UPDATED: June 28, 2025
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About Alcohol
I've recently been following Substack’s Posts about the proposed warnings on alcoholic beverages. Many of those Posts refer to the alleged benefits of “drinking in moderation.” It seems that most of those articles are written by people who partake, with an implicit bias in favor of drinking.
Almost two-thirds of American adults drink occasionally, based upon Gallup’s polls. At least half of U.S. doctors drink alcohol, creating a confirmation bias that makes it difficult for any evidence that conflicts with pre-existing beliefs to gain traction. One study explored the prevalence of alcohol use disorders among American surgeons, and another study characterized the severity of alcohol use disorders (AUD) among physicians.
The human attraction to alcohol in permissive cultures could be explained by the drunken monkey hypothesis. Our primate ancestors may have found fermented fruit more easily due to the odor of ethanol. Equating the smell and taste, along with inebriation, with nourishment and its concomitant survival value suggests that a propensity for drinking beer and wine with meals could be in our genes.
Putting this hypothetical innate tendency aside, I have been persuaded by the latest evidence that no amount of alcohol is beneficial. In response to my pro-alcohol medical colleagues, I will present the science-based arguments against drinking. Most notable among them is the 2022 study that found one in five deaths among U.S. adults 20 to 49 years of age could be attributed to excessive consumption of alcohol.
Who Abstains?
There are a number of reasons why a third of U.S. adults choose not to drink alcohol. There has been a growing awareness of the negative health effects of alcohol consumption, including issues with weight management, and the risks of alcohol abuse and addiction. Negative experiences with alcohol, such as hangovers, accidents, and regrettable personal behavior or that of family members, can all play a role.
The desire to maintain a healthy lifestyle, with a focus on physical fitness and cognitive performance, motivates a reduction in alcohol consumption, particularly by younger people. Older adults may reduce or abstain from alcohol due to health concerns or adverse medication interactions.
There are also religious and cultural beliefs that discourage drinking or prohibit alcohol consumption. Changing social norms have resulted in an increased acceptance of non-drinkers. Finally, simply not liking the taste of alcohol, or not wanting to waste money on it, can discourage people from drinking.
A major obstacle to public health efforts regarding alcohol consumption is the lack of public awareness about the risks. Not only is overall awareness dismal, but beliefs vary regarding the type of alcohol, and some people actually believe that red wine can decrease their cancer risk, according to a 2023 study. More than half of U.S. adults reported not knowing how alcoholic beverages affected cancer risk.
Challenging Entrenched Beliefs
Responding to recent Substack articles about alcohol, I cited research indicating that no amount of ethyl alcohol (ethanol) can be considered beneficial, and that it is likely to be harmful in any quantity. My position is that the toxicology dictum, “The dose makes the poison,” should not be used to justify drinking, especially when potential risks can be incurred with the very first drop. Ethanol is clearly a poison, and like nicotine, it is also an addictive one. With both alcohol and tobacco, it’s the cumulative doses that do the greatest damage.
Notorious medical contrarian and online provocateur, Vinay Prasad, currently one of RFK Jr.’s henchmen in the MAHA assault on science and public health, cherry-picked studies for his Substack Post, and used them to justify excluding people who don't drink from his dinner parties. My polite response to his article, in which I presented evidence of harms from even small amounts of alcohol, resulted in him deleting my comment and blocking me.
I would at least consider the possibly that people who vigorously defend their alcohol use, or get angry at those who disparage their beloved beverage, might have an addiction problem. Let’s remember what that great Amercan fount of wisdom, Homer Simpson, had to say about it: “Alcohol is a way of life. Alcohol is my way of life, and I plan to keep it.”
In contrast, another article explored the subjective pleasures of drinking and weighed them against alcohol's objective perils. My similar counterpoint to its author resulted in a very gracious and thoughtful reply. Also worthy of consideration is an informative, two-part series explaining the many pitfalls and challenges that are faced by studies on the effects of drinking.
