The Alcohol References
Here is an abridged form of them.
One person asked me to provide references about alcohol and longevity, or health in general. The evidence against alcohol isn’t anecdotal, it is robust. Substack is the perfect place to provide those references (below), and a summary of what the evidence shows. Others have in chats questioned why sometimes we, physicians, have advocated for alcohol in moderate amounts, and now many physicians advocate for abstinence.
While alcohol has been used throughout history as medicine, there are levels clearly toxic. Alcohol was used as a sedative when we surgeons had no anesthetic agents. Alcohol was one of the first muscle relaxants, as well as anxiety and depression. It was all we had, but medicine advances. Modern medicine has allowed us to replace alcohol with much better and more effective agents: we have safer drugs for anesthesia, muscle relaxation, pain relief, depression, and anxiety.
Attila the Hun died of cirrhosis from alcohol abuse in 453 AD. Socrates suffered from alcoholism, so did Alexander the Great. Hence, our knowledge of the addictive and morbid effects of alcohol has been documented along with history. The question is, where do we draw the line between dangerous levels of alcohol and a potential therapeutic level of alcohol, and does that line even exist.
Many nations have, at times, outlawed alcohol consumption. Often those movements were often tied to religious sects. The religious prohibition against alcohol has never helped reduce or eliminate alcohol consumption.
So over time, we have continued to study the use of alcohol to find the level where alcohol is safe and effective, and where it becomes toxic. Unfortunately, we are not finding that line - meaning, where alcohol might be effective, it is also toxic.
The Case Against Drinking Alcohol
The medical case against drinking alcohol centers on substantial health risks across multiple organ systems, with evidence indicating that no level of consumption is entirely safe [1-3]. Alcohol is the eighth leading cause of death in the United States, accounting for approximately 178,000 deaths annually, and contributes to over 200 health conditions [1-2].
Health Risks
Cancer Risk: Risk increases even at low consumption levels. Alcohol is a carcinogen associated with cancers of the oral cavity, pharynx, larynx, esophagus, colon, rectum, liver, and female breast, with breast cancer risk rising at less than one drink per day. Smokers who drink alcohol have an increased risk of head and neck cancers, cancers of the throat, and lung cancer. Alcohol is not only a direct cause of cancer, but also a promoter of cancer.
Cardiovascular Effects: These effects occur across all drinking levels. Even 1-2 drinks per day increases blood pressure, and less than one drink daily raises the risk of atrial fibrillation. More on this below.
Liver Disease: A major consequence, with 90-100% of heavy drinkers developing steatosis (fatty liver) , and 10-35% progressing to steatohepatitis (inflammed fatty liver) if drinking continues.
Other Organ Systems: Extensively affected, including gastrointestinal bleeding (43% increased risk with >2 drinks/day), pancreatitis, peripheral neuropathy, cognitive deficits, and increased suicide risk [1, 6-7].
The Global Burden of Disease Study 2020 found that the level of alcohol consumption minimizing health loss is zero standard drinks per week. The World Health Organization now states there is no safe level of alcohol consumption, reflecting the accumulating evidence that any alcohol use carries health risks that outweigh potential benefits for most populations.
Alcohol and the Mediterranean Diet Controversy
The role of alcohol within the Mediterranean diet remains highly controversial, with traditional observational studies suggesting benefits from moderate wine consumption but recent evidence increasingly challenging this view [1-3]. As a fan of the Mediterranean diet, I have seen these controversies played out in many lectures.
The Mediterranean diet traditionally includes low-to-moderate wine intake with meals (up to one glass daily for women, two for men), primarily red wine, as one component of the overall dietary pattern [1-3]. The one glass for women is a five ounce glass (12 grams of alcohol) - far smaller than what most will get from a glass of wine.
Observational studies have shown mixed results. Multiple cohort studies found that moderate wine consumption within a Mediterranean dietary pattern was associated with reduced cardiovascular mortality and all-cause mortality, with some suggesting wine’s polyphenol content (particularly resveratrol, quercetin, and catechins) may provide additional benefits beyond other alcoholic beverages [4-6]. One Italian study found that high adherence to both the Mediterranean diet and a Mediterranean alcohol-drinking pattern (regular, moderate intake with meals, avoiding binge drinking) appeared to mitigate harmful effects of alcohol on mortality risk.
