HEALTH ASPECTS OF MODERATE ALCOHOL CONSUMPTION

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1 GETTING THE FACTS RIGHT ON HEALTH ASPECTS OF MODERATE ALCOHOL CONSUMPTION Alcohol consumption is sometimes perceived as incompatible with a healthy lifestyle. In reality, numerous scientific studies show that otherwise healthy adults who consume alcoholic beverages in moderation may face a lower risk for a number of conditions, in particular age-related risks such as coronary heart disease, ischemic stroke, diabetes and dementia. Drinking patterns are of key relevance: regular moderate drinking (versus heavy episodic drinking) has been shown to be associated with certain beneficial health effects. Public health policies should not disregard the health effects of moderate consumption and should focus on alcohol misuse and abuse Setting the scene: definitions & health aspects of drinking Beneficial health aspects of moderate consumption on major diseases Alcohol consumption and certain alcohol related diseases Evidence in support of balanced health policies KEY POINTS The effects of alcohol on consumers health are complex and consumption can have both positive and negative consequences. Patterns of drinking are of key relevance; harmful consumption patterns are known to have adverse health consequences. Health benefits and risks may vary between individuals and different drinking behaviours. Moderate alcohol use has been reported to be associated with a reduction in risk of circulatory system diseases: the main cause of death in the EU. Circulatory system deaths, including heart diseases, are far more common than cancer deaths and specific (clearly) alcohol related diseases in general: absolute and relative risks need to be considered. For healthy adults, moderate alcohol consumption may have beneficial effects on other health conditions. Independent studies conducted over 30 years indicate potential beneficial effects of moderate alcohol intake on certain blood, brain, and heart-related diseases for otherwise healthy adults. Moderate drinking has not been shown to increase the risk of chronic liver disease. Overall chronic liver disease seems to be unrelated to per capita consumption. In 2010, it is reported that around 4% of all-cancer types are alcohol related and alcohol related cancer deaths were responsible for 1.2% of all-cause mortality in the EU. Light drinkers appear to face a lower all-cancer mortality risk than abstainers and moderate drinkers seem to have the same all-cancer mortality risk as abstainers. According to the majority of all-cause mortality risk studies, the all-cause mortality risk is significantly lower for moderate drinkers compared to lifelong abstainers and excessive drinkers. Contemporary government recommended drinking guidelines appear to reflect the evidence on both adverse & beneficial health effects of drinking. Public health policy measures should be targeted & culturally/contextually sensitive. 1 This document aims to provide a balanced perspective on benefits and negative consequences of alcohol use on people s health in pointing to evidence that is often ignored in the public debate. We encourage readers to review the vast body of literature regarding the health effects of alcohol consumption.

2 1 Setting the scene: definitions & health aspects of drinking KEY POINTS The effects of alcohol on consumers health are complex and consumption can have both positive and negative consequences. Patterns of drinking are of key relevance. Some health benefits are associated with moderate drinking and certain adverse health events are associated with heavy episodic and/or longer-term heavy drinking. Effects of alcohol consumption depend on many factors Patterns of consumption (e.g. frequency, quantity of alcohol consumed, with or without food, time of the day, place and social context); Age and gender (women should drink less due to their typically lower weight and water-to-body-mass ratio); Body size and weight; Genes or genetic predisposition; Mental & physical health status and medical conditions. The pattern of drinking is of key relevance, in particular heavy episodic and long-term heavy drinking behaviours need to be addressed from a health perspective, as these drinking patterns increase the risk of acute and chronic health conditions. On the other hand, moderate drinking is associated with reduced risk of many chronic diseases, such as cardiovascular disease (Graff-Iversen et al 2013). What are drinking patterns? Drinking patterns describe 3 important aspects of drinking: (1) WHO individuals, the characteristics of those who drink; (2) WHERE drinking settings, or where drinking takes place, as well as its role in everyday life and in a particular culture; (3) HOW/WHY drinking behaviours, or how people drink, whether moderately or to extremes, over what time period, and the activities that may accompany drinking. Definition of safe/low-risk/moderate drinking Since so many individually differing factors represent important elements when talking about alcohol consumption and health, it is difficult to provide populationwide drinking guidelines that inform individual consumers about health risks and benefits taking all alcohol related diseases into account. An emerging consensus definition is that moderate drinking refers to no more than 3 standard drinks/day for healthy men (approx. 