Earlier this month, Lucile Randon – at 118 years, the world’s oldest person – died in Toulon, France. Born in 1904 and also known as Sister André of the Catholic religious order Daughters of Charity, Randon survived two World Wars, a Great Depression and a global pandemic; in 2021, she recovered from a three-week bout of Covid-19.
What was the secret to her spectacular longevity? No doubt Randon benefitted from good genes, a simple diet and the meaningful life of a nun. But according to staff at her nursing home, she also enjoyed a few indulgences, notably a fondness for chocolate and a daily glass of wine. And while that may seem delightfully charming for someone who dedicated her life to helping others, according to just-released recommendations for Canadians’ alcohol consumption, those seven glasses of wine per week thrust Randon into the “high risk” category for alcohol-related health problems.
According to Canada’s self-declared experts on the dangers of drinking, anything more than two drinks per week puts every adult at risk of a long list of health perils, including numerous cancers, pancreatitis, hemorrhages, epilepsy and tuberculosis, as well as many grave non-medical calamities such as road injuries, accidents and domestic violence. It’s a grim report that boasts loudly of being built upon a foundation of literally thousands of scientific studies. And it is meant to shock Canadians into drastically reducing their alcohol consumption. Why, just think how long Sister André could have lived had she been told to stay off the booze.
Any Amount is Too Much
On January 17, the Canadian Centre on Substance Use and Addiction (CCSA) released its final recommendations for updating Canada’s existing Low Risk Drinking Guidelines. Current guidelines, established in 2011, recommend that Canadian men drink no more than 15 standard alcoholic beverages per week and women, 10. (A standard drink in Canada comprises one 341 ml bottle of beer, a 5 oz. glass of wine or a 1.5 oz. shot of hard liquor.) The CCSA wants to change that. Its new Guidance on Alcohol and Health claims that anything more than two drinks per week poses a clear health risk for adults of either sex. Three to six drinks per week puts drinkers in the “moderate risk” zone. Anything more – such as Sister André’s daily glass of wine – is deemed “increasingly high risk.” The CCSA’s new proposed standard would thus take the current safe drinking maximum of no more than two drinks per day and lower it to two per week.
“Fundamentally, no amount of alcohol is entirely safe,” advises Peter Butt, co-chair of the CCSA’s latest alcohol guidance effort and Associate Professor of Academic Family Medicine at the University of Saskatchewan. “Therefore, we need to inform Canadians about the risk they are taking when they consume alcohol.”
In making the case that the wisest amount of beer, wine or spirits is none at all, Butt goes to great lengths to stress the science behind his view. In an interview, he explains that the revised standards are based on a systematic review of almost 6,000 peer-reviewed academic studies, with “the best quality evidence” selected for use in modelling the effects of drinking on human health. Based on this rigorous approach, he dismisses as a myth the commonly-held notion that moderate amounts of alcohol can have a beneficial impact on your overall physical health or well-being.
Rather, Butt asserts, the inescapable conclusion is that every drink you take brings you inexorably closer to cancer and a wide range of other terminal diseases. It is a deliberate strategy meant to shock Canadians into reconsidering their entire relationship with alcohol. “We know these numbers will be challenging for some people,” he says. “It’s going to create discomfort.” But, he stresses once again, “This is a scientific document.”
Despite Butt’s conviction, however, many other experts express serious concerns about how scientific or conclusive the CCSA’s claims really are. Or how relevant Canadians should consider these alleged health risks. The addiction research community is often accused of harbouring a strong bias towards abstinence and, as we shall see, there’s plenty of evidence to support such skepticism buried in these new guidelines. It is also possible to see the stirrings of a new anti-alcohol public health narrative based on the previous, and highly successful, campaign against tobacco. Whatever the urge behind it, the purveyors of these new recommendations seem determined to stop Canadians from enjoying themselves.
Canada’s current Low Risk Drinking Guidelines were created by the CCSA, an independent research and advocacy agency primarily funded by Ottawa, in 2011. The recommended 15 drinks per week for men and 10 for women were in line with most other countries’ standards. And the guidelines fit with how most Canadians view alcohol; 83 percent of adults say they conform to these weekly limits.
