What are the health risks of drinking alcohol?

Drinking alcohol raises the risk of many serious diseases and health conditions.^1,2 Annually in the United States, an estimated 88 000 people (about 26 000 women and 62 000 men) die from alcohol-related causes.³ In the US in 2016, alcohol-impaired driving resulted in 10 497 deaths.⁴ Globally, more than 1 500 000 deaths (1 180 500 men and 319 500 women) occurred due to alcohol-related cancer, liver cirrhosis, and alcohol-related injury.^5,6

Health Risks Related to Alcohol Consumption

Moderate Drinking

• Cancer^7,8
  • Female breast
  • Oral cavity and pharynx
  • Esophageal
• Hypertension - men⁹

Greater Than Moderate Drinking

• All-cause death^2,10
• Cancer^2,7,8
  • Colorectal
  • Larynx
• Hypertension - women⁹
• Cardiovascular disease (CVD)^11-16 (such as heart failure, stroke, arrhythmias, coronary artery disease, cardiomyopathy)
• Injury and accidents^17-19 (such as alcohol poisoning, falls, drowning, motor vehicle)
• Birth defects and fetal alcohol spectrum disorder^20-23 with maternal alcohol use

Heavy Consumption

• Cancer^2,7,8
  • Liver
  • Stomach
  • Pancreas
  • Lung
• Liver disease^24,25
• Pancreatitis^26,27

Definitions

Standard Alcoholic Drink in the US

The standard alcoholic drink in the US is defined as 14 g of pure alcohol. That is roughly:

• 12 ounces of regular beer, which is usually about 5% alcohol
• 5 ounces of wine, which is typically about 12% alcohol
• 5 ounces of distilled spirits, which is about 40% alcohol

Moderate Alcohol Consumption

The Dietary Guidelines for Americans 2015-2020 states that if alcohol is consumed, it should be in moderation—up to one drink per day for women and up to two drinks per day for men—and only by adults of legal drinking age.²⁸ For those who choose to drink, moderate alcohol consumption is recommended.

Binge Drinking and Heavy Alcohol Consumption

According to the 2016 National Survey on Drug Use and Health (NSDUH), 16.3 million people age 12 and older engaged in heavy alcohol use and 65.3 million engaged in binge drinking in the past month.²⁹

According to the US National Institute on Alcohol Abuse and Alcoholism,  binge drinking is defined as drinking a large amount of alcohol in a short amount of time so that the blood alcohol concentration reaches 0.08 g/dL.³⁰ This usually occurs if a woman has four drinks or a man has five drinks within about a two-hour period. The US Substance Abuse and Mental Health Services Administration (SAMHSA) defines binge drinking as ≥4 alcoholic drinks for women or ≥5 for men on the same occasion (within a couple hours of each other) on at least one day in the past month.²⁹

Heavy drinking has multiple definitions and includes:

• Drinking on average >50 g to >60 g of pure alcohol per day (depending on clinical study definition)^7,12,25,31
• Binge drinking on five or more days in a month (population survey definition)²⁹

Alcohol Use Disorders

According to the 2016 NSDUH, 15.1 million people age 12 or older had an alcohol use disorder.³⁰ Alcohol use disorders (AUD) are defined as alcohol dependence and alcohol abuse.^6,29 In the US, the prevalence of AUD is 8.5% of adults (4.9% of women; 12.4% of men).⁶

Study Details for Alcohol Health Risks

There are extensive meta-analyses as well as original studies that support the health risks associated with alcohol consumption. This article is intended as a brief overview to outline the possible risks to patients. Therefore, a sampling of high-quality source material is presented. This is not intended to be an exhaustive review of each risk.

Death

A meta-analysis determined the all-cause mortality ratios of people with AUD compared with the age-specific general population by analyzing 81 observational studies which included 853 722 people with AUD with 221 683 observed deaths.⁶ The overall pooled relative risk (RR) of all-cause death for men with AUD was 2.98 (95% confidence interval [CI] [2.68 – 3.31], p<0.001). For women the RR was considerably higher at 4.57 (95% CI [3.94 – 5.47], p<0.001). The risk for people in clinical samples (those in treatment programs) was considerably higher than those in the general population surveys, likely reflecting a more severe disorder in people who seek treatment. Likewise, the risk was much higher in younger adults with the relative risk for people age 40 or less being nine times higher for men and 13 times higher for women compared to a 2-fold risk for people age 60 or older.

