Critique 058: A misguided statement on alcohol and health from a coalition in Australia – 28 September 2011
A coalition known as the Alcohol Policy Coalition in Australia has released a document entitled “Cancer, Cardiovascular Disease and Alcohol Consumption.”
The Alcohol Policy Coalition (APC) describes itself as “a coalition of health agencies who share a concern about the level of alcohol misuse and the health and social consequences on the community.” Members of the APC are the Australian Drug Foundation, Cancer Council Victoria, Heart Foundation (Victoria), Turning Point Alcohol and Drug Centre, and VicHealth.
The policy statement begins by discussing the relation of alcohol and cancer. “Alcohol is a known cause of cancer. . . . There is convincing evidence that alcohol causes cancer of the mouth, pharynx, larynx, oesophagus, bowel (in men) and breast (in women), and probable evidence that alcohol increases the risk of bowel cancer (in women) and liver cancer.”
The statement continues discussing alcohol and cardiovascular disease. “Long-term excessive drinking is associated with heart disease, stroke, blood pressure, heart failure, congenital heart disease, arrhythmias, shortness of breath, cardiac failure and other circulatory problems. Although the negative impact of alcohol consumption varies from person to person, on a global level the adverse effect of alcohol on cardiovascular disease outweighs any protective effect by between two and three-fold. Some research suggests small doses of alcohol offers some protection against cardiovascular disease. However this view is contested.”
The coalition ends with suggestions for policy reform: “The Alcohol Policy Coalition (APC) supports the National Health and Medical Research Council (NHMRC) guidelines to reduce lifetime health risks from drinking alcohol. These recommend that healthy men and women should drink no more than two standard drinks on any day.” The authors then state: “In line with this the APC has developed a range of position statements to guide government policy to reduce alcohol related harms.” These relate to changes in policy regarding affordability, availability, and promotion of alcohol.
The International Scientific Forum on Alcohol Research appreciates that the authors of this report are concerned about alcohol abuse, as are we all. Further, policy statements often vary by country according to the specific conditions in each country. However, guidelines should always be based on sound, balanced, and up-to-date scientific data, and Forum members were surprised by the publication of what they considered to be a biased and unscientific statement.
As one reviewer stated: “It is shocking that an alliance of organizations, some of which are government agencies, would agree to stand behind such a deliberately misleading misrepresentation of the science addressing the effect of alcohol consumption on human health.” In the opinion of Forum members, the paper disregards the vast majority of well controlled studies which show significant and concrete public health benefits of moderate alcohol consumption. “Instead this Position Statement conflates the effects of excessive and moderate alcohol consumption, and in so doing creates confusion and concern, with the apparent purpose of advancing a prohibitionist agenda.” It would be important to bring an honest appraisal of the best science forward for the purpose of improving public health, a mission not achieved by this paper.
Setting guidelines for alcohol consumption: As described by Harding and Stockley,1 “The objective of guidelines is to influence and change behavior among target populations. It follows, therefore, that several factors then become relevant: behavior that is thought to be in need of change, the culture and mindset of the target populations, and the kind of message that is likely to be effective. Recommendations that seek to reduce overall alcohol consumption in a population may also reduce that of moderate consumers. This effect may eventually be reflected in an increased incidence of cardiovascular disease within a population and is likely to have an economic impact and an effect on general health. Indeed, in the developed world, cardiovascular disease is the leading cause of mortality, accounting for 25% to 50% of all deaths. It is important, therefore, when formulating recommendations on maximum levels of alcohol consumption to recognize these potential problems and to seek ways of resolving them.”1
Smallwood2 has stated that “No society has yet solved the riddle of achieving the ideal balance where the majority can enjoy the social and health benefits of moderate drinking, while the harm that alcohol causes is minimized.” It is the opinion of the Forum that this balance — between seeking to reduce abuse while not decreasing beneficial effects of moderate drinking — is clearly not met in the Australian coalition paper.