This first set of guidelines thus embraced a strong sense of balance. While noting that alcohol is implicated in many serious diseases and issues, the 2011 CCSA study reported “that there is also evidence of health benefits in relation to diabetes and some cardiac diseases.” The 15/10 drinks per week rule for men and women was selected because that was the point at which the “potential health risks and benefits from drinking exactly cancel each other out.” One or two drinks per day was, in essence, the sweet spot for drinking. The old rules even acknowledged that it was okay to have a few more on special occasions, recognizing the role alcohol plays in significant cultural and social events.
“It was a reasonable set of guidelines,” says Dan Malleck, Professor of Health Sciences at Brock University in St. Catharines, Ontario who studies the history of liquor regulation. “It generally reflected global standards and it was scientifically credible because it recognized both sides of the debate,” that is the risks and benefits of alcohol consumption. “It basically said, ‘Enjoy in moderation but don’t go crazy.’” As Malleck notes in an interview, this sense of equilibrium has disappeared entirely from the new CCSA recommendations. In its place is the notion that every drink you take is a step closer to your grave.
Butt admits the CCSA’s latest recommendations – which have not yet been adopted by Ottawa as official policy – are substantially different in tone and content from the earlier report, which he also wrote. “The evidence has shifted considerably in the last 10 to 11 years,” he insists. That review of nearly 6,000 recent studies revealed substantial new health risks arising from drinking, he says, in particular seven forms of cancer and various other deadly diseases and consequences. The notion of a health benefit from moderate alcohol has also been conclusively demolished during this time. Finally, he notes that many other countries are also reducing their recommended drinking levels in similar fashion.
How Many Studies?
Drawing attention to Butt’s claim that the CCSA is merely following the latest science on drinking, the notion that this work is based on almost 6,000 scientific studies has become central to the narrative of the new recommendations. This factoid has been repeated in numerous media reports. The CCSA document itself touts “a total of 5,915 systematic reviews” (emphasis in original) were involved in preparing the final report. And yet, as Malleck notes, of these 5,915 studies, no fewer than 5,899 – or 99.7 percent – were eventually discarded by the CCSA researchers. “They whittled the list down to just 16 studies,” Malleck states. Butt acknowledges this fact, claiming the elimination process was meant to ensure only the “best quality” studies were incorporated in the final product. The fact the CCSA’s proposals to radically remake how Canadians regard and consume alcohol are ultimately based on just over a dozen studies is not highlighted in bold anywhere in the document.
Based on the evidence of these 16 studies, as well as previous research from Australia when that country reviewed its drinking guidelines in 2017, the report lays out the terrible toll purportedly wrought by alcohol use in Canada. This includes 18,000 deaths per year, of which 7,000 are cancer deaths. Risk tables add further detail to this grim proposition: just one drink per day raises your risk of oral or pharynx cancer by 37 percent, colorectal cancer by 9 percent and epilepsy by 18 percent. Three drinks per day doubles your risk of tuberculosis (TB).
All this may be scientifically correct. But is it useful? Malleck points out that many of the cancers and other conditions listed by the CCSA are quite rare and/or confounded by factors other than alcohol use. TB, for example is most prevalent in Africa, where it is driven by the confluence of poverty, inadequate housing and high HIV infection rates. According to the single research study cited by the CCSA as the authority on this condition, the rate of TB per 100,000 in South Africa is 251.7. In Canada, it’s 1.8. At three drinks per day, a Canadian “might be twice as likely to get TB, but you still have a very, very slight chance per million of getting it. Is this really worth freaking out about?” Malleck asks.
Malleck criticizes the CCSA for focusing exclusively on relative rather than absolute risks. Instead of explaining the overall (or absolute) odds a person might face for getting a certain disease based on their drinking habits, the CCSA report instead looks at how those chances increase with each drink consumed. This effect may be measurably positive, but it is also generally very tiny and quite possible irrelevant for most Canadians. It also pre-determines a result claiming to “prove” drinking raises health risks. Placing a big focus on miniscule risks in this way deliberately “generates a sense of panic that completely distorts the evidence,” Malleck adds. “The red flag of cancer can be very scary for people. And while I don’t want to negate the horrible toll of cancer, to say that alcohol is ‘causing cancer’ is a huge distortion.”
And despite the fact the CCSA piggy-backed on earlier Australian research, the outcome seems far more generous Down Under. “To reduce the risk of harm from alcohol-related disease or injury, healthy men and women should drink no more than 10 standard drinks a week and no more than 4 standard drinks on any one day,” state the Australian Guidelines to Reduce Health Risks from Drinking Alcohol. And while an Australian standard drink is slightly smaller than a Canadian drink, these guidelines make no mention of any two-drink per week maximum.
