“Healthy Drinking” FAQ: A Goldmine for Industry, a Minefield for Health

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On March 17, 2018, a bombshell New York Times expose revealed systematic collusion between Big Alcohol and the National Institute on Alcohol Abuse and Alcoholism (NIAAA). NIAAA, ostensibly an organization devoted to combating the harms of alcohol use, had sent staffers and hand-picked researchers to lobby industry groups for over $67 million to fund the Moderate Alcohol and Cardiovascular Health (MACH15) study. In exchange, the industry had the opportunity to vet all procedures and staff years before the study was even registered.

The solicitation process itself created enough issues surrounding ethics and bias to study to call for its immediate termination. But studies that can be used to promote the concept of “healthy drinking” are the alcohol industry’s holy grail, and a problem that public health practitioners must be ready to confront. Below are frequently asked questions about “healthy drinking” research.

• Q: Is alcohol good for you?
  
  A: The short answer is no. Alcohol is a toxin with the potential to generate addiction. It is responsible for 88,000 deaths per year in the U.S. Drinking too much is tied to a range of harms, from cancer to diseases of the heart and liver, to car crashes and assaults.
  
  There are some studies that show that low levels of alcohol intake are associated with less heart disease and, more arguably, cognitive decline, but these benefits are debatable. What’s more, as drinking goes up, the benefits go away and alcohol instead worsens those conditions. A recent study showed that nothing caused more early-onset dementia than alcohol use.
  
  
• Q: Why would anyone argue against these “pro-alcohol” findings?
  
  A: The public health community is wary of promoting these studies due in large part to selection bias. In short, when studying the effects of alcohol intake, researchers often compare drinkers and non-drinkers. However, non-drinkers often abstain for health reasons. This can make it seem like non-drinkers are less healthy because they do not drink when the truth is they do not drink because they are less healthy.
  
  Similarly, a recent “super ager” study reported alcohol use as a predictor of very old age. However, those individuals may simply have been robust enough to survive to a ripe old age as regular drinkers, while less hardy colleagues had already died before the study started!
  
  Another, larger reason to be wary of promoting these results comes from the fact that what may be good individual health can still be bad population health.
  
  
• Q: What is the difference between individual and population health when it comes to drinking?
  
  A: Whether or not one drink a day is healthy for a single individual (and I’m not saying it is), if everybody in the United States were to drink one drink a day, there would definitely be additional incidences of harms. In particular, individuals who did not drink before being urged to by Big Alcohol and/or NIAAA would instantly increase their susceptibility to certain cancers, neurological issues, injuries, and life disruption. There is no guarantee that a teetotaler, once urged to start drinking, would have the same ease maintaining a one-per-day pace as the idealized low-level drinker. Creating a new heavy drinker would put that person at extreme risk.
  
  Any honest evaluation of whether “healthy drinking” exists needs to look at its effects on a randomized population over an extended period of time.
  
  
• Q: Isn’t MACH15 meant to be exactly that kind of longitudinal study?
  
  A: While the MACH15 study is a longitudinal clinical trial, hence its expense and the industry’s eagerness to foot the bill, it is clearly meant to only look at the outcomes that might be improved by drinking. It is not designed to evaluate cancers, long-term cognitive declines, or gastrointestinal issues, much less emergent psychiatric or psychosocial problems. Laws and best practices protecting research participants means that outside investigators cannot get those answers themselves.
  
  Moreover, the selection bias is at work in MACH15 as well, since any participant who shows indications they might be vulnerable to harms from even low-level alcohol use is excluded. These exclusion criteria make for good research design, but also make it impossible for this trial to give an accurate idea of the population health impacts of drinking.
  
  
• Q: Why not just use it to suggest drinking only to the healthiest people?
  
  A: The range of exclusion criteria the MACH15 researchers use are much wider than those given by your doctor during your average checkup. Since the study designers have openly declared they are trying to pave the way for doctors to recommend drinking to patients who do not drink, the study uses the population least likely to be harmed by drinking to put beers in everyone’s hands.
  
  Also bear in mind that the alcohol industry is not regulated by the FDA. A NIAAA decision to recommend drinking opens the door for Big Alcohol to make overblown health claims about their products. This would be like tobacco manufacturers using nicotine’s alleged ability to aid concentration as a reason to put cigarette machines (back) in college dormitories.