From my sane, sober, and somewhat jaded half-century perspective on medicine, “The alcohol industry has been getting away with murder by poisoning people for profit.” That’s an intentionally inflammatory statement, and I hope it got your attention. If you’re wondering how the alcohol industry has remarkably avoided both cancer litigation and additional regulation, perhaps that’s due to alcohol’s manufacturers and trade groups wielding enormous political influence. They spend huge amounts of money on lobbying efforts and making campaign contributions to American politicians (which elsewhere in the world would be called “bribes”).
Those efforts have prevented any legislated restrictions on advertising. The industry’s public relations messaging promotes positive images of alcohol consumption, while framing over-indulgence and addiction as problems due to a lack of individual responsibility. Employed as a strategy to forestall any restrictions, the alcohol industry funds research that produces favorable data and conclusions.
Health Concerns
Comparing ethanol with nicotine, another known carcinogen, “light smoking” (ie. one to four cigarettes per day) is associated with a significantly higher risk of dying from ischemic heart disease and all-cause mortality. I expect that a similarly convincing conclusion about “light drinking” will emerge from future studies. Meanwhile, remember the famous quote by Carl Sagan: “Absence of evidence is not evidence of absence.”
To identify a “safe” level of alcohol consumption, valid scientific evidence would need to demonstrate that below a certain threshold there is no health risk. Although humans can vary in their susceptibility to the effects of poisons, there is no persuasive evidence for an amount of alcohol below which its carcinogenic effects do not appear.
Ireland, at one time having one of the world’s highest per capita rates of alcohol consumption, still has a huge problem with alcoholism (alcohol use disorder), which affects more than a third of men and women in the 15-24 years age group. In 2026, Ireland will become the first country to require comprehensive warnings on alcohol products. Beer, wine, and liquor will be labeled in red capital letters warning that: “THERE IS A DIRECT LINK BETWEEN ALCOHOL AND FATAL CANCERS” and “DRINKING ALCOHOL CAUSES LIVER CANCER.”
Beyond Cancer
Many thanks to toxicologist Dr. Brian H. Mathison for his contribution to our knowledge base. In considering the toxicology of alcohol, it is crucial to emphasize the necessity of complete abstinence during pregnancy. Abstaining from alcohol is equally vital for both men and women when attempting to conceive, as it promotes reproductive health.
While Fetal Alcohol Syndrome (FAS) became a recognized descriptor for developmental abnormalities, delays, and growth issues in the late 20th century, the historical connection between alcohol consumption and fetal harm dates back to ancient times. However, I was unable to find specific historical texts that definitively link alcohol to fetal problems.
There are, however, biblical references—such as the account of Samson’s mother, who was instructed by an angel to avoid alcohol during pregnancy, suggesting potential risks to the unborn child. These early references do not address modern concepts of alcohol-induced fetal harm. Nevertheless, few would dispute that alcohol, through its well-established mechanisms and metabolism to acetaldehyde (a known carcinogen), as well as its endocrine-disrupting properties, presents significant risks.
This raises an obvious question: If alcohol is so detrimental to the developing fetus, how can it be considered beneficial or safe for adult consumption? The principle that "the dose makes the poison" does not adequately address these concerns. The notion that any substance can be harmful in excess but safe in small quantities draws from ancient wisdom. The Temple of Apollo at Delphi famously bore the inscription, “Nothing in Excess,” embodying the Greek ideal of moderation, which is consistent with the broader tradition of balance and self-control in ancient philosophy.
Food and Beverage Safety Issues
America's approach to food and beverage safety differs fundamentally from that of other developed nations. U.S. government agencies typically take a “risk-based” approach to policy-making, by identifying substances with potential health risks and assessing the probability of exposure doing harm. With our ruthlessly capitalistic, for-profit healthcare system, most of the cost for agencies being wrong is borne by we, the people.
In stark contrast to risk-based policies is the “hazard-based,” precautionary approach. If a study shows a substance can be toxic to lab animals, the aim is to entirely eliminate the potential for harm, regardless of level or frequency of exposure. The European Union nations and Great Britain put the welfare of their citizens ahead of corporate interests.
I am obviously a proponent the precautionary approach, and personally prefer to err on the side of safety, rather than take unnecessary risks. That’s why I still mask-up in crowded indoor public spaces, and have remained covid-free for the entirety of the pandemic. It’s a small inconvenience, with a huge payoff.
