Is a little alcohol bad for you?

We spoke to two researchers who disagree about the answer to this question. But they do agree about why it's so hard to answer to begin with. Guests: Dylan Scott, senior correspondent at Vox; Kenneth Mukamal, physician and academic researcher at the Beth Israel Deaconess Medical Center; Timothy Naimi, director of the University of Victoria’s Canadian Institute for Substance Use Research For show transcripts, go to ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠vox.com/unxtranscripts⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠For more, go to ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠vox.com/unexplainable⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠And please email us! ⁠⁠⁠[email protected]⁠⁠⁠We read every email. Support Unexplainable (and get ad-free episodes) by becoming a Vox Member today: ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠vox.com/members⁠⁠⁠⁠⁠⁠⁠⁠Thank you! Learn more about your ad choices. Visit podcastchoices.com/adchoices

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• 1:25Speaker 00

  Dylan Scott, senior correspondent and senior good pal of mine.

• 1:31Speaker 02

  Byrd Pinkerton, pal of mine and co-host of Unexplainable.

• 1:36Speaker 00

  You have a mystery for me, I believe, about alcohol.

• 1:40Speaker 02

  I do. So if you're anything like me, you know, I think we both grew up in the 90s, you have heard some very mixed messages about what drinking moderate amounts of alcohol can do for your health.

• 1:55Speaker 03

  Just in time for the weekend, a new warning about the dangers of alcohol and cancer.

• 2:00Speaker 02

  It feels like every week you read the news and there's a new study about alcohol and it's saying the exact opposite of the study you were reading about last week.

• 2:10Speaker 03

  Several studies have shown moderate drinking may be good for your overall health, but

• 2:15Speaker 04

  No amount of alcohol is good for your health. Less drinking means less risk.

• 2:20Speaker 02

  So I decided like I want to get to the bottom of this for myself and for our audience. Like I want to actually understand what to think about the health effects of drinking moderate amounts of alcohol.

• 2:37Speaker 00

  Okay. And so what, what did you find? Like what are the health effects of drinking moderate amounts of alcohol?

• 2:44Speaker 02

  Well, this is unexplainable. So I found it was unexplainable, but in a way that I think is really interesting and revealing because this story of alcohol's health effects and our imperfect attempts to measure it is, I think, the story of, of how it's really, really hard to isolate and pin down the health effects of all kinds of things that we really would want answers about. These things that we interact with and consume all of the time.

• 3:20Speaker 00

  Okay, let's, uh, let's go.

• 3:38Speaker 02

  You know, I think to start, we should establish that the science is pretty settled when it comes to heavy drinking. Alcohol is bad for you. It has neurological effects. It causes liver disease and we've known that for hundreds and hundreds of years.

• 3:56Speaker 00

  How much is, uh, too much though, I guess? Or like what, what is a lot of alcohol?

• 4:03Speaker 02

  This was one of the things that, you know, surprised me when I looked into this and I think it would surprise a lot of people, which is that what normal people think is a lot of drinking and what scientists and doctors think is a lot of drinking, there's a pretty big gap there.

• 4:20Speaker 02

  But looking at the scientific definition, for some people, the limit is two drinks per day. Anything above that is heavy drinking. And for other people, it can be just one drink per day, and anything above that is heavy drinking. And like, you know, a drink can be a pretty small amount. Even one can of beer, if it has really high alcohol content, can be more than one drink. And so if you're drinking more than that limit each day, the researchers that I talked to were in agreement that that's going to be a problem. There are heart risks, there are cancer risks, it's damaging your liver, and you would do better to drink less.

• 5:00Speaker 00

  But what if you are drinking like just a glass of wine every two days or whatever?

• 5:06Speaker 02

  I mean, this is where things get contentious. This is where all of the argument is.

• 5:14Speaker 02

  So let's start with sort of the pro alcohol side. And we can start with a researcher who has made the case that maybe some small amount of alcohol might actually be good-ish for you.

• 5:26Speaker 05

  My name is Ken Mukamal. I'm a primary care physician at Beth Israel Dekus Medical Center.

