The Conflict Between Public Health Goals and the Temperance Mentality

Indeed, the "red wine paradox" — noted in France, where much red wine is drunk and French men have a substantially lower death rate from heart disease than do American men — has been the most popular version of the positive effects of alcohol, particularly since 60 Minutes featured a segment on this phenomenon in 1991. However, Protestant-Catholic, Northern-Southern European, dietary and other differences correspond with red wine consumption and confuse efforts to account for specific differences in disease rates. Furthermore, epidemiological studies have not found that the form of alcoholic beverage affects heart disease rates.

Does Alcohol Prevent Cardiovascular Disease? If So, at What Levels of Drinking?

The depth of American antialcohol feeling is expressed in the controversy over alcohol's protective effect against coronary artery and heart disease (both terms, which have the same meaning, are used by the authors discussed in this article). In a comprehensive 1986 review, Moore and Pearson¹⁶ concluded, "The strength of existing evidence makes new and expensive population-based studies of the association of alcohol consumption and CAD [coronary artery disease] unnecessary." Nonetheless, in a 1990 article on the negative effects of alcohol for the cardiovascular system based primarily on alcoholic drinking, Regan¹⁷ declared "a preventive effect of mild to moderate drinking on coronary artery disease is, at present, equivocal, largely due to the question of appropriate controls." The primary justification for this doubt has been the British Regional Heart study, in which Shaper et al.¹⁸ found that non-drinkers were at minimal risk for coronary artery disease (as opposed to ex-drinkers, who were older and who may have quit drinking due to health problems).

Nearly one of two people in the United States dies of cardiac causes. Two thirds of these deaths are due to coronary artery disease, which is caused by the fatty deposits in the blood vessels characteristic of atherosclerosis. The less common forms of cardiovascular disease include cardiomyopathy and ischemic (or occlusive) stroke and hemorrhagic stroke. Ischemic (occlusive) stroke behaves like coronary artery disease in response to drinking.^19,20 Nonetheless, all other sources of cardiovascular mortality taken together increase at lower levels of drinking than does coronary artery disease.²⁰ The most likely mechanism in alcohol's positive effect on coronary artery disease is that it increases high-density lipoprotein (HDL) levels.²¹

Following are the conclusions of research on the relationship of drinking to coronary artery disease:

1. Alcohol reduces CAD substantially and consistently, including incidence, acute events, and mortality. The large population multivariate prospective studies on alcohol and coronary artery disease reported since the 1986 Moore and Pearson review¹⁶ include those shown in Tables 2 and 3,^19-23 along with the American Cancer Society study.²⁴ These six studies had populations in the tens and even hundreds of thousands; taken together, they numbered about a half million subjects of varying ages, both genders, and different economic and racial backgrounds — including groups at high risk for coronary artery disease. The studies were able to adjust for concurrent risk factors — including diet, smoking, age, high blood pressure, and other medical conditions — and to allow for separate analyses of lifetime abstainers and ex-drinkers,^20,23 drinkers who reduced their consumption for health reasons,¹⁹ all nondrinkers,²² and coronary artery disease risk candidates.^20,21 The studies consistently found coronary artery disease risk is reduced by drinking. Taken together, they make the risk-reduction link between alcohol and coronary artery disease close to irrefutable.
2. An inverse linear relationship between drinking and coronary artery disease risk through the highest levels of drinking has been observed in large-scale multivariate studies. Studies adjusting risk of coronary artery disease for concurrent risk factors correlated with drinking level, such as high-fat diets^19,22 and smoking, indicate that risk is reduced at higher levels of drinking than previously thought. Relative to abstinence, more than two drinks daily optimally reduced risk for coronary artery disease (by 40% to 60%) (Table 2). This protective effect is robust even at the level of six drinks or more, although the Kaiser²⁰ and American Cancer Society²⁴ mortality studies showed an upturn in coronary disease risk at higher levels of drinking (see Table 3 for the Kaiser²⁰ findings). Although the American Cancer Society study of 276,802 men reported a lesser degree of risk reduction from drinking, the study is anomalous in its remarkably high abstinence rate of 55% (twice the rate for men reported by the Gallup survey⁶).
3. Overall mortality risk levels off at three and four drinks daily, owing to the rise in other causes of death, such as cirrhosis, accidents, cancer, and cardiovascular diseases other than coronary artery disease such as cardiomyopathy^20,24 (see Table 3 for Kaiser²⁰ findings). However, some major sources of alcohol-related death in the United States — such as accident, suicide, and murder — vary from society to society and are not inevitable consequences of high levels of drinking. For example, different policies towards drinkers can reduce drinking accidents,²⁵ and violence towards oneself and others cannot be shown to be a result simply of a chemical reaction called "alcoholic disinhibition."²⁶
4. Style, mood, and setting elements of drinking can affect the health consequences of drinking as much as the amount of alcohol consumed. Little epidemiologic attention has been given to patterns of drinking, although one study found that binge drinking led to more coronary occlusions than regular daily drinking.²⁷ Harburg and associates have shown that mood and setting when drinking are better predictors of hangover symptoms than is the amount of alcohol consumed,²⁸ and that hypertension can be better predicted from a drinking measure including psychosocial variables than solely from amount of alcohol consumed.²⁹
5. The beneficial effects of drinking extend to all population and risk categories, including those who are at risk for and those who have symptoms of coronary artery disease. Suh et al.²¹ found a reduction of coronary artery disease mortality in asymptomatic men at risk for coronary artery disease. Klatsky et al.²⁰ found even greater than average reduction of risk of coronary artery disease mortality from drinking for women and elderly subjects. For patients who were either at risk or symptomatic for coronary artery disease, coronary artery disease mortality was reduced by consumption of up to six drinks daily and optimal risk reduction was achieved at three to five drinks per day (Table 3). These results indicate a powerful secondary prevention benefit from drinking for coronary artery disease patients.

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