30g alcohol) and no more than 2 standard drinks/day for healthy women (approx. 20g alcohol). Additionally, 1 or 2 days of abstinence per week are sometimes recommended, despite unreliable supporting evidence. Moreover, abstinence in particular circumstances is strongly recommended, such as during pregnancy, under medication, or underage. The objective of drinking guidelines is to convey a complex issue in a simple way, so that people can make relatively informed decisions. According to WHO, a standard drink refers to: 285 ml beer 30 ml spirits 120 ml wine 60 ml aperitif According to a recent meta-analysis consumption of alcohol, up to 4 drinks per day in men and 2 drinks per day in women, was inversely associated with total mortality, maximum protection being 18% in women [ ] and 17% in men. [ ] Our findings, while confirming the hazards of excess drinking, indicate potential windows of alcohol intake that may confer a net beneficial effect of moderate drinking, at least in terms of survival (Di Castelnuovo et al 2006, p. 2437). Note that other studies of a different design, such as the Global Burden of Disease come to different conclusions. 2

3 1 A number of independent studies also report that moderate drinkers may benefit psychologically, e.g. feelings of pleasure, happiness or stress relief (Arntzen et al, 2010). For instance, Chan et al (2009) conclude: regular alcohol consumption is associated with increased quality of life in older men and women (p. 294). Goldberg et al (1999) find that compared with abstainers, moderate drinkers exhibit improved mental status characterized by decreased stress and depression, lower absenteeism from work, and decreased incidence of dementia (including Alzheimer s disease) (p. 505). Very recently, Valencia et al (2013, p. 703) conclude: Alcohol drinkers, including those with heavy drinking, reported better physical HRQL [health related quality of life] than non-drinkers. The consequences of alcohol misuse The term binge/heavy episodic drinking generally refers to the consumption of 5 or more standard alcohol units/ drinks in one sitting (usually defined as drinking in excess of 50g/60g of pure alcohol), which increases the risk of acute consequences, such as alcohol related falls or, if combined with driving, road traffic accidents. Longer-term heavy drinking is associated with alcohol related chronic diseases, such as alcoholic liver disease. Such drinking habits can also enhance negative psychological states and lead to mental and behavioural disorders including anxiety, depression, insomnia and sexual dysfunction (mental and behavioural disorders due to the use of alcohol were responsible for 0.4% of all-cause mortality in the EU in 2010 according to Eurostat data). Therefore heavy episodic & longer-term heavy drinking behaviours (alcohol abuse more generally) are of public concern and should be avoided or at least reduced. The emerging consensus definition for low-risk drinking is 2 and 3 drinks per day for healthy women and men respectively. 3

4 2 Beneficial health aspects of moderate consumption on major diseases KEY POINTS Moderate alcohol use has been reported to reduce the risk of circulatory system diseases: the main cause of death in the EU. Circulatory system deaths, including heart diseases, are far more common than cancer deaths and specific (clearly) alcohol related diseases in general: absolute and relative risks need to be considered. For healthy adults, moderate alcohol consumption may have beneficial effects on other health conditions. Independent studies conducted over 30 years indicate potential beneficial effects of moderate alcohol intake on blood, brain, and heart-related diseases for otherwise healthy adults. The health benefits of moderate consumption on EU s top mortality causes: absolute vs. relative risks In 2010, 39% (1,898,416 people in absolute terms) of all deaths (4,852,998) in the EU were caused by diseases of the circulatory system, including blood, heart and brain diseases: the main cause of death in the EU (see Eurostat). That is to say, more than the entire population of Estonia and Luxembourg combined passes away each year due to diseases of the circulatory system. Indeed, a US study, which serves as the National Institutes of Health s formal position paper on the health risks and potential benefits of moderate alcohol use and which focuses solely on coronary heart disease finds that if all current consumers of alcohol abstained from drinking, another 80,000 CHD [coronary heart disease] deaths would occur each year (Gunzerath et al 2004, p. 829). If one assumes the lowest percentage (about 10% across studies) of ischaemic and other heart diseases deaths (1,050,543 deaths in absolute terms in the EU in 2010) saved due to alcohol consumption in the EU, then if people totally abstained from drinking, more than 100,000 ischaemic and other heart disease deaths would occur each year in the EU. Britton & McPherson (2001) hold that there are approximately 2% fewer deaths annually in England and Wales than would be expected in a non-drinking population (p. 383). The 2 major causes of all-cause mortality in the EU (Eurostat) Heart diseases represent 55% of the circulatory system diseases and a large evidence - base shows that the risk of heart diseases is reduced by alcohol intake, especially by moderate consumption. On the other hand, around 4% of all cancer deaths appear to be alcohol related. For the US, Nelson et al (2013) find: Alcohol consumption resulted in an estimated 18,200 to 21,300 cancer deaths, or 3.2% to 3.7% of all US cancer deaths (p. 641). Next to the frequency of a disease, it is important from a public health perspective to distinguish between absolute and relative risks to identify the right objectives and tools. In the case of alcohol, moderate consumption generates a large risk reduction of a frequent disease (heart diseases). A small risk reduction of a frequent disease may offset a large risk increase of a very rare disease. Other causes of deaths. Diseases of the circulatory system Cancers % 39.1% 25.9%

