How bad is alcohol?

What is alcohol like for your health?

Problems with studying this:

• People under-report their drinking. Some studies find that most people who describe themselves as “lifetime abstainers” (never drank) are actually former drinkers.
• There’s no standard definition of “a drink” across countries. What people pour is often more than what researchers consider a serving.
• Reachers sometimes make shit up, like a widely-shared graph that was going around based on a researcher who doubled everyone’s reported drinking level.

A bunch of (probably confounded) studies conclude that light-to-moderate drinking is a bit good and then it gets bad. One of many studies showing a J-shaped curve:

But another common conclusion is “It seems suspicious that alcohol is ever good for you.”
– Some of these studies probably don’t fully control for confounders. For example, lifetime abstainers are more likely to be less educated and lower-income, which might be the real things causing worse health outcomes.
– People misrepresenting their drinking might be more likely to claim no drinking at all, which could explain the left-hand end of that curve.

Even if you think the pattern basically holds, it holds most for older white men.

The benefits are mostly from lower heart disease and diabetes, which don’t tend to kill young people. Several sources say things like “any benefits from alcohol don’t start until age 40,” because you’re more likely to die in an accident after drinking than you are to avoid a heart attack before that age.

A given amount of alcohol is worse for women’s health. “Women are more exposed than men to death for any cause at moderate to high levels of alcohol consumption, probably owing to increasing risk of cancer. Experimental evidence shows that when men and women consume the same amount of alcohol, women experience higher blood alcohol concentrations. Women metabolize ethanol differently and have a lower gastric alcohol dehydrogenase activity, resulting in higher blood ethanol levels and higher risk of liver disease.” (source) However, at a population level men experience more direct harm from alcohol because they drink more as a group than women.

One large study of a US population makes a fleeting mention that they found health benefits only for white people: “Beneficial effects of moderate drinking on mortality . . .  were found in non-Hispanic white subjects but not in other ethnic groups.” One US study finds that the lowest risk for black men is 0 drinks per week and the lowest risk for black women is 2 drinks a week. A large study of a Taiwanese population finds the J-shaped curve, though.

This overview from the Harvard School of Public Health seems reasonable to me. (Apart from the bizarre mention that women are 10 times more likely to die from heart disease than breast cancer, but might want to avoid alcohol despite heart benefits because they fear breast cancer more.)

Personally, I treat alcohol as something like sugar: I don’t eat sugar because I think it’s good for me, but because it’s enjoyable. I try to moderate both because I think too much will be bad for my long-term health. (This doesn’t entirely hold because alcohol can have much worse effects than sugar can.) My goal is to average under 3 drinks a week, and rarely to have more than one serving a day.

You know your risk factors

There are a few factors that might make light drinking a better bet healthwise — like you’re older and at risk for heart disease. And there are a lot of factors that might make drinking net negative — family or personal history of alcoholism, younger age, medications that interact badly with alcohol, cancer risk.

Because I had some family history of alcoholism, for the first 15 years or so of adulthood I had a rule that I didn’t drink more than one day in a row and didn’t drink when I was sad.

Alcohol makes people do dumb stuff

A coworker once told me the first rule of self-defense is to stay away from drunk people, and I think this is solid advice. 

In the 1990s, 20 to 40% of people convicted of violent crimes in the US are estimated to have been under the influence of alcohol at the time of the crime. About 75% of violence between spouses reported to the police involved alcohol use on the part of the offender (source for all).

About half to ⅔ of rapes among college students involve alcohol (on the part of the perpetrator, the victim, or both). (source) 

As my kids get older, I want them to understand they’ll be safer in lower-alcohol settings, both by not getting drunk themselves and not being alone with someone who’s drunk. Avoiding drunkenness also reduces the chance you’ll do bad things to other people.

Alcohol is really bad for public health

The WHO estimates that 3 million people a year die because of alcohol (5% of deaths) — because of accidents, digestive disease including liver disease, cardiovascular disease, cancer, alcohol use disorder, and murder. That doesn’t include health lost from prenatal alcohol exposure, nonfatal accidents, nonfatal violence, and other health problems.

The health burden is a lot worse in some places than others, worst in Eastern Europe and Sub Saharan Africa.  For example, here are years of healthy life lost due to alcohol-related injuries (WHO):

Harm is worse for those already in worse conditions (existing health problems, more exposure to contagious disease, more crowded housing conditions increasing domestic violence, less access to healthcare). WHO: “Greater ‘harm per litre’ [for the poor] is a consistent finding for many different kinds of harms from drinking – e.g. chronic diseases such as liver cirrhosis; injuries from drinking, both to the drinker and to others around the drinker; and infectious diseases where drinking plays a role in vulnerability to or spread of the infection or in disrupting the treatment regime.”

