5
A Spirited Denial
“please drink responsibly” is the standard fine print accompanying alcohol advertising in the United States. And while we could reasonably debate the alcohol manufacturers’ sincerity in saying it, it’s undeniably good advice: alcohol is a causal factor in more than 5 percent of all deaths worldwide, which amounts to about 3 million deaths a year. Alcohol hits the young hardest: globally, 13.5 percent of deaths among people between the ages of 20 and 39 are alcohol-related.1
With this knowledge, one might well wonder how these drinks ever achieved their popularity in the first place. One might even sympathize with popular demands for their prohibition. But alcohol is different, of course. For many of us, a drink or two does relieve stress and increase our enjoyment of social situations. A glass or two of wine with dinner is lovely. We believe that the litany of ill effects pertains only to excessive drinking by people who have drinking problems. By drinking in moderation, we believe that we will be spared some of the undesired outcomes, like cirrhosis, and we’ll most certainly avoid alcohol-related deaths from driving.
“Drink responsibly” is a fabulous and useful marketing pitch, but it is also dishonest. I hate to be the bearer of bad news (again), but even when consumed in moderation, wine, beer, and hard (distilled) liquors shorten more lives than they extend. I’m not trying to frighten everyone into abstaining from their nightly beer or glass of wine or snifter of brandy. After digging into the research in depth, and even as I better understand the science and concede the risk, I personally have no intention of forgoing a beer after work. On the danger scale, alcohol in moderation is no match for, say, cigarette smoke, which on average cuts ten years off the life of every smoker.2 But in following the alcohol industry’s money as it works with unflagging zeal to sow doubt and uncertainty in the face of the best science concerning even moderate drinking, there is a lot going on. When it comes to the manipulation of the epidemiology and basic science pertinent to its products, Big Booze belongs in the same class and the same book with Big Tobacco as well as Big Pharma and Big Sugar, both of which will figure prominently in later chapters.
In keeping with the product defense model that was developed by the tobacco industry, much of the money from the alcohol industry is channeled through a trade organization with a misleading name: the Alcoholic Beverage Medical Research Foundation (ABMRF, more recently called ABMRF/The Foundation for Alcohol Research). And to their credit, this group funds some serious medical research. But what it also does is challenge others’ medical research and epidemiology, using all of the classic methods of the product defense industry.
ABMRF was launched in 1982 by beer and malt beverage producers in the United States and Canada. Its first president, Thomas B. Turner, was a former dean of the Johns Hopkins University Medical School, an affiliation that brought great prestige and credibility to the new organization. His first board of directors mixed well-known scientists with titans of the brewing industry whose names alone suffice for identification: August A. Busch III, William K. Coors, and Peter Stroh.
According to the history written by Turner himself in 1993, “[B]y the middle of the twentieth century, a new effort at prohibiting all alcoholic drinks was in the making.” As historical narratives go, this was wildly alarmist. In the many decades that followed the demise of Prohibition in 1933, there has been no serious movement in that direction. It wasn’t going to happen—but higher taxes and stricter controls on labeling and advertising might. Turner also expressed concern that the National Institute on Alcohol Abuse and Alcoholism (NIAAA) was focused on “the clinical and biochemical basis of the more dire results of alcohol consumption and treatment.” In other words, the government’s research focused on the effects of heavy consumption. Of course, the industry knew better than to attempt to defend that stigmatized behavior. It would be happy to study “those factors that lead or permit a minority of individuals to go beyond the limits of sensible drinking.” And the new organization would go one important step further; it would step into the breach left by NIAAA and support research into the whole range of consumption levels. It would prove what Turner and the brewers believed: if we drink in moderation, “no deleterious health effects would be observed.”3
According to Turner and the ABMRF, alcohol is not just safe when enjoyed in moderation. It is positively beneficial, particularly when it comes to life expectancy. For decades, industry scientists have promoted (and still are promoting) the idea that alcohol’s effects on overall life expectancy could be best represented in a J-shaped curve (Figure 5.1)
figure 5.1 The J-Shaped Curve
The horizontal axis plots alcohol consumption in number of drinks per day; the farther right on this scale, the more drinking. The vertical axis plots mortality rates; the higher on this scale, the greater the risk of dying.