5 2 The beneficial effect of moderate alcohol consumption for healthy adults on other diseases: two cases Numerous studies find at least 30% reduced risk of diabetes (type II) for moderate drinkers compared to abstainers (Rasouli et al 2013, Joosten et al 2011, Baliunas et al 2009, K oppes et al 2005, Goldberg et al 1999). A systematic review of 32 studies by Howard et al (2004, p.211) concludes: Compared with no alcohol use, moderate consumption (1 to 3 drinks/day) is associated with a 33% to 56% lower incidence of diabetes and a 34% to 55% lower incidence of diabetes-related coronary heart disease. Studies also report that drinkers and in particular moderate drinkers have a lower dementia and Alzheimer risk of around 30% compared to abstainers (Weyerer et al 2011, Solfrizzi et al 2011 & 2007, Anstey et al 2006 & 2009, Collins et al 2009, Goldberg et al 1999). In a review and meta-analysis of 143 papers, Neafsey et al (2011, p.465) conclude: The benefit of moderate drinking applied to all forms of dementia (dementia unspecified, Alzheimer s disease, and vascular dementia) and to cognitive impairment (low test scores). Literature review: the health benefits of moderate consumption on heart, blood and brain diseases Heart Diseases There is a wealth of evidence on the potential beneficial effect of moderate alcohol consumption for healthy adults on cardiovascular diseases. Rimm et al (2007, p.s3) states that an inverse association between alcohol consumption and coronary heart disease (CHD) has been shown in epidemiologic studies for more than 30 years. Recent statements that ex-drinkers classified as non-drinkers might change the findings is rejected by Rimm et al: there is substantial evidence to refute the sick quitter hypothesis. Moreover, within the group healthy men (who did not smoke, exercised, ate a good diet, and were not obese) [ ] men who drank moderately had a significantly lower CHD risk compared with abstainers. Therefore, Rimm et al conclude that the inverse association of alcohol to CHD is causal, and not confounded by healthy lifestyle behaviors (p. S3). Most recently, Jones et al (2013) conclude: Consistent with established evidence, our findings suggest a mechanism by which moderate alcohol consumption might reduce cardiovascular disease [ ] (p. 369). Similarly, Thompson (2013) concludes: The J- shaped relationship between alcohol consumption and cardiovascular risk has been studied and confirmed in multiple studies; while it complicates the formulation of public policy on alcohol consumption, it cannot be dismissed (p. 419). In a meta-analysis of 84 studies, Ronskey et al (2011, p. 13) found that the risk for cardiovascular disease mortality was 25% lower for alcohol drinkers relative to non drinkers, while the risk for incident coronary disease decreased by 29% or the risk for coronary heart disease mortality by 25%. Corrao et al (2000) meta-analysis finds a 20% decreased relative risk of coronary heart disease for an alcohol intake of 20g/day (approx. 2 standard drinks) and still a small protective effect up to 72g/day. Tolstrup et al (2009) 5

6 2 find a decreased risk for coronary heart disease of 20% and the maximal benefit seem to be obtained at 1 to 2 drinks per day for women and 2 to 3 drinks per day for men (p. 510). The conclusions of Roerecke M, Rehm J. (2014) not only support a Jshaped curve for alcohol consumption and IHD but provide additional support suggesting that the effect may be causal, i.e., related to the alcohol consumption and not to other associated lifestyle factors. Some studies find beneficial effects also for younger adults: A Spanish study by Arriola et al (2008, p.124) finds that in men aged years, alcohol intake was associated with a more than 30% lower CHD [coronary heart disease] incidence. Our study is based on a large prospective cohort study and is free of the abstainer error. Similarly, Hvidtfeldt et al (2010, p.1589) find that: alcohol is also associated with a decreased risk of coronary heart disease in younger adults; however, the absolute risk was small compared with middle-aged and older adults. A very recent study (based on a Spanish population sample again) by Galan et al (2013) concludes: Moderate alcohol intake is associated with improved HDL-cholesterol, fibrinogen, and markers of glucose metabolism, which is consistent with the reduced CHD [coronary heart disease] risk of moderate drinkers in many studies (p. 1). Blood & brain diseases as well as mental health Further reading and evidence: van de Wiel and de Lange, 2008; Suzuki et al, 2009; Djousse et al, 2009; McIntosh, 2008; Tolstrup et al, 2006, 2010; Bagnardi et al, 