weyerer et al 2011,
Solfrizzi et al 2011 & 2007, Anstey et al 2006 & 2009,
Collins et al 2009, Goldberg et al 1999). In a review and
meta-analysis of 143 papers, Neafsey et al (2011, p.465)
conclude: ‘The benefit of moderate drinking applied to all
forms of dementia (dementia unspecified, Alzheimer’s
disease, and vascular dementia) and to cognitive
impairment (low test scores)’.
Numerous studies find at least 30% reduced risk of diabetes
(type II) for moderate drinkers compared to abstainers
(Rasouli et al 2013, Joosten et al 2011, Baliunas et al 2009,
K oppes et al 2005, Goldberg et al 1999). A systematic
review of 32 studies by Howard et al (2004, p.211)
concludes: ‘Compared with no alcohol use, moderate
consumption (1 to 3 drinks/day) is associated with a 33%
to 56% lower incidence of diabetes and a 34% to 55%
lower incidence of diabetes-related coronary heart
disease’.
Literature review: the health benefits of moderate consumption on heart,
blood and brain diseases
Heart Diseases
There is a wealth of evidence on the potential beneficial effect of moderate alcohol consumption for healthy adults on
cardiovascular diseases. Rimm et al (2007, p.S3) states that ‘an inverse association between alcohol consumption and coronary
heart disease (CHD) has been shown in epidemiologic studies for more than 30 years’. Recent statements that ex-drinkers
classified as non-drinkers might change the findings is rejected by Rimm et al: ‘there is substantial evidence to refute the “sick
quitter” hypothesis’. Moreover, within the ‘group “healthy” men (who did not smoke, exercised, ate a good diet, and were not
obese) […] men who drank moderately had a significantly lower CHD risk compared with abstainers’. Therefore, Rimm et al
conclude ‘that the inverse association of alcohol to CHD is causal, and not confounded by healthy lifestyle behaviors’ (p. S3).
Most recently, Jones et al (2013) conclude: ‘Consistent with established evidence, our findings suggest a mechanism by which
moderate alcohol consumption might reduce cardiovascular disease […]’ (p. 369). Similarly, Thompson (2013) concludes: ‘The Jshaped relationship between alcohol consumption and cardiovascular risk has been studied and confirmed in multiple studies;
while it complicates the formulation of public policy on alcohol consumption, it cannot be dismissed’ (p. 419).
In a meta-analysis of 84 studies, Ronskey et al (2011, p. 13) found that the risk for ‘cardiovascular disease mortality’ was 25%
lower for alcohol drinkers relative to non drinkers, while the risk for ‘incident coronary disease’ decreased by 29% or the risk for
‘coronary heart disease mortality’ by 25%. Corrao et al (2000) meta-analysis finds a 20% decreased relative risk of coronary
heart disease for an alcohol intake of 20g/day (approx. 2 standard drinks) and still a small protective effect up to 72g/day.
Tolstrup et al (2009)
5
2
find a decreased risk for coronary heart disease of 20% and ‘the maximal benefit seem to be obtained at ≈1 to 2 drinks per day
for women and 2 to 3 drinks per day for men’ (p. 510). The conclusions of Roerecke M, Rehm J. (2014) not only support a “Jshaped” curve for alcohol consumption and IHD but provide additional support suggesting that the effect may be causal, i.e.,
related to the alcohol consumption and not to other associated lifestyle factors.
Some studies find beneficial effects also for younger adults: A Spanish study by Arriola et al (2008, p.124) finds that ‘in men
aged 29-69 years, alcohol intake was associated with a more than 30% lower CHD [coronary heart disease] incidence. Our
study is based on a large prospective cohort study and is free of the abstainer error’. Similarly, Hvidtfeldt et al (2010, p.1589)
find that: ‘alcohol is also associated with a decreased risk of coronary heart disease in younger adults; however, the absolute
risk was small compared with middle-aged and older adults’. A very recent study (based on a Spanish population sample
again) by Galan et al (2013) concludes: ‘Moderate alcohol intake is associated with improved HDL-cholesterol, fibrinogen,
and markers of glucose metabolism, which is consistent with the reduced CHD [coronary heart disease] risk of moderate
drinkers in many studies’ (p. 1).