The message of the J curve: Nondrinkers—those to the far left of the horizontal scale—have a somewhat higher mortality risk than the moderate drinkers at the bottom of the curve. The bottom of the curve—lowest mortality risk at a few drinks per day—is where we all ought to be!
If correct, this graph would be the ultimate proof of the industry’s basic claim that drinking in moderation is positively beneficial. And at first glance, it is a reasonable proposition. Many studies, some as far back as the 1920s (i.e., pre-Prohibition), do show higher death rates among both nondrinkers (the left edge of scale) and heavy drinkers (the right edge) than those in the middle—the people who drink “moderately.”
But the first glance doesn’t hold up under greater scrutiny. The problem is what epidemiologists call selection bias. Very different types of people inhabit different parts of the curve, and these differences are more—much more—than just how much alcohol they drink.
The heavy drinkers on the far right include people with other characteristics that go along with heavy drinking, including smoking and poor diet, most prominently. Their greatly elevated risk of dying early is therefore driven by a combination of factors, all of which must be taken into account in a truly rigorous study.
Back on the left side of the curve, the epidemiological challenge is perhaps even more daunting. These nondrinkers include people who have made the choice not to drink, perhaps for religious reasons (many Seventh Day Adventists, for example). The great majority of these teetotalers will also abstain from smoking. Some of them also avoid eating meat. As a group, these nondrinkers have a very healthy profile comprising a combination of healthful factors. And just like the unhealthful factors in the high-risk category, all of them need to be considered. But this left edge of the curve is also inhabited by individuals who may avoid alcohol consumption for one of many reasons, including ill health. In many studies, it includes former drinkers. Another complicating factor. Any given study needs to be careful dealing with all this. Many are not.
This essential nuance does the alcohol industry no favors, of course. The industry has invested millions to make the case for the J-curve—and every other manifestation of the claim—that alcohol in moderation is beneficial. Much of the funding goes to sympathetic scientists who are happy to be the beneficiaries of the manufacturers’ largesse. A year before ABMRF was officially founded with Turner as its first director, he had been the lead author of the key paper that would subsequently frame the industry’s PR campaign over the next several decades. The title was “Beneficial Side of Moderate Alcohol Use,” produced with the financial support of the brewers and published in Johns Hopkins’ own publication, the Johns Hopkins Medical Journal. The paper’s product defense message was straightforward: “(A)ccumulating data indicate that the moderate use of alcoholic beverages by adults may reduce the risk of myocardial infarction, improve the quality of life of the elderly, relieve stress, and contribute to nutrition.”4
One question: what is “moderate”? Turner and his team reviewed studies of health conditions recognized at the time as alcohol-related, and they concluded that, for an average-size man, moderate drinking was anything less than 80 grams of alcohol—a little less than six drinks a day, or five drinks three days in a row. These were the levels “below which adverse effects on health are rarely observed.” (Turner eventually decided that the numbers for women should be a little lower.) The notable exceptions—that is, factors that could be affected by fewer than five or six drinks a day—were the risk of traffic accidents and fetal alcohol syndrome, although in both cases Turner claimed the evidence was not at all definitive. No other illnesses or adverse events were caused by moderate drinking, according to Turner.5
ABMRF used its Johns Hopkins link to great advantage in touting any other study it funded that supported the industry’s positions. Immediately after publication of a suitable study, the Johns Hopkins press office would issue a press release, lending the study greater credence and strengthening the link between the two bodies. Over time, however, the industry’s fervent advocacy of “moderate” drinking became too much for the prestigious university. The culminating episode was publication of a study by a Canadian researcher long associated with ABMRF, which the New York Times summarized under a headline that read “Less Illness Found in Beer Drinkers.”6
Such findings would have been a boon for bartenders everywhere, but alas, it didn’t hold up. Unaffiliated outside experts decided to take a closer look at the methodology that had produced this delightful conclusion, and it didn’t survive under scrutiny. It turned out that the researchers had used responses collected in door-to-door surveys, which for fairly obvious reasons aren’t reliable: survey subjects voluntarily reporting to a stranger at their front door might have felt strongly inclined to understate their consumption. Or how often they got sick. Or maybe both. Or maybe the opposite. Who knows? As science, it is laughable, because there’s no way of validating how these thousands of people portrayed themselves while standing at their door and talking to someone with a clipboard.
