Alcohol: Balancing Risks and Benefits

Moderate drinking can be healthy—but not for everyone. You must weigh the risks and benefits.

–Introduction
–What’s Moderate Alcohol Intake? What’s a Drink?
–The Downside of Alcohol
–Possible Health Benefits of Alcohol
–Genes Play a Role
–Shifting Benefits and Risks
–The Bottom Line: Balancing Risks and Benefits

Introduction

Throughout the 10,000 or so years that humans have been drinking fermented beverages, they’ve also been arguing about their merits and demerits. The debate still simmers today, with a lively back-and-forth over whether alcohol is good for you or bad for you.

It’s safe to say that alcohol is both a tonic and a poison. The difference lies mostly in the dose. Moderate drinking seems to be good for the heart and circulatory system, and probably protects against type 2 diabetes and gallstones. Heavy drinking is a major cause of preventable death in most countries. In the U.S., alcohol is implicated in about half of fatal traffic accidents. [1] Heavy drinking can damage the liver and heart, harm an unborn child, increase the chances of developing breast and some other cancers, contribute to depression and violence, and interfere with relationships.

Alcohol’s two-faced nature shouldn’t come as a surprise. The active ingredient in alcoholic beverages, a simple molecule called ethanol, affects the body in many different ways. It directly influences the stomach, brain, heart, gallbladder, and liver. It affects levels of lipids (cholesterol and triglycerides) and insulin in the blood, as well as inflammation and coagulation. It also alters mood, concentration, and coordination.

What’s Moderate Alcohol Intake? What’s a Drink?

Loose use of the terms “moderate” and “a drink” has fueled some of the ongoing debate about alcohol’s impact on health.

In some studies, the term “moderate drinking” refers to less than 1 drink per day, while in others it means 3-4 drinks per day. Exactly what constitutes “a drink” is also fairly fluid. In fact, even among alcohol researchers, there’s no universally accepted standard drink definition. [2]

In the U.S., 1 drink is usually considered to be 12 ounces of beer, 5 ounces of wine, or 1½ ounces of spirits (hard liquor such as gin or whiskey). [3] Each delivers about 12 to 14 grams of alcohol on average, but there is a wider range now that microbrews and wine are being produced with higher alcohol content.

Is Red Wine Better?

Some experts have suggested that red wine makes the difference, but other research suggests that beverage choice appears to have little effect on cardiovascular benefit.

Learn more about whether the type of alcohol consumed has any effect on health.

The definition of moderate drinking is something of a balancing act. Moderate drinking sits at the point at which the health benefits of alcohol clearly outweigh the risks.

The latest consensus places this point at no more than 1-2 drinks a day for men, and no more than 1 drink a day for women. This is the definition used by the U.S. Department of Agriculture and the Dietary Guidelines for Americans 2020-2025, [3] and is widely used in the United States.

The Dark Side of Alcohol

Not everyone who likes to drink alcohol stops at just one. While many people drink in moderation, some don’t.

Heavy drinking can take a toll on the body. It can cause inflammation of the liver (alcoholic hepatitis) and lead to scarring of the liver (cirrhosis), a potentially fatal disease. It can increase blood pressure and damage heart muscle (cardiomyopathy). Heavy alcohol use has also been linked with several cancers: The World Cancer Research Fund and American Institute for Cancer Research indicate that there is convincing evidence linking alcohol to cancers of the mouth, pharynx, larynx, esophagus, breast, liver, colon, and rectum. [4] The International Agency for Research on Cancer concluded that both the ethanol in alcohol and acetaldehyde, a chemical formed from the breakdown of ethanol, are carcinogenic to humans in high amounts. [5] The risk is multiplied for drinkers who also smoke tobacco or have a poor diet.

Problem drinking also touches drinkers’ families, friends, and communities. According to the National Institute on Alcohol Abuse and Alcoholism and others:

In 2014, about 61 million Americans were classified as binge alcohol users (5 or more drinks on the same occasion at least once a month) and 16 million as heavy alcohol users (5 or more drinks on the same occasion on 5 or more days in one month). [6]
Alcohol plays a role in one in three cases of violent crime. [7]
In 2015, more than 10,000 people died in automobile accidents in which alcohol was involved. [8]
Alcohol abuse costs about $249 billion a year. [9]

Even moderate drinking carries some risks. Alcohol can disrupt sleep and one’s better judgment. Alcohol interacts in potentially dangerous ways with a variety of medications, including acetaminophen, antidepressants, anticonvulsants, painkillers, and sedatives. It is also addictive, especially for people with a family history of alcoholism.

