To Drink or Not to Drink

Introduction by Jon Samet

Entering adulthood, most adults grapple with a decision as to whether they will drink alcoholic beverages and, if so, how much will they consume, and how often. In making those decisions, they will consider the risks—some quite well known—and the immediate benefits—enjoyment and social. They may also be aware of possible longer-term benefits to their health, particularly that those who drink in moderation may have less heart disease and live longer than those who do not drink at all.   

If those seeking answers to these questions turn to web searches and the media, they will find a confusing plethora of information. Search on “What are the risks and benefits of drinking alcohol” as a starting point. In general, the guidance highlights the risks of excessive drinking, avoiding any drinking while pregnant, and drinking “less” rather than “more”. The bottom line from the American Heart Association is:   

“Drink alcoholic beverages only in moderation, if at all. Understand the potential effects on your health if you do indulge. And don’t start drinking for unproven health benefits.”   

Health Canada offers: 

“Drinking less is better. We now know that even a small amount of alcohol can be damaging to health.” 

A January 2025 Surgeon General’s Advisory highlighted the cancer risk from alcohol consumption, noting that alcohol is a risk factor for seven different cancers and contributes to 100,000 cancer cases and 20,000 cancer deaths each year. The Advisory gave the following message: 

“For individuals, be aware of the relationship between alcohol consumption and increased cancer risk when considering whether or how much to drink. Cancer risk increases as you drink more alcohol.”  

These recommendations draw on decades of research, both epidemiological and experimental, on alcohol and health. However, despite the resulting voluminous evidence, there is still uncertainty on some aspects, including alcohol consumption and longevity. The most recent authoritative look at the evidence was carried out by the National Academies of Sciences, Engineering, and Medicine, a body originally established by President Lincoln to provide guidance on matters of science to the government. The committee was chaired by Dr. Ned Calonge, associate dean for public health practice and professor of epidemiology at the Colorado School of Public Health, and professor of family medicine at the University of Colorado School of Medicine. In the commentary that follows, Dr. Calonge provides an overview of that report and its findings.   

This new National Academies report is particularly timely given recent warnings on the harms of alcohol consumption. Health concerns have been affecting drinking patterns in the United States, with Gallup polls showing that more and more people, particularly young adults, view alcohol consumption as harmful. At a new high, 45% of respondents in a 2024 poll considered drinking one or two drinks per day as harmful, and only 8% thought that there was a benefit of moderate drinking. The commentary from Dr. Calonge provides the latest effort to authoritatively assemble what we know about the impact of alcohol on health.   

Alcohol and Health: New Report Findings

by Ned Calonge, MD, MPH 

The United States has a long and complex societal relationship with alcohol consumption. Perhaps the most striking comment on alcohol use and American culture comes from our history of two separate amendments to the U.S. Constitution related to alcohol: one (the 18th Amendment in 1919) to prohibit the manufacture, sale, transportation, import, and export of alcohol as a beverage and the other (the 21st Amendment in 1933) to repeal the first. Today, alcohol consumption by nonpregnant adults at levels deemed to be “moderate” or “responsible” is generally considered acceptable, other than by some notable faiths and cultures in which total abstinence is supported and practiced.  

According to the National Institute of Alcohol Abuse and Alcoholism, well over half of Americans consume at least some alcohol every year, and more people over age 12 have used alcohol in the past year than any other drug or tobacco product. For many, drinking alcoholic beverages is part of daily life and intrinsic to many social scenarios. 

There is also a major economy revolving around alcoholic beverages, ranging from farming to produce ingredients, industry for manufacturing and packaging, distribution, sales, and marketing efforts that support consumer access, and the service industry that provides public and social settings for consumption. In the U.S., the market for alcoholic beverages generated a revenue of $470.7 billion in 2023 and it is expected to rise to a trillion dollars by 2030. 

Why do people drink alcohol? Many alcohol-containing beverages provide flavors and sensations that people enjoy. Alcohol has other characteristics that likely impact the decision to consume it, specifically its effect on how we act and respond in social situations based on how alcohol may affect self-confidence, inhibition, stress/anxiety, mood, pleasure, and enjoyment. Furthermore, there is a cultural sense of alcohol consumption as a rite of passage or a sign of adulthood that likely influences the decision to drink alcoholic beverages.  

Consumption Level and Associated Risks and Benefits 

While small doses of alcohol may not have noticeably negative effects, higher doses of alcohol can impact judgement and cause physical impairment. There is a fine line between an amount providing desired effects seen as pleasurable and effects that are adverse, and an individual may not appreciate where they are in relation to that line as they drink alcoholic beverages. The harms of acute intoxication and habitual heavy drinking are well known, and, as with other drugs that are addictive, use at low levels carries a risk of increasing consumption and excessive and harmful use. Based on the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), over 20 percent of those who consume alcohol will develop an alcohol use disorder (AUD) sometime during their lifetime. AUD is the most common substance use disorder in the United States according to the National Institute on Drug Abuse, although the progression of drinking is likely dependent on drinking patterns and individual characteristics, including ancestry/genetics.  

In addition to AUD, heavy alcohol use is associated with a plethora of negative health outcomes. It is classified as a human carcinogen by the American Cancer Society, the U.S. Surgeon General’s Office, the National Institutes of Health and the International Agency for Research on Cancer. The strongest causal links are for cancers of the mouth, pharynx, larynx, esophagus, liver, colon and rectum, and female breast. For the cancers of the head and neck and also of the esophagus, smoking synergistically increases the risk of alcohol consumption. There are emerging findings suggesting links with prostate cancer and other cancers as well. In terms of cardiovascular disease, heavy drinking is associated with high blood pressure and an increased risk of heart attack and stroke. AUD is associated with important declines in neurocognition including memory and cognition, affecting key functions such as problem solving and decision making.    