The study was titled “Alcohol Consumption and Morbidity in the Canada Health Survey: Inter-Beverage Difference,” which sounds authoritative.7 Adding to its authority was the press release issued by Johns Hopkins, which didn’t include any explanation of the methods employed in the study. From there, a veteran science writer for the Times simply summarized the press release. And that’s illustrative of how a successful PR campaign works.
So the dissemination of questionable science just coincidentally happened to yield stunningly good news for the companies that paid for the study? The ensuing scandal (within the field, at least) was too much for Johns Hopkins, which used this episode as the rationale for severing its relationship with ABMRF, even though the organization was still directed by the former dean of its medical school.3
For ABMRF, the work goes on. Today, most of the money we know about (and there is likely plenty we don’t) flows through three entities: ABMRF, the European Foundation for Alcohol Research, and the Institut de Recherches Scientifiques sur Les Boissons (the Institute for Scientific Research on Drinks). This model for funding industry-favorable research is the same used extensively by the tobacco industry and quite a few others. The scientists on the boards of these organizations are by definition conflicted, since they are selected by and paid by the industry, often because they have published studies that align with the industry’s positions. These research bodies are unlikely to fund research that opposes the needs of the industry.
The alcohol industry’s research foundations have of course funded hundreds of scientists whose work has potential to suit the industry’s interests. For the most part these grants are quite small, and the funding is a tiny proportion of the total alcohol research funding flowing from U.S. and EU government agencies. These industry grants are important, however. By offering small amounts of funding (ABMRF has capped awards at $50,000 per year but generally provides less) to junior faculty who would otherwise have difficulty gaining financial support, the grants help shape the careers of these researchers, focusing them on issues and methods the industry supports and tying them into the industry network.8
Of course, as ever, product defense research is of little value if it isn’t accompanied by public relations. The industry has gone well beyond simply funding researchers and putting out press releases. It has become sophisticated in its promotion of the message that alcohol drinking in moderation is beneficial to health, and alcohol manufacturers have formed literally dozens of national and transnational organizations that public health advocates label “social aspects and public relations organizations,” or SAPROs. Ostensibly set up to provide a social good—education and warning about the harms of excessive drinking—the SAPROs appear to be exemplars of corporate social responsibility, fulfilling a public good. But while warning us that we shouldn’t drink and drive, and that designated drivers are the best way to get home, these same organizations use these platforms to subtly, and not so subtly, promote the positive aspects of alcohol consumption.9
One particularly impressive effort came out of a 2006 conference, “The Harms and Benefits of Moderate Drinking,” jointly sponsored by a SAPRO called the International Center for Alcohol Policy (ICAP, now renamed the International Alliance for Responsible Drinking), and the industry-funded Boston University Institute on Lifestyle and Health. While this conference in Cambridge, Massachusetts, included researchers who disagreed on the validity of the J-curve, the abstract of the official conference summary (the only element that many physicians and reporters would read) perfectly presented the intended takeaway:
[M]oderate drinking when defined as excluding any binge drinking, has been shown to have predominantly beneficial effects on health… the consensus of the conference was that the total scientific evidence strongly supports an inverse association between moderate alcohol consumption and the risk of cardiovascular diseases, and possibly diabetes, cognitive decline, and total mortality.10
This report on the meeting gave the impression of being authoritative, although it never went through peer review and was simply a report of the opinions of the conference organizers, paid by the alcohol industry, which also paid the scientific journal Annals of Epidemiology to publish all the papers in a special supplement. To juice the impact of the summary touting the J-curve, the industry bankrolled the printing of thousands of copies of the summary and distributed them free to the 66,000 subscribers to the American Journal of Medicine and the American Journal of Cardiology9 This end-run infuriated several of the conference participants, who objected to this alcohol marketing effort, asserting that the widely promoted summary “did not convey the degree to which there was debate at the symposium regarding apparent protective effects for alcohol on coronary heart disease and the opinion regarding the matter was highly polarized.”11
More than a decade later, with extensive evidence pointing in the opposite direction, the industry is still recommending the summary, including its perfect abstract, to all comers.12
In the classroom, when talking with students about the common mistakes made by epidemiologists, including those manifested in numerous alcohol industry studies in support of the J-curve, I always introduce a different but equally unfortunate analysis involving another popular beverage. By coincidence, it’s a study that was overseen by Brian MacMahon, a former ABMRF board member and the longtime chair of the department of epidemiology of the Harvard School of Public Health.