Alcohol Increases Risk of Developing Breast Cancer

There is convincing evidence that alcohol consumption increases the risk of breast cancer, and the more alcohol consumed, the greater the risk. [10-14]

A large prospective study following 88,084 women and 47,881 men for 30 years found that even 1 drink a day increased the risk of alcohol-related cancers (colorectum, female breast, oral cavity, pharynx, larynx, liver, esophagus) in women, but mainly breast cancer, among both smokers and nonsmokers. 1 to 2 drinks a day in men who did not smoke was not associated with an increased risk of alcohol-related cancers. [15]
In a combined analysis of six large prospective studies involving more than 320,000 women, researchers found that having 2-5 drinks a day compared with no drinks increased the chances of developing breast cancer as high as 41%. It did not matter whether the form of alcohol was wine, beer, or hard liquor. [10] This doesn’t mean that 40% or so of women who have 2-5 drinks a day will get breast cancer. Instead, it is the difference between about 13 of every 100 women developing breast cancer during their lifetime—the current average risk in the U.S.—and 17 to 18 of every 100 women developing the disease. This modest increase would translate to significantly more women with breast cancer each year.

A lack of folate in the diet or folic acid, its supplement form, further increases the risk of breast cancer in women. [14] Folate is needed to produce new cells and to prevent changes in DNA. Folate deficiency, as can occur with heavy alcohol use, can cause changes in genes that may lead to cancer. Alcohol also increases estrogen levels, which fuel the growth of certain breast cancer cells. An adequate intake of folate, at least 400 micrograms a day, when taking at least 1 drink of alcohol daily appears to lessen this increased risk. [16, 17]

Researchers found a strong association among three factors—genetics, folate intake, and alcohol—in a cohort from the Nurses’ Health Study II of 2866 young women with an average age of 36 who were diagnosed with invasive breast cancer. Those with a family history of breast cancer who drank 10 grams or more of alcoholic beverages daily (equivalent to 1 or more drinks) and ate less than 400 micrograms of folate daily almost doubled their risk (1.8 times) of developing the cancer. Women who drank this amount of alcohol but did not have a family history of breast cancer and ate at least 400 micrograms of folate daily did not have an increased breast cancer risk. [14]

Folate and Alcohol

Folate, the B vitamin that helps guide the development of an embryo’s spinal cord, has equally important jobs later in life. One of the biggest is helping to build DNA, the molecule that carries the code of life. In this way, folate is essential for accurate cell division.

Alcohol blocks the absorption of folate and inactivates folate in the blood and tissues. It’s possible that this interaction may be how alcohol consumption increases the risk of breast, colon, and other cancers.

Getting extra folate may cancel out this alcohol-related increase. In the Nurses’ Health Study, for example, among women who consumed 1 or more alcoholic drinks a day, those who had the highest levels of this B vitamin in their blood were 90% less likely to develop breast cancer than those who had the lowest levels of the B vitamin. [18] An earlier study suggested that getting 600 micrograms a day of folate could counteract the effect of moderate alcohol consumption on breast cancer risk. [17] There was no association with folate and increased breast cancer risk among women who drank low or no alcohol daily.

Alcohol and Weight Gain

One serving of alcohol on average contains 100-150 calories, so even a moderate amount of 3 drinks a day can contribute 300+ calories. Mixed drinks that add juice, tonic, or syrups will further drive up calories, increasing the risk of weight gain over time.

However, a prospective study following almost 15,000 men at four-year periods found only an increased risk of minor weight gain with higher intakes of alcohol. [19] Compared to those who did not change their alcohol intake, those who increased their intake by 2 or more drinks a day gained a little more than a half-pound. It was noted that calorie intake (not from alcohol) tended to increase along with alcohol intake.

Possible Health Benefits of Alcohol

What are some of the possible health benefits associated with moderate alcohol consumption?

Cardiovascular Disease

More than 100 prospective studies show an inverse association between light to moderate drinking and risk of heart attack, ischemic (clot-caused) stroke, peripheral vascular disease, sudden cardiac death, and death from all cardiovascular causes. [20] The effect is fairly consistent, corresponding to a 25-40% reduction in risk. However, increasing alcohol intake to more than 4 drinks a day can increase the risk of hypertension, abnormal heart rhythms, stroke, heart attack, and death. [5, 21-23]

Alcohol and Heart Disease: Prospective Studies

Learn more about the results of some large prospective cohort studies of alcohol consumption and cardiovascular disease.

