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BMJ No 7123 Volume 315 Editorial Saturday 20/27 December Christmas 1997 issue
Festive cheer for all?Headaches for alcohol policymakersSee Clinical review, p 1664Christmas and alcohol are inextricably linked. But the evidence based party goer has to weigh up a complex body of research. Like smoking, heavy drinking increases the risk of death from many causes. However, as Sir Richard Doll points out on page 1664, there is now convincing evidence that one can reduce one's risk of heart disease by drinking a moderate amount each day in middle and old age.(1) For many people the emphasis on cardioprotective effects may bring reassurance, and for some this will be justified. For most people, however, the relevant comparison is not with non-drinkers but with "safe" drinkers.(2) From this viewpoint the excess of coronary heart disease deaths in non-drinkers is likely to be smaller than the excess of deaths from other causes in heavy drinkers. Furthermore, media euphoria over the cardioprotective effect obscures a more complex message. The evidence for a cardioprotective effect is largely based on studies of people aged over 40. Thus we do not know whether alcohol also reduces the relative risk of coronary heart disease in younger people. Even if it does, however, a reduction in risk becomes important only if the risk is significant to begin with, which is not the case for younger people. In this age group other causes of alcohol related death, especially accidents, are likely to outweigh any possible benefit. A message that appears to promote drinking also risks simply moving the distribution of existing drinkers to the right, increasing the proportion of heavy drinkers without changing the proportion of abstainers.(3) This possibility is supported by a recent survey of English regions which showed that the prevalence of heavy drinking was associated with average alcohol consumption but not with the proportion of abstainers.(4) Furthermore, there are still many gaps in our knowledge of the cardiovascular effects of very high levels of consumption. The associations observed in published cohort studies are inconsistent with the huge changes in mortality from circulatory disease associated with changes in alcohol consumption in Russia in the 1980s and 1990s.(5) It is at least plausible that the cohort studies tend to exclude those who drink very heavily, especially in binges, so that the risks of very heavy drinking are underestimated. In contrast, heavy binge drinking is so common in Russia that the effect emerges at a population level. The suggestion that the pattern of drinking may be important is supported by the Kuopio heart study, which found a sevenfold increase in the risk of fatal myocardial infarction among those drinking six or more bottles of beer in a single session.(6) While the health effects of alcohol consumption are much better understood than 10 years ago, the alcohol market is changing, with increasing numbers of sales outlets and promotion of new types of drink such as alcopops. This is against a background of evidence of increasing alcohol related harm, such as the rising death rate from cirrhosis in Britain.(7) International comparisons also give grounds for concern as a survey of European countries in 1993-4 found that the United Kingdom had some of the highest percentages of 15 year olds drinking at least once per week, with Wales having the highest levels seen anywhere.(8) Our increasing knowledge of the health effects of alcohol has raised almost as many questions as it has answered. As Doll notes, we now need to understand the balance of risks and benefits of different levels of drinking at different ages for both men and women and learn more about the cardiovascular effects of very heavy drinking. We also need to know more about how to change alcohol related behaviour. Is it possible to persuade older non-drinkers to drink a little for the benefit of their health, and is it possible to do this without increasing the number of people, especially teenagers, who drink at levels that are dangerous? Doll's message is clear: "In middle and old age some small amount of alcohol within the range of one to four drinks each day reduces the risk of premature death." (1) Researchers must now fill in the detail and help politicians in the difficult task of translating the evidence into an effective policy. Ian R White
Lecturer in medical statistics
References 1 Doll R. One for the heart.
BMJ 1997;315:1664-8.
2 Holman C D J, English D R. An improved aetiologic fraction for
alcohol caused mortality. Aust J Pub Health
1995;19:138-41.
3 Rose G, Day S. The population mean predicts the number of
deviant individuals. BMJ 1990;301:1031-4.
4 Colhoun H, Ben-Shlomo Y, Dong W, Bost L, Marmot M. Ecological
analysis of collectivity of alcohol consumption in England: importance
of average drinker. BMJ 1997;314:1164-8.
5 Leon D, Chenet L, Shkolnikov V M, Zakharov S, Shapiro J,
Rakhmanova
6 Kauhanen J, Kaplan G A, Goldberg D E, Salonen J T. Beer bingeing
and mortality: results from the Kuopio ischaemic heart disease risk
factor study, a prospective population based study. BMJ
1997;315:846-51.
7 World Health Organisation. Health for all
database. Copenhagen: WHO, 1997.
8 Harkin A M, Anderson P, Lehto J. Alcohol in Europe: a
health perspective. Copenhagen: WHO, 1995.
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