MacMahon was the lead author of a 1981 paper that reported an association between pancreatic cancer and … coffee.13 You may remember the headlines. They were numerous, and understandably big. This was a finding that hit home. In an interview on the widely watched Today Show, MacMahon told the host, “I will tell you that I myself have stopped drinking coffee”—no doubt alarming the millions who require some caffeine in the morning in order to get going.14 MacMahon’s study was deeply flawed, beginning with the choice of its control subjects. In selecting these subjects, he chose people with noncancerous diseases of the digestive system, many of whom had likely stopped drinking coffee because of their conditions. So instead of demonstrating that coffee causes pancreatic cancer, MacMahon’s study came closer to demonstrating only that digestive illnesses cause people to give up coffee. (Multiple subsequent studies have exonerated coffee as causing pancreatic cancer.)
Similarly, the overall benefit in life expectancy from moderate drinking—the J-curve effect—almost disappears in analyses that limit comparisons to people who are pure abstainers (i.e., not those who are forced to abstain because of a health condition) versus those who drink occasionally.15
Some may also recall a major to-do in 1991 stemming from a 60 Minutes piece extolling the “French Paradox”: how despite a diet rich in fats and cholesterol, the incidence of coronary heart disease in France was 40 percent less than in the United States. Why? As the story goes, it was the wine; more specifically, red wine; more specifically still, French red wine.16 As in the coffee example, there was more to the story than meets the eye, but nevertheless there remains pretty convincing evidence that alcohol (but not red wine specifically) may well provide a small but real protective effect on heart attacks. One huge recent study looking at cardiovascular disease, combining 83 studies involving 600,000 current drinkers, found a slightly (6 percent) lower risk for heart attacks among people who consumed up to seven drinks a week, or one per day on average.17
My reading of the very extensive literature on what the alcohol industry terms “moderate” drinking: the benefits of very moderate intake are probably real, but limited only to the small decrease in heart attack risk. However, that benefit is outweighed by increases in deaths from other causes, and as a result the J-curve is illusory. The reality is that even one drink a day, on average, results in a small increase in overall mortality risk. More than one drink, but still in the range of “moderate” consumption, results in greater risk of both cardiovascular disease and cancer. Heavier drinking, even if only occasional, has other associated risks.18 Add it all up and alcohol becomes the third-highest cause of death and disability caused by disease worldwide. (It accounts for about 18 percent of deaths from violence, including car wrecks, of course.)1This doesn’t mean we should stop all alcohol consumption immediately. But we need to be aware of the risks and trade-offs, even at low levels of consumption.
The science of “observational epidemiology” on display in each of these studies has its limits (as does all science), but it is also the basis of much of what we know about the relationships between diet (including alcohol) and disease. The best studies attempt to differentiate among the subjects’ risk factors (including their environmental exposures—food, drink, work) and then correlate each factor with health or disease status. The challenges are great, and there always remain some uncertainties.
