A Drink a Day Keeps the Doctor Away?

Two recent editorials in Alcoholism: Clinical and Experimental Research debated whether to prescribe 1 drink a day for lifetime abstainers starting between the ages of 40 and 50 years. Arguing for the recommendation, Rubin made the following points:

• Numerous observational studies suggest that, compared with abstinence and higher levels of use, “moderate” alcohol use is associated with decreased all-cause mortality.
• Studies suggest that, when compared with abstinence, “moderate” alcohol use is associated with decreased rates of myocardial infarction, ischemic stroke, osteoporosis, type II diabetes mellitus, rheumatoid arthritis, and dementia.
• There is no strong evidence that “moderate” alcohol use increases cancer risk.
• Risk of alcohol dependence developing in lifelong abstainers who begin drinking alcohol after age 40 years is “trivial.”

Rubin concludes: “the overwhelming evidence suggests physicians should counsel lifelong non-drinkers at about 40 to 50 years of age to relax and take a drink a day, preferably with dinner.” Greenfield and Kerr countered with the following points:

• Observational studies that show benefit from “moderate” alcohol use are uncontrolled and limited by misclassification (e.g., inclusion of “sick quitters” in the abstainer group) and residual confounding.
• A meta-analysis indicated no benefit of “moderate” alcohol use for all-cause or cardiovascular mortality among the studies judged to be without misclassification error.
• Another meta-analysis of 261,991 individuals indicated that those with the variant of alcohol dehydrogenase 1B gene associated with less alcohol use had reduced risk of cardiovascular disease across all levels of alcohol use. This suggested that decreasing alcohol consumption, even in people with “light” to “moderate” use, would reduce cardiovascular risk.
• Daily consumption of < 1.5 standard drinks a day accounts for 26%–35% of cancer deaths attributable to alcohol.
• Individuals are abstinent for many reasons (e.g., religious beliefs) and may not be receptive to advice to start drinking.
• Advice to start drinking may have unintended consequences, including drinking in excess of safer limits and indirect transmission of the “wrong message” to people with current use, who might increase their consumption.

Greenfield and Kerr conclude: “we respectfully urge caution in prescribing drinking to abstainers, even lifetime abstainers, over 40 years of age” and call for a randomized controlled trial.

Comments:

In my own clinical practice, I can recall only a few instances of a lifelong abstainer patient asking me if he or she should start drinking to improve their health. These queries generally were made with some levity and occurred after the news media publicized an observational study’s finding of alcohol’s benefit. I would respond, “No, I don’t think we’re quite ready to make that recommendation yet… But have you thought about exercising more?” Should I change my approach to this recommendation? Would my abstaining patients follow the recommendation if I made it? Certainly, many lifelong abstainers have done so for a reason and may not appreciate the recommendation and perhaps may even have decreased quality of life should they not enjoy the drink a day. What would be the optimal dose and duration of use? Should I urge my non-abstaining patients who drink less than one drink a day to increase their intake?

Although many observational studies suggest a health benefit of “light”-to-“moderate” drinking, the medical literature also has many examples of preventive interventions that showed a beneficial effect in observational studies but not when tested in high-quality randomized controlled trials. Further caution is warranted because alcohol is classified as a carcinogen by some national and international health organizations. Since there remains clinical equipoise (i.e., uncertainty about the potential benefit of moderate alcohol use in the context of known potential harms) in this matter, I agree with Greenfield and Kerr about the need to give serious consideration to a randomized controlled trial. The conduct of such a trial poses many challenges and might be most efficiently done in patients at high risk for cardiovascular disease or as secondary prevention.

Kevin L. Kraemer, MD, MSc

Reference:

Rubin E. To drink or not to drink: that is the question. Alcohol Clin Exp Res. 2015;38(12):2889–2892.
Greenfield TK, Kerr WC. Physicians’ prescription for lifetime abstainers aged 40 to 50 to take a drink a day is not yet justified. Alcohol Clin Exp Res. 2015;38(12):2893–2895.