2008; Carrao et al, 2004, Collins et al, 2009; Mukamal et al, 2003, 2010; Heines and Rimm, 2001; Brien et al, 2011; Flesch et al, 2001; Chiuve et al, 2010; Janszky et al, 2009, Le Strat Y & Gorwood P 2011, Jones A et al. 2013, Movva and Figueredo, 2013, Wakabayashi I Moderate alcohol intake is also associated with a reduced risk of other blood and brain diseases: Streppel et al (2009) find that compared to non-drinkers long-term light alcohol intake [ ] (20 g per day) [ ] was strongly and inversely associated with cerebrovascular [ lower risk of 57%], total cardiovascular [ lower risk of 30%] and all-cause mortality [lower risk of 25%] (p. 534). There is also evidence that moderate alcohol consumption has beneficial effects on blood circulation diseases, such as lower-extremity arterial disease and venous thromboembolism (Mukamal et al 2008, Lutsey et al 2009) as well as stroke (Ronksley et al, 2011; Goldberg et al 1999; Rodgers, H. et al. 1993). For instance, Mukamal et al (2005) find that consumption of 10.0 to 29.9 g of alcohol per day [that is about 1 to 3 drinks] on 3 to 4 days per week appeared to be associated with the lowest risk (p. 11) for ischaemic stroke: 32% lower compared to abstainers. A study with a Spanish population finds that consumption of up to 30 g/day of alcohol was protective against all stroke types combined (Caicoya, 1999, p. 677). A very recent systematic review and meta-analysis finds that consuming two drinks per day is associated with a reduced risk of ischaemic stroke (Petra et al, 2010). Most recently, Jimenez et al (2012, p. 939) find that Light-to-moderate alcohol consumption was associated with a lower risk of total stroke in women. A beneficial effect was observed for women who consumed up to 29.9g ethanol/day (approx. 3 standard drinks). However, there are also findings showing that heavy episodic and regular heavy drinking increases the risk of hemorrhagic stroke. Studies reporting psychological benefits and overall wellbeing related to moderate alcohol use are already listed on page 3 of this factsheet. 6

7 3 Alcohol consumption and certain alcohol related diseases KEY POINTS Moderate drinking has not been shown to increase the risk of chronic liver diseases; longer-term heavy drinking does. Per capita consumption appears to be relatively unrelated to overall chronic liver disease deaths: patterns of consumption and other factors appear to be more important. Alcohol-related liver diseases are divided into three subcategories: Fatty liver disease (reversible condition characterised by an accumulation of fatty tissue in the liver, causing liver enlargement). Alcoholic hepatitis (inflammation of the liver). Alcoholic cirrhosis (consequence of chronic liver disease where normal liver tissue is replaced by scar tissue). Standardised death rate for chronic liver diseases per 100,000 inhabitants Source: Eurostat 2010 (latest available data) <5 5, , , ,1 25 >25 EU figures show the changes in death rates per 100,000 inhabitants between 2006 and Liver diseases are usually the results of at least a decade of heavy drinking Moderate consumption is usually not associated with chronic liver diseases (American Liver Foundation (2007), National Institute for Diabetes and Digestive and Kidney Disease (2003), McCullough (1999), Szabo (2007). A recent meta-analysis by Rehm et al (2010) finds that the risk for chronic liver diseases would increase only with an alcohol intake above 36 grams per day for men (between 3 and 4 drinks) and 24g for women (between 2 and 3 drinks). Gunji et al (2009, p.2189) find that moderate alcohol consumption has no negative but rather beneficial consequences as regards fatty liver. They conclude that light ( g/week) and moderate ( g/week) alcohol consumption significantly and independently reduced the likelihood of FL [Fatty Liver]. Notice, about 10-15% of heavy drinkers develop cirrhosis, according to WHO (1990, p. 56). In 2010, 79,691 deaths caused by chronic liver disease were recorded in the EU, accounting for 1.6% of all-cause mortality. However, only a fraction of all chronic liver diseases are related to alcohol abuse, and this fraction differs from country to country. According to WHO, 10 to 15% of heavy drinkers develop cirrhosis. 7

8 3 Alcohol consumption certain related diseases In support of balanced health Per capita consumption does policies not adequately explain the disparities of chronic liver disease deaths among EU countries The chart below shows that chronic liver disease deaths are higher in Slovakia, Finland or Poland compared to Ireland, onic liver diseases France or but Demark, longer-term although heavy per drinking capita consumption is chronic liver significantly disease deaths: higher in patterns the latter of consumption countries. Sweden and other and Ireland have almost identical liver disease death rates but per capita consumption in Ireland was almost twice as Per high capita as in Sweden. consumption does not explain the disparities of chronic liver disease deaths among EU A comparison of Member States demonstrates that the link Member States between chronic liver disease and per capita consumption The chart appears below weak shows at best. that When chronic looking liver disease at individual deathsmember are higher in Slovakia, States Finland over or Poland time, compared per capita to Ireland, alcohol France consumption