Given these limits, the only really convincing way to demonstrate that truly moderate drinking improves health would be with volunteers assigned to different groups and given different “treatments”—in other words, a randomized clinical trial exactly like the ones used to determine a potential prescription drug’s effectiveness and side-effects in treating a targeted medical condition. These randomized trials are the gold standard, and the alcoholic beverage industry has long wanted to support one—with one unspoken stipulation. The industry would have to be sure that the study would produce the desired results about the benefits of moderation.
But how could the industry make this happen? Specifically, what levers could they pull to ensure a study that was sweeping in scope and convenient in findings?
It’s not surprising that the industry’s recent attempt to do so begins with Washington’s revolving doors between public and private work. The examples that get the most attention are political appointees who leave high-paying corporate jobs to spend a few years regulating their old industries, only to return to even higher-paying jobs in those same industries later, this time with insider knowledge about how to best avoid regulation.
Less well known, but probably more common, is the migration of career staffers from within the federal agencies. After twenty or more years in federal service, employees become vested in their pensions, at which point many of these civil servants change sides and join the businesses they formerly worked with or regulated—and at a much higher salary. The National Institutes of Health (NIH) isn’t immune to these influences. Neither is the National Institute on Alcohol Abuse and Alcoholism (NIAAA), one of its 27 specialized institutes and centers, and the one responsible for researching the effects of consuming alcoholic beverages. NIAAA’s current director, George Koob, was an academic scientist before coming to the institute, and in that capacity he was a recipient of research funds from ABMRF, the industry’s main trade group. He also served on AMBRF’s medical advisory board.19 In 2012, shortly after Samir Zakhari retired as director of the NIAAA’s Division of Metabolism and Health Effects (a career spanning 25 years), he joined the Distilled Spirits Council of the U.S. (DISCUS) as its Senior Vice President for Scientific Affairs.
In 2013, a small group of NIAAA professional staff, researchers who had mostly become administrators, had bought into the need for a randomized clinical trial and engaged executives from across the alcoholic beverage industry about funding the once-and-for-all study that would show the positive impact of moderate drinking. To succeed, this trial would have to be large and therefore expensive, likely more than a hundred million dollars. NIAAA could never fund this with taxpayer money. The only potential source for financial support was the industry itself. And to make that happen, the federal staffers no doubt also realized that the methodology for the study would have to be acceptable to the industry. A compliant methodology would make the industry pretty confident about the results.
Recall that in 1993, ABMRF had disparaged the NIAAA for historically being too interested in the harmful effects of alcohol, which the industry considered an issue only with excessive consumption. These executives must have been only too delighted to learn of the institute’s sudden interest in moderate consumption. And thus was born the Moderate Alcohol and Cardiovascular Health trial (MACH). Between 2013 and 2014, NIAAA staffers secretly met numerous times with representatives of the liquor industry and the academic scientists that the NIAAA staff had pre-selected to run the study. The federal staffers hid these activities from higher-ups at NIAAA (which at the time was undergoing a transition to its new director, Koob) and, of course, the media and therefore the public.20
One of the leaders of the effort was Harvard’s Kenneth Mukamal, who had written a paper calling for a trial like the one eventually planned. According to documents obtained by the New York Times, in 2013 and 2014, Mukamal traveled to meetings and discussed the study designs with members of the alcohol industry. Also present was Ken Warren, whose retirement as acting director of NIAAA gave way to Koob—and who was now serving as an advisor to Anheuser-Busch InBev, the world’s largest brewing company and parent company of Anheuser-Busch.21 (There’s that revolving door we were talking about.)
During this period, the collaborators designed a study that called for 8,000 volunteers age 50 or older, who by definition were at increased risk for cardiovascular disease or diabetes because of their age. The 8,000 would be randomized into two groups: one group would agree to drink one drink per day (they could choose from wine, beer, or distilled liquor); the other would not drink alcohol at all. It is noteworthy that the first group of participants would be allowed to choose their beverage; if the results of the study were positive, then the data would not promote one beverage over another. The time period would be six years—long enough to observe development of heart disease or diabetes, but not new cases of cancer.