Name, Participants	Duration	Association with Moderate Alcohol Consumption*
CALIBER programme: 1,937,360 adults (51% women) aged 30+	6 years	Increased risk of cardiovascular events (e.g., unstable angina, myocardial infarction, ischemic stroke, heart failure) in non-drinkers and heavy drinkers compared with moderate drinkers. [23]
Japan Collaborative Cohort Study for Evaluation of Cancer Risk cohort: 97,432 men and women aged 40–79	10 years	12%–20% decreased risk of all-cause mortality in men and women who consumed less than 23 grams per day of alcohol; heavy drinking increased the risk of all-cause mortality. [24]
Health Professionals Follow-up Study: 38,077 male health professionals aged 40–75	12 years	35% reduced risk of myocardial infarction. [25]
Eastern France cohort: 34,014 men and women	10–15 years	25–30% reduced risk of cardiovascular death. [26]
Cancer Prevention Study II: 489,626 men and women aged 30–104	9 years	30–40% reduced risk of cardiovascular death; mortality from all causes increased with heavier drinking, particularly among adults under age 60. [27, 28]
Physicians’ Health Study: 22,071 male physicians aged 40–84	11 years	30–35% reduced risk of angina and myocardial infarction, 20–30% reduced risk of cardiovascular death [29]
Kaiser Permanente cohort: 123,840 men and women aged 30+	10 years	40% reduction in fatal myocardial infarction, 20% reduction in cardiovascular mortality; 80% increase in fatal hemorrhagic stroke. [30]
Nurses’ Health Study: 85,709 female nurses aged 34–59	12 years	17% lower risk of all-cause mortality; an earlier report showed a 40% reduction in risk of CHD and 70% reduction in risk of ischemic stroke. [31]

* compared with non-drinkers

The connection between moderate drinking and lower risk of cardiovascular disease has been observed in men and women. It applies to people who do not have heart disease, and also to those at high risk for having a heart attack or stroke or dying of cardiovascular disease, including those with type 2 diabetes, [32, 33] high blood pressure, [34, 35] and existing cardiovascular disease. [34, 35] The benefits also extend to older individuals. [36]

The idea that moderate drinking protects against cardiovascular disease makes sense biologically and scientifically. Moderate amounts of alcohol raise levels of high-density lipoprotein (HDL, or “good” cholesterol), [37] and higher HDL levels are associated with greater protection against heart disease. Moderate alcohol consumption has also been linked with beneficial changes ranging from better sensitivity to insulin to improvements in factors that influence blood clotting, such as tissue type plasminogen activator, fibrinogen, clotting factor VII, and von Willebrand factor. [37] Such changes would tend to prevent the formation of small blood clots that can block arteries in the heart, neck, and brain, the ultimate cause of many heart attacks and the most common kind of stroke.

Drinking Patterns Matter

What you drink (beer or wine) doesn’t seem to be nearly as important as how you drink. Having 7 drinks on a Saturday night and then not drinking the rest of the week isn’t at all the equivalent of having 1 drink a day. The weekly total may be the same, but the health implications aren’t. Among participants in the Health Professionals Follow-up Study, consumption of alcohol on at least three or four days a week was inversely associated with the risk for myocardial infarction. The amount consumed, under 10 grams a day or more than 30 grams, didn’t seem to matter as much as the regularity of consumption. [25] A similar pattern was seen in Danish men. [38]

A review of alcohol consumption in women from the Nurses’ Health Study I and II found that smaller amounts of alcohol (about 1 drink per day) spread out over four or more days per week had the lowest death rates from any cause, compared with women who drank the same amount of alcohol but in one or two days. [39]

The most definitive way to investigate the effect of alcohol on cardiovascular disease would be with a large trial in which some volunteers were randomly assigned to have 1 or more alcoholic drinks a day and others had drinks that looked, tasted, and smelled like alcohol but were actually alcohol free. Many of these trials have been conducted for weeks, and in a few cases months and even up to 2 years, to look at changes in the blood, but a long-term trial to test experimentally the effects of alcohol on cardiovascular disease has not been done. A recent successful effort in the U.S. to launch an international study was funded by the National Institutes of Health. Although the proposal was peer-reviewed and initial participants had been randomized to drink in moderation or to abstain, post hoc the NIH decided to stop the trial due to internal policy concerns. Unfortunately, a future long trial of alcohol and clinical outcomes may never be attempted again, but nevertheless, the connection between moderate drinking and cardiovascular disease almost certainly represents a cause-and-effect relationship based on all of the available evidence to date.