Further reading and evidence: van de Wiel and de Lange, 2008;
Suzuki et al, 2009; Djousse et al, 2009; McIntosh, 2008; Tolstrup
et al, 2006, 2010; Bagnardi et al, 2008; Carrao et al, 2004,
Collins et al, 2009; Mukamal et al, 2003, 2010; Heines and
Rimm, 2001; Brien et al, 2011; Flesch et al, 2001; Chiuve et al,
2010; Janszky et al, 2009, Le Strat Y & Gorwood P 2011, Jones A
et al. 2013, Movva and Figueredo, 2013, Wakabayashi I. 2013.
Blood & brain diseases as well as mental health
Moderate alcohol intake is also associated with a reduced risk of other blood and brain diseases: Streppel et al (2009) find
that compared to non-drinkers ‘long-term light alcohol intake […] (20 g per day) […] was strongly and inversely associated with
cerebrovascular […lower risk of 57%], total cardiovascular […lower risk of 30%] and all-cause mortality [lower risk of 25%]’
(p. 534). There is also evidence that moderate alcohol consumption has beneficial effects on blood circulation diseases, such
as lower-extremity arterial disease and venous thromboembolism (Mukamal et al 2008, Lutsey et al 2009) as well as stroke
(Ronksley et al, 2011; Goldberg et al 1999; Rodgers, H. et al. 1993). For instance, Mukamal et al (2005) find that ‘consumption
of 10.0 to 29.9 g of alcohol per day [that is about 1 to 3 drinks] on 3 to 4 days per week appeared to be associated with the
lowest risk’ (p. 11) for ischaemic stroke: 32% lower compared to abstainers.
A study with a Spanish population finds that consumption of up to ‘30 g/day of alcohol was protective against all stroke types
combined’ (Caicoya, 1999, p. 677). A very recent systematic review and meta-analysis finds that consuming two drinks per
day is associated with a reduced risk of ischaemic stroke (Petra et al, 2010). Most recently, Jimenez et al (2012, p. 939) find
that ‘Light-to-moderate alcohol consumption was associated with a lower risk of total stroke’ in women. A beneficial effect
was observed for women who consumed up to 29.9g ethanol/day (approx. 3 standard drinks). However, there are also
findings showing that heavy episodic and regular heavy drinking increases the risk of hemorrhagic stroke. Studies reporting
psychological benefits and overall wellbeing related to moderate alcohol use are already listed on page 3 of this factsheet.
6
Alcohol
consumption and
certain “alcohol
related” diseases
KEY
POINTS
3
• Moderate drinking has not been shown to increase the risk of chronic liver
diseases; longer-term heavy drinking does.
• Per capita consumption appears to be relatively unrelated to overall chronic
liver disease deaths: patterns of consumption and other factors appear to be
more important.
Standardised death rate for chronic liver
diseases per 100,000 inhabitants –
Source: Eurostat 2010 (latest available data)
Alcohol-related liver diseases are divided into three
subcategories:
• Fatty liver disease (reversible condition characterised
by an accumulation of fatty tissue in the liver, causing
liver enlargement).
EU figures show the changes
in death rates per 100,000 inhabitants between 2006 and 2010.
<5
5,1–10
10,1–15
15,1–20
20,1–25
>25
• Alcoholic hepatitis (inflammation of the liver).
• Alcoholic cirrhosis (consequence of chronic liver disease
where normal liver tissue is replaced by scar tissue).
Liver diseases are usually the results of at
least a decade of heavy drinking – Moderate
consumption is usually not associated with
chronic liver diseases
(American Liver Foundation (2007), National Institute
for Diabetes and Digestive and Kidney Disease (2003),
McCullough (1999), Szabo (2007).