Cancer

The International Agency for Research on Cancer identified cancers of the female breast, head and neck, esophagus, liver, colon, and rectum as having sufficient evidence to support a causal link with alcohol consumption.⁸ A 2015 meta-analysis reviewed 572 studies (n=486 538 cases of cancer) to assess the effect of alcohol on 23 types of cancer.⁷ They found that light to heavy alcohol consumption was related to an increased dose-risk of cancer for:

Another meta-analysis found that the risk of breast cancer in women increases linearly by 7.1% (95% CI [5.5 – 8.7%], p<0.00001) for every 10 g of alcohol consumed per day.^8,32 This is based on a pooled analysis of data from 58 515 women with breast cancer in 53 studies. Analysis of women who drank versus those who reported never drinking found the relative risk of breast cancer related to alcohol intake of 35 – 44 g per day was 1.32 (95% CI [1.19 – 1.45], p<0.00001).³² The relative risk was higher for women who drank ≥45 g of alcohol per day at 1.46 (95% CI [1.33 – 1.61], p<0.00001). 

Cardiovascular Disease

Greater than moderate and heavy drinking increases the risk of developing several cardiovascular problems including arrhythmias, coronary artery disease, heart failure, stroke, cardiomyopathy, and sudden cardiac death.

A meta-analysis of 17 studies (n=458 811) found that heavy drinkers (>60 g/day) compared to non-drinkers had a significantly higher risk of stroke (pooled RR 1.62, 95% CI [1.32 – 1.98]).¹³

Both short-term and long-term heavy alcohol drinking can cause cardiac arrhythmias, usually atrial fibrillation.³³ A meta-analysis of 14 studies (130 820 participants with 7558 cases) found the pooled relative risk of the heavy drinkers (≥4 drinks a day) versus nondrinkers was 1.36 (95% CI [1.18 – 1.57], p=0.08).³⁴

Alcoholic cardiomyopathy is a type of heart muscle disease found in people with chronic heavy alcohol use.¹¹ Various studies estimate that between 23% and 40% of cases of idiopathic dilated cardiomyopathy are related to alcohol abuse.

A large prospective cohort study of 85 067 women found that those who consumed ≥30 g of alcohol a day had a RR of 1.15 (95% CI [0.70 – 1.87]) of sudden cardiac death compared to non-drinkers.³⁵

Hypertension

Excessive alcohol consumption causes about 16% of hypertension cases worldwide.^36,37 Drinking more than two alcoholic drinks per day raises the risk of high blood pressure.^38,39 A 2018 meta-analysis of 18 high-quality cohort studies calculated the risk for hypertension based on different levels of alcohol intake.⁹ The analysis included 361 254 adults (235 347 women and 125 907 men) with 90 160 hypertension cases (57 734 women and 32 426 men). For men, the relative risk of hypertension by amount of alcohol intake was: 1.19 (95% CI [1.08 – 1.31], I-squared=61.1%, p=0.001) for 1 – 2 drinks/day, 1.51 (95% CI [1.30 – 1.74], I-squared=67.0%, p=0.002) for 3 – 4 drinks/day, 1.68 (95% CI [1.31 – 2.14], I-squared=93.8%, p=0.000) for 5+ drinks/day. For women, there was no increased risk at 1 – 2 drinks/day (RR 0.94, 95% CI [0.88 – 1.01]). Over this consumption level for women, there is an increased risk of hypertension (RR 1.42, 95% CI [1.22 – 1.66]).

According to the 2017 American College of Cardiology/American Heart Association hypertension guidelines, alcohol is a substance that has the potential to impair blood pressure control.⁴⁰ They recommend limiting alcohol to ≤1 drink daily for women and ≤2 drinks for men. In the United States, 1 “standard” drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz of regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12% alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol).^40-42 Evidence reviewed by the panel shows that for heavy drinkers, reducing alcohol intake to this amount may result in a reduction of blood pressure by -4 mm Hg systolic and -3mm Hg diastolic or more, regardless of other interventions.^40,43-46

Liver Disease

An analysis of US death certificate data from 1999 to 2016 found that death from liver cirrhosis increased from 1999 to 2016 by 65% to 34 174 deaths annually.²⁴ The highest average increase of 10.5% (95% CI [8.9% – 12.2%], p<0.001) in cirrhosis deaths occurred from 2009 to 2016 in people aged 25 to 34 years due entirely to alcohol-related liver disease.