Beyond the Heart

The benefits of moderate drinking aren’t limited to the heart. In the Nurses’ Health Study, the Health Professionals Follow-up Study, and other studies, gallstones [40, 41] and type 2 diabetes [32, 42, 43] were less likely to occur in moderate drinkers than in non-drinkers. The emphasis here, as elsewhere, is on moderate drinking.

In a meta-analysis of 15 original prospective cohort studies that followed 369,862 participants for an average of 12 years, a 30% reduced risk of type 2 diabetes was found with moderate drinking (0.5-4 drinks a day), but no protective effect was found in those drinking either less or more than that amount. [32]

The social and psychological benefits of alcohol can’t be ignored. A drink before a meal can improve digestion or offer a soothing respite at the end of a stressful day; the occasional drink with friends can be a social tonic. These physical and social effects may also contribute to health and well-being.

Genes Play a Role

Twin, family, and adoption studies have firmly established that genetics plays an important role in determining an individual’s preferences for alcohol and his or her likelihood for developing alcoholism. Alcoholism doesn’t follow the simple rules of inheritance set out by Gregor Mendel. Instead, it is influenced by several genes that interact with each other and with environmental factors. [1]

There is also some evidence that genes influence how alcohol affects the cardiovascular system. An enzyme called alcohol dehydrogenase helps metabolize alcohol. One variant of this enzyme, called alcohol dehydrogenase type 1C (ADH1C), comes in two “flavors.” One quickly breaks down alcohol, the other does it more slowly. Moderate drinkers who have two copies of the gene for the slow-acting enzyme are at much lower risk for cardiovascular disease than moderate drinkers who have two genes for the fast-acting enzyme. [44] Those with one gene for the slow-acting enzyme and one for the faster enzyme fall in between.

It’s possible that the fast-acting enzyme breaks down alcohol before it can have a beneficial effect on HDL and clotting factors. Interestingly, these differences in the ADH1C gene do not influence the risk of heart disease among people who don’t drink alcohol. This adds strong indirect evidence that alcohol itself reduces heart disease risk.

Shifting Benefits and Risks

White wine being poured into a glass from a bottle

The benefits and risks of moderate drinking change over a lifetime. In general, risks exceed benefits until middle age, when cardiovascular disease begins to account for an increasingly large share of the burden of disease and death.

For a pregnant woman and her unborn child, a recovering alcoholic, a person with liver disease, and people taking one or more medications that interact with alcohol, moderate drinking offers little benefit and substantial risks.
For a 30-year-old man, the increased risk of alcohol-related accidents outweighs the possible heart-related benefits of moderate alcohol consumption.
For a 60-year-old man, a drink a day may offer protection against heart disease that is likely to outweigh potential harm (assuming he isn’t prone to alcoholism).
For a 60-year-old woman, the benefit/risk calculations are trickier. Ten times more women die each year from heart disease (460,000) than from breast cancer (41,000). However, studies show that women are far more afraid of developing breast cancer than heart disease, something that must be factored into the equation.

The Bottom Line: Balancing Risks and Benefits

Given the complexity of alcohol’s effects on the body and the complexity of the people who drink it, blanket recommendations about alcohol are out of the question. Because each of us has unique personal and family histories, alcohol offers each person a different spectrum of benefits and risks. Whether or not to drink alcohol, especially for “medicinal purposes,” requires careful balancing of these benefits and risks.

Your healthcare provider should be able to help you do this. Your overall health and risks for alcohol-associated conditions should factor into the equation.
If you are thin, physically active, don’t smoke, eat a healthy diet, and have no family history of heart disease, drinking alcohol won’t add much to decreasing your risk of cardiovascular disease.
If you don’t drink, there’s no need to start. You can get similar benefits with exercise (beginning to exercise if you don’t already or boosting the intensity and duration of your activity) or healthier eating.
If you are a man with no history of alcoholism who is at moderate to high risk for heart disease, a daily alcoholic drink could reduce that risk. Moderate drinking might be especially beneficial if you have low HDL that just won’t budge upward with diet and exercise.
If you are a woman with no history of alcoholism who is at moderate to high risk for heart disease, the possible benefits of a daily drink must be balanced against the small increase in risk of breast cancer.
If you already drink alcohol or plan to begin, keep it moderate—no more than 2 drinks a day for men or 1 drink a day for women. And make sure you get adequate amounts of folate, at least 400 micrograms a day.