Alcohol and cancer: Forum members found many statements included in this report to be inaccurate. Regarding alcohol and cancer, the paper states: “Every drinking occasion contributes to the life-time risk of harm from alcohol, therefore, any reduction in the dose – that is the amount and frequency of alcohol consumed – will reduce the annual and life-time risk of alcohol related harm.” This statement is not substantiated because there are threshold effects in the association of alcohol intake and cancer mortality. As an example, the comprehensive review of the association of lifestyle factors and cancer that was done by the World Cancer Research Fund (WCRF) in cooperation with the American Institute for Cancer Research found thresholds for the association of alcohol intake and colorectal cancers (30 g/day of ethanol) and liver cancers.3 In a review of alcohol and cancer, Boffetta and Hashibe4 stated that drinking, especially heavy drinking, increases cancer risk, but they concluded that “Total avoidance of alcohol, although optimum for cancer control, cannot be recommended in terms of a broad perspective of public health, in particular in countries with high incidence of cardiovascular disease.” 4
Beneficial effects of moderate drinking: Scientific data over more than three decades have clearly shown that moderate drinkers are at considerably lower risk of cardiovascular disease; and newer studies also indicate that they are at lower risk of dementia and many other diseases of ageing. The Australian paper states: “A 2005 paper in The Lancet argued that ‘any coronary protection from light to moderate drinking will be very small and unlikely to outweigh the harms,” which is not supported by current data. For example, Ronksley et al5 recently synthesized results from 84 longitudinal cohort studies comparing alcohol drinkers with non-drinkers. Those authors reported: “The pooled adjusted relative risks for alcohol drinkers relative to non-drinkers in random effects models for the outcomes of interest were 0.75 (95% confidence interval 0.70 to 0.80) for cardiovascular disease mortality (21 studies), 0.71 (0.66 to 0.77) for incident coronary heart disease (29 studies), 0.75 (0.68 to 0.81) for coronary heart disease mortality (31 studies), 0.98 (0.91 to 1.06) for incident stroke (17 studies), and 1.06 (0.91 to 1.23) for stroke mortality (10 studies).” 5
Papers contesting protective effects of moderate drinking: While the authors of the Australian paper state that moderate drinking has been shown to reduce the risk of cardiovascular diseases, they add: “However this view is contested,” and they list references to two earlier position statements and one scientific report about “errors” in prospective studies;6 the latter report has been greatly discussed and largely discredited.7-9
A recent summary paper by Fuller9 set out to determine the extent to which potential “errors” in many early epidemiologic studies led to erroneous conclusions about an inverse association between moderate drinking and coronary heart disease. The analysis was based on prospective data for more than 124,000 persons interviewed in the U.S. National Health Interview Surveys of 1997 through 2000 and was designed to avoid the pitfalls of some earlier studies. The results support the vast majority of well-done prospective studies and indicate that moderate consumers of alcoholic beverages have lower coronary heart disease and all-cause mortality. The author contends that these results lend credence to the argument that the inverse relation between alcohol and mortality is causal.9
Demonstrated mechanisms of protective effects of moderate drinking: There have been hundreds of excellent experimental studies that have supported a protective effect of moderate drinking on cardiovascular and other diseases of ageing. These were well summarized by Brien et al10 who stated: “Favourable changes in several cardiovascular biomarkers (higher levels of high density lipoprotein cholesterol and adiponectin and lower levels of fibrinogen) provide indirect pathophysiological support for a protective effect of moderate alcohol use on coronary heart disease.” Among many other summary papers on mechanisms by which moderate consumption of alcohol is associated with less cardiovascular and neurologic disease is that of Collins et al.11
The latest version of the Dietary Guidelines for Americans12 includes the statement: “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.” 12
Neafsey and Collins13 carried out a meta-analysis of 74 studies on cognitive impairment, based on a total of more than 250,000 subjects, that provided risk estimates for varying levels of alcohol consumption in a comprehensive meta-analysis. Their results found that moderate drinking either reduced or had no effect on the risk of dementia or cognitive impairment.13