• 5:33Speaker 02

  I do think it's worth pointing out that Ken has been in the news in the past, and he has faced some criticism from his peers about his research allegedly being influenced by the alcohol industry. Like, back in 2018, he was leading a study on alcohol's health effects for the NIH, and that study got shut down because the NIH found some suggestion that there was bias in the study's design. But, you know, even with that history, I thought it was really helpful to talk to Ken and to get his perspective on the research. And I also thought it was interesting, like, he's staked out this position, but he doesn't really seem to have a personal investment in drinking alcohol.

• 6:16Speaker 05

  Although a sizable part of my research career has been related to alcohol, we had hardly drank at all in my house. My dad was a chemical engineer, and if he happened to open a beer, it was like, you know, a major event in the house. And in fact, I continued hardly to drink at all.

• 6:30Speaker 02

  But even so, part of the reason he wanted to study alcohol is that, as he said, he's actually a primary care doctor. So he's not like just a cardiologist by training who's only worried about your heart. He's not only a liver doctor or a kidney doctor. He's worried about the whole person. And for him, alcohol was a really good fit because alcohol touches on so many aspects of people's lives. Decades ago, as he was starting to think about this, he developed this question about whether some amount of alcohol might be helpful.

• 7:07Speaker 05

  This was right around the time that in clinical medicine more generally, when I was going through training at that time, we were moving into the idea that when people had heart attacks, that one of the ways that we could either treat them or prevent them was to do things like giving people baby aspirin, right? And that eventually turned into like, you know, lore all over the world.

• 7:26Speaker 02

  Aspirin is a blood thinner and heart attacks happen basically because the flow of blood to the heart is blocked in some way. And so thinning out the blood might help.

• 7:38Speaker 05

  And indeed, the New England Journal had published a sort of small paper, like in the early 1980s, showing that aspirin prolongs how long it takes somebody to clot their blood. And if you give them aspirin plus alcohol, it was markedly longer than even just with aspirin alone. So I'll be honest, I'm thinking to myself, well, if that's true, and we're spending all this time, you know, trying to give people aspirin and stuff, like, why aren't we washing down that aspirin with a little bit of alcohol? If that data from the early 1980s was right, and we're seeing that alcohol has a little bit of blood thinning effect, and we're looking for additional blood thinners, like, it seems like the natural next thing to do.

• 8:19Speaker 02

  And his boss actually didn't totally shoot this idea down. And, you know, Ken told me, like, there are better blood thinning options than alcohol. So the idea wasn't like, let's, you know, give everybody who's having a heart attack a shot of whiskey. But, you know, he was still interested, like, could naturally thinning your blood this way, you know, prevent heart attacks just over the long term? And could there be other positive impacts that alcohol might have on your health somehow?

• 8:51Speaker 00

  So if you're like, having a glass a day, is your blood just like, a little bit thinner? And maybe that prevents heart attacks?

• 8:57Speaker 02

  This more like, kind of, long-term, small-dose exposure, prophylactic approach? Yes, that's what he was curious about. And he, you know, went down this long rabbit hole for many years after that, looking for some answers. He was mostly looking at, you know, these big data sets, these things that are called cohort studies, or large population-based studies.

• 9:21Speaker 05

  More or less, the idea is quite simple, right? We're gonna take lots of people, we're gonna ask them some universal standard questions, including things like, how often do you drink alcohol? When you drink, how much do you have? What's the most that you have? And then, using that information, we're gonna then sort people into bins, and then wait and see what happens. Now, these are not experiments, I want to emphasize that, because that's gonna then come back to haunt us a little bit. These are not situations where I ask you to drink a certain amount, or ask you not to drink a certain amount, and manipulate it the way that, say, I would do with mice in a laboratory. These are just, you chose to drink, or you didn't choose to drink, and I'm gonna follow

• 10:05Speaker 05

  along and see what happens. And, in our case, they involved anywhere from, you know, a few thousand to tens of thousands of people, followed for anywhere from three or five years to 25 years.

• 10:20Speaker 02

  And so, you know, Ken's looking at these studies where people have reported their alcohol consumption, and then he's looking at data that shows their health outcomes.

• 10:30Speaker 02

  And he's going through the numbers and he found a slight link in small doses to some potential health benefits from drinking alcohol.

• 10:40Speaker 05

  To the extent that there's sort of a simple message that I could offer, it's that where we see, well, I'll call quote benefits of alcohol. These are not proven, it's definitely causal, but to the extent that we see any, it's predominantly for things like diabetes and heart disease.

