Critique 029: What should we advise about alcohol consumption? A debate amongst scientists
A Letter to the Editor entitled "What should we advise about alcohol consumption?" was recently published by Maurizio Ponz de Leon in Intern Emerg Med.1 Dr. de Leon argues that the message of health benefits of moderate drinking "seems to me hazardous and extremely dangerous to diffuse in the general population." His reasons included (1) many people may be unable to distinguish between lowmoderate and high consumption of wine, beer or spirits, and alcohol metabolism may differ remarkably from one subject to another; (2) alcohol remains a frequent cause of car crash, and governments (in almost all western countries) try to convince or force people to abstain from drinking before driving; and (3) to consider alcohol as a medication whose consumption may contribute to improved health is another source of concern. Dr. de Leon asks: "Are we truly at the point of prescribing alcohol consumption in order to reduce the risk of stroke and coronary damage?" He concluded "more studies are needed before we can give sensible recommendations on alcohol consumption to the general population."
The de Leon editorial has prompted considerable response from other scientists, including further Letters to the Editor of the journal by Di Castelnuovo, Costanzo, Donati, Iacoviello, and de Gaetano,2 and by Estruch and Lamuela-Raventos.3 In addition, the original editorial has stimulated considerable debate among members of the International Scientific Forum on Alcohol Research. Among key arguments presented by the Forum members, all experts in scientific research on alcohol, are that messages to the public should not be "paternalistic" (we will tell you what is best for you since you are not smart enough to understand the facts), and that guidelines must always be based on sound, balanced scientific data rather than on uninformed opinion. Forum members emphasized that there are certain people who should not drink at all (including former abusers of drugs or alcohol, people with certain medical conditions, children and adolescents, and people with religious or moral proscriptions against alcohol), and there can never be a general recommendation for everybody to consume alcohol. On the other hand, physicians should not withhold from their patients and the public scientifically sound and balanced data on alcohol and health. And the data are extremely strong supporting a role for moderate alcohol intake, for appropriate adults, for the reduction in risk of coronary artery disease and other diseases of ageing.
Several Forum members pointed out that it was unfortunate that the journal had chosen to publish the original letter that castigates alcohol from an author with good scientific credentials, but little to no apparent research expertise in the subject of alcohol and health. Many Forum members disagreed with the statement of de Leon that "Many people may be unable to distinguish between lowmoderate and high consumption of wine, beer or spirits." A leading scientist dealing with this subject for decades, Dr. Arthur Klatsky, has written: "Most people know very well what the difference is between light to moderate drinking and binge or excessive drinking. While some patients may rationalize their heavy drinking because of its purported health effects, I have yet to find someone who had developed alcohol abuse because of messages about the health effects of moderate drinking." Medical practitioners, in his view, "have a 'solemn duty' to tell the truth about alcohol consumption, as they understand it, to all of their patients." While pointing out that certain individuals will not benefit from the consumption of alcohol, several Forum members believed that it would be unethical for physicians to withhold from middle-aged or elderly subjects at risk of cardiovascular disease information on the potential benefits of light-to-moderate drinking