What about news headlines saying no amount of alcohol is safe?

A 2022 cohort study looked at weekly alcohol intake and the risk of cardiovascular disease (CVD) using mendelian randomization. [45] This is a research method that examines types of genes and their association with health. The authors, several of whom are affiliated with genetic biotechnology companies, deduced that certain gene variants predicting a person’s likelihood to be a heavy drinker vs. abstainer were associated with developing CVD. They did find that people who possessed genes predicting high alcohol intake indeed drank more, and therefore had greater risk of developing CVD. News headlines about the study suggested that no amount of alcohol is good for the heart.
- However, the study’s results contradict these headlines, as its findings mirrored those from previous cohort studies showing the lowest CVD risk among light/moderate drinkers (1-15 drinks a week), and risk sharply increasing in heavy/abusive drinkers (averaging >20 drinks a week). Yet the authors concluded that it wasn’t light/moderate drinking that protected the heart; rather, it was lifestyle factors associated with light/moderate drinking like exercising more and not smoking (as predicted by people possessing certain gene variants). Interestingly the study found that light/moderate drinkers had healthier habits than even the abstainers. When adjusting for these healthy habits, the protective effect from alcohol lessened slightly. Regardless, their overall conclusion still showed that light/moderate drinkers had the lowest risk of CVD and supported the additional benefit of healthy lifestyle behaviors. It may also be worth noting that the genetic variants studied were associated with alcohol use disorder (AUD) and not specific to general alcohol intake.
A 2018 analysis in The Lancet of the global impact of alcohol on injury and disease made headlines when it concluded that even moderate drinking is unsafe for health—and the risks outweigh any potential benefits. However, according to Dr. Walter Willett, professor of epidemiology and nutrition at Harvard T.H. Chan School of Public Health, it can be “misleading” to lump the entire world together when assessing alcohol’s risk. (For example, while tuberculosis is very rare in the U.S., it was the leading alcohol-related disease identified in the study.) In an interview with TIME, Willett said that while there is “no question” that heavy drinking is harmful, there are plenty of data supporting the benefits of moderate drinking, and it remains a decision that should be determined at the individual level: “There are risks and benefits, and I think it’s important to have the best information about all of those and come to some personal decisions, and engage one’s health care provider in that process as well.

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Biddinger KJ, Emdin CA, Haas ME, Wang M, Hindy G, Ellinor PT, Kathiresan S, Khera AV, Aragam KG. Association of Habitual Alcohol Intake With Risk of Cardiovascular Disease. JAMA Network Open. 2022 Mar 1;5(3):e223849-. Author disclosures: Dr. Haas reported receiving personal fees and stock and stock options from Regeneron Pharmaceuticals outside the submitted work. Dr. Ellinor reported receiving grants from Bayer AG and IBM Health and personal fees from Bayer AG, MyoKardia, Quest Diagnostics, and Novartis during the conduct of the study. Dr. Kathiresan reported being an employee of Verve Therapeutics; owning equity in Verve Therapeutics, Maze Therapeutics, Color Health, and Medgenome; receiving personal fees from Medgenome and Color Health; serving on the advisory boards for Regeneron Genetics Center and Corvidia Therapeutics; and consulting for Acceleron, Eli Lilly and Co, Novartis, Merck, Novo Nordisk, Novo Ventures, Ionis, Alnylam, Aegerion, Haug Partners, Noble Insights, Leerink Partners, Bayer Healthcare, Illumina, Color Genomics, MedGenome, Quest Diagnostics, and Medscape outside the submitted work. Dr. Khera reported receiving personal fees from Merck, Amarin Pharmaceuticals, Amgen, Maze Therapeutics, Navitor Pharmaceuticals, Sarepta Therapeutics, Verve Therapeutics, Silence Therapeutics, Veritas International, Color Health, and Third Rock Ventures and receiving grants from IBM Research outside the submitted work. Dr. Aragam reported receiving speaking fees from the Novartis Institute for Biomedical Research.

Last reviewed April 2022

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