Drinking Justifications Abound
The human brain has an amazing ability to come up with justifications for just about anything; “The Devil made me do it,” or, “I was only following orders.” Rationalization is a psychological defense mechanism that produces seemingly logical or reasonable explanations that justify one’s behaviors and impulses. Our brain essentially generates excuses to protect our self-esteem and enable us to avoid feeling guilt, shame, and anxiety.
Comedian W.C. Fields was proud of his alcohol addiction. Asked why he drank so much liquor, Fields responded, “Because I get thirsty, my boy.” When asked why he didn't just drink water, Fields replied, “Because the fish screw in it!” Fields died from a massive esophageal hemorrhage secondary to cirrhosis of the liver. He was 66 years old.
I expect to get a lot of pushback on this, and lose a number of subscribers, but if the shoe fits, wear it. If you don’t smoke but still drink, think about it. You know that smoking is harmful, but are likely in denial about drinking. The reality is that there is no established “safe” amount of alcohol that can be consumed on a regular basis without harming one's health.
Drinking in Moderation
Ethanol is a toxic chemical with “empty calories” and no nutritional value. It is frequently consumed in quantities sufficient to produce at least a mild intoxication (aka “buzz”). Even small quantities can produce cognitive and motor impairments. Alcohol’s effect on the brain causes problems with balance and coordination, impair judgement, and make the person on the barstool who you've been eyeing seem much more attractive than they actually are.
FWIW, there’s nothing attractive about being loud and stupid. Larger quantities of alcohol have proven fatal at drinking parties hosted by college fraternities. It is well known that ethanol has deleterious effects on multiple organ systems, and the more one imbibes, the greater the damage.
I’m all in favor of “moderation”... in principle. You know the saying, “Everything in moderation, including moderation.” The reality is that our life choices often involve trade-offs. The trick is to know what things are okay in moderation, and how much of a dose is actually moderate, specifically for you. Clearly, one person’s idea of moderation can be the source of another person’s overdose. If you have a beer belly, or your friends wouldn’t let you drive, you might want to reconsider your definition of moderate.
“Moderate drinking” has been defined as no more than one drink a day for women, and no more than two for men. For women, “heavy” or “at risk” drinking means more than seven drinks per week, or more than three in any day. For men, it's more than 14 drinks in a week, or more than four in a day.
One drink equals:
1.5 ounces of liquor such as whisky, vodka, rum, or tequila.
5 ounces of wine.
12 ounces of beer.
Contrary to popular belief (or wishful thinking), there are no health benefits conferred by drinking in moderation. That's a huge change from decades-old studies that suggested moderate alcohol consumption wasn't dangerous. Recently, experts in data analysis have uncovered major flaws in the research that led to those earlier, erroneous conclusions.
A 2024 systematic review of previous studies supports the conclusion that no amount of alcohol is healthy. Dr. Ben Jones thoroughly debunks the “alcohol in moderation” myth, and explains the critical flaw in the study that has been used for decades to justify drinking:
Newer studies, using the powerful technique of Mendelian randomization, indicate that any apparent protective associations of low alcohol intake are spurious. The precautionary principle insists that the burden of proof falls upon studies demonstrating that consuming alcohol in any amount is as healthy and safe as consuming none at all. So far, only crickets!
Doctors are Divided
By some estimates, half the physicians in the U.S. still think that it is okay for their patients to have a drink or two a day. Almost 40 years ago, the World Health Organization (WHO) concluded that alcohol is a human carcinogen. In the decades since, research has continued to support that conclusion.
In 2023, the WHO and its International Agency for Research on Cancer issued a statement saying, “There is also clear evidence of an increased risk of cancer from light or moderate alcohol drinking. No safe amount of alcohol consumption for cancers can be established.” Trump has pulled the U.S. out of the WHO, but that doesn’t mean they should be ignored.
I count myself fortunate in never having been much of a drinker. I didn’t acquire a liking for wine and beer, or anything harder. However, I would typically bring my hosts a bottle of wine whenever they invited me for dinner, and drink a small glass with them, just to be sociable. That was before social gatherings were brought to a screeching halt by the COVID-19 pandemic.
