Why Moderation is Still a Valid Concept: In Conversation with Jennifer Tujague
Western societies are currently re-examining their relationship with wine and alcohol. For the last couple of years, the “no-safe level of alcohol” narrative has come to the forefront, with headlines highlighting new studies leading to the conclusion that there is no alcohol consumption without health risks, deeply challenging our established understanding of moderation.
So, has the science really changed, or is moderation still a valid concept?
Jennifer Tujague is Chief Scientist at the International Alliance for Responsible Drinking (IARD), a position she has occupied since 2013. IARD is a membership organization gathering 13 of the world’s largest producers of beers, wines and spirits coming together under around their shared objective of reducing harmful use of alcohol. She talked to Areni about the current research on alcohol, wine and health.
The below interview has been shortened and edited for clarity.
Areni:
How did you get into your current role?
I’ve always been really interested in food and nutrition and health and the complexities of the research in that area. And a while back, in the 2000s, I had worked for a research group in California, the Alcohol Research Group, on methodology and measurement of alcohol studies. I find it fascinating, because alcohol is a pretty complex and difficult subject to study. It’s wrapped up in behaviours that we may not also have for other foods or beverages that we consume. And it also affects the body in different ways that other foods do. So it’s really that complexity that makes it just endlessly interesting.
You’re working for a group which is financed by major companies of the alcohol industries. How can we be sure that what you work on and what you publish and the science that you are relying on is actually not influenced by vested interest?
An excellent question. My responsibility and the responsibility of my team is to educate and inform our members on what the research says because they are not scientists, they don’t have a background in those areas at all. It’s a pretty big responsibility to be able to distil that information accurately and credibly so that themselves can feel comfortable speaking about issues coming up in alcohol and health.
To do that well, we have first to build this foundation of knowledge around each issue in alcohol and health: the relationship between alcohol and cardiovascular disease, liver disease, cancer, metabolic dysfunction, anything. And we as a group of scientists adhere to basic principles of scientific integrity. So those are principles around being transparent not only about who we’re funded by and who we work for, but also about our methods and how we process information, how we collect information and what’s included in our systematic reviews.
Then there are other principles around accountability and objectivity: how do we make sure that we are minimizing our potential biases – because everybody has a bias – and the important thing is to acknowledge that, and put in place procedures to minimize a potential bias or conflict of interest.
As we’re going through and conducting systematic reviews, we have several places where the researchers are checked and double checked and triple checked by others people on the team. There’s this very iterative process of documenting what we have found, the studies that we have pulled, the information from the studies, and then how we summarize it in a document.
Can you give us an idea of how big your database is? How many papers on alcohol has been published in research globally?
Hundreds of thousands. We are very fortunate to have full-time research librarians, research managers who comb the world of peer-reviewed published research and pull that into our research database. It currently contains about 180,000 scientific articles, covering everything related to alcohol health and alcohol policy. It’s a pretty vast universe out there.
I come from a time where the research was saying that “A glass of red wine a day keeps the doctor away” and that moderate consumption of wine as part of a Mediterranean diet could reduce your risk of cardiovascular disease. But now we hear that there is no safe level of alcohol and that there is no alcohol consumption without health risks. Has science really changed or is moderation still a valid concept today?
That’s a great question because we do hear a lot of mixed messages in the media about alcohol and health. There is a lot of noise out there. What does the research really say? Has the science really changed or is it just the way that we talk about it that’s changed? Are we just hearing certain views that are a little bit louder or noisier than others?
It can be quite confusing. We hear the same thing in diet and in food with contradictory evidence about what’s healthy and what’s not healthy. But if you really take a step back, you see that what has been true for a long time is still basically true. We’ve always known that you need to eat a good amount of fruits and vegetables and foods that are rich in lean proteins and whole grains. That part hasn’t changed and that is still true despite the fact that we hear all this news about different types of diets.
For alcohol, I would say that the big picture hasn’t really changed either: moderation is still the main message. The fact that heavy drinking is associated with a lot of health issues is still correct.
What we see in the big picture is that, in general, alcohol consumption has this J shape relationship with overall health with all-cause mortality. Light to moderate drinkers have this slightly reduced risk and associated with their drinking and heavier drinkers have an increased risk. And that’s kind of the message that we’re used to hearing.
“When it comes to moderation, if you really take a step back, you see that what has been true for a long time is still basically true. The fact that heavy drinking is associated with a lot of major health issues is still true. The fact that moderation is a valid concept is still true.”
Jennifer Tujague
Some people are claiming that in previous research, finding those types of results has been flawed or biased because they didn’t take into account the fact that their non-drinker reference group was made up of former drinkers who may have stopped drinking because of their ill health or that moderate drinking is really just related to other healthy lifestyle behaviours.
