Editor's note: This video was recorded December 12, 2024, prior to a call from the US Surgeon General to add a warning on the labels of alcoholic beverages about the link between alcohol and cancer.
This transcript has been edited for clarity.
Neha Pathak, MD: Welcome, Dr Koob. It’s a pleasure to have you here today to discuss an incredibly important and evolving topic: alcohol consumption and its impact on health. Clinicians have seen a shift in recommendations, and also cultural perceptions, about alcohol over the past several decades. Part of this shift is coming as we learn more about the different thresholds of risk for different harms from alcohol.
Before we dig in, I'd love to start with the basics. What are the latest recommendations for safe alcohol consumption?
George Koob, PhD: We adhere to and support the dietary guidelines: a maximum of two drinks daily for males (14 drinks per week) and one drink daily for females (7 drinks per week) [of legal drinking age]. But you have to use common sense; you're not supposed to consume all 14 drinks on a Friday night.
Pathak: Just 2 days ago, the panel released intake recommendations for the upcoming 2025-2030 guidelines, which are unchanged from the 2020-2024 recommendations. Has emerging evidence shifted the way we should be counseling our patients about the harms of alcohol, given the need to individualize our counseling?
Koob: Some patients probably shouldn't drink at all. This includes those who are pregnant or thinking about becoming pregnant, and those who already have an underlying condition that is exacerbated by alcohol — ranging from acute respiratory distress syndrome to pancreatitis to liver disease. Some individuals metabolize alcohol differently. They don't feel well when they drink alcohol.
That's one piece. The other piece is the fact that harm risk increases with the number of drinks consumed. An average of only one drink a day increases the probability of breast cancer in females by a small percentage.
“Not feeling well” when drinking alcohol is an important metric. Your body is trying to tell you something. Listen to it.
Pathak: Many of my primary care patients believe that red wine is part of a healthy diet and it prevents disease. How should we counsel our patients about that?
Koob: It's a myth that red wine per se confers health benefits; any benefits realized are more likely related to dietary or socioeconomic factors. Higher-income groups tend to drink more red wine compared with lower-income groups. No evidence exists to show that the antioxidants in red wine convey any major beneficial effect.
Wine is alcohol, contrary to popular belief in some quarters. And the more you drink, the higher the risk for problems associated with alcohol. Some of the original studies that claimed beneficial effects of red wine used abstainers as the control group. Unfortunately, those individuals are often already ill and that's why they abstain from alcohol. When you use people with low alcohol intake rather than abstainers as the control group, these differences fall apart.
We see a dose-dependent increase even in cardiovascular problems such as arrhythmias and hypertension. I spoke with a Mayo Clinic cardiologist when I was giving a talk there not too long ago. He considers screening for alcohol misuse a key part of his treatment of hypertension now.
Pathak: That’s very important information. Do you have any sort of insights or information beyond what you told us about personalizing alcohol counseling based on the risk for the patient, their personal health risks and risky behavior?
Koob: We now know that 200 different diseases and conditions are exacerbated by alcohol. I've already listed some of them, but what many Americans probably don't know is that 4%-6% of cancer is now attributed to alcohol. Alcohol is the third most preventable cause of cancer in the United States; the leading cause is tobacco, and the second is being overweight.
People need to realize that alcohol affects every part of your body, more or less — acute respiratory distress syndrome; pancreatitis; gastrointestinal bleeds; the cardiovascular effects I mentioned such as arrhythmias and hypertension, not to mention falling off ladders. One third of accidents associated with water sports involve alcohol.
Two years ago, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) put out the Healthcare Professional's Core Resource on Alcohol, which includes 14 units that should be useful to primary care doctors or anyone in the health professions. You can get CME credits for them. There is a section on screening, brief intervention, and referral to treatment, which should be a key part of patient intake for any physician, because alcohol misuse is a window on many medical conditions.
Pathak: That's a key point. It’s critical that, in addition to the other general screens that we're doing, we think about alcohol use‒disorder screening. For patients who do have an alcohol use disorder, there is a question about whether nonalcoholic products are a good alternative. Should clinicians recommend them?
Koob: By and large, the answer would be yes. They're a great alternative. At least from what I’ve read, they're fairly tasty these days — for example, the new nonalcohol beers.
The only downside is that the cues associated with a non‒alcohol-containing beverage can elicit craving in patients who are still in recovery. You need to be aware of that and perhaps approach these alternatives with a bit of caution. Some individuals may be able to partake of these non‒alcohol-containing beverages without suddenly wanting to shift over to the other side.
Pathak: Thinking about alcohol screening, how can clinicians identify whether a patient is being completely forthright about their alcohol consumption? How can we approach these conversations so that we're not judgmental and yet still effective in our screening?
Koob: We want to avoid perpetuating the social stigma that patients don't tell the truth. Most people probably do tell the truth as best they can. Screens like the AUDIT-C, which is three questions, can be done in 3 minutes. People probably respond to that pretty accurately.
Pathak: Any final points that you'd like to make?
Koob: We are the NIAAA. If you type that into any search engine, you'll come to all the resources we have. We have "Rethinking Drinking" for people to understand what you and I have been talking about, what is a standard drink, and what are the guidelines.
We have a treatment navigator. You can even type in a zip code and find a treatment provider in your area. Physicians as well as patients can use that. I already mentioned the Healthcare Professional's Core Resource on Alcohol, which really tells you everything you want to know about alcohol as a healthcare provider. An update of the resource will be available soon.
Pathak: Thank you so much for joining us today, Dr Koob. We appreciate your insights and keeping us up to date.