My wine bottles have been sitting in their rack gathering dust ever since. After looking into the latest research on alcohol and health, I can no longer, in good conscience, give people wine, just as I wouldn't gift a smoker with a carton of cigarettes. I don't want to be an enabler of harmful habits.
Some studies suggest that drinking red wine with meals, as part of the Mediterranean diet, may pose the lowest risk when it comes to alcohol consumption, but that could be due to the effect of an overall healthier diet and lifestyle, the higher socioeconomic status of those who drink wine with their meals, the slower alcohol absorption due to its ingestion with food, and some of the nonalcoholic components in red wine, such as resveratrol.
Alcohol Costs Everyone
One reason that I'm taking the time to write about this subject is that I don't want to share in the economic burden caused by alcohol, ranging from higher motor vehicle insurance rates due to drunk drivers, to the increased health insurance premiums and higher taxes needed to pay for the care for patients with alcohol-related illnesses. The toll of alcohol on America’s economy was estimated at about $249 billion dollars per year in 2010. Rising healthcare costs suggest that it’s even higher now.
Alcohol-related motor vehicle crashes cost the U.S. about $51 billion each year. In 2022, 13,524 people died in alcohol-impaired driving fatalities, according to the National Highway Traffic Safety Administration (NHTSA). Alcohol accounted for 32 percent of total vehicle traffic fatalities in which 42,514 people died. All of those alcohol-related deaths were preventable.
According to the findings of a large study, people over the age of 60 with health-related or socioeconomic risk factors, and who drink alcohol regularly, are at an increased risk of early death, particularly from cancer and diseases of the heart and blood vessels. This places an even greater burden upon Medicare, as well as our entire healthcare system.
No Medical Consensus Yet
Doctors still aren’t willing to tell their patients that any amount of alcohol consumption presents health risks, and studies show no health benefits. Studies show that even a modest reduction in drinking can lead to improved blood pressure, liver function, and mental health. Cessation can lower the risk for cancer and heart disease, improve quality of sleep, and increase energy levels.
Wine moms take note: A 2020 meta-analysis of 22 cohort studies showed that the average risk for breast cancer rises by about 10 percent for every 10 grams of alcohol a woman drinks per day. The study found no evidence that wine is any different from any other form of alcohol. While the risk will likely vary widely from person to person, women with a family history of breast cancer might decide that having a glass of wine with dinner isn't worth it.
While three recent reports on the health impacts of alcohol agree on some things, such as moderate drinking increasing cancer risk, they don’t agree about all-cause mortality, the health effects of light drinking, or how to weigh the effects of alcohol as a sedative and social lubricant. The confusion is mainly due to the inherent weaknesses of observational studies, the employment of different study methodologies, and potential conflicts of interest involving government and its relationship with the alcohol industry.
What the Best Studies Show
The randomized, double-blind, placebo-controlled clinical trial (RCT) is considered to be the gold standard in medical research when it comes to establishing a causal connection between a treatment and its outcome. While not as convincing as an RCT, Mendelian randomization studies are the next best thing.
Short-term RCTs aren't able to tell us if there's a safe level of alcohol consumption, and long-term RCTs are impractical. It is also unethical to continually administer low doses of poisons to human subjects to determine their long-term effects. However, as with a number of good observational studies, the available RCT data indicates that generally, the more that people drink, the greater the likelihood of health problems.
The findings of Mendelian randomization studies corroborate those of recent observational studies and RCTs. Some of them even more strongly suggest that the lowest levels of alcohol consumption are still harmful. To reiterate, a preponderance of evidence indicates that no amount of alcohol is considered beneficial.
The best research evidence that we have so far is the “Alcohol consumption and the risk of all-cause and cause-specific mortality—a linear and nonlinear Mendelian randomization study.” It concluded that there is no evidence for any protective benefits from modest levels of alcohol consumption. The study is the first one to apply a new method for examining multiple, cause-specific mortality types.