But also, alcohol is fun

Obviously a lot of people drink because of the euphoric and relaxing effects, and lots of delightful experiences have been had while buzzed. A lot of people drink moderately and don’t seem to experience harm from it.

Could we get something better?

At a population level, alcohol has a bad ratio of harm to enjoyment, and I hope society can move toward drugs with a better ratio. As a resident of a state where cannabis has been legal for a few years, I hope we can also settle on something less stinky.

(Note this scale was authored by a vocal advocate for psychedelics. Less soapbox-y takes like this one by German addiction doctors still typically include alcohol as one of the most harmful drugs.)

Policy steps

I feel like the dominant narrative is “The US tried Prohibition and that didn’t work.” The research on the effects of US Prohibition is actually pretty unclear, due to scanty statistics and rapid urbanization as a confounder at the time. Organized crime increased, and domestic violence likely decreased but is less measured.

Like a typical American, I hadn’t thought about experiments outside the US. I started thinking about this differently after hearing gender researcher Alice Evans on the topic. There was a natural experiment in 2020 when South Africa suddenly banned alcohol: 14% reduction in injuries, 20% reduction in violence. “For every single week of the ban, there were 77 fewer homicides, 790 fewer assaults and 105 fewer rapes.” Of course, it’s hard to keep that reduction going once the black market has a chance to adjust. Especially in areas with an established home/local brewing industry, like Uganda, people switch to unregulated brews.

The Northern Territory of Australia has a tragic thing going on that I don’t fully understand. Some areas that had banned alcohol for 15 years recently un-banned it. “Since then, NT police statistics show that reported property offences have jumped by almost 60% over the past 12 months, while assaults increased by 38% and domestic violence assaults were up 48%.” (source) The bans were quickly replaced, and crime has decreased.

The US’s history with Prohibition made me think of prohibition as an all-or-nothing thing, but there are intermediate options like shorter hours for liquor stores and higher taxes. From a study in upstate New York: “Every 1 h increase in weekly outlet business hours was associated with a greater reported incidence of violent crimes generally, more reported aggravated assaults and more reported non-gun violence. The estimated cost from having licensed premises open after 1 a.m. was $194 million in 2009.”

Several towns near me recently banned single-serving alcohol bottles (apparently because of littering concerns more than public health.)

Related:
– Open Philanthropy on alcohol policy in low and middle income countries 
– An argument for higher alcohol taxes in the US

Social spaces and friend groups

In general, I think it’s a good idea to select social groups that have habits you’d like to end up with.

One community I’m part of, Morris dancing, has a strong association with beer: you dance, then you go to a pub or bar. But I rarely see people who seem drunk to the point of bad decisions or physical danger. When I got to college I had to learn that the smell of beer no longer meant a nice friendly Morris setting, but meant 20-year-olds about to make questionable decisions.

Even in spaces where drinking is common, I think it’s good to preserve the option to not drink — by sometimes not drinking, by not pushing others, and by pushing back against anyone who’s pressuring people to drink.

Jeff ended up with a college friend group that was selected partly for not drinking. They were disproportionately Mormons, other serious Christians, and folk dancers. It was an unusually good and long-lasting friend group. I’d be happy if our kids end up with a similar friend group.

An awkward conclusion

I feel weird continuing to consume alcohol, because if I could wave a magic wand and make it disappear from the planet, I’d do it.

If I’d lived before US Prohibition, I can imagine being enthused about trying to establish a bright line about abolishing alcohol. Best sentence of the Wikipedia article about temperance activist Carrie Nation: “Her methods escalated from simple protests to serenading saloon patrons with hymns accompanied by a hand organ, to greeting bartenders with pointed remarks such as, ‘Good morning, destroyer of men’s souls.'”

But as far as I can, tell the only really successful anti-alcohol movements have been religions (Islam and Mormonism), and I wouldn’t wave that wand. Alcohol is easy to brew at home — I’ve done it, though it caused an ant problem. So I don’t expect widespread prohibition to work, unless by some and big change like the invention of a better and cheaper drug, or everyone becoming uploads.

In the current world, I don’t see much harm from light drinking (except to one’s own health). But there’s still something a little uncomfortable here. Jeff is totally opposed to drinking, and maybe he’ll win me over someday.

Resources for alcohol problems

A while ago I was annoyed by how hard it is to find info about alcohol treatment, because so much of the info is by rehab centers that want to sell you their services.

• An overview by me. An overview by psychiatrist Scott Alexander.
• SAMHSA (US agency on substance abuse) hotline and treatment finder
• NHS (UK) alcohol resources and find an alcohol addiction service
• Alcohol Change – UK directory of resources
• Rethinking Drinking – information for people assessing their drinking and considering change
• Books on alcohol recovery