France also has a “least risk” 10 drink per week standard, although it suggests skipping at least one day each week. In the United States, the 2020-2025 Dietary Guideline recommends no more than 14 drinks per week for men and seven for women, quite similar to Canada’s current (though perhaps soon-to-be discarded) guidelines. This U.S. standard was developed by the National Institute for Alcohol Abuse and Alcoholism in Bethesda, Maryland, widely regarded as the world’s premier alcohol harms research organization. The concept of a two-drink per week maximum is a unique Canadian contribution to a modern-day revival of the Temperance movement.
The Tobacco Playbook
Beyond seeking to establish new and dramatically lower guidelines for drinking, the CCSA report also calls on governments to implement a comprehensive bottle-labelling strategy to inform Canadians about the amount of alcohol in their beverages. Of course, all alcoholic beverage containers sold in Canada already plainly state the alcohol percentage within. Butt, however, claims there’s substantial confusion about what constitutes a “standard drink” and so Canadians need better information.
It barely needs stating that the hugely successful public health campaign against smoking also began with basic warning labels. This has since grown to require that pictures of diseased lungs and other horrifying images take up most of the exterior of cigarette packaging. Butt claims he has no immediate plans to demand “pictures of cirrhotic livers on beer cans.” Yet he also says, “It seems only reasonable for Canadians to be informed that this product, which is heavily regulated and intended to be ingested, is actually carcinogenic.”
The CCSA’s special emphasis on cancer is again reminiscent of earlier anti-tobacco lobbying. Note also that the Canadian Cancer Society is currently promoting Dry February (in addition to other organizations advocating Dry January) as a way of inserting itself into a national conversation about alcohol. This despite the enormous differences between tobacco and alcohol – nine of every ten cases of lung cancer are attributable to smoking whereas the CCSA report shows most cancer risks arising from alcohol to be vanishingly small. Malleck observes that “it is not lost on the public health establishment that it was cancer that brought the tobacco industry to its knees. And here we have another big industry allegedly trying to kill us all.” These initial demands for labelling are “one more step in the demonization of drinking,” he snaps.
The CCSA’s report is also noteworthy for the amount of space it allocates to the purported role of alcohol in domestic violence, car accidents and other injuries. There is an entire section entitled Women’s Health and Alcohol with subsections on Intimate Partner Violence, Sexual Violence and Victimization and the claimed connection to men’s drinking. The point being made here is that the risks of alcohol are not limited to the drinker, but are likely to harm others not directly participating in the risky behaviour. This focus on non-drinkers again finds an equivalent in the debate over second-hand smoke. Drinking is being reframed from something that was until now considered to be an individual choice that could, under certain circumstances, cause individual harms into something that causes harm not only to the user but to innocent others as well. Butt doesn’t dispute this analogy, or the potential solutions. “There are certainly aspects of the industry playbook and the public health playbook that parallel alcohol and tobacco,” he admits.
Twisting the J-Curve
The fact Randon and many other exceptionally long-lived individuals drank in moderation is not a new or surprising phenomenon to the medical profession. That moderate drinkers appear to live longer and have better heart health than either extreme – abstainers or heavy drinkers – was first proposed by pioneering biostatistician Raymond Pearl of Johns Hopkins University in his 1926 book Alcohol and Longevity. This relationship is often referred to in the medical community as a “curvilinear relationship between drinking over time and mortality risk,” or more colloquially as the “J-Curve” due to the graphical shape of the relationship. The base of the J reflects the fact moderate drinkers (usually defined as one or two drinks per day) tend to live a little bit longer than abstainers and quite a bit longer than bingers.
Father of the J-Curve: American biostatistician Raymond Pearl first reported the positive effects of moderate drinking on lifespan in his 1926 book Alcohol and Longevity.
There are numerous medical reasons for the J-Curve’s long track record. With respect to heart health, the presence of ethyl alcohol chemically reduces plasma viscosity and platelet aggregation (affecting clotting ability), improves various cellular functions and relaxes the arteries. All this is beneficial for avoiding or surviving heart attacks. Alcohol also offers an apparent protective effect for diabetes, improves a body’s response to vaccinations and otherwise aids the immune system. The presence of a J-Curve when measuring human longevity, rather than just susceptibility to particular diseases, may also signal the fact that people who drink moderately tend to be moderate in other aspects of their life as well, reflecting the ancient Greek philosopher Aristotle’s doctrine of the Golden Mean. Regardless of its causality, this concept was fully embedded in Canada’s 2011 drinking guidelines.