• 10:59Speaker 02

  So he's saying that there may be a slight benefit, a slight positive health effect for your heart from low level drinking.

• 11:08Speaker 05

  If there's any benefit, there's benefits from drinking small amounts frequently. And in fact, binge drinking, for the most part, obliterates any of the benefits that you see from frequent drinking.

• 11:21Speaker 00

  He doesn't sound super sure about this, that we're like confident, like when he says, if there's any benefit, he's not making like a particularly definitive statement.

• 11:35Speaker 02

  No, he's not. And I mean, this is what I found the most interesting after digging into this.

• 11:45Speaker 02

  Ken actually spent a lot of our time in our conversation, talking less about like the specific data he found and what it showed, and more about like the problems with the data itself.

• 11:58Speaker 05

  This is not high quality evidence in the same way that you would want, say, to have a new drug approved. It's just not.

• 12:11Speaker 00

  What's wrong with the evidence? That is after the break.

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• 15:53Speaker 04

  Alcohol withdrawals? That's great.

• 15:56Speaker 00

  So Dylan Scat, before the break, you basically told me that our data on alcohol is bad. Why is that?

• 16:08Speaker 02

  Well, it might be most helpful to start with, like, what would high-quality data even look like? And in an ideal world, what you would do is set up a randomized control trial. Like, you'd have two groups of people, and one group would drink, and the other group wouldn't drink. And you would follow them both over time, and you'd track what happened with their health. And at the end of this trial, you would be able to measure what the health effects of alcohol actually were. And that is the gold standard that we use for approving pharmaceutical drugs, for example.

• 16:48Speaker 00

  I can see why it would be...

• 16:51Speaker 07

  Pretty impossible to get like a thousand people or whatever into a randomized control trial and basically be like, "You have to drink two bottles of IPA every day for the rest of time, and you can't drink any alcohol, but you have to drink two bottles of orange juice," or something. Like, that's not realistic in the world we live in.

• 17:15Speaker 02

  No, no, exactly. So instead, we have the setup we were describing before the break. We have these observational studies that just ask people about their real lives, you know, how much alcohol they drink. And, you know, we try to follow them over the course of their lives just as they unfold naturally, try to deduce some health effects from that observational data. But that kind of study, it has some pretty big problems.

• 17:43Speaker 08

  And I'll just try to do a thumbnail sketch about what most of the evidence is about and what its problems are. And you can, like, edit it out of your thing if you want to.

• 17:54Speaker 02

  This is Tim Namie. He is the director of the University of Victoria's Canadian Institute for Substance Use Research. He has been doing research since the 1990s. And at first glance, it would seem that he fundamentally disagrees with our first researcher, Ken. Like, Ken is out here saying, "There's a possibility that a small amount of alcohol might be good for your health." And Tim thinks the opposite.

• 18:25Speaker 08

  The science is very consistent for 40 years that, like, when it comes to alcohol, that less is better.

• 18:30Speaker 02

  He is basically saying, "There is no amount of alcohol that is good for you."

• 18:36Speaker 08

  It's not that people shouldn't enjoy alcohol or shouldn't drink alcohol. It's just that there are many things in life that we do that come with some risks. And it's okay, right? But it's just like, I guess, as a scientist and a public health person, I like to call BS when I think there's been a bit of BS. And I think we've seen over the past 20 years that that kind of health halo around particularly wine and particularly so-called moderate drinking has kind of fallen away. At no level of consumption was there a significant protective effect.

• 19:13Speaker 02

  But when we talked to Tim and he was explaining to me why he doesn't think that glass of red wine has any kind of health halo, I realized that he was actually saying a lot of the same things that I was hearing from Ken. Because, you know, as it turns out, they're both looking at the same kind of data, and they both agree on this key central point.

• 19:38Speaker 08

  I think the evidence base is pretty crappy.

• 19:40Speaker 02

  In fact, you know, a lot of Tim's argument for why he's calling BS on the idea that a small amount of alcohol could have some health benefits is because of his frustration with the data sets that we're drawing on. Like, he says that, for one thing, a lot of studies out there aren't asking questions that are specific enough.