Excluded from consideration would be heavy drinkers and people with history of drug or alcohol abuse, liver or kidney disease, and some types of cancer. Women with close relatives with breast cancer were also not eligible to participate, since they were presumably at higher risk for alcohol-related breast cancer.22 Researchers at 16 medical centers in the United States, Europe, South America, and Africa would track the participants, counting the number of deaths, as well as heart attacks, strokes, and other events. Members of the groups assigned to drink would be given some reimbursement for their alcohol purchases.20
Mukamal’s slide presentation to the NIAAA staffers and the alcohol executives promoted the study as “a unique opportunity to show that moderate alcohol consumption is safe and lowers risk of common diseases.”23 An NIAAA staff member also sent an email to an industry source, noting that “one of the important findings will be showing that moderate drinking is safe.” These are virtually admissions that the MACH team—government and academic researchers working together in solicitation of industry money—were going into the study believing it would give them and the industry the finding the industry had long coveted. For their part, the industry saw it as such. One email from the leadership of SpiritsEUROPE, representing that continent’s largest liquor manufacturers, gloated about “the possibility of clinical trials to show the J-curve in all its glory.”20
Given the potential PR value of a randomized clinical study under federal auspices that yielded bulletproof results, it is not surprising that AB InBev, Heineken, Diageo, Pernod Ricard, and Carlsberg pledged $67.7 million toward what was shaping up as a $100 million budget. The industry’s money would be routed through the NIH Foundation, the institutes’ vehicle for receiving private-sector funds for NIH-funded studies (necessary because, by law, private parties are not permitted to voluntarily contribute to government agencies for specific activities).
Following the revelations by the New York Times in 2018, NIAAA director Koob got out in front of any public notion of conflict of interest, declaring that MACH would be an unbiased test of whether alcohol “in moderation” protects against heart disease. “The money from the Foundation for the NIH has no strings attached,” he told the New York Times, whose reporter Roni Caryn Rabin also noted that Koob was raising his voice during the interview. “Whoever donates to that fund has no leverage whatsoever—no contribution to the study, no input to the study, no say whatsoever.”19
No input? The industry participated in the planning and design of the MACH study from day one. Details about that collusion (I use the term advisedly) continued to trickle out through Freedom of Information Act requests lodged by Rabin and the Times. As more details leaked to the press, national outrage increased, and NIH Director Francis Collins appointed an advisory committee of senior scientists to examine the origin and development of the MACH trial. This group concluded the study had been rigged to find beneficial effect, but not negative outcomes. One quote: “Interactions among several NIAAA senior staff members and industry appear to intentionally bias the framing of the scientific premise in the direction of demonstrating a beneficial health effect of moderate alcohol consumption.”20
There are two specific elements of the MACH methodology that would yield results that could be easily misinterpreted (no doubt with the help the industry’s marketing teams) to show the moderation benefits, with no negative effect on cancer risk, cirrhosis, auto crashes, family violence, or any of the other outcomes of alcohol consumption:
The committee’s investigation found that the MACH study was also rigged in another way: the selection of its principal investigator. The PI in such studies is not a figurehead; he or she runs the show. Mukamal, the Harvard physician-scientist who helped promote and set up the study with industry representatives (long before it was ever announced to the public), clearly wanted the job. The team at NIAAA went to great lengths to assist him in preparing his application but provided no similar help, and in fact made it difficult, for other scientists who might want to apply. In the end, the choice of PI was easy; Mukamal was the only applicant.
Not that his selection turned out to mean anything. The MACH study died the death it richly deserved. The NIH advisory committee’s report to Francis Collins was damning and useful, but the basic facts had already doomed the initiative long before Collins killed it. No doubt wanting to avoid further damage to its reputation, Anheuser-Busch InBev, which had pledged $15.4 million, pulled its funding.