A recent meta-analysis by Rehm et al (2010) finds that
the risk for chronic liver diseases would increase only
with an alcohol intake above 36 grams per day for men
(between 3 and 4 drinks) and 24g for women (between 2
and 3 drinks).
In 2010, 79,691 deaths caused by chronic liver disease
were recorded in the EU, accounting for 1.6% of all-cause
mortality. However, only a fraction of all chronic liver
diseases are related to alcohol abuse, and this fraction
differs from country to country.
Gunji et al (2009, p.2189) find that moderate alcohol
consumption has no negative but rather beneficial
consequences as regards fatty liver. They conclude that
‘light (40-140 g/week) and moderate (140-280 g/week)
alcohol consumption significantly and independently
reduced the likelihood of FL [Fatty Liver]’.
“”
Notice, ‘about 10-15% of heavy drinkers develop cirrhosis’,
according to WHO (1990, p. 56).
According to WHO,
10 to 15% of heavy
drinkers develop
cirrhosis.
7
3
Alcohol
In support of
balanced health
consumption
policies
Per capita
consumption does
not adequately
d certain
related
explain the disparities of chronic liver
diseases
disease deaths among EU countries
The chart below shows that chronic liver disease deaths are
higher in Slovakia, Finland or Poland compared to Ireland,
France or
although
capita consumption is
ronic liver diseases
butDemark,
longer-term
heavyper
drinking
significantly
higher
in
the
latter
countries.
and
o chronic liver disease deaths: patterns of consumptionSweden
and other
Ireland have almost identical liver disease death rates but
per capita consumption in Ireland was almost twice as
as in Sweden.
Per high
capita
consumption does not explain the
disparities of chronic liver disease deaths among EU
A comparison of Member States demonstrates that the link
Member
States
between chronic liver disease and per capita consumption
appears
weak
at best.
at individual
The chart
below
shows
that When
chroniclooking
liver disease
deathsMember
are higher in
States
over
time,
per
capita
alcohol
consumption
Slovakia, Finland or Poland compared to Ireland, France or Demark,and
although
chronic
liver disease
deaths
appear
in some
per capita
consumption
is significantly
higher
in therelated
latter countries.
Sweden
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not identical
in othersliver
all. Chronic
deaths
and Ireland
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beIreland
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demonstrates
the linksuch
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and other
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2006 data, because it covers more MS than the latest data for 2010.
per capita consumption in litres of pure alcohol
The above chart shows a very weak correlation between chronic liver
disease deaths and per capita consumption in various EU MS at best (black
line). It rather demonstrates the absence of a correlation, meaning that
other factors are more important, such as patterns of drinking.
The left chart map shows the standardised death rate for chronic liver
diseases per 100.000 inhabitants for different MS in 2010 (latest available 8
data). Changes since 2006 are listed in the table (source: Eurostat).
KEY
POINTS
3
• In 2010, around 4% of all cancer types are reported by the WHO to be
“alcohol related” and alcohol related cancer deaths were responsible for
1.2% of all-cause mortality in the EU.
• Light drinkers appear to face a lower all-cancer mortality risk than abstainers:
moderate drinkers appear to have the same all-cancer mortality risk as
abstainers, according to the latest meta-analysis by Jin et al (2013).
• Selected cancer types: a literature review.
About 8 of the estimated 200 cancers
are reported to be alcohol related: alcohol
intake increases the risk of those
cancer types
Overall, light drinkers seem to face a lower all-cancer
mortality risk than abstainers and moderate drinkers
appear to face no increased all-cancer mortality risk,
according to the most recent meta-analysis by Jin et al
(2013) covering cohorts from Asia, Europe and the US.
‘Evidence suggests a connection between heavy alcohol
consumption and increased risk for cancer, with an
estimated 2 to 4 percent of all cancer cases thought
to be caused either directly or indirectly by alcohol.
A strong association exists between alcohol use and
cancers of the oesophagus, pharynx, and mouth, whereas
a more controversial association links alcohol with liver,
breast, and colorectal cancers’ [National Institute on
Alcohol Abuse and Alcoholism (1993), Rehm et al 2010,
p.11, and Corrao et al (2004) meta-analysis].
