How much should we really drink? 

Source: ft.com

Simon Kuper

February 7 2020

At midnight last Saturday, I toured Paris’s nightlife district of Bastille to see how young people today are drinking. Feeling like the ghost of my own youth, I walked into a bar. Three people were sitting around a laptop managing the music. Others played on their phones. Nobody was even being loud. The ambience felt like a coffee shop in mid-morning.

Out on the streets, what shocked me most was the cigarette-smoking. I passed perhaps a thousand people, average age about 25. The score for possible drunks: one woman sitting outside a cinema with her head in hands, suffering from either drink, drugs or emotion, and two men singing loudly and tunelessly on the rue de Lappe.

The French, whose greatest fear is loss of dignity, have never been big on public drunkenness. But many of the quiet carousers I saw were tourists. On show was a generational trend: across developed countries, young people today are dryer than before. Though we journalists are trained to create moral panics about each new generation, I came home disgusted at another generation of young people: my own. What degenerates we were.

Researchers have identified sharp declines in drinking by young people in Europe, North America and Australia. In the UK, for instance, only 48 per cent of males aged 16 to 24 now drink at least once a week, down 16 percentage points since 2005, according to the Office for National Statistics.

A century after Prohibition began in the US, the question is whether the rest of us should go dry too. A landmark study published in the medical journal The Lancet in 2018, covering 195 countries and territories from 1990 to 2016, suggested that “The level of alcohol consumption that minimised harm across health outcomes was zero.” Even one drink a day raised the risk of dying.

Are “teen-totallers” right? Does the Lancet study mean that even moderate drinkers should stop? The freshly published, frequently scary book Drink? The New Science of Alcohol and Your Health, by David Nutt, professor of neuropsychopharmacology at Imperial College London, adds material for angst. Alcohol – the molecule named after the Arabic al-kuhl – is linked to heart attacks, strokes and at least eight cancers as well as cirrhosis.

Drink is associated worldwide with 2.8m premature deaths a year. That’s about a million more than are killed by war, homicides and traffic combined. And alcohol’s supposed protective effects on the heart have been overblown – inevitably, given that it was about the most welcome finding in medical history.

Like nearly three-quarters of British drinkers, I claim to stay within the UK’s recommended limit of 14 alcoholic units a week. (Any doctor will assume I’m under-reporting my intake: the volume of alcohol sold typically vastly exceeds the volume that people say they drink.)

Recently I tried to cut down to near nothing, but failed. I found that a glass of an evening established a mental barrier between work and home life, and especially between work and going out. Anyway, wine tastes nice. So I approached this topic with some anxiety.

Fast reassurance came from David Spiegelhalter, chair of the Winton Centre for Risk and Evidence Communication at Cambridge university. He argues that any dangers of moderate drinking are so modest as to be scarcely discernible. He points to the Lancet’s press release, which spells out absolute levels of risk. It says that if 100,000 15- to 95-year-olds drank nothing in a year, 914 of them would develop a health problem that can be caused by drinking and classified as “alcohol-related” in one year. But if all 100,000 drank one alcoholic drink daily, 918 of them would develop such a problem – four additional people.

Spiegelhalter has done the maths: this means that 25,000 people would have to drink the equivalent of 400,000 bottles of gin a year to produce one additional health problem in one person. “Which indicates a rather low level of harm in occasional drinkers,” he notes drily.

What if those people pushed the boat out and had two drinks a day? Using his measures that equals 2.5 units of alcohol, slightly above the UK’s daily recommended limit. In that case, 977 people out of 100,000 would develop health problems – up from 914 if nobody drank. This means that for one person to experience one extra problem, 1,600 people would have to drink a total of 50,000 bottles of gin in a year. “Which still indicates a very low level of harm in drinkers drinking just more than the UK guidelines,” concludes Spiegelhalter.

Annie Britton, professor of epidemiology at University College London, largely concurs: “Whilst it’s best for your health not to drink alcohol, if you do drink a little, the risk of harm is low (unless you are driving etc, mixing with medications).” Your lifetime chances of dying from an alcohol-related condition are at most 1 per cent if you drink 14 units or fewer a week, ideally including at least two dry days, writes Nutt.

In any case, nobody can be sure that teetotallers are healthier than moderate drinkers. That’s because non-drinkers – about one person in five in developed western countries – are atypical. Some are teetotal because of health problems, and others because they can’t afford alcohol, or because they are Muslims, who in Europe have a low average socio-economic status. Such factors could explain why “never-drinkers” have (according to another paper in The Lancet in 2018, by Angela Wood of Cambridge university and colleagues) a 20 per cent higher overall death rate than moderate drinkers.