However, the evidence for removing alcohol is strengthening. The Global Burden of Disease Study 2020 concluded that the level of alcohol consumption minimizing health loss is zero standard drinks per week. Even within the Mediterranean diet context, alcohol remains a Group 1 carcinogen associated with cancers of the digestive tract, liver, and breast, with risks beginning at less than one drink per day. The International Agency for Research on Cancer recommends abstention from alcohol regardless of dietary pattern.
The Mediterranean diet provides health benefits independent of alcohol. The protective cardiovascular and metabolic effects are primarily attributable to extra virgin olive oil, whole grains, legumes, nuts, fruits, and vegetables—all rich in polyphenols and other bioactive compounds without alcohol’s risks [2-3, 9]. An ongoing randomized trial (UNATI) enrolling over 10,000 current drinkers will directly compare abstention versus moderation advice to help resolve this controversy [1-2].
The current evidence suggests that the Mediterranean diet’s benefits do not require alcohol consumption, and other components can provide similar or superior health effects without the associated risks.
Alcohol and Pregnancy
No safe level of alcohol consumption during pregnancy has been established—any amount can potentially cause harm to the developing fetus [1-3]. The National Institute on Alcohol Abuse and Alcoholism and other major medical organizations recommend complete abstinence from alcohol throughout pregnancy and when attempting to conceive.
Risks at Low Levels: Even low levels of prenatal alcohol exposure are associated with adverse outcomes. Consumption of as little as one drink per day during any trimester has been linked to behavioral problems in offspring. Maternal consumption of three drinks per week early in gestation has been associated with reduced positive affect and impaired self-regulation in infants. Lower levels of alcohol exposure throughout pregnancy correlate with morphological, cognitive, and motor deficits [4-5].
Binge Drinking and Severe Outcomes: Binge drinking poses particularly severe risks, but harm can occur at any level of consumption. Alcohol exposure increases risks for miscarriage, stillbirth, and Sudden Infant Death Syndrome.
Fetal Alcohol Spectrum Disorders (FASD): The spectrum of potential fetal harm ranges from subtle neurodevelopmental effects to FASD, which affect an estimated 1-5% of U.S. first-graders and represent a leading cause of intellectual disability and birth defects.
For the mother, alcohol use during pregnancy carries the same health risks as in non-pregnant individuals, without any established threshold below which these risks disappear.
Alcohol and Cardiovascular Health
This is the time of year when Holiday Heart Syndrome begins to fill the emergency rooms. Alcohol consumption is associated with increased risk of atrial fibrillation, holiday heart syndrome, sudden cardiac death, and alcoholic cardiomyopathy through both acute electrophysiological effects and chronic structural remodeling. The relationship varies by consumption pattern and cardiac condition, with even low-to-moderate intake linked to some arrhythmias.
Atrial Fibrillation (AF)
Atrial fibrillation shows a dose-dependent relationship with alcohol, with no clear safe threshold identified [1]. Even consumption of less than one drink per day is associated with increased AF risk, and the relationship appears fairly linear without differential effects by beverage type [1-2]. Meta-analyses confirm that heavier consumption predicts heightened AF risk, while sustained moderate-to-heavy drinking over multiple years progressively increases risk in young adults [1, 3]. Meaning, the older you get, the more prone you are to atrial fibrillation.
A randomized trial demonstrated substantial AF burden reduction among those instructed to abstain from at least 10 drinks weekly, and continuous alcohol monitoring revealed heightened odds of AF occurring within hours of drinking [1].
Holiday Heart Syndrome
Holiday heart syndrome describes acute arrhythmias following binge drinking, most commonly AF but also other supraventricular arrhythmias and occasionally ventricular arrhythmias [4-5]. The MunichBREW II study found that clinically relevant arrhythmic episodes, including AF and ventricular tachycardias, occurred primarily during the recovery period following binge drinking rather than during active consumption [6]. The morning after hangover may include sudden cardiac death from an arrhythmia.