or Demark, and although per capita chronic consumption liver disease significantly deaths higher appear in the related latter countries. in some Sweden and Ireland countries have but almost not identical in others liver all. Chronic disease liver deathdisease rates but deaths per capita consumption might in be Ireland better was explained almost by twice factors as high other as in than Sweden. per capita A Member States consumption, (MS) comparisonamely demonstrates drinking that patterns the link such between as longer- and heavy per capita drinking, consumption and other is very contributing weak at factors, best. Chronic such liver chronic liver diseaseterm disease as deaths non-commercial might be better alcohol, explained poor by diet, other living factors conditions, than per capita consumption, health-care namely system, drinkingetc. patterns, (Szucs e.g. et al longer-term 2005). This heavy chart drinking, uses and other contributing 2006 data, factors, because such it covers as non-commercial more Member alcohol, States poor than diet, living conditions, the latest health-care data for system, etc. (see Szucs et al 2005). This chart uses 2006 data, because it covers more MS than the latest data for per capita consumption in litres of pure alcohol The above chart shows a very weak correlation between chronic liver disease deaths and per capita consumption in various EU MS at best (black line). It rather demonstrates the absence of a correlation, meaning that other factors are more important, such as patterns of drinking. The left chart map shows the standardised death rate for chronic liver diseases per inhabitants for different MS in 2010 (latest available data). Changes since 2006 are listed in the table (source: Eurostat). 8

9 3 KEY POINTS In 2010, around 4% of all cancer types are reported by the WHO to be alcohol related and alcohol related cancer deaths were responsible for 1.2% of all-cause mortality in the EU. Light drinkers appear to face a lower all-cancer mortality risk than abstainers: moderate drinkers appear to have the same all-cancer mortality risk as abstainers, according to the latest meta-analysis by Jin et al (2013). Selected cancer types: a literature review. About 8 of the estimated 200 cancers are reported to be alcohol related: alcohol intake increases the risk of those cancer types Overall, light drinkers seem to face a lower all-cancer mortality risk than abstainers and moderate drinkers appear to face no increased all-cancer mortality risk, according to the most recent meta-analysis by Jin et al (2013) covering cohorts from Asia, Europe and the US. Evidence suggests a connection between heavy alcohol consumption and increased risk for cancer, with an estimated 2 to 4 percent of all cancer cases thought to be caused either directly or indirectly by alcohol. A strong association exists between alcohol use and cancers of the oesophagus, pharynx, and mouth, whereas a more controversial association links alcohol with liver, breast, and colorectal cancers [National Institute on Alcohol Abuse and Alcoholism (1993), Rehm et al 2010, p.11, and Corrao et al (2004) meta-analysis]. According to Eurostat data, in 2010, alcohol related cancer deaths (lip, oral cavity, pharynx and oesophagus) accounted for 1.2% of all mortality causes in the EU (up to 5% if considering also controversially alcohol related cancer deaths such as breast, colon, liver and intrahepatic bile ducts). Alcohol related cancer deaths amounted to 4.4% of all cancer deaths (up to 18.7% when considering again the more controversially alcohol related cancer deaths). Light drinkers seem to face a lower all-cancer mortality risk compared to abstainers: moderate drinkers seem to face no increased risk Most cancer types are multifactoral diseases, which means that several factors may increase the risk of developing cancer, including, for example, smoking, unhealthy diet, certain infections, exposure to radiation, environmental pollutants, age, and/or genetic faults, amongst others. The pattern of consumption is of importance: mostly longer-term heavy drinking is considered as a risk increase for the few alcohol related cancers. Some studies find that moderate drinking reduces the risk of some cancer types while other studies find that even moderate drinking may increase the risk of a couple of cancer types such as female breast cancer (see literature review on the next page). 9 In 2013, a meta-analysis investigated the relationship between drinking and all-cancer mortality and finds a 9% reduced risk for light drinkers (approx. 1.5 standard drinks/day) and no risk increase for moderate drinkers (1.5 to 5 standard drinks/day). Note that Jin et al have a very generous definition of moderate drinking (1.5 to 5 drinks/day), as usually +2 drinks/day and +3 drinks/day are regarded as limits for women and men respectively. Jin et al (2013, p.807) conclude: This meta-analysis confirms the health hazards of heavy drinking ( 50 g/day) and benefits of light drinking ( 12.5 g/day). According to the most recent European study (consisting of EU-10 countries and people aged years) by Bergmann et al (2013), the relative risk of death from alcohol related cancers (p. 1782) was lower for men consuming up to 24g/ day compared to abstainers. For women, decreased risk of dying from alcohol related cancers was only observed up to 12g/day.