According to Eurostat data, in 2010, alcohol related
cancer deaths (lip, oral cavity, pharynx and oesophagus)
accounted for 1.2% of all mortality causes in the EU (up
to 5% if considering also controversially alcohol related
cancer deaths such as breast, colon, liver and intrahepatic
bile ducts). Alcohol related cancer deaths amounted to
4.4% of all cancer deaths (up to 18.7% when considering
again the more controversially alcohol related cancer
deaths).
In 2013, a meta-analysis investigated
the relationship between drinking and
all-cancer mortality and finds a 9%
reduced risk for light drinkers (approx.
1.5 standard drinks/day) and no risk
increase for moderate drinkers (1.5 to
5 standard drinks/day). Note that Jin
et al have a very generous definition of
moderate drinking (1.5 to 5 drinks/day),
as usually +2 drinks/day and +3 drinks/day
are regarded as limits for women and
men respectively.
Light drinkers seem to face a lower
all-cancer mortality risk compared to
abstainers: moderate drinkers seem
to face no increased risk
Jin et al (2013, p .807) conclude: ‘This
meta-analysis confirms the health
hazards of heavy drinking (≥50 g/day) and
benefits of light drinking (≤12.5 g/day)’.
According to the most recent European
study (consisting of EU-10 countries and
people aged 25-70 years) by Bergmann
et al (2013), ‘the relative risk of death
from alcohol related cancers’ (p. 1782)
was lower for men consuming up to 24g/
day compared to abstainers. For women,
decreased risk of dying from alcohol
related cancers was only observed up to
12g/day.
Most cancer types are multifactoral diseases, which means
that several factors may increase the risk of developing
cancer, including, for example, smoking, unhealthy diet,
certain infections, exposure to radiation, environmental
pollutants, age, and/or genetic faults, amongst others.
The pattern of consumption is of importance: mostly
longer-term heavy drinking is considered as a risk increase
for the few alcohol related cancers. Some studies find that
moderate drinking reduces the risk of some cancer types
while other studies find that even moderate drinking may
increase the risk of a couple of cancer types such as female
breast cancer (see literature review on the next page).
9
3
Bladder cancer
The most recent met-analysis by Pelucchi et al (2012) concludes: ‘This meta-analysis of epide
absence of any material association between alcohol drinking and bladder cancer risk, even a
Brain cancer
A very recent meta-analysis by Galeone et al (2013) finds a 7% lower risk for drinkers comp
lower risk for drinkers of developing meningioma compared to abstainers. The authors c
associated with adult brain cancer, though a potential effect of high doses deserves further st
Colorectal cancers
Some studies show the risk of suffering from colorectal cancer does not increase with alcoho
adjustment for age, sex, height and smoking status. For example, Park et al. (2009) investiga
associated with increased risk of colorectal cancer (CRC) among a UK population (24.244
consumption [up to 21 units/week compared with non-drinkers] was not associated with CRC
height, and smoking status. […] No significant associations were observed between consump
spirits) and CRC risk when compared with non-drinkers after adjustment for lifestyle and die
population-based UK cohort, we did not find any significant adverse effect of alcohol over the
[for men and women]’ (347).
Multiple myeloma
Literature review: effects of drinking on various
selected cancer types
in recent publications & meta-analyses A recent meta-analysis by Rota et al (2014) attempts to assess the relationship between alc
conclude: ‘The present meta-analysis of published data found no strong association betwee
favorable effect
emerged
for moderate-to-heavy alcohol drinkers’ (p. 113).