Sudden Cardiac Death (SCD)
Sudden cardiac death demonstrates a U-shaped relationship with total alcohol consumption, where consumption of less than 2-6 drinks per week is associated with lowest risk, but heavier intake increases SCD risk [8].
Alcoholic Cardiomyopathy
Alcoholic cardiomyopathy results from chronic heavy consumption through direct toxic effects. Alcohol kills heart muscle cells. This accounts for one-third of all non-ischemic dilated cardiomyopathy cases [10]. Think of this like a stretched out heart, with poor ability to pump blood. Chronic excess promotes atrial fibrosis (scaring of the filling chambers of the heart), left atrial enlargement, neurohormonal dysregulation, and endothelial injury [1, 4]. Importantly, abstinence or significant alcohol reduction can reverse systolic dysfunction in patients with alcoholic cardiomyopathy [9-10].
The American Heart Association emphasizes that heavier consumption (binge drinking or more than or equal to 3 drinks daily) is consistently associated with worse outcomes across all cardiovascular entities studied, while the risk associated with 1-2 drinks daily on AF remains uncertain and warrants further randomized trials [1]. And when we say 1 drink, we mean 12 grams of alcohol - not more.
Alcohol and Longevity
Mendelian randomization studies, which avoid confounding, show no protective effect. Genetic analyses demonstrate a linear increase in mortality risk with alcohol consumption, with no evidence of benefit at low intake levels (23,24). One such study found that alcohol consumption decreased lifespan by 1.09 years per logged drink per week, and 1.47 years in men, even after adjusting for smoking and education (23).
In spite of people in some small areas having modest drinking and longer lives, there is no evidence that alcohol is the reason. There is every reason to believe the opposite.
Caution
If you drink more than three drinks per day, and are considering quitting, please talk to your doctor. Stopping alcohol at those levels can lead to death, and should be done under medical supervision.
References
Piano, M. R., Marcus, G. M., Aycock, D. M., et al. (2025). Alcohol Use and Cardiovascular Disease: A Scientific Statement From the American Heart Association. Circulation, 152(1), e7-e21. doi:10.1161/CIR.0000000000001341.
Berger, D., De Aquino, J. P., Charness, M. E., et al. (2025). Common Alcohol-Related Concerns. National Institute on Alcohol Abuse and Alcoholism. Practice Guideline.
GBD 2020 Alcohol Collaborators. (2022). Population-Level Risks of Alcohol Consumption by Amount, Geography, Age, Sex, and Year: A Systematic Analysis for the Global Burden of Disease Study 2020. Lancet (London, England), 400(10347), 185-235. doi:10.1016/S0140-6736(22)00847-9.
GBD 2016 Alcohol Collaborators. (2018). Alcohol Use and Burden for 195 Countries and Territories, 1990-2016: A Systematic Analysis for the Global Burden of Disease Study 2016. Lancet (London, England), 392(10152), 1015-1035. doi:10.1016/S0140-6736(18)31310-2.
Levesque, C., Sanger, N., Edalati, H., et al. (2023). A Systematic Review of Relative Risks for the Relationship Between Chronic Alcohol Use and the Occurrence of Disease. Alcohol, Clinical & Experimental Research, 47(7), 1238-1255. doi:10.1111/acer.15121.
Jeste, D. V., Lieberman, J. A., Fassler, D., et al. (2022). Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association. Practice Guideline.
Meza, V., Arnold, J., Díaz, L. A., et al. (2022). Alcohol Consumption: Medical Implications, the Liver and Beyond. Alcohol and Alcoholism (Oxford, Oxfordshire), 57(3), 283-291. doi:10.1093/alcalc/agac013.
Barbería-Latasa, M., Gea, A., & Martínez-González, M. A. (2022). Alcohol, Drinking Pattern, and Chronic Disease. Nutrients, 14(9), 1954. doi:10.3390/nu14091954.