The new CCSA report does the exact opposite – it declares a direct assault on the very existence of the J-Curve. While Butt allows that this topic is “hotly debated,” he says CCSA research rejects any evidence of curvilinear associations. “We did not observe a J-shape curve,” the report states firmly. Butt suggests the beverage industry is largely to blame for the perpetuation of this now-discredited concept. “It is interesting how much industry has invested in the promotion of the J-Curve,” he argues. “You just have to dig deeper into who is funding the research.” (Allegations that industry is actively suppressing or manipulating the research on alcohol can be considered another parallel with the war on tobacco.)
In sorting through 6,000 scientific studies to find the single “best quality” research on alcohol and its effect on coronary heart disease the CCSA settled on a 2017 paper from the Journal of Studies on Alcohol and Drugs by two researchers at the University of Victoria and three international co-authors. As with the other 15 studies the CCSA relied upon, this is a meta-analysis – a study of other studies. And it is noteworthy for claiming to disprove the existence of the J-Curve. “Our major conclusion is that the hypothesis that low-volume alcohol use can confer cardio-protection cannot be confirmed,” the authors state.
Curiously enough, when the researchers considered the accumulated evidence of the 45 studies they collected, dating from 1980 to 2016 and covering nearly 3 million individuals, the results actually contradict their own conclusions. The pooled data show, they admit, “significantly decreased risk of coronary heart disease among male drinkers who drank [up to three drinks] per day and female drinkers who drank [up to two drinks] per day.” That’s right, the paper initially confirms the existence of the J-Curve for heart health. As critics of the paper have since pointed out, only after torturing the data with “flawed…and improper” statistical methods that separate Asian from white subjects, among other adjustments, are the authors finally able to wave away the J-Curve.
This less-than-convincing conclusion is belied by a host of other academic studies, some more recent than 2017, that come to an entirely different conclusion:
- A 2006 meta-analysis of 34 studies collectively including more than 1 million subjects found “Low levels of alcohol intake (1-2 drinks per day for women and 2-4 drinks per day for men) are inversely associated with total mortality in both men and women.”
- A 2010 study following 1,824 middle-aged subjects over the span of two decades found “even after adjusting for all covariates, accumulated risk for abstainers and heavy drinkers remains consistently higher across 20 years than that for light and moderate drinkers.”
- A 2018 study of subjects over the age of 90 at the University of California Irvine found that “consuming about two glasses of beer or wine daily was associated with 18% reduced risk of premature death.”
- A 2018 PLOS Medicine study reported “J-shaped associations were observed between average lifetime alcohol consumption and overall mortality, cardiovascular-related mortality and combined risk of death or cancer.”
- A 2021 study in BMC Medical covering over 48,000 men and women found that “Alcohol consumption was associated with all assessed outcomes in a J-shaped manner.” It found a protective effect for heart health from alcohol of up to several drinks per day.
- A 2022 study covering nearly half a million Taiwanese adults concluded that “modest drinking is associated with significantly reduced risk of all-cause mortality” as well as a reduction in a host of specific diseases included diabetes, heart disease, respiratory disease and suicide. One drink per day, what the CCSA’s new guidelines consider “high risk,” was associated with an increased life expectancy of nearly one year. “It appears that a little drinking could be better than none,” it concludes.
“As a cardiologist, I can tell you that there are hundreds of well-done studies that repeatedly show a J-Curve,” says Martin Juneau, the former director of prevention at the Montreal Heart Institute and Professor of Medicine at Université de Montréal. Juneau readily admits that alcohol is not beneficial for all heart conditions, including arterial fibrillation or high blood pressure. He also frets about his patients who over-indulge. “But,” he says, “if you want to prevent heart attacks, which is always the number one concern, then alcohol is protective.” He points to several data tables in the CCSA report that actually prove his point on heart health (see Tables 1-4, pages 25-28), despite the overall message being entirely contradictory.