Oesophagus, pharynx, and mouth cancers’ association
with
alcohol
Pancreatic cancer
A recent
Tramacere
et aletc.:
(2010)
finds isthat
people who
consume
Several factors increase the risk of the above cancer types,
such meta-analysis
as age, familyby
history,
smoking,
alcohol
considered
as one
of up to 3
pancreatics between
cancer compared
to abstainers,
but the
the above
risk increased
by 22%types.
for people who
those risk factors. However, many studies only find an association
heavy alcohol
intake and
listed cancer
‘Given
the
moderate
increase
in
risk
and
the
low
prevalence
of
heavy
drinkers
in most popul
For example, a very recent French study by Radoi et al (2013, p.268) concludes: ‘alcohol drinking increased this risk only in heavy
small fraction of all pancreatic cancers’ (1474). Rohrmann et al (2009) conclude that there
drinkers who were also smokers’. Also Takacs et al (2011) find an increased risk for heavy drinkers, but at the same time find that
risk of pancreatic cancer’ (785).
moderate alcohol consumption reduced the risk of oral cancer among women by 30%, compared to abstainers.
Thyroid cancer
A recent study by Meinhold et al (2010) finds that ‘the thyroid cancer risk decreased with gre
Breast cancer
consumption)’ (1) and they conclude that there is ‘a potential protective
Breast cancer
Breast cancer is related to numerous risk
elements (see American Cancer Society),
some of which are unchangeable, such as age,
genes, family history, personal history of breast
cancer, ethnicity, dense breast tissue, menstrual
periods, etc, and some are life-style related,
such as having children, birth control, hormone
therapy, breast feeding, obesity, physical
activity, and alcohol consumption amongst
others (see illustrating chart on the right). Most
scientific studies find a linear dose-response risk
relationship between alcohol consumption and
breast cancer, meaning that even light alcohol
intake represents a risk increase, though the
size of the risk increase is relatively small.
Factors Influencing Initiation and
Progression of Breast Cancer
Breast implants
Shift work
Environmental
factors (BPA)
Increased age
Signaling
pathways
Radiation exposure,
abortion, miscarriage
BC
Diet
Postmenopausal
hormone
therapy
Epigenetics
Delayed child bearing
Oxidative stress
Obesity
dense breast tissue
smoking
Early menarche
Delayed
menopause
WORLD SPIRITS ALLIANCE FORUM, July, 2013
Family history (genetics):
BRCA1, BRCA2, TP53
FGFR2, TNRC9, MAP3K1,
LSP1, CASP8, TGFβ1
18
Lymphoma
A recent meta-analysis by Tramacere et al (2012, p.2791) ‘provides quantitative evidence of a favourable role of alcohol
drinking on NHL risk’. Klatsky et al 2009 conclude that ‘alcohol drinking is associated with slightly lower risk for HM
[hematologic malignancies]’ (p. 746).
Prostate cancer
Rota et al (2012) conclude their meta-analysis as follows: ‘This comprehensive meta-analysis provided no evidence of a material
association between alcohol drinking and prostate cancer, even at high doses’ (p. 350).
Bladder cancer
The most recent meta-analysis by Pelucchi et al (2012) concludes: ‘This meta-analysis of epidemiological studies provides
definite evidence on the absence of any material association between alcohol drinking and bladder cancer risk, even at high
levels of consumption’ (p. 1586).
10
Breast c
(see Am
unchang
persona
breast t
life-style
control,
physical
others
scientifi
relation
breast c
represe
increase
3
Brain cancer
A very recent meta-analysis by Galeone et al (2013) finds a 7% lower risk for drinkers compared to abstainers of developing
glioma and a 29% lower risk for drinkers of developing meningioma compared to abstainers. The authors conclude: ‘Alcohol
drinking does not appear to be associated with adult brain cancer, though a potential effect of high doses deserves further
study’ (p. 514).
Colorectal cancers
Some studies show the risk of suffering from colorectal cancer does not increase with alcohol consumption up to 21 units/
week, before or after adjustment for age, sex, height and smoking status. For example, Park et al (2009) investigate whether
or not moderate alcohol consumption is associated with increased risk of colorectal cancer (CRC) among a UK population
(24,244 participants). The authors find that ‘total alcohol consumption [up to 21 units/week compared with non-drinkers] was
not associated with CRC risk before or after adjustment for age, sex, weight, height, and smoking status. […] No significant
associations were observed between consumption of specific alcoholic beverages (beer, sherry, or spirits) and CRC risk when
compared with non-drinkers after adjustment for lifestyle and dietary factors’ (p. 347). Park et al conclude that ‘in this populationbased UK cohort, we did not find any significant adverse effect of alcohol over the moderate range of intake on colorectal
cancer risk [for men and women]’ (p. 347). However, a recent systematic review and meta-analysis by Zhu et al (2014) finds
‘that alcohol intake is related to a significant increase of risk for colorectal adenoma’ (p. 325) a precursor of colorectal cancer.