Alcohol and mortality: Forum members were also surprised that the Australian statement misrepresented the large amount of scientific data regarding alcohol and mortality: Klatsky and Udaltsova7 carried out Cox proportional hazards model analyses of 21,535 deaths through 2002 in the Kaiser Permanente study. New methodology was used to stratify light-moderate drinkers into groups felt more or less likely to include “under-reporters” of alcohol consumption. Their analysis confirms that the relation of alcohol drinking to total mortality is J-shaped, with reduced risk for lighter drinkers and increased risk for persons reporting more than 3 drinks per day. Their data indicate further that the apparent magnitude of benefit of lighter drinking is probably reduced by systematic underreporting.7
In a meta-analysis of 34 prospective studies, Di Castelnuovo et al14 found that consumption of alcohol, up to 4 drinks per day in men and 2 drinks per day in women, was inversely associated with total mortality; the maximum protection was 18% in women (99% CI 13%-22%) and 17% in men (99% CI 15%-19%).14 Holahan et al15 showed that even when adjusting for sociodemographic factors, former problem drinking status, health factors, and social-behavioral factors, moderate drinking was associated with considerably lower risk of all-cause mortality. In comparison with “moderate drinkers” (subjects reporting up to 3 drinks/day), abstainers had 51 % higher mortality risk and heavy drinkers had 45% higher risk.15
Moderate drinking as a component of a “healthy lifestyle”: In a recent report, the US Centers for Disease Control and Prevention (CDC) included “a moderate consumption of alcohol” as one of “four healthy lifestyle behaviors that exert a powerful and beneficial effect on mortality.”16 The other low-risk behaviors were non smoking, eating a healthy diet, and physical activity. These authors state: “The number of low-risk behaviors was inversely related to the risk for mortality. Compared with participants who had no low-risk behaviors, those who had all 4 experienced reduced all-cause mortality (adjusted hazard ratio [AHR]=0.37; 95% CI 0.28, 0.49), mortality from malignant neoplasms (AHR=0.34; 95% CI 0.20, 0.56), major cardiovascular disease (AHR=0.35; 95% CI 0.24, 0.50), and other causes (AHR=0.43; 95% CI 0.25, 0.74).” 16 Considering the potential dangers of excessive drinking, the CDC researchers carried out sensitivity analyses omitting moderate alcohol use; the mortality risk for those who also consumed alcohol was significantly lower than for those having only the three other behaviors.16
Others have similarly shown that including moderate alcohol intake as a component of a healthy lifestyle has significant effects on lowering morbidity and mortality for a number of diseases.17-19 For example, Mukamal et al17 reported that men who were already at low risk of cardiovascular disease on the basis of body mass index, physical activity, smoking, and diet, moderate alcohol intake was associated with significantly lower risk for myocardial infarction. Joosten et al19 reported “In subjects already at lower risk of type 2 diabetes on the basis of multiple low-risk lifestyle behaviors, moderate alcohol consumption was associated with an approximately 40% lower risk compared with abstention.”
Further, as recently demonstrated by Sun et al,20 in addition to lower mortality, moderate drinkers surviving to age 70 and beyond tended to have less disability and more signs of “successful ageing.” For “regular” moderate drinkers (who consumed alcohol on 5-7 days per week), there was an almost 50% greater chance of such successful ageing as was the case for non-drinkers.20
Effects of the pattern of alcohol consumption on health outcomes: Forum members noted that there was no mention in the document from Australia of the importance of the pattern of drinking. It has been clearly shown that regular moderate intake is associated with considerable health benefits, while occasional heavy intake (binge drinking) relates to most of the adverse health and societal effects. Rehm et al 21 found that most of the increases in mortality associated with “moderate drinking” (when defined as the average number of drinks per week) were no longer present when binge drinkers were excluded from this group. Ruidavets et al22 found that regular and moderate alcohol intake throughout the week, the typical pattern in middle-aged men in France, is associated with a low risk of ischaemic heart disease, whereas the binge drinking pattern more prevalent in Belfast confers a higher risk.
A recent animal experiment supports these findings of the importance of drinking pattern on disease. Liu et al23 recently showed in an experimental study in mice that many indices of cardioprotection were seen from regular moderate drinking, but adverse effects resulted from binge drinking.