If you look back at the research that’s been conducted over let’s say the last 20, 25 years, you’ll find that in fact at least half of the studies are able to control for former drinkers and try to eliminate that bias. And of those that do that, about 70% of them still find that same J Curve relationship.
So we know for sure that high level of consumption of alcohol is detrimental to your health and this is not going to change. What do we know about light and moderate drinking today in terms of health risks and what would be the health risk related to light to moderate drinking?
It’s a difficult question to answer, for a couple of reasons. One is because there’s no universal definition of what light or moderate consumption is, and researchers use different definitions.
How do these definitions differ?
In some studies, researchers will use their country’s drinking guidelines. In the US, they would use up to one drink a day for women and up to two drinks a day for men, as the cut-off for moderate drinking, and then anything over that would be heavier drinking.
Other studies might use something like a 10 gram per day standard.
They might want to look at something more refined like an occasional drinker. So that would be even less. It depends on the researcher’s questions.
[Another reason why questions about the risk of moderate drinking are difficult to answer is] because health risks also aren’t universal. There are a few things like age group, the sex and country or region where risks associated with alcohol will differ. For example, in many parts of the world, young men up to the age of 25 or maybe about 35, have a much higher risk of an alcohol related injury or death from an alcohol related injury much more so than older men do, or than women.
In fact, for men in that age group, one of the leading causes of morbidity and mortality is injuries and alcohol related injury. So modeling studies should tell us that those risks start to increase even with lower amounts of alcohol consumption. So that’s one of the big risks that we would attribute to some people for moderate drinking.
I was just going through the new campaign from Balance Northeast, a program working to reduce alcohol harms in the UK. They’ve just launched their new campaign with the hashtag Alcohol is Toxic. And their headline is actually this one, “Alcohol is a group one carcinogen, which causes seven types of cancer including bowel and breast cancer.”
What’s the relationship between alcohol and cancer?
First of all, alcohol has been identified as a carcinogen since the 1988, it’s not new. The Group 1 status relates to the level of certainty of the evidence. It’s not a designation about the size of risk, it’s just about the certainty of the evidence.
That designation does not relate to the dose of the exposure and the related risk associated with it.
Now what we know from places like the World Cancer Research Fund – they conduct systematic reviews about alcohol and certain cancer types – is that alcohol is a risk factor for these seven types of cancers, And according to the WCRF, there’s an increase in risk with any amount of alcohol for some cancers, but for others, the risk is apparent at higher amounts of consumption. The WCRF conducts comprehensive reviews on the subject, so we feel fairly certain that evidence is reasonable. And in fact, when we did our own reviews on the subject, our IARD findings lined up pretty with WCRF’s.
Breast cancer is the one that we hear most about because it is relatively common. It’s not a rare form of cancer. And risk seems to increase even with light drinking in women.
When we talk about no risk from the very first drop of alcohol, what kind of risk am I taking? Is it one in a million chance to develop cancer?
I can’t give you your risk or your statistics because that risk is going to depend on a lot of factors that only you and your doctor are aware of. And even at a population level, the risks can be slightly different in one population versus another. Your risk is very individual really. You may have a history of breast cancer in your family, or you may have other risk factors that would lead you and your doctor to come up with what’s best for you. And for some people, the best choice is not to drink alcohol.
David Spiegelhalter, professor of statistics at Cambridge said that “the Lancet study means 25,000 light drinkers need annual equivalent of 400,000 bottles of gin for one serious health problem among them each year.” So with these numbers, I understand there’s a risk, but it’s so small. Does it really deserve all the headlines that we see everywhere?
I’m really happy to leave the statistics to Sir David Spiegelhalter who is a proper statistician, but that does sound like it’s fairly small increase in risk.
What’s important is that people are informed so that they can make informed choices.
Why is there so much focus on cancer, rather than an overall look at the relationship between alcohol and health in general?
I think part of the reason is that cancer is an emotional and a scary topic for many of us. And part of that is because we may feel that we have less control over preventing cancer than we do for other diseases like let’s say heart disease. Both of those have been around for ages, but I think people feel like they understand heart disease and how to prevent it, and they know that there are procedures and medications available.
Actually, there are a lot of risk factors in common. So the things that we do to protect our heart will also help us reduce our risk for cancer. But I think most people feel like there’s so much unknown about cancer, and that’s what makes it a little scarier.
I’m looking at the meta analysis published between 2000 and 2023 on alcohol consumption and all causes of mortality. Could you comment that graph for me?