This novel analytical method, known as the “doubly-ranked approach,”overcomes certain limitations found in previous nonlinear Mendelian randomization studies. There are, however, some cautions in drawing conclusions that the authors acknowledge, including potential biases and possible over-generalizations. It is also unknown if the true biological relationship between alcohol and mortality is more complex than has been assumed in this analysis.
While not a “slam-dunk” conclusion, the dose-response relationship between alcohol consumption and all-cause mortality clearly suggests that the less we drink, the better off we will be. This annotated graph, taken from the above study, indicates that not drinking at all further lowers the risk (green arrows):
If that’s not enough to make you reconsider your relationship with alcohol, another Mendelian randomization study, using linear and non-linear statistical analyses of data from the U.K. Biobank, investigated the relationship between alcohol consumption and dementia risk. The study, published in 2024, found that for current drinkers there is a positive, linear, causal relationship between alcohol consumption and dementia. Any J-shaped associations found by conventional epidemiological analyses are considered to be spurious. The authors conclude that there was no safe level for alcohol consumption and still avoid dementia.
Alcohol Apologetics
Despite our best efforts to remain neutral, by its very nature the human mind is biased toward confirmation of its pre-existing beliefs. That's why double-blinded RCTs are so powerful when neither the subjects nor the researchers know who got the placebo until the study has been completed.
If I were an alcohol apologist, I'd define "modest" as being more than the amount I personally consume, and cherry-pick observational studies that showed alcohol’s beneficial effects. I'd then point to individual differences in susceptibility to alcohol's toxic effects, rationalize its use as an anxiolytic, sedative, and social lubricant, stress the psychological benefits of social drinking, and cite how alcohol’s toxicity can be ameliorated by consuming it along with food.
However, as an unapologetic physician, I am committed to first doing no harm. Applying the precautionary principle, if I have not seen any convincing evidence that low doses of alcohol are clearly beneficial, then I cannot in good conscience recommend consuming a known poison in any amount.
I find the linear association of alcohol's impact on all-cause mortality, shown in the graph above, persuasive enough to recommend against drinking. Of course, we each get to choose our own personal vices and poisons, but when it comes to doctors advising their patients, that's a whole other story:
Changing People’s Attitudes
It seems that more people have been catching on lately, and deciding that being poisoned for profit is not something that they want to do. However, when weighing the known perils of an activity against its transient pleasures, people differ in their risk tolerance.
A personal example: Despite being an advanced skier, there is still an inherent risk that comes with the sport. I’ve had a few injuries over the years, but still find the fun factor to be worth the risks. Drinking, on the other hand, has never felt like fun. So for me, not drinking at all has been an easy choice.
A 2024 Gallup poll found that the overall U.S. attitudes toward drinking alcoholic beverages have been changing over recent decades. 65 percent of respondents aged 18 to 34 years said that drinking alcohol can have negative health consequences. In contrast, only 39 percent of those 55 or older said that drinking is bad for one’s health. This attitude gap between younger and older people is the largest ever recorded by Gallup.
A 2025 CNN poll found that half of U.S. adults believe moderate drinking is bad for one’s health. Only eight percent of respondents said drinking in moderation is good for your health. 74 percent supported warning labels about alcohol consumption and cancer risk, as recommended by Biden’s Surgeon General. A 2025 Fox News poll, found that nearly four out of five registered voters support the updated labels.
As a physician, I am less concerned about making a “fair and balanced” presentation of the science than I am about persuading people to avoid, or at least reduce their consumption of alcohol. That’s because I have personally witnessed too many tragic outcomes for both patients and friends.
I feel a very strong “duty to warn” that takes priority over simply educating people about the pros and cons. It is my practice to “err on the side of caution” in medical matters for which there is not yet a consensus. For a detailed explanation of why there is not yet a consensus, I highly recommend Dr. Eric Topol’s article:
If you are a dedicated drinker, you might not find any scientific evidence for its harms convincing. However, if you’re not totally committed to drinking, and what I’ve presented here hasn’t changed your mind, I sincerely hope that it will at least get you thinking about a life without alcohol. Perhaps, in the future, this information will empower you, when you are ready, willing, and able to make a change.
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