References from Forum critique
1. Harding R, Stockley CS. Communicating through government agencies. Ann Epidemiol 2007;17:S98–S102.
2. Smallwood R. Communicating with the public: Dilemmas of a chief medical officer. Ann Epidemiol 2007;17:S103–S107
3. Food, Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective. AICR, Washington DC, 2007.
4. Boffetta P, Hashibe M. Alcohol and cancer. Review. Lancet Oncol 2006;7:149–156.
5. Ronksley PE, Brien SE, Turner BJ, Mukamal KJ, Ghali WA. Association of alcohol consumption with selected cardiovascular disease outcomes: a systematic review and meta-analysis. BMJ 2011;342:d671; doi:10.1136/bmj.d671
6. Fillmore K, Stockwell T, Chikritzhs T, Bostrom A and Kerr W, ‘Moderate Alcohol Use and Reduced Mortality Risk: Systematic Error in Prospective Studies and New Hypotheses’, Ann Epidemiol, 2007, May;17(5 Suppl):S16-23.
7. Klatsky A, Udaltsova N. Alcohol drinking and total mortality risk. Ann Epidemiol. 2007;17 (Suppl):S63-S67.
8. Panel Discussion I: Does alcohol consumption prevent cardiovascular disease? Proceedings of an international conference. Ann Epidemiol 2007;17:S37–S39.
9. Fuller TD. Moderate alcohol consumption and the risk of mortality. Demography 2011. DOI 10.1007/s13524-011-0035-2
10. Brien SE, Ronksley PE,Turner BJ, Mukamal KJ, Ghali WA. Effect of alcohol consumption on biological markers associated with risk of coronary heart disease: systematic review and meta-analysis of interventional studies. BMJ 2011;342:d636; doi:10.1136/bmj.d636.
11. Collins MA, Neafsey EJ, Mukamal KJ, Gray MO, Parks DA, Das DK, Korthuis RJ. Alcohol in moderation, cardioprotection, and neuroprotection: Epidemiological considerations and mechanistic studies. Alcohol Clin Exp Res 2009;33:206–219.
12. US Department of Agriculture, Dietary Guidelines for Americans 2010. http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/Chapter3.pdf
13. Neafsey EJ, Collins MA. Moderate alcohol consumption and cognitive risk. Neuropsychiatric Disease and Treatment 2011:7:465–484.
14. Di Castelnuovo A. Costanzo S, Bagnardi V, Donati MB, Iacoviello L, de Gaetano G. Alcohol dosing and total mortality in men and women: an updated meta-analysis of 34 prospective studies. Arch Intern Med. 2006;166:2437-2445.
15. Holahan CJ, Schutte KK, Brennan PL, Holahan CK, Moos BS, Moos RH. Late-Life Alcohol Consumption and 20-Year Mortality. Alcoholism: Clinical and Experimental Research 2010;34:on line November 2010
16. Ford ES, Zhao G, Tsai K, Li C. Low-risk lifestyle behaviors and all-cause mortality: Findings from the National Health and Nutrition Examination Survey III Mortality Study. American Journal of Public Health 2011; 10.2105/AJPH.2011.300167.
17. Mukamal KJ, Chiuve SE, Rimm EB. Alcohol consumption and risk for coronary heart disease in men with healthy lifestyles. Arch Intern Med 2006;166:2145-2150.
18. Chiuve SE, McCullough ML, Sacks FM, Rimm EB. Healthy lifestyle factors in the primary prevention of coronary heart disease among men. Benefits among users and nonusers of lipid-lowering and antihypertensive medications. Circulation 2006;114:160-167.
19. Joosten MM, Grobbee DE, van der A DL, Verschuren WWM, Hendriks HFJ, Beulens JWJ. Combined effect of alcohol consumption and lifestyle behaviors on risk of type 2 diabetes. Am J Clin Nutrition, published on-line 21 April 2010. doi:10.3945/ajcn.2010.29170
20. Sun Q, Townsend MK, Okereke OI, Rimm EB, Hu FB, Stampfer MJ, Grodstein F. Alcohol consumption at midlife and successful ageing in women: A prospective cohort analysis in the Nurses’ Health Study. PLoS Med 8(9): e1001090. doi:10.1371/journal.pmed.1001090
21. Rehm J, Patra J, Taylor B. Harm, benefits, and net effects on mortality of moderate drinking of alcohol among adults in Canada in 2002. Ann Epidemiol 2007;17:S81–S86.