Santos-Buelga, C., González-Manzano, S., & González-Paramás, A. M. (2021). Wine, Polyphenols, and Mediterranean Diets. What Else Is There to Say?. Molecules (Basel, Switzerland), 26(18), 5537. doi:10.3390/molecules26185537.
Gosdin, L. K., Deputy, N. P., Kim, S. Y., Dang, E. P., & Denny, C. H. (2022). Alcohol Consumption and Binge Drinking During Pregnancy Among Adults Aged 18-49 Years - United States, 2018-2020. MMWR. Morbidity and Mortality Weekly Report, 71(1), 10-13. doi:10.15585/mmwr.mm7101a2.
Breitkopf, D. M., & Hill, M. (2019). Prepregnancy Counseling. American College of Obstetricians and Gynecologists. Practice Guideline.
Wozniak, J. R., Riley, E. P., & Charness, M. E. (2019). Clinical Presentation, Diagnosis, and Management of Fetal Alcohol Spectrum Disorder. The Lancet. Neurology, 18(8), 760-770. doi:10.1016/S1474-4422(19)30150-4.
Hasin, D., & White, A. (2025). Varied Vulnerability to Alcohol-Related Harm. National Institute on Alcohol Abuse and Alcoholism. Practice Guideline.
Oei, J. L. (2020). Alcohol Use in Pregnancy and Its Impact on the Mother and Child. Addiction (Abingdon, England), 115(11), 2148-2163. doi:10.1111/add.15036.
Han, M., Lee, S. R., Choi, E. K., et al. (2022). Habitual Alcohol Intake and Risk of Atrial Fibrillation in Young Adults in Korea. JAMA Network Open, 5(9), e2229799. doi:10.1001/jamanetworkopen.2022.29799.
Gupta, S., Ahimsadasan, N., Dalsania, K., et al. (2025). Alcohol and Cardiovascular Disease. The American Journal of Cardiology. doi:10.1016/j.amjcard.2025.09.035.
Manolis, T. A., Apostolopoulos, E. J., Manolis, A. A., Melita, H., & Manolis, A. S. (2022). The Proarrhythmic Conundrum of Alcohol Intake. Trends in Cardiovascular Medicine, 32(4), 237-245. doi:10.1016/j.tcm.2021.03.003.
Brunner, S., Krewitz, C., Winter, R., et al. (2024). Acute Alcohol Consumption and Arrhythmias in Young Adults: The MunichBREW II Study. European Heart Journal, 45(46), 4938-4949. doi:10.1093/eurheartj/ehae695.
Brunner, S., Winter, R., Werzer, C., et al. (2021). Impact of Acute Ethanol Intake on Cardiac Autonomic Regulation. Scientific Reports, 11(1), 13255. doi:10.1038/s41598-021-92767-y.
Tu, S. J., Gallagher, C., Elliott, A. D., et al. (2022). Alcohol Consumption and Risk of Ventricular Arrhythmias and Sudden Cardiac Death: An Observational Study of 408,712 Individuals. Heart Rhythm, 19(2), 177-184. doi:10.1016/j.hrthm.2021.09.040.
Heymans, S., Lakdawala, N. K., Tschöpe, C., & Klingel, K. (2023). Dilated Cardiomyopathy: Causes, Mechanisms, and Current and Future Treatment Approaches. Lancet (London, England), 402(10406), 998-1011. doi:10.1016/S0140-6736(23)01241-2.
Day, E., & Rudd, J. H. F. (2019). Alcohol Use Disorders and the Heart. Addiction (Abingdon, England), 114(9), 1670-1678. doi:10.1111/add.14703.
. Impact of Alcohol Consumption on Lifespan: A Mendelian Randomization Study in Europeans.
Jiesisibieke ZL, Schooling CM.
Scientific Reports. 2024;14(1):25321. doi:10.1038/s41598-024-73333-8.
Kassaw NA, Zhou A, Mulugeta A, et al.
International Journal of Epidemiology. 2024;53(2):dyae046. doi:10.1093/ije/dyae046.
I will never understand how any woman can drink during her pregnancy. It’s infuriating to me. Everything you consume goes to the baby. Nothing bypasses them.