Did the alcoholic beverage industry call the shots here? Yes, and in league with loyal partners in Washington. The MACH scandal is a particularly dramatic example of “industry capture” of the federal agency in charge of regulating it, or at least of a sizable number of its staff. The emails and documents uncovered in the investigation make clear that the NIAAA staff and the industry were on the same page, all firmly believing in the J-curve, with the federal staffers eager to convince the beverage manufacturers to pony up.
Most people know that cirrhosis of the liver, which often leads to liver cancer, is strongly linked with heavy alcohol consumption. What’s less known is how the link between alcohol and other cancers is also an established fact. Cancer may not be as well-known a consequence of alcohol consumption as, say, traffic deaths or intimate partner violence, but it certainly isn’t unimportant. In 1987, the International Agency for Research on Cancer (IARC, part of the World Health Organization, and mentioned in many other chapters here) conducted a review of the literature to date and classified alcohol consumption as a human carcinogen, linking it with increased risk of cancers of the mouth, larynx, pharynx, esophagus, and liver.24 Other studies continued to accumulate. In 2000, the U.S. National Toxicology Program conducted its own in-depth review and seconded IARC’s conclusion.25 In 2007, IARC convened a fresh panel of experts to review all the new work, and then again in 2009.With each review, the panels reported strengthened human and animal evidence: alcohol as a causal factor in all of the cancers identified in 1987, plus colorectal and female breast cancers, two of the most common.26 (With breast cancer: the higher the consumption, the greater the risk, particularly for women already at increased risk. But even one drink a day provides a small but statistically significant increase in risk.)27
According to the World Health Organization, in 2016 (the most recent year statistics were available), alcohol was responsible for 4.2 percent of all cancer deaths worldwide.1 This causal relationship between alcohol and cancer is powerful but not well-known. A national poll in the United States, commissioned by the 40,000-member American Society of Clinical Oncology, found that only 30 percent of Americans know that drinking alcohol is a risk factor for cancer.28 In England the numbers are even lower. One survey found only 13 percent of English adults so informed.29 The alcoholic beverage industry would like for those numbers to stay right there or, preferably, go down. Its uncertainty campaign focuses on two claims: the risk is very low to begin with, and extremely low with moderate consumption. The industry’s PR flacks will acknowledge that heavy drinking or “binging” will increase risk of cancer and heart disease as well, but they go to great lengths to reassure their customers that drinking in moderation simply isn’t dangerous.
Here I need to point out that one generally accepted component of our understanding of cancer causation is that there is no threshold below which a human carcinogen does not increase cancer risk. Very low exposures increase your individual risk by a very low amount, and low exposure to a population of millions will likely still result in quite a few cases, with no possibility of identifying which cases would not have occurred without that exposure. At least theoretically, therefore, every exposure increases risk. The increase in risk associated with each sip of wine is so infinitesimally small as to be almost meaningless, but the glass of wine every evening for twenty years is not quite so meaningless. And this is what the epidemiological evidence confirms. I also note that, as far as we can tell, there probably isn’t a better or worse form of alcohol. Wine, beer, spirits—all increase your risk of cancer some small amount.