• 20:01Speaker 08

  Most of what informs our information about the relationship between alcohol and, say, heart disease is based on what we call big cohort studies. These are studies that are designed to ultimately study, like, heart disease, cancer, but they weren't really designed with alcohol in mind. Why is that important? It's important because typically, they're only asking people at one point, like, at the beginning of the study, for example, like, "Okay, how many days a week do you drink? And how much do you drink on the days you drink?" And then from that, they calculate an average consumption.

• 20:35Speaker 02

  We know there's a big health difference between one drink every night versus having seven drinks in a week, and they were all consumed within two hours on Saturday night. But, you know, depending on the way the researchers phrase their questions or just the information they choose to collect, in theory, both of those could be recorded as, "I had seven drinks this week." And that imprecision makes it hard, in general, to interpret some of the data we have on alcohol and its health effects.

• 21:07Speaker 00

  That does seem... Like fixable, though, right? In the, in the design of either future studies or, or current studies.

• 21:16Speaker 02

  I mean, sure. You know, we could, we could design a perfect survey question to ask about people's alcohol use. But even if we did, there are other things that are not so easily fixed, like the lack of randomness in studies like this. Because, you know, you're not, when you're not randomizing things truly, like when you're just having people report how much they're drinking and then letting them go about their lives, there are a lot of ways that the, the cultural context in which they live could affect the data that you're getting.

• 21:50Speaker 02

  You know, we could go back, I think, to like the idea that moderate drinkers are seeing some positive health effects to their drinking. As Tim pointed out, you know, moderate drinkers actually tend to fit a certain profile and they share other things in common.

• 22:04Speaker 08

  The problem is, the so-called moderate drinkers, especially in developed countries, tend to be very socially advantaged. These people also have higher education, they have higher incomes, their children smile at them, they go to the gym, they drive BMWs. I mean, this is, this is a big problem, right?

• 22:24Speaker 02

  So basically, Tim's argument here is that maybe it's not that little bit of alcohol consumption that's good for you. It's that the people who tend to have lots of other healthy things going for them in their lives tend to be the ones who are drinking only a little bit. And that might kind of bump up the numbers, you know, showing positive health effects from their drinking.

• 22:46Speaker 08

  So it makes it appear like, oh, moderate drinking, you know, gives you straight teeth and it gives you a good job and it gives you a BMW. But in fact, it's the BMW and the nice job that lets you buy a nice bottle of wine.

• 23:02Speaker 02

  And on the flip side, you know, he said, we also need to be really careful about how we think about and study non-drinkers.

• 23:09Speaker 08

  Those people are actually, in many cases, not never drinkers, but are in fact former drinkers. Former drinkers, we know, are very unhealthy. They tend to be unhealthy. And it may be because they drank a lot or had bad effects of alcohol and they stopped drinking. But what we know about former drinkers is, for a variety of reasons, they tend to not do well.

• 23:32Speaker 02

  Some folks might not be drinkers at the time of the study, but they might have been heavy drinkers before the study even started. But at the time of the study, when the researchers are collecting all this data, they would report that they actually don't drink. So this could really, this could really influence the results that this study ultimately reports. And I've seen, you know, other studies have pointed out that like, some of the people who are really, really heavy drinkers, they die at such a young age that they don't end up getting included in these studies. And so, you know, all of these things are the problems with observational studies and relying on observational data to draw firm conclusions about the health effects of different things.

• 24:15Speaker 02

  Unless you're controlling for all of this stuff, it becomes really hard to isolate for the specific health effects of alcohol.

• 24:23Speaker 00

  But like, my understanding is that you can find ways to correct data for stuff like this, right? Like, if, if you ask people who join your study, did you or have you had a problem with alcohol? Can't you kind of control for all those factors, I guess, or like, weight the study accordingly?

• 24:45Speaker 02

  I mean, you can certainly try. And, you know, Tim Namy is a co-author on a recent, really big meta-analysis of all the prior research of cardiovascular effects from alcohol use. And that's exactly what they were trying to do. You know, they were trying to slice and dice this data to account for all kinds of different things, you know, gender and age and race and even this abstainer bias that they were cognizant of. And but, you know, there's, there's an art to doing that kind of work. You know, different people could choose to weigh different variables to different degrees. And that's what leads to some of these differences of opinion that we've seen between different scientists.