10 3 Literature review: effects of drinking on various Multiple myeloma selected cancer types in recent publications & meta-analyses Breast cancer Breast cancer is related to numerous risk elements (see American Cancer Society), some of which are unchangeable, such as age, genes, family history, personal history of breast cancer, ethnicity, dense breast tissue, menstrual periods, etc, and some are life-style related, such as having children, birth control, hormone therapy, breast feeding, obesity, physical activity, and alcohol consumption amongst others (see illustrating chart on the right). Most scientific studies find a linear dose-response risk relationship between alcohol consumption and breast cancer, meaning that even light alcohol intake represents a risk increase, though the size of the risk increase is relatively small. Lymphoma A recent meta-analysis by Tramacere et al (2012, p.2791) provides quantitative evidence of a favourable role of alcohol drinking on NHL risk. Klatsky et al 2009 conclude that alcohol drinking is associated with slightly lower risk for HM [hematologic malignancies] (p. 746). Prostate cancer Rota et al (2012) conclude their meta-analysis as follows: This comprehensive meta-analysis provided no evidence of a material association between alcohol drinking and prostate cancer, even at high doses (p. 350). Bladder cancer Bladder cancer The most recent met-analysis by Pelucchi et al (2012) concludes: This meta-analysis of epide absence of any material association between alcohol drinking and bladder cancer risk, even a Brain cancer A very recent meta-analysis by Galeone et al (2013) finds a 7% lower risk for drinkers comp lower risk for drinkers of developing meningioma compared to abstainers. The authors c associated with adult brain cancer, though a potential effect of high doses deserves further st Colorectal cancers Some studies show the risk of suffering from colorectal cancer does not increase with alcoho adjustment for age, sex, height and smoking status. For example, Park et al. (2009) investiga associated with increased risk of colorectal cancer (CRC) among a UK population ( consumption [up to 21 units/week compared with non-drinkers] was not associated with CRC height, and smoking status. [ ] No significant associations were observed between consump spirits) and CRC risk when compared with non-drinkers after adjustment for lifestyle and die population-based UK cohort, we did not find any significant adverse effect of alcohol over the [for men and women] (347). A recent meta-analysis by Rota et al (2014) attempts to assess the relationship between alc conclude: The present meta-analysis of published data found no strong association betwee Oesophagus, pharynx, and mouth cancers association favorable effect with emerged alcohol for moderate-to-heavy alcohol drinkers (p. 113). Pancreatic cancer Several factors increase the risk of the above cancer types, A recent such meta-analysis as age, family by history, Tramacere smoking, et al etc.: (2010) alcohol findsis that considered people who as one consume of up to 3 those risk factors. However, many studies only find an association pancreatics between cancer compared heavy alcohol to abstainers, intake and but the above risk increased listed cancer by 22% types. for people who For example, a very recent French study by Radoi et al Given (2013, the p.268) moderate concludes: increase alcohol in risk and drinking the low increased prevalence this of risk heavy only drinkers in heavy in most popul small fraction of all pancreatic cancers (1474). Rohrmann et al (2009) conclude that there drinkers who were also smokers. Also Takacs et al (2011) find an increased risk for heavy drinkers, but at the same time find that risk of pancreatic cancer (785). moderate alcohol consumption reduced the risk of oral cancer among women by 30%, compared to abstainers. Thyroid cancer A recent study by Meinhold et al (2010) finds that the thyroid cancer risk decreased with gre consumption) (1) and they conclude that there is a potential protective Breast cancer Increased age Radiation exposure, abortion, miscarriage Delayed child bearing Factors Influencing Initiation and Progression of Breast Cancer Environmental factors (BPA) WORLD SPIRITS ALLIANCE FORUM, July, 2013 The most recent meta-analysis by Pelucchi et al (2012) concludes: This meta-analysis of epidemiological studies provides definite evidence on the absence of any material association between alcohol drinking and bladder cancer risk, even at high levels of consumption (p. 1586). Diet Obesity dense breast tissue smoking BC Early menarche Delayed menopause Breast implants Shift work Signaling pathways Postmenopausal hormone therapy Epigenetics Oxidative stress Family history (genetics): BRCA1, BRCA2, TP53 FGFR2, TNRC9, MAP3K1, LSP1, CASP8, TGFβ1 18 Breast c (see Am unchang persona breast t life-style control, physical others scientifi relation breast c represe increase 10