Hepatosteatosis (fatty liver disease) develops in about 20% of all alcoholics and heavy drinkers.²⁵ There are usually no symptoms and the problem can be reversed if alcohol use is stopped or lowered significantly early enough in the process. Alcoholic hepatitis occurs when biopsy-visible changes to the liver such as inflammation, fibrosis, or degeneration occur. When people develop this, they often have symptoms. It can result in death in severe cases and progress to cirrhosis if heavy drinking continues. Cirrhosis is the end result of most chronic liver disease. It occurs when scar tissue replaces healthy liver tissue. It has serious symptoms and can cause death. About 10% to 15% of heavy drinkers eventually develop cirrhosis.

Pancreatitis

It is estimated that chronic heavy alcohol consumption accounts for about 70% of all cases of pancreatitis.²⁶  A 2015 systematic review and meta-analysis of seven studies (n=157 026 with 3618 cases of pancreatitis) examined the relationship between pancreatitis and alcohol consumption.²⁷ Samokhvalov AV et al. found that alcohol consumption beyond 40 g per day by either sex had an increased risk for both acute and chronic pancreatitis and the risk increased with the amount consumed. For chronic pancreatitis the relative risk increased by dose (at 25 g of alcohol per day RR 1.58, 95% CI [1.32 – 1.90]; at 50 g/day RR 2.51, 95% CI [1.74 – 3.61]; at 75 g/day RR 3.97, 95% CI [2.30 – 6.85]; 100 g/day RR 6.29, 95%CI [3.04 – 13.02]; p=0.091).

Injury and Accidents

Alcohol-related injury and death in the US result from a variety of factors such as motor vehicle accidents, falls, violence, and alcohol poisoning, among many others.

One study found that 16.4% of injuries out of a total 14 026 patients presenting to 37 emergency departments across 18 countries between 2001 to 2011 were attributable to alcohol.⁴⁷ In a systematic review and meta-analysis of 28 articles encompassing 39 datasets, Taylor et al. found that the risk of injury increases non-linearly as alcohol consumption increases. For non-motor vehicle injury, such as falls, accidents, homicides, suicides, and drownings, the OR increases.¹⁹ For non-motor vehicle injury, the OR increased by 1.30 (95% CI [1.26 – 1.34]) per 10 g increase of pure alcohol consumption to an OR of 24.2 at 140 g (95% CI [16.2 – 36.2]). The odds increase even more for motor vehicle injury from an OR of 1.24 (95% CI [1.18 – 1.31]) for a 10 g in pure alcohol increase to 52.0 (95% CI [34.50 – 78.28]) at 120 g of alcohol.

In 2018, the National Highway Traffic Safety Administration reported that 10 874 people died in alcohol-impaired motor vehicle accidents during 2017.⁴⁸ They also cite that in 2010 the economic costs (for example, medical costs, emergency medical services, lost productivity, legal expenses, property damage) of alcohol-impaired crashes was estimated to be $44 billion. Statistics for the number of non-fatal alcohol-impaired crashes were unavailable.

A CDC analysis of data from the 2010 – 2012 National Vital Statistics System found that on average 2221 alcohol poisoning deaths occurred annually in the US in people age ≥15 years old.¹⁸ They further estimated that about 6 people die every day in the US from alcohol poisoning and they are mostly adult men.

Fetal Alcohol Spectrum Disorder (FASD) and Birth Defects

A systematic review of 13 articles found that prenatal alcohol exposure can severely damage the brain, as well as adversely affect the heart, kidney, liver, gastrointestinal tract, and endocrine system of the developing fetus.²⁰ FASD is a group of conditions that may develop in a child whose mother drank alcohol during pregnancy. It can include physical as well as behavioral and learning problems.²¹ The estimated prevalence of FASD based on a 2017 meta-analysis was 22.5 (95% CI [8.3 – 42.9]) per 10 000 among the general US population.^22,23

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