Multiple myeloma
A recent meta-analysis by Rota et al (2014) attempts to assess the relationship between alcohol intake and cancer of plasma
cells. The authors conclude: ‘The present meta-analysis of published data found no strong association between alcohol drinking
and MM risk, although a modest favorable effect emerged for moderate-to-heavy alcohol drinkers’ (p. 113).
Pancreatic cancer
A recent meta-analysis by Tramacere et al (2010) finds that people who consume up to 3 drinks/day had a reduced risk of 8%
of developing pancreatic cancer compared to abstainers, but the risk increased by 22% for people who consumed more than
3 drinks/day. They conclude: ‘Given the moderate increase in risk and the low prevalence of heavy drinkers in most
populations, alcohol appears to be responsible only for a small fraction of all pancreatic cancers’ (p. 1474). Rohrmann et al
(2009) conclude that there is ‘no association of alcohol consumption with the risk of pancreatic cancer’ (p. 785).
Thyroid cancer
A recent study by Meinhold et al (2010) finds that ‘the thyroid cancer risk decreased with greater alcohol consumption (2
drinks per day vs no consumption)’ (p. 1) and they conclude that there is ‘a potential protective role’ (p. 1) of moderate alcohol
consumption for both men and women.
11
Evidence
in support of
balanced health
policies
KEY
POINTS
4
• The all-cause mortality risk is significantly lower for moderate drinkers
compared to lifelong abstainers, according to the majority of all-cause
mortality risk studies.
• Contemporary government recommended drinking guidelines appear to
reflect the evidence on both adverse & beneficial health effects of drinking.
• Public health policy measures should be targeted & culturally/contextually
sensitive.
Lower all-cause mortality risk for drinkers,
in particular moderate drinkers, compared
to abstainers
men’ (supplementary data p. 2) risk was lower for those
consuming up to 45g/day compared to abstainers. The
highest all-cause mortality risk reduction for women was
achieved at a daily intake of 15g, according to Bergmann
et al (2013).
According to the vast majority of all-cause mortality risk
studies, drinkers, and in particular moderate drinkers, face
a significantly lower all-cause mortality risk compared
to abstainers, also in studies that distinguish between
former drinkers and abstainers (Fuchs et al 1995, Doll et
al 2005, Sun et al 2011). Below, further studies with
similar findings:
Study
Drinking quantity
Risk reduction
Bagnardi et al,
2004
Up to 6 drinks/
day
Protective effect
Gunzerath et al,
2004
Up to 2 drinks/
day
Highest
protective effect
Gaziano et al,
2005
1 drink/day
Highest
protective effect
Di Castelnuovo
et al, 2006
Up to 2 drinks/
day (women)
and 4 drinks/day
(men)
18% for women,
17% for men
Djousse et al,
2009
Up to 1,5 drinks/ 35%
day
Lee et al, 2009
1 drink/day
Highest effect:
28%
Streppel et al,
2009
2 drinks/day
25%
Costanzo et al,
2010
Up to 2,5 drinks/ Highest effect
day
Ronksley et al,
2011
All drinkers
together
Drinking guidelines (e.g. from US, Canada
or UK where systematic reviews have taken
place) reflect the evidence on adverse &
beneficial health effects of drinkings
In light of the available scientific evidence, current drinking
guidelines (where available) are well chosen to balance
beneficial and negative impacts of alcohol consumption from
a societal health perspective: three standard drinks/day for
men and two standard drinks/day for women for otherwise
healthy adults appear to optimize negative and beneficial
aspects of drinking. Similarly, a peer-reviewed study by
Gunzerath et al (2004) found that: ‘The current scientific
knowledge on the risks and benefits related to various levels
of alcohol consumption does not suggest a need to modify
the existing guidelines on moderate alcohol use’ (p. 841).
