New study —
The risks and harms associated with drinking alcohol have been systematically evaluated over the years and are well documented. The World Health Organization has now published a statement in The Lancet Public Health: when it comes to alcohol consumption, there is no safe amount that does not affect health.
It is the alcohol that causes harm, not the beverage
Alcohol is a toxic, psychoactive, and dependence-producing substance and has been classified as a Group 1 carcinogen by the International Agency for Research on Cancer decades ago – this is the highest risk group, which also includes asbestos, radiation and tobacco. Alcohol causes at least seven types of cancer, including the most common cancer types, such as bowel cancer and female breast cancer. Ethanol (alcohol) causes cancer through biological mechanisms as the compound breaks down in the body, which means that any beverage containing alcohol, regardless of its price and quality, poses a risk of developing cancer.
The risk of developing cancer increases substantially the more alcohol is consumed. However, latest available data indicate that half of all alcohol-attributable cancers in the WHO European Region are caused by “light” and “moderate” alcohol consumption – less than 1.5 litres of wine or less than 3.5 litres of beer or less than 450 millilitres of spirits per week. This drinking pattern is responsible for the majority of alcohol-attributable breast cancers in women, with the highest burden observed in countries of the European Union (EU). In the EU, cancer is the leading cause of death – with a steadily increasing incidence rate – and the majority of all alcohol-attributable deaths are due to different types of cancers.
Risks start from the first drop
To identify a “safe” level of alcohol consumption, valid scientific evidence would need to demonstrate that at and below a certain level, there is no risk of illness or injury associated with alcohol consumption. The new WHO statement clarifies: currently available evidence cannot indicate the existence of a threshold at which the carcinogenic effects of alcohol “switch on” and start to manifest in the human body.
Moreover, there are no studies that would demonstrate that the potential beneficial effects of light and moderate drinking on cardiovascular diseases and type 2 diabetes outweigh the cancer risk associated with these same levels of alcohol consumption for individual consumers.
“We cannot talk about a so-called safe level of alcohol use. It doesn’t matter how much you drink – the risk to the drinker’s health starts from the first drop of any alcoholic beverage. The only thing that we can say for sure is that the more you drink, the more harmful it is – or, in other words, the less you drink, the safer it is,” explains Dr Carina Ferreira-Borges, acting Unit Lead for Noncommunicable Disease Management and Regional Advisor for Alcohol and Illicit Drugs in the WHO Regional Office for Europe.
Despite this, the question of beneficial effects of alcohol has been a contentious issue in research for years.
“Potential protective effects of alcohol consumption, suggested by some studies, are tightly connected with the comparison groups chosen and the statistical methods used, and may not consider other relevant factors”, clarifies Dr Jürgen Rehm, member of the WHO Regional Director for Europe’s Advisory Council for Noncommunicable Diseases and Senior Scientist at the Institute for Mental Health Policy Research and the Campbell Family Mental Health Research Institute at the Centre for Addiction and Mental Health, Toronto, Canada.
We are missing the bigger picture
Globally, the WHO European Region has the highest alcohol consumption level and the highest proportion of drinkers in the population. Here, over 200 million people in the Region are at risk of developing alcohol-attributable cancer.
Disadvantaged and vulnerable populations have higher rates of alcohol-related death and hospitalization, as harms from a given amount and pattern of drinking are higher for poorer drinkers and their families than for richer drinkers in any given society.
“So, when we talk about possible so-called safer levels of alcohol consumption or about its protective effects, we are ignoring the bigger picture of alcohol harm in our Region and the world. Although it is well established that alcohol can cause cancer, this fact is still not widely known to the public in most countries. We need cancer-related health information messages on labels of alcoholic beverages, following the example of tobacco products; we need empowered and trained health professionals who would feel comfortable to inform their patients about alcohol and cancer risk; and we need overall wide awareness of this topic in countries and communities,” adds Dr Ferreira-Borges.
No level of alcohol consumption is safe when it comes to human health, according to a WHO statement released in January, 2023. The data behind this dire warning come from a 2021 study that estimated the number of incident cancers attributable to alcohol consumption in the EU in 2017—light to moderate drinking (1–2 drinks per day) was responsible for 23 300 new cases of cancer. New Canadian guidelines take a strong stance too, suggesting that any more than two drinks per week puts your health at risk. Does this mean the days of safely enjoying a tipple are officially behind us?
The risks and harms associated with alcohol are well documented, and the substantial harms of heavy or binge drinking are not debated. But health benefits of lower levels of alcohol intake have been widely reported. Many studies have shown that low or moderate amounts of alcohol (particularly red wine) can reduce risk for cardiovascular disease, diabetes, and even death—possibly due in part to a tendency to reduce systemic inflammatory mediators. These benefits might be limited to adults older than 40 years, according to a 2022 analysis from the Global Burden of Disease study, which found no such benefit at younger ages.
Potential benefits of light to moderate alcohol consumption have also been reported among patients with rheumatoid arthritis. A meta-analysis of eight prospective studies reported a reduced risk of developing rheumatoid arthritis among those who consumed alcohol (up to 12 g per day, or roughly eight drinks per week) compared with non-drinkers. Another meta-analysis concluded that individuals with rheumatoid arthritis who consume alcohol have lower disease scores and better self-reported health assessments than non-drinkers. But these effects are complicated. For example, patients with high disease activity and low quality of life were more likely to stop drinking in a study from the USA. But a study from Swedensuggested that people with rheumatoid arthritis who stopped drinking ended up worse off with regard to both disease activity and quality of life compared with those who continued drinking, despite both variables being comparable at baseline.
Dire warnings like these seem to have become commonplace (a similar statement about alcohol and cancer was issued by the American Society of Clinical Oncology in 2017) and have the potential to be ignored by many people as undesirable and unattainable. WHO correctly argues that no studies have addressed whether the potential benefits of alcohol on cardiovascular disease and diabetes outweigh the risks with regard to cancer, and that the harms of alcohol fall disproportionately on disadvantaged and vulnerable populations. In view of these truths, a why-risk-it approach might seem sensible. But interpretation of the seemingly conflicting reports requires consideration of many factors, including the varying levels of alcohol intake considered light to moderate, competing risk factors for disease, choice of comparator groups, and the known pitfalls of self-reported alcohol consumption. It is also important to put the results of these studies in the context of absolute levels of risk (versus relative risk) associated with alcohol intake, which are generally quite small.
Individuals with rheumatic disease taking medications are often counselled to reduce or eliminate alcohol intake, but it might be more realistic to simply advise patients about risk at an individual level. That said, determining risk for people with rheumatic diseases is challenging; we do not know how alcohol-related risk estimates translate to those with rheumatic disease, who are already at higher risk of cardiovascular disease and cancer compared with the general population. More data are needed to help patients make informed decisions—decisions that must also take medications into account. For example, the hepatotoxicity of the foundation drug methotrexate could be increased by alcohol, resulting in a lack of clarity about whether there is a so-called safe level of alcohol for those taking it. Whereas the ACR recommends that alcohol be avoided, the UK National Health Service suggests that patients on methotrexate can drink the same amount as everyone else (up to 14 units of alcohol per week based on UK national recommendations).
WHO calls for increased education on the cancer risks associated with alcohol consumption—perhaps including health warnings on alcohol labels—and few would argue against better-informing the public with regard to health. But the absolute risks of light to moderate drinking are small, and while there is no known safe level of drinking, it seems reasonable that the quality of life gained from an occasional drink might be deemed greater than the potential harm.