That basic fact about cancer causation directly contradicts the industry’s message that “moderate” drinking is actually good for you, and it has been a challenge for the industry since the early twentieth century, when a French pathologist published the first paper linking absinthe consumption to esophageal cancer. In 1989, immediately following IARC’s headline-earning designation of alcohol consumption as a human carcinogen, Thomas Turner (the same doctor who went from being dean of Johns Hopkins’ medical school to the first president of ABMRF, the industry’s main research arm) and several ABMRF-affiliated scientists, including Harvard’s Brian MacMahon, a former board member, conducted their own “critical review” of the literature and concluded that “there is not adequate and consistent scientific evidence that the moderate use of alcohol is associated with enhanced risk” of any of the cancer types identified by IARC. ABMRF and other industry groups had been diligent for decades in questioning the findings of studies that implicate alcohol in cancer causation. In fact, Turner and his colleagues were so confident that “the weight of the evidence that alcohol is at most a minor factor in cancer causation,” they ensured that the ABMRF provided little support to research that might question that conclusion.3
In the 1980s, with the increasing study of breast cancer as a possible repercussion of alcohol use, the Distilled Spirits Council of the United States (DISCUS) hired H. Daniel Roth, one of the product defense veterans going all the way back to the tobacco wars that began in the 1970s. He provided much of the “evidence” the tobacco industry used to oppose OSHA’s effort to issue a standard to reduce workplace exposure to cigarette smoke. He attempted to accomplish for alcohol what he had for cigarettes: review the scientific literature and reject the existence of a causal link seen in so many studies.30 With both environmental tobacco smoke and alcohol consumption, he opined that there were too many biases and confounders to allow sound conclusions. In both cases, just sow doubt and uncertainty, early and often.
To this day, the industry feels that it has to defend the claim that light or moderate drinking is actually beneficial. Its minions across the globe never sleep. Much of the information they provide is misleading; some is simply wrong. Samir Zakhari (mentioned above as one of the many federal researchers and administrators who take advantage of the revolving door in Washington, moving between government and industry) has been a key figure downplaying the link between alcohol and cancer, always citing his career at the NIAAA to give credibility to his position. Following a well-publicized alcohol and cancer symposium in Wellington, New Zealand, Zakhari wrote in an op-ed in Wellington’s daily newspaper: “Attributing cancer to social moderate drinking is simply incorrect and is not supported by the body of scientific literature.”31 In 2017, responding to yet another review of the evidence reaching the same conclusion as the IARC panels,32 the DISCUS rebuttal quoted Zakhari laying out the organization’s basic position: “Based on my own 40-year career as a biomedical scientist, including 26 years at the National Institute of Alcohol Abuse and Alcoholism, the science regarding cancer and alcohol consumption is far from settled. In fact, the existing epidemiological studies do not demonstrate causation, nor do they account for the multitude of confounding factors… This is particularly true for moderate consumption. For example, there are some studies that suggest an association between moderate alcohol consumption and an increased risk of breast cancer. However, there also are numerous studies that show no association.”33
Such statements perturb many in the public health community, and they mobilize to counter them. In January 2018, the first statement issued by the American Society of Clinical Oncologists on “Alcohol and Cancer” acknowledged that the “importance of alcohol drinking to the overall burden of cancer is often underappreciated” and that “even modest use of alcohol may increase cancer risk.” The statement called for more public education about the risks of alcohol consumption. In 2018, the journal Drug and Alcohol Review published an extensive review of the claims made by 27 of the industry’s favorite SAPROs (these “social aspects and public relations organizations” introduced earlier) concerning the link between alcohol and cancer. This review was led by Mark Petticrew of the London School of Hygiene and Tropical Medicine, and included Elisabete Weiderpass, who became director of IARC in 2019. Their work identified three classic product defense strategies through which the evidence for the link was misrepresented, and provided examples of each:34
This all is very troubling. These advocacy groups may provide some useful information, but when paired with denials and misdirection, to what end? Their policy advocacy is shaped by the needs of the industry, not by a commitment to public health. They actively oppose policies like warning labels and excise taxes, aimed at reducing alcohol consumption across the board. Instead, they promote policy solutions that sound good but do little to actually decrease drinking.
The alcoholic beverage industry should support studies on the effectiveness of public education and policy, but not if they shape those efforts to privilege sales over public health. Many questions on the alcohol-and-cancer causation remain, but we can’t leave it to industry-affiliated scientists to answer them, or even to pose them. With alcohol, as with all other products that cause harm, industry should be required to pay for the research, but the structure of this research—setting the agenda, selecting the researchers who get funded—must be independent, or the studies will be conflicted, with all credibility forfeited.