However, looking at the evidence at lower consumption levels, the evidence on health effects of alcohol is less clear and less consistent, showing a mixture of both potential health benefits and health harms. On the one hand, there is a significant body of evidence that examines the health effects of moderate drinking, generally defined as daily consumption of less than or up to 1–2 drinks, each containing about 14 grams of alcohol. At this level of consumption, there are studies that suggest an increased risk of breast cancer—and perhaps other cancers—associated with moderate drinking. On the other hand, there are studies showing that, compared to non- and never-drinkers, moderate drinkers have a decreased risk of all-cause mortality (that is, death from any cause) and a decreased risk of having a heart attack or stroke, and of dying from any of the various cardiovascular diseases. 

These challenges fuel the controversy over whether alcohol use in moderation may be beneficial, versus the assertion that there is no safe level of alcohol. 

There are underlying physiological reasons for both increased and decreased risks for various diseases at moderate consumption levels. There are studies suggesting that moderate daily drinking has modest favorable effects on blood pressure and blood lipid levels. However, alcohol consumed in moderation is still metabolized by the body to acetaldehyde, considered to be responsible for the increased risk of cancer. 

Beyond its biological effects, there are other consequences of alcohol consumption that are more difficult to measure, but also linked with health outcomes, such as social connectivity. Joining others to interact “over a drink” in private and public settings is a common behavior that may well provide measurable social connectivity benefits. However, there are also potential harms related to alcohol and social connectivity. Evidence for this occurred during the COVID-19 pandemic when stress increased during the period of isolation that accompanied social distancing interventions. This perfect storm was temporally related to increased drinking, with alcohol sales rising by almost 3 percent in the United States and research finding increases in consumption.  

Research on the health effects of moderate drinking is challenging, particularly as actual randomized trials are neither feasible nor ethical. Consequently, the evidence comes from epidemiological studies—observational studies that follow people and track their health in relation to reported alcohol consumption. While the evidence base from such studies is substantial, interpretation is challenged by threats of bias inherent in non-experimental studies, where the observed associations may be due to factors other than alcohol use. Exposure measurement, i.e., assessing consumption of alcohol-containing beverages, is challenged by the inherent bias of the under-reporting of alcohol consumption as well as by the lack of standardized cutoffs for amount consumed. There is variation due to drinking patterns, including binge drinking and drinking only with meals, and to different types of alcohol consumed such as wine, beer, and spirits. Finally, the comparison group for drinkers used in alcohol studies has been identified as a major source of bias. This is because categories of “nondrinkers” often include former drinkers, who may have stopped drinking for health reasons including AUD and whose past consumption levels and associated health issues may well exceed those included in moderate drinking exposure levels. These challenges fuel the controversy over whether alcohol use in moderation may be beneficial, versus the assertion that there is no safe level of alcohol. 

Various Reports, Different Findings 

There are four recent reports on moderate alcohol use and health that have conflicting findings. In January 2025, the National Academies of Sciences, Engineering and Medicine released a consensus study, “Review of Evidence on Alcohol and Health”; I was chair of the study committee for this report. The committee reviewed the recent (back to 2010) research evidence on moderate alcohol consumption to inform the U.S. Department of Agriculture’s 2025 edition of their Dietary Guidelines for Americans. The committee paid particular attention to selecting studies that limited the impact of the known challenges to research on moderate drinking and health, especially excluding studies where the comparison group may have included former drinkers. While the committee looked at a wide range of outcomes, there were only three conclusions that were supported by a sufficient amount of high-quality evidence: 

• Moderate alcohol consumption is associated with a lower risk of all-cause mortality, 
• Moderate alcohol consumption is associated with a lower risk of cardiovascular disease mortality, and 
• Moderate alcohol consumption is associated with a higher risk of (female) breast cancer. 

It’s important to note that insufficient evidence for an association is not the same as evidence of no association; for the other outcomes in the study, there may still be important associations. 

Other reports this year included a modeling study sponsored by the Health Services and Resources Administration, which used evidence and expert opinion to build models of risks of moderate drinking and found no benefits for all-cause mortality or cardiovascular disease, and the U.S. Surgeon General’s Advisory summarizing the risk of cancer and alcohol, which concluded there is no “safe” level of alcohol consumption. Both these reports used different methods and included and excluded different studies than the National Academies’ committee did, so the reports and their conclusions aren’t comparable. Finally, the American Heart Association recently published a study and a scientific statement that also concluded there was no increase in risk or even a possible risk reduction for moderate drinking in regard to coronary artery disease, stroke, sudden death and possibly heart failure.  

While the controversy over the potential risks and benefits of the regular consumption of 1-2 drinks of alcohol a day persists, it is not possible based on reports such as the American Heart Association and National Academies reports to ascertain the overall balance for public health of possible decreases in cardiovascular disease risk and possible increases in cancer risk. Certainly, one could conclude there is insufficient evidence to recommend any amount of daily alcohol use to improve health. Individuals making choices about moderate alcohol use should be aware of the potential health impacts, both beneficial and adverse, for their decision-making.   

Acknowledgement: Much of the information in this report was taken from the National Academies of Sciences, Engineering and Medicine’s consensus study report, Review of Evidence on Alcohol and Health (2025). 

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This article is part of a monthly column, The Jon Samet Report, on the biggest issues facing us today in public health, written by the former dean of the Colorado School of Public Health, Jon Samet, a pulmonary physician and epidemiologist, and Professor of Epidemiology and Occupational and Environmental Health, and his colleagues. Dr. Samet is a global health leader, shaping the science and conversation on issues ranging from tobacco control to air pollution to chronic disease prevention and more. Each month, he shares expert insights on public health issues from local to global.