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Complete abstinence is easier than perfect moderation.
—St. AugustineThe paper concluding “light and moderate alcohol intake might have a protective effect on all-cause and CVD-specific mortality” (1) and the unbalanced accompanying editorial (2) deserve comments. First, this new post hoc analysis from the National Health Interview Surveys should be considered hypothesis-generating at best. However, the sophistication of the multivariable adjustments contrasted with a 9% attrition rate and a limited reliability of data: first, self-report for hypertension and even alcohol use; and second, arbitrary and limited number of categories for confounding variables thus potentially generating residual confounding (e.g., education level or smoking status); and third, no sensitivity analysis to assess how robust the association is to potential unmeasured/uncontrolled confounding (3). Accordingly, the validity, reliability, and generalizability of the findings deserve scrutiny.
Second, the term “moderate alcohol use” is usual but should be avoided in medical literature. Public health advocates use the term “drinking at low risk.” In the United Kingdom, as in France, the Chief Medical Officer warns both men and women to keep health risks from alcohol to a low level: “it is safest not to drink more than 14 units a week on a regular basis.” Moreover, in this U.S. study 1 alcoholic drink–equivalent contains 14 g of alcohol (1), but it is 8 and 10 in the UK and in France, respectively. Self-reporting is also challenging as the result depends on the size of the glass and the strength (i.e., usually 125 to 175 ml and 11° to 14° for wine). “Moderate alcohol use” is a marketing tool of the industry to promote sales as shown by the flawed French and UK Responsibility Deal (4). The one-third of Health eHeart participants who believed alcohol to be heart healthy drank substantially more alcohol than the others and cited the lay press as the origin of that perception (5).
Third, alcohol is classified as a human carcinogen (class 1) by the International Agency for Research on Cancer, with a dose-related increase in prevalence of several cancers either exponentially (e.g., oral cavity and pharyngeal cancers) or linearly (e.g., esophageal and breast cancer), beginning at the level of the first to second drink per day.
Fourth, in the study by Zhao et al. (1), the representation of their reference 27, ignored by de Gaetano and Costanzo (2) contrasted with the authors’ conclusion (see ref. 27 in Zhao et al. ). This Mendelian randomization based on individual participant data suggests that “reduction of alcohol consumption, even for light to moderate drinkers, is beneficial for cardiovascular health.”
Advertising for alcohol has skyrocketed and the increase in alcohol use, not only high-risk drinking, in the United States constitute a public health crisis.
Please note: Dr. Braillon has reported that he has no relationships relevant to the contents of this paper to disclose.
- 2018 American College of Cardiology Foundation
- Zhao M.,
- Veeranki S.P.,
- Bo Xi B.
- de Gaetano G.,
- Costanzo S.
- Vander Weele T.J.,
- Ding P.
- Braillon A.
- Whitman I.R.,
- Pletcher M.J.,
- Vittinghoff E.,
- et al.