These are the reasons why Alcohol Justice cannot support the idea of healthy drinking, especially not as currently pushed aggressively by NIAAA and Big Alcohol. When it comes to picturing the health effects of long-term alcohol use, here is a great deal still to be filled in. Before we get there, we must refrain from making careless recommendations that could ruin lives.

TAKE ACTION to tell Congress to kill the deceptive MACH15 study.

READ MORE about NIAAA's backroom deals with Big Alcohol.

READ MORE about the industry's deceptive health claims.

Cancer Warnings Make Big Alcohol a Mean Drunk

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And when the industry gets mean, it reaches for its lawyers.

Roman philosopher Pliny the Elder once stated in vino veritas. It took another two thousand years for Europe to get around to putting veritas on its vino. Ireland is currently debating a robust bill to address alcohol harm that includes, for the first time in Europe, a large warning that alcohol increases risk of cancer.

Academic literature has long documented the relationship between cancer and drinking, with the International Agency for Research on Cancer labeling ethanol as a carcinogen back in 1987. However, these findings have been slow to make their way to public consciousness. This may be changing.

In November 2017, the American Society of Clinical Oncology (ASCO) issued warnings that even slight drinking can raise the risk of breast cancer. Heavier drinking dramatically raises risks of oral, pharyngeal, esophageal, and colorectal cancers-and, of course, cancer of the liver. Speaking to the New York Times, Dr. Clifford Hudis, chief executive of ASCO, cautioned, "The more you drink, the higher the risk. It's a pretty linear dose-response."

As ASCO was making this determination, the province of Yukon in Canada launched a bold experiment: to test cancer-risk warnings in a major liquor store in Whitehorse. Though vast in terrain, Yukon has only around 35,000 residents, allowing Health Canada to fund an experiment comparing buyer behavior in a store that uses the health warnings to ones in stores that sell alcohol as-is. Public health professionals were optimistic about its impact. "If results demonstrate an effect on consumer behavior," Yukon Chief Medical Officer of Health Brendan Hanley, MD, told MedScape, "there is potential for some important policy changes, not just locally but nationally and internationally, to address responsible alcohol consumption."

This message was heard loud and clear by the Canadian alcohol industry, which promptly issued threats of litigation. The province quickly backed down and stripped off the cancer warnings. John Streicker, the Yukon legislator tasked with overseeing the province's state-run liquor stores, was open about the effectiveness of the threat. "We need to do the responsible things," he told the New York Times, "which is to judge whether [litigation] is the best use of our money for our citizens. The hard choice is whether to pay for lawyers or whether to pay for harm reduction."

Yet no sooner had Canada put down the torch then Ireland picked it up. Minister for Health Simon Harris assembled a comprehensive harm minimization bill and put it up for debate. Included in its provisions are minimum unit pricing, restrictions on advertising, and point-of-sale controls. It also calls for at least one-third of the bottle to be covered in health warnings, including warnings that alcohol is a carcinogen. The bill has already passed the Seanad (Ireland's Senate) and is before the other deliberative body, the Dail.

This surge across the English-speaking world of recognition of alcohol's role in cancer has found a home in the United Kingdom as well. In early 2018, the Royal Society for Public Health (RSPH) began agitating for health labeling as well. Shirley Cramer, CBE, of the RSPH noted that 90% of U.K. residents are aware of alcohol's carcinogenic effects. When it comes to health disclosures, she observed, "alcohol continues to lag behind. If we are to raise awareness and reduce alcohol harm, this must change."

Needless to say, both proposals have raised outrage from Big Alcohol's mouthpieces. A representative of U.K.'s liquor standards body the Portman Group complained that "there was little public interest in a radical overhaul of drinks labelling and strong opposition to cramming more information on packs." The Alcohol Beverage Federation of Ireland likewise complained that cancer advisories would be "devastating for drinks companies," and would cripple the industry "when the sector already faces major uncertainty, with Brexit negotiations ongoing."

Public health advocates should find these complaints heartening. Since these warnings are intended to encourage consumers to drink less and protect their health, Big Alcohol's objections means they are likely to work. Of course, if current behavior is any pattern, the alcohol control world won't know for sure until the first lawsuit is filed.

READ MORE about Big Alcohol's efforts to "pinkwash" cancer links.

READ MORE about minimum unit pricing in Scotland-and the lawsuits the country had to win to put it into place.