282 Editorials | JNCI Vol. 101, Issue 5 | March 4, 2009
For 40 days and 40 nights, Noah, his wife, his three sons and their
wives, and myriads of animal pairs remained safe in their Ark while
massive flooding destroyed the rest of the world. After several more
weeks, the Ark settled on dry land, and Noah and his family
emerged. What was among Noah’s first acts upon leaving the Ark?
He “drank of the wine and became drunk,” and his sons had to pro-
tect him from embarrassment ( 1 ). Thus, the book of Genesis reports
one of the first episodes demonstrating the dangers of alcohol.
Alcoholic beverages have been with us throughout the human
history. During the last century, ill-advised efforts were made to
eliminate its dangers by passing a constitutional amendment pro-
hibiting its manufacture, sale, and distribution. As is well known,
this created a social disaster and was later repealed. Beyond its social
dangers, many of alcohol’s medical dangers are well known and have
been known for a long time, including acute intoxication; chronic
destructive addiction; cirrhosis of the liver; dilated cardiomyopathy;
fetal alcohol syndrome; and increased risks for hypertension, stroke,
cardiac arrhythmias, and fatal motor vehicle accidents.
Over the past 20 – 30 years, the medical position on alcohol has
become somewhat more nuanced. Investigations of large-scale
observational cohorts have suggested that light to moderate drink-
ing may be associated with decreased mortality rates and with
decreased risk of cardiovascular disease ( 2 ). Some studies ( 3 ), but
not all ( 4 , 5 ), have suggested that wine may provide additional ben-
efi ts over and above the effects of alcohol, perhaps because of
antioxidant or other types of effects of non-alcohol grape chemicals
like resveratrol ( 6 ). Some investigators have been so intrigued by
the possible benefi ts of low-dose alcohol that they have gone so far
as to consider mechanisms by which alcohol can have salutary car-
diovascular effects ( 4 ). These include increased levels of high- density
lipoprotein cholesterol and a decreased tendency to thrombosis.
Combining these reported biological benefi ts with epidemiological
fi ndings, some medical organizations have stated that low levels of
alcohol consumption maybe considered safe ( 7 ) or may be a legiti-
mate “item of discussion between physician and patient” ( 8 ).
In this issue of the Journal, Allen et al. ( 9 ) present fascinating
fi ndings that should give us pause. Allen et al. have systematically
surveyed more than 1 million women who between 1996 and 2001
attended breast cancer screening clinics in the United Kingdom.
They found that after 7 years of follow-up, even light to moderate
levels of alcohol consumption were predictive of an increased risk
of several common cancers, including those of the breast, rectum,
liver, esophagus, and oropharynx. Taking into account the preva-
lence of alcohol consumption and its observed relative risks, the
authors estimated that about 13% of cancers of the breast, aerodi-
gestive tract, liver, and rectum could be attributed to alcohol.
Because of an enormous sample size, systematic survey method-
ology, and an ability to capture nearly all incident diagnoses of
cancer, the authors could make a number of important, heretofore
unappreciated, discoveries. Previous investigations have focused
on the association between alcohol and mortality ( 5 ), including
mortality due to cancer, but have not been able to so carefully
assess the association of alcohol intake with the subsequent diag-
nosis of cancer. Allen et al. could estimate the association of differ-
ent levels of alcohol intake with many different kinds of cancer.
Perhaps more importantly, they could evaluate key interactions for
specifi c cancer types; for example, they demonstrated that alcohol
use was strongly predictive of cancer of the upper aerodigestive
tract but only in current smokers. From a standpoint of cancer risk,
the message of this report could not be clearer. There is no level
of alcohol consumption that can be considered safe.
How are we to interpret the fi ndings of Allen et al. given
previous investigations suggesting that alcohol may be safe or
even benefi cial when taken in relatively low doses ( 2 , 4 )? Despite
their study’s many strengths, there are some important limita-
tions that must be considered. The study was limited to women
who were seen in breast cancer screening clinics; there is evi-
dence that these women may be different in some respects from
those of the general population ( 10 ). Nearly all the baseline
clinical data were based on answers to a questionnaire, not
direct measurement; this might be considered an acceptable
sacrifi ce given the study’s enormous sample size. This is also a
limitation inherent to essentially all epidemiological investiga-
tions of alcohol use; it is doubtful that a systematic bias exists
whereby women who are destined to develop cancer will mis-
classify their alcohol intake. Finally, the authors provide no
information on all-cause mortality or incident cardiovascular
disease events, despite the ability of their data to provide this
information. We must hope that the authors plan to report on
these outcomes in future publications.
Despite these limitations, the message from this report takes on
a greater sense of urgency when considering the limitations of the
many investigations suggesting benefi cial cardiovascular effects of
alcohol. Some have suggested that there is no real cardioprotective
Affiliation of authors: Division of Prevention and Population Sciences,
National Heart, Lung, and Blood Institute, Bethesda, MD.
Correspondence to: Michael S. Lauer, MD, FACC, FAHA, Division of
Prevention and Population Sciences, National Heart, Lung, and Blood
Institute, 6701 Rockledge Dr, Rm 10122, Bethesda, MD 20892 (e-mail:
See “Funding” and “Notes” following “References.”
Published by Oxford University Press 2009.