22. Ruidavets J-B, Ducimetièere P, Evans A, Montaye M, Haas B, Bingham A, Yarnell J, Amouyel P, Arveiler D, Kee F, Bongard V, Ferrières J. Patterns of alcohol consumption and ischaemic heart disease in culturally divergent countries: the Prospective Epidemiological Study of Myocardial Infarction (PRIME). BMJ 2010;341:c6077 doi:10.1136/bmj.c6077.
23. Liu W, Redmond EM, Morrow D, Cullen JP. Differential effects of daily-moderate versus weekend-binge alcohol consumption on atherosclerotic plaque development in mice. Atherosclerosis 2011, doi:10.1016/j.atherosclerosis.2011.08.034
A group known as the Alcohol Policy Coalition in Australia has released a document entitled Cancer, Cardiovascular Disease and Alcohol Consumption. Forum members agree that excessive alcohol use has many adverse effects on the individual and on society, and efforts to reduce such use is important. On the other hand, they were disturbed that the coalition statement was limited almost exclusively to the effects of abusive drinking, was based primarily on extremely limited sources of information (mainly position statements by other organizations, and not publications based on sound research), and indicated a strong bias against alcohol.
Forum members contend that the Australian report misrepresents the extensive scientific data available on alcohol and health. The report specifically ignores scientific data indicating that in all developed countries, moderate consumers of alcohol are at much lower risk of essentially all of the diseases of ageing: coronary heart disease, ischemic stroke, diabetes, and dementia. And conspicuously absent from the Australian report is a description of the lower total mortality among middle-aged and elderly people associated with moderate alcohol consumption, a finding that has been found consistently throughout the world. Further, there is no mention in the report of the key relevance of the pattern of drinking, although regular moderate drinking (versus binge drinking only on week-ends, even when the total volume of alcohol is the same) has been shown to be a strong determinant of beneficial effects of alcohol consumption.
Scientific data over many decades have shown that while excessive or irresponsible alcohol use has severe adverse health and societal effects, regular moderate drinking is associated with beneficial effects on health. And a very large number of experimental studies, including results from human trials, have described biological mechanisms for the protective effects of both alcohol and the polyphenolic components of wine.
There have been a number of comprehensive meta-analyses published that Forum members believe can provide much more accurate, up to date, and scientifically balanced views of the current status of the health effects of alcohol consumption. Such documents are better sources of data upon which policy decisions should be based.
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Comments on this critique by the International Scientific Forum on Alcohol Research were provided by the following members:
Erik Skovenborg, MD, Scandinavian Medical Alcohol Board, Practitioner, Aarhus, Denmark
Arne Svilaas, MD, PhD, general practice and lipidology, Oslo University Hospital, Oslo, Norway
Gordon Troup, MSc, DSc, School of Physics, Monash University, Victoria, Australia
Francesco Orlandi, MD, Dept. of Gastroenterology, Università degli Studi di Ancona. Italy
Harvey Finkel, MD, Hematology/Oncology, Boston University Medical Center, Boston, MA, USA
Andrew L. Waterhouse, PhD, Marvin Sands Professor, Department of Viticulture and Enology, University of California, Davis, CA, USA
Tedd Goldfinger, DO, FACC, Desert Cardiology of Tucson Heart Center, Dept. of Cardiology, University of Arizona School of Medicine, Tucson, Arizona, USA
R. Curtis Ellison, MD, Section of Preventive Medicine & Epidemiology, Boston University School of Medicine, Boston, MA, USA
Ulrich Keil, MD, PhD, Institute of Epidemiology and Social Medicine, University of Münster, Münster, Germany
David Vauzour, PhD, Senior Research Associate, Department of Nutrition, Norwich Medical School, University of East Anglia, Norwich, UK