• 25:28Speaker 07

  Is there any hope of getting better data? Like, I don't know, I, I personally would like to have better data on this thing. That's, that's pretty ubiquitous in modern society.

• 25:42Speaker 02

  Yes, I agree. And there are researchers who are trying to use things like genetics to improve the data we have. You know, they're studying people who have a genetic tendency to drink or not to drink, and looking at their health outcomes. And then we've got other researchers who are trying to set up studies to measure the specific biological mechanisms that might explain some of the benefits or, you know, negative consequences that we're seeing. And so, you know, I think that would make people feel more confident, at least that like, okay, it's actually the alcohol that's doing something here. And it's not just that, you know, these people have to happen to have certain drinking patterns

• 26:23Speaker 02

  or their health outcomes are actually being determined by, you know, having a BMW or their kid is smiling at them, whatever it may be. But, uh, you know, overall, I mean, I thought, look, I thought Ken made a compelling point that even though this is hard, even though the answers may not be perfect, we could and should try to do better.

• 26:46Speaker 05

  At least for me, the fact that something is hard is not a reason not to do it, especially when something as important as this, right? Lot of people drink alcohol, over half Americans are drinking alcohol. How is it that we don't know exactly what the hell this stuff does? If half of Americans are doing it? And the fact that it's hard is a cop out answer, I think, for not having good information.

• 27:08Speaker 00

  Were you surprised by this at the end that we don't have better answers?

• 27:13Speaker 02

  You know, it honestly, it simultaneously did and did not surprise me. You know, I've reported on health for a long time, reported a lot on how people's behavior affects their health. And this is a recurring theme that, you know, understanding how people's behavior affects their wellbeing is really difficult. With caffeine or chocolate or sugar, you know, these substances that we're consuming all the time. And we want to understand what they're doing to our bodies. We've run into this problem again and again, where it's really hard to set up a proper randomized trial that would really give us the answers that we want.

• 27:54Speaker 02

  And so instead, we're left with this imperfect observational data that leaves us a little bit uncertain about exactly what conclusions we should be drawing with it.

• 28:04Speaker 00

  What should people do in the face of this imperfect data? Should they start drinking? Should they stop drinking entirely?

• 28:12Speaker 02

  I think the most important thing is that people just be aware of the facts that we've been covering on this episode. Because as we've said, you know, the researchers who we talked to were all in agreement that once you're drinking heavily, according to the scientific definitions, you're inviting some pretty serious health risks. And I don't think anybody would say, you know, you should start drinking because it's going to be good for your health. But I don't think anybody we talked to would say like, absolutely everyone, you know, we need to go back to prohibition. Everybody should stop drinking. Like, I myself enjoy drinking, but I am approaching 40 now. I write about healthcare. I've been following this research.

• 28:55Speaker 02

  And I've, you know, I do try to moderate my drinking even more these days because I am aware of all this stuff.

• 29:03Speaker 02

  But I still get to enjoy that glass of wine with dinner or have a beer when we're grilling out on the back patio. I don't, I try to don't worry about it too much. It's really, I think, about just informed consumption. People should be informed. They should know what they're getting into. And beyond that, we each got to make our own choices.

• 29:29Speaker 00

  Dylan has a lot more reporting on alcohol and health. He has especially been digging into the influence that industry has on what we think about moderate drinking and its health effects. So we will link to his recent piece on that in the transcript. And you can hear him on Today Explained tomorrow, talking about the alcohol research that RFK Jr.'s health department has buried. In the meantime, this episode was produced by me, Bird Pinkerton. It was edited by Julia Longoria. Meredith Hodnot runs our show. Noam Hassanfeld makes our music. Christian Ayala did the mixing and the sound design for this episode. Melissa Hirsch checked the facts.

• 30:12Speaker 00

  Jorge Just is a wonderful fact. And I am always, always grateful to Brian Resnick for co-creating the show. If you have thoughts about this episode, we are at [email protected], and I love hearing from you all. If you want to support the show, perhaps, and help us keep making it, please join our membership program. It is at vox.com/members, and you will get ad-free podcasts, you'll get unlimited access to Vox journalism, and you'll be supporting this show. In fact, if you sign up because you love Unexplainable, please tell our bosses that. It would make a very big difference.

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