Alcohol, Cardiovascular Disease, and Cancer: Treat With
Michael S. Lauer , Paul Sorlie
JNCI | Editorials 283
effect of alcohol ( 11 – 13 ). Epidemiological investigations are severely
limited by failure to account for a number of important confound-
ers, including socioeconomic status, social networks, mental health,
reverse causality, and healthy cohort effects ( 11 – 13 ). The suppos-
edly benefi cial effects of alcohol seen in epidemiological studies may
parallel the experience with hormone replacement therapy, where a
number of observational reports suggested benefi t, but defi nitive
clinical trials showed harm ( 11 ). A major difference, however, is that
a randomized trial of low-dose alcohol cannot happen.
Even if there are modest benefi cial cardiovascular effects of
alcohol, the current report of Allen et al. should remind us that we
must consider these within a broader public health context. The
current report, as well as a number of previous investigations,
focused on middle-aged women. Among women, the major cause
of death by far during the middle years is cancer ( 14 ). Although it
is true that cardiovascular disease is the leading cause of death
among women overall, this primarily applies to women older than
75 years. It might be reasonable to suspect that many women in the
lay public who are asking physicians about any possible safe effects
of alcohol are middle aged; for this large group, the only reason-
able recommendation we can make is that there is no clear evi-
dence that alcohol has medical benefi ts.
Still, when we think about the story of alcohol, we are left with
complexities. Yes, the fi rst recorded episode of alcohol use in
Genesis was not a pretty one, but later in Genesis , we are told of two
prisoners who appeared before Joseph for interpretation of their
dreams. One prisoner, a baker, was executed, but the other, the
keeper of the king’s wines, was saved ( 15 ). Despite its attractions,
alcohol has been the proximate cause of a great deal of human mis-
ery, now with additional documentation by the elegant report of
Allen et al. Perhaps the complex story of alcohol can be best
summed up by what the great professor Albus Dumbledore said
about truth in one of his conversations with his student Harry
Potter: “It is a beautiful and terrible thing, and should therefore be
treated with great caution” ( 16 ).
1. Genesis 9:21 [Stone Edition translation]. In: Nosson S, ed. Brooklyn, NY:
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lar system: research challenges and opportunities . J Am Coll Cardiol .
2005 ; 45 ( 12 ): 1916 – 1924 .
3. Gronbaek M , Becker U , Johansen D , et al . Type of alcohol consumed and
mortality from all causes, coronary heart disease, and cancer . Ann Intern
Med . 2000 ; 133 ( 6 ): 411 – 419 .
4. Rimm EB , Klatsky A , Grobbee D , Stampfer MJ . Review of moderate
alcohol consumption and reduced risk of coronary heart disease: is the
effect due to beer, wine, or spirits ? BMJ . 1996 ; 312 ( 7033 ): 731 – 736 .
5. Fuchs CS , Stampfer MJ , Colditz GA , et al . Alcohol consumption and
mortality among women . N Engl J Med . 1995 ; 332 ( 19 ): 1245 – 1250 .
6. Stervbo U , Vang O , Bonnesen C . A review of the content of the putative
chemopreventive phytoalexin resveratrol in red wine . Food Chem . 2007 ;
101 ( 2 ): 449 – 457 .
7. Pearson TA . Alcohol and heart disease . Circulation . 1996 ; 94 ( 11 ):
3023 – 3025 .
8. Goldberg IJ , Mosca L , Piano MR , Fisher EA . AHA Science Advisory:
wine and your heart: a science advisory for healthcare professionals from
the Nutrition Committee, Council on Epidemiology and Prevention, and
Council on Cardiovascular Nursing of the American Heart Association .
Circulation . 2001 ; 103 ( 3 ): 472 – 475 .
9. Allen NE , Beral V , Casabonne D , et al . Moderate alcohol intake and
cancer incidence in women . J Nat Cancer Inst . 2009 ; 101 ( 5 ): 296 – 305 .
10. Banks E , Beral V , Cameron R , et al . Comparison of various characteristics
of women who do and do not attend for breast cancer screening . Breast
Cancer Res . 2002 ; 4 ( 1 ): R1 .
11. Fuchs FD , Chambless LE . Is the cardioprotective effect of alcohol real?
Alcohol . 2007 ; 41 ( 6 ): 399 – 402 .
12. Fillmore KM , Stockwell T , Chikritzhs T , Bostrom A , Kerr W . Moderate
alcohol use and reduced mortality risk: systematic error in prospective
studies and new hypotheses . Ann Epidemiol . 2007 ; 17 ( suppl 5 ): S16 – S23 .
13. Jackson R , Broad J , Connor J , Wells S . Alcohol and ischaemic heart dis-
ease: probably no free lunch . Lancet . 2005 ; 366 ( 9501 ): 1911 – 1912 .
14. National Center for Health Statistics . Preliminary Work Table 3 . Deaths
from 113 selected causes, injury by fi rearms, drug-induced deaths, and
alcohol-induced deaths by 10-year age groups, race and sex: United States ,
National Center for Health Statistics ; 2006 . Available at: http://www.cdc.
gov/nchs/datawh/statab/unpubd/mortabs.htm . Accessed December, 2008.
15. Genesis 40:21 – 22. In: Nosson S, ed. Brooklyn, NY: Artscroll/Mesorah ,
1993 . Available at: http://www.amazon.com/Chumash-Stone-Artscroll-
16. Rowling JK . The Tales of Beedle the Bard . New York, NY : Childrens High
Level Group in association with Arthur A . Levine Books An Imprint of
Scholastic, Inc ; 2008 .
Drs M.S.L. and P.S. are employees of the National Heart, Lung, and Blood
Institute / National Institutes of Health . No specifi c funding was provided for
The views expressed are those of the authors and do not refl ect the views of the
National Heart, Lung, and Blood Institute, National Institutes of Health, or the
US Department of Health and Human Services.