11 3 Brain cancer A very recent meta-analysis by Galeone et al (2013) finds a 7% lower risk for drinkers compared to abstainers of developing glioma and a 29% lower risk for drinkers of developing meningioma compared to abstainers. The authors conclude: Alcohol drinking does not appear to be associated with adult brain cancer, though a potential effect of high doses deserves further study (p. 514). Colorectal cancers Some studies show the risk of suffering from colorectal cancer does not increase with alcohol consumption up to 21 units/ week, before or after adjustment for age, sex, height and smoking status. For example, Park et al (2009) investigate whether or not moderate alcohol consumption is associated with increased risk of colorectal cancer (CRC) among a UK population (24,244 participants). The authors find that total alcohol consumption [up to 21 units/week compared with non-drinkers] was not associated with CRC risk before or after adjustment for age, sex, weight, height, and smoking status. [ ] No significant associations were observed between consumption of specific alcoholic beverages (beer, sherry, or spirits) and CRC risk when compared with non-drinkers after adjustment for lifestyle and dietary factors (p. 347). Park et al conclude that in this populationbased UK cohort, we did not find any significant adverse effect of alcohol over the moderate range of intake on colorectal cancer risk [for men and women] (p. 347). However, a recent systematic review and meta-analysis by Zhu et al (2014) finds that alcohol intake is related to a significant increase of risk for colorectal adenoma (p. 325) a precursor of colorectal cancer. Multiple myeloma A recent meta-analysis by Rota et al (2014) attempts to assess the relationship between alcohol intake and cancer of plasma cells. The authors conclude: The present meta-analysis of published data found no strong association between alcohol drinking and MM risk, although a modest favorable effect emerged for moderate-to-heavy alcohol drinkers (p. 113). Pancreatic cancer A recent meta-analysis by Tramacere et al (2010) finds that people who consume up to 3 drinks/day had a reduced risk of 8% of developing pancreatic cancer compared to abstainers, but the risk increased by 22% for people who consumed more than 3 drinks/day. They conclude: Given the moderate increase in risk and the low prevalence of heavy drinkers in most populations, alcohol appears to be responsible only for a small fraction of all pancreatic cancers (p. 1474). Rohrmann et al (2009) conclude that there is no association of alcohol consumption with the risk of pancreatic cancer (p. 785). Thyroid cancer A recent study by Meinhold et al (2010) finds that the thyroid cancer risk decreased with greater alcohol consumption (2 drinks per day vs no consumption) (p. 1) and they conclude that there is a potential protective role (p. 1) of moderate alcohol consumption for both men and women. 11

12 4 Evidence in support of balanced health policies KEY POINTS The all-cause mortality risk is significantly lower for moderate drinkers compared to lifelong abstainers, according to the majority of all-cause mortality risk studies. Contemporary government recommended drinking guidelines appear to reflect the evidence on both adverse & beneficial health effects of drinking. Public health policy measures should be targeted & culturally/contextually sensitive. Lower all-cause mortality risk for drinkers, in particular moderate drinkers, compared to abstainers According to the vast majority of all-cause mortality risk studies, drinkers, and in particular moderate drinkers, face a significantly lower all-cause mortality risk compared to abstainers, also in studies that distinguish between former drinkers and abstainers (Fuchs et al 1995, Doll et al 2005, Sun et al 2011). Below, further studies with similar findings: Study Drinking quantity Risk reduction Bagnardi et al, Up to 6 drinks/ Protective effect 2004 day Gunzerath et al, 2004 Gaziano et al, 2005 Di Castelnuovo et al, 2006 Djousse et al, 2009 Up to 2 drinks/ day Highest protective effect 1 drink/day Highest protective effect Up to 2 drinks/ day (women) and 4 drinks/day (men) Up to 1,5 drinks/ day 18% for women, 17% for men 35% Lee et al, drink/day Highest effect: 28% Streppel et al, drinks/day 25% Costanzo et al, 2010 Ronksley et al, 2011 Up to 2,5 drinks/ day All drinkers together Highest effect 13% The latest meta-analysis by Di Castelnuovo et al 2006 concludes that: the benefit of light to moderate drinking remained in a range of undoubted public health value (15%-18%) (p. 2442). According to the most recent European study (consisting of 10 EU countries and people aged years) by