To Drink or Not to Drink: That Is the Question

ALTHOUGH EPIDEMIOLOGY IS a highly respected and important branch of medicine and public health, many studies turn out to be confounded, of limited usefulness, or of little interest. However, the importance of the field is emphasized by the appearance of “black swan” events, defined as occurrences that are not expected, are unpredictable and have a significant impact. Examples include the relationship between smoking and lung cancer, the link between high serum cholesterol and atherosclerosis, and the risk of skin cancers from excessive exposure to sunlight. One of the most recent and potentially useful “black swans” relates to numerous epidemiological studies that demonstrate beneficial effects of moderate alcohol consumption. Many publications that have demonstrated a benefit of moderate drinking include the admonition that abstainers should not be encouraged to begin drinking alcoholic beverages because of the risk of alcohol abuse. However, the incidence of lifelong abstainers who begin drinking at the age of about 40 years and who then become chronic alcoholics is trivial (Grant and Dawson, 1997; Mahalick et al., 2013; Verges et al., 2012) and new drinking habits at that age would generally be restricted to the level of 1 standard drink (14 g ethanol [EtOH]) a day. This could take the form of an occasional cocktail, wine, or beer with dinner, etc. Considering the rates of absorption and metabolism of EtOH, blood alcohol levels should be too low to impair driving or other motor skills. In any event, any putative risk of excessive alcohol consumption by middle-aged abstainers should be measured against the benefits of moderate alcohol ingestion. The most important parameter to be considered is probably all cause mortality, although I list specific benefits in the following discussion.