Juneau echoes Malleck’s complaints about the CCSA’s focus on relative rather than absolute risks, calling the report’s deliberate choices in this regard “bad science.” Disputing the notion of a mortal threat arising from every drink taken, Juneau considers the health risks to be “very, very slight until you get to about 14 drinks per week. And after that, it takes off really quickly.” In other words, the real health concern from alcohol is binging, not moderate use. But if that’s the case, what explains the CCSA’s extraordinary effort at trying to convince Canadians that any amount of alcohol is deadly?
“In Canada, there is a certain a group of researchers, primarily based in Western Canada, who are very opposed to alcohol. I see a lot of moral ideology in their work,” Juneau states. Prodded for specifics, he mention the work of UVic’s Centre for Addictions Research of B.C. (now known as the Canadian Institute for Substance Use Research, or CISUR) and in particular Tim Stockwell, a psychologist at CISUR, as chief examples of this observed propensity to “always be on the side of no alcohol.” Stockwell and Jinhiu Zhao, also of CISUR, are the two Canadian co-authors of the 2017 study the CCSA used to dismiss the existence of the J-Curve. As for how this particular paper came to be chosen out of the thousands considered on coronary heart health, Juneau says, “I think they did a little cherry picking…I think they selected papers that confirmed their theory. There are studies that should be there, but aren’t.”
Efforts at promoting official abstinence by whatever means may be ascribed to the fact public health officials have great trouble accepting as good something they consider harmful or “sinful.” As Christopher Snowden, director of Lifestyle Economics at the British-based Institute of Economic Affairs, explained in a 2020 essay on the J-Curve in The Spectator, “There are people in the temperance and ‘public health’ lobbies who do not want to accept the benefits of alcohol consumption. As a result, this epidemiological finding has been subject to more scrutiny than anything else in the field of alcohol research. It is precisely because it has been subjected to the greatest scrutiny that we know it to be robust.”
This relentless scrutiny of the J-Curve is how science is supposed to work, of course. Replication is crucial to the scientific process. Yet the doggedness with which its opponents conduct their campaign against the J-Curve often seems to stray beyond the mere search for knowledge. In a recent blog post, Snowden refers to the authors of that crucial 2017 CISUR study as “neo-temperance zealots.”
And it’s not just insiders who have spotted the CCSA’s inherent bias towards abstinence. Well-known Canadian economist and frequent food industry commentator Sylvain Charlebois of Dalhousie University has also described the general tone of CCSA’s work as, “almost as if alcohol should be outlawed.” After reviewing an earlier version of its report, Charlebois quipped that putting CCSA in charge of setting Canada’s drinking guidelines, “would be like asking People for the Ethical Treatment of Animals to review guidelines for the beef industry.”
Relax, Maybe Have a Drink
In the wake of the CCSA report’s release earlier this month, cardiologist Juneau said he was inundated with phone calls, emails and texts from patients worried about media reports explaining the new, dramatically lower drinking guidelines. “I told them, relax, the science has not changed in the last month,” he says. The connection between drinking and health is a complex subject that requires thoughtful individual assessment of the risks and benefits, rather than sweeping condemnation and hysteria. “If you have high blood pressure, then I tell my patients not to drink at all,” he says. “But if you want to prevent heart attacks, or if you have already had a heart attack, then one drink per day for women and two per day for men is fine.”
Juneau’s wisdom on drinking, distilled from his three decades as a practicing cardiologist, is that red wine is better for your health than hard liquor. Drinking with dinner is ideal. Binging is always bad. He contrasts the Anglo-Saxon and Scandinavian approach to drinking heavily on weekends with Quebec’s more Mediterranean-style relationship with the grape that emphasizes small amounts daily in social settings. And he observes that most people are far more accepting of small risks than Temperance-minded scientists assume. Significantly, none of these concepts are to be found in the CCSA report. Rather it insists that all alcohol is identical, rigorously ignores any cultural or social component to how we drink and fixates on the puritanical belief that every drop you take brings you closer to death.
“The danger of research like this,” says Juneau, “is that it can make people feel guilty about doing something that is perfectly natural and has been enjoyed by humans for thousands of years. I say, if you drink, don’t panic.”
In Part II, the broader social, cultural and economic implications – including the many benefits – of drinking and how new alcohol guidelines could put it all at risk.
Peter Shawn Taylor is senior features editor of C2C Journal. He lives in Waterloo, Ontario and enjoys beer and wings after hockey every Thursday night.
Source of main image: Papin Lab/Shutterstock.