Bergmann et al (2013), the all-causes of death among men (supplementary data p. 2) risk was lower for those consuming up to 45g/day compared to abstainers. The highest all-cause mortality risk reduction for women was achieved at a daily intake of 15g, according to Bergmann et al (2013). Drinking guidelines (e.g. from US, Canada or UK where systematic reviews have taken place) reflect the evidence on adverse & beneficial health effects of drinkings In light of the available scientific evidence, current drinking guidelines (where available) are well chosen to balance beneficial and negative impacts of alcohol consumption from a societal health perspective: three standard drinks/day for men and two standard drinks/day for women for otherwise healthy adults appear to optimize negative and beneficial aspects of drinking. Similarly, a peer-reviewed study by Gunzerath et al (2004) found that: The current scientific knowledge on the risks and benefits related to various levels of alcohol consumption does not suggest a need to modify the existing guidelines on moderate alcohol use (p. 841). Poli et al (2013) conclude: No abstainer should be advised to drink for health reasons [...] Moderation in drinking and development of an associated lifestyle culture should be fostered (p. 487). The most recent Swedish study by Bellavia et al (2014) finds that compared to abstainers, among women [ ] any category of alcohol consumption was associated with a substantially improved survival (p. 293). For men, improved survival materialised only up to 30g alcohol/day. Singling out the two main causes of deaths (cardio vascular disease and cancers), the authors find that compared to lifetime abstainers, women [consuming between 1-30g/d] had lower risk of both CVD and cancer mortality (p ). For men, consumption of 10-15g/day resulted in a 15% lower cancer risk mortality. 12

13 4 French case: High Council for Public Health In 2009, the French National Cancer Institute (INCa) sent a brochure to doctors all around the country entitled: Cancer nutrition and prevention, accompanied by a letter calling for alcohol abstention. Citing several scientific articles, it claimed that a single glass of alcohol per day could increase the risk of cancer. As a consequence, the Health Minister requested the High Council for Public Health (High Council) to assess the veracity of these facts and to release an opinion on whether the government should review its drinking recommendations. The High Council opinion concluded that the INCa brochure did not take beneficial health aspects of moderate consumption into account, especially as regards cardiovascular diseases and therefore advised public health bodies to look at the entire spectrum of diseases and evidence before drafting new policies. Furthermore, the High Council was concerned that the INCa message was not in line with overall public health objectives and that therefore the drinking guidelines of up to 2 drinks for women and up to 3 drinks for men should be maintained. Canadian case: The Canadian Centre on Substance Abuse Outside Europe, drinking guidelines were recently reassessed based on the available scientific evidence such as in Australia, the US and Canada. The Canadian Centre on Substance Abuse concluded that the low-risk drinking guidelines up to 2 standard drinks/day for women and up to 3 standard drinks/day for men with some non-drinking days per week to minimize tolerance and habit formation (Butt et al 2011, p. 8) are worth maintaining. Bergmann et al (2013), 80% of men and 88% of women were light to moderate alcohol users in the 10 EU countries covered by that analysis. There are also strong differences among Member States as regards moderate and problem consumption habits, e.g. 95% of Italians and 65% of Irish people fall into the moderate drinking group, according to EUROBAROMETER. Adequate health policy measures should not penalize the vast majority of responsible drinkers but target and help heavy episodic and longer-term heavy drinkers. Public health bodies should look at the entire spectrum of evidence before drafting policies. Public health policy measures should be targeted & culturally/context sensitive More than 82% of the EU population are moderate drinkers and less than 7% reported 5+ drinks consumption in one sitting at least once in the last 30 days, according to EUROBAROMETER Similarly, according to Health policy measures should fit to the cultural context. Finally, from a public health perspective, not only the positive and negative relative risks of various diseases need to be considered, but also the absolute risk, e.g. the frequency of a disease. 13

14 Bibliography The full bibliography related to this Factsheet is available at: spirits.eu spiritseurope rue Belliard, 12 Bte Brussels, Belgium Tel: + 32 (2) info@spirits.eu 14