This is a table of results of 22 studies that were published between 2000 and 2023 on all cause mortality, so that’s death from all causes combined. These are meta-analysis studies: big studies that pool the results of a number of individual studies into one set of risk estimates. We first wanted to know: what does that risk relationship look like? If we compare the light to moderate drinkers with a non-drinking group, was the risk at least the same or lower than the risk of a non-drinker?
And we found that there are no cases where the light or moderate drinking group had a higher risk than the non-drinking group.
“There are no cases where the light or moderate drinking group had a higher risk than the non-drinking group. “
Jennifer Tujague
Next, we looked to see if there was a statistically significant lower risk for a light to moderate drinking group compared to a non-drinking group. And in all but three meta-analyses, we found that that was true.
And then finally, we wanted to look at this question about former drinkers and if that was really the explanation because the claim is two things. One, that most studies don’t control for former drinkers, but when they do, those J shaped results disappear.
What we found is that in fact about half of the meta-analyses were able to adjust or control for those former drinkers by separating them out or excluding them altogether. So about half of them were able to control for that. And all of those studies but three still found a J shaped curve.
If I summarize, there are some type of cancers for which risk starts even at moderate level of alcohol consumption, but all in all, when we look at all causes of mortality, moderate drinkers have a better chance of a longer life than non-drinkers, right?
That’s what the all cause mortality results show, yes.
“There are some type of cancers for which risk starts even at moderate level of alcohol consumption, but all in all, when we look at all causes of mortality, moderate drinkers have a better chance of a longer life than non-drinkers.”
Do you think that the concept of no safe level is somewhat misleading?
For me, that concept or that phrase seems like an oversimplification of a very complex issue. And it just doesn’t seem to match up with most people’s common sense and understanding of the risks related to alcohol consumption. It seems to be presuming that any consumption of any amount of alcohol at any time by any person is automatically unsafe. And I think that can be potentially misleading.
It doesn’t seem to sit with the bigger picture evidence about what I was just talking about. And the fact that any amount at any time may be harmful to health, that might be true for some people, but it might be false for some people.
It’s important to have a more nuanced understanding of risk. And it’s also more important for us to understand that there’s a big difference between the risks associated with light drinking than there is associated with heavy drinking.
One of the things that I take from our conversation is: know your situation, know your genetic heritage, know your situation in life, and then calculate the risk for yourself.
Or even better consult with your own healthcare providers.
From your perspective, what are the most efficient ways to promote moderate consumption of alcohol?
Promoting moderate drinking should include actively offering more choices and providing plenty of water and food whenever alcohol is served to encourage slower pacing and really slower absorption of alcohol. It’s really important to eat if you’re consuming alcohol. That’s probably a number one message for me.
Promoting moderate drinking should include actively offering more choices and providing plenty of water and food whenever alcohol is served to encourage slower pacing and really slower absorption of alcohol.
Jennifer Tujague
One of the ways that industry members can promote moderate drinking is by sharing moderation and advice like this through your communication channels: stick with one to two drinks, have something to eat, alternate alcohol drinks with water and other these types of tips
The other side of moderation is avoiding harmful consumption and the ones that should be front of mind should be when not to drink. And so for some people, and in some circumstances, any amount of alcohol is not a good idea.
We are publishing this interview during Dry January, and there’s always that big question about the interest and the importance of those sobriety months in the calendar. From your point of view, how are these sobriety months helping the general conversation on alcohol health and moderation?
People often use Dry January as an opportunity to reflect on their own drinking, which is hopefully something that they can carry over throughout the year because we should be mindful of our drinking all the time, not just one or two months of the year. And I think that the popularity and the visibility of Dry January may be helping to encourage growth in a great proliferation of choices around beverage, alcohol and non-alcohol, and making those more available to people so that they can practice moderation and feel comfortable in any type of environment.
What are the next big steps that IARD are taking to reduce the harmful effects of alcohol?
IARD members are developing robust standards to reduce underage drinking, promote moderation, and reduce harmful consumption among adults. And we are reaching out throughout the value chain to amplify this effort. So from producers to retailers to delivery providers, social media platforms and influencers. One example is e-commerce.
During Covid, when so much commerce moved to an online platform, we developed a set of principles and consulted with public health stakeholders, which led to developing training on those standards, standards that are now being embedded in a lot of places. [like Amazon or Uber Eats]
One last thought about wine, alcohol, health and moderation to leave our audience with?
Moderation can work. It might not be for everyone and there’s certainly people for whom the best choice is not to consume alcohol. For those who choose to drink, being mindful about your moderation all year round is a great idea. And like I said, always enjoy some food while you’re drinking alcohol.