Poli et al (2013) conclude: ‘No abstainer should be advised
to drink for health reasons [...] Moderation in drinking and
development of an associated lifestyle culture should be
fostered’ (p. 487).
The most recent Swedish study by
Bellavia et al (2014) finds that compared
to abstainers, among ‘women […] any
category of alcohol consumption was
associated with a substantially improved
survival’ (p. 293). For men, improved
survival materialised only up to 30g
alcohol/day. Singling out the two main
causes of deaths (cardio vascular disease
and cancers), the authors find that
‘compared to lifetime abstainers, women
[consuming between 1-30g/d] had lower
risk of both CVD and cancer mortality’
(p. 294-95). For men, consumption of
10-15g/day resulted in a 15% lower
cancer risk mortality.
13%
The latest meta-analysis by Di Castelnuovo et al 2006
concludes that: ‘the benefit of light to moderate drinking
remained in a range of undoubted public health value
(15%-18%)’ (p. 2442).
According to the most recent European study (consisting
of 10 EU countries and people aged 25-70 years) by
Bergmann et al (2013), ‘the all-causes of death among
12
4
— French case: High Council for
Public Health —
Bergmann et al (2013), 80% of men and 88% of women
were light to moderate alcohol users in the 10 EU countries
covered by that analysis.
In 2009, the French National Cancer Institute (INCa) sent
a brochure to doctors all around the country entitled:
‘Cancer nutrition and prevention’, accompanied by a letter
calling for alcohol abstention. Citing several scientific
articles, it claimed that a single glass of alcohol per day
could increase the risk of cancer. As a consequence, the
Health Minister requested the High Council for Public
Health (High Council) to assess the veracity of these facts
and to release an opinion on whether the government
should review its drinking recommendations.
There are also strong differences among Member States
as regards moderate and problem consumption habits,
e.g. 95% of Italians and 65% of Irish people fall into the
moderate drinking group, according to EUROBAROMETER.
Adequate health policy measures should not penalize the
vast majority of responsible drinkers but target and help
heavy episodic and longer-term heavy drinkers.
The High Council opinion concluded that the INCa
brochure did not take beneficial health aspects of
moderate consumption into account, especially as regards
cardiovascular diseases and therefore advised public
health bodies to look at the entire spectrum of diseases
and evidence before drafting new policies. Furthermore,
the High Council was concerned that the INCa message
was not in line with overall public health objectives and
that therefore the drinking guidelines of up to 2 drinks for
women and up to 3 drinks for men should be maintained.
“”
— Canadian case: The Canadian Centre on
Substance Abuse —
Public health
bodies should look
at the entire spectrum
of evidence before
drafting policies.
Outside Europe, drinking guidelines were recently
reassessed based on the available scientific evidence such
as in Australia, the US and Canada. The Canadian Centre
on Substance Abuse concluded that the low-risk drinking
guidelines – up to 2 standard drinks/day for women and up
to 3 standard drinks/day for men with ‘some non-drinking
days per week to minimize tolerance and habit
formation” (Butt et al 2011, p. 8) – are worth
maintaining.
Public health policy measures should be
targeted & culturally/context sensitive
Health policy measures should fit to the cultural context.
Finally, from a public health perspective, not only the
positive and negative relative risks of various diseases
need to be considered, but also the absolute risk, e.g. the
frequency of a disease.
More than 82% of the EU population are moderate
drinkers and less than 7% reported 5+ drinks consumption
in one sitting at least once in the last 30 days, according
to EUROBAROMETER 2009. Similarly, according to
13
Bibliography
The full bibliography related to this Factsheet
spirits.eu
is available at: http://spiritszone.eu/public/files/cp.as-141-2014-bibliography-health-factsheet-rev-1.docx
spiritsEUROPE
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