But perhaps the most reassuring fact I encountered about moderate drinking is the venue of Nutt’s book launch last Tuesday: the Ealing wine bar he co-owns with his daughter. Indeed, his book doesn’t promote abstention, but just more conscious imbibing: “Make drinking a positive, active pleasure rather than a reflex and habit, or something you’ve always done, or self-medication for stress and anxiety.”

Nutt has called alcohol cumulatively Britain’s most harmful drug (because far more people take it than, say, heroin), a statement that possibly prompted his sacking as the government’s chief drugs adviser in 2009. However, his book also cites research suggesting it is society’s most beneficial drug. Above all, alcohol reduces the terror of meeting people. It’s the sociability drug.

For me, the book’s scariest line was nothing to do with drink, but the fact that being five kilos overweight (about my level) takes 0.9 years off your life expectancy.

Moderate drinking is almost certainly fine. However, lots of people aren’t moderate drinkers. In the UK in 2016, about 10.8m drank at levels posing some risk to their health, reports Nutt. A standard image of a dangerous drinker is the homeless person reeking of McEwan’s, but far more common is the respectable executive who has a couple of beers after work most evenings and then opens a bottle at dinner. (British drinking in recent years has shifted somewhat from pub to home.)

Many dangerous drinkers have families and good jobs. In a survey by the ONS, one in 10 Britons in the managerial and professional classes admitted to drinking on at least five days in the previous week, a higher proportion than in the “routine and manual” classes. Someone who drinks a couple of glasses almost daily will probably feel sluggish much of the time, and perform subpar at work, but then in most jobs, perfection isn’t required.

You almost certainly know people who are slowly killing themselves with drink. You may be one yourself. And their numbers have soared in past 60 years or so, despite the recent slight fall-off in drinking in developed countries.

In the 1950s, few people drank heavily. Most couldn’t afford it, and female drinkers were frowned upon. But the global trend is that as incomes rise (up to about $30,000 per capita), people spend some of their extra money on alcohol. Along the way, notes Richard Musson, consultant to the drinks industry, many switch from their nation’s traditional drink to something that feels more modern: Italians and French from wine to beer, northern Europeans the other way round, while many Chinese forsake rice wine for western drinks.

In the UK, female drinkers have joined men, and alcohol has gone from luxury to staple. Average annual intake peaked in 2004 at 11.6 litres of pure alcohol per person, according to the British Beer & Pub Association. The figure has since fallen to 9.8 litres – still about double the mid-1950s’ average. Dangers rise exponentially with each unit drunk over the recommended limit, so a bottle a day is much more than twice as harmful as half a bottle.

One problem specific to Britain is that measures are so large. A “unit” of alcohol is a deceptive word. A traditional British pint containing 5.2 per cent alcohol equals 3 units. If you drank only that on a night out, it would mark you out, in many circles, as a “lightweight”, yet it’s already above the recommended daily limit, as is a standard pub 175ml glass of wine (2.1 units). In most countries, alcohol comes in smaller measures, which makes it easier to moderate.

The broader problem is social. It’s not simply that drinking to excess is considered acceptable. In many contexts, not drinking to excess is considered unacceptable. I remember a night in Tokyo in 2002 with two fellow British journalists during the World Cup in Japan. Both were (and still are) excellent writers. After a couple of pints, I was sated, and began nursing a glass I never finished. Meanwhile, they kept ordering more.

My refusal to share the collective experience marked me as an outsider. They had over a dozen pints each. I haven’t socialised with either man since. They wouldn’t want me. They may well have felt fine the morning after, or at least no worse than usual. Nutt writes of the US alcoholics he treated in the 1980s: “Almost none of them had ever experienced a hangover. So you could theorise that they’d never had a deterrent to drinking too much.”

Those journalists, and at least a couple of close friends of mine, are courting death. It could come suddenly, through a heart attack, or quickly through cancer, or it might accumulate over decades in a damaged liver. Nutt notes that whereas British death rates from all diseases have fallen since the 1970s, deaths from liver disease (80 per cent of which are caused by alcohol) have quintupled.

The lag effect from long-term drinking may explain the all-time high of 1.26m alcohol-related hospital admissions in Britain in 2018/2019, reported this week by the UK’s Institute of Alcohol Studies (using a relatively broad definition of “alcohol-related). The record came despite a long-term fall in admissions rates for under-18s, especially boys.

Some countries have managed to reduce heavy drinking. Russian alcohol consumption halved between 2008 and 2018, according to government statistics, driven partly by strict new state policies (such as higher excise taxes and no sales after 11pm) and partly by a new health-conscious middle class. Scotland has cut intake through setting minimum unit prices for alcohol. Nutt’s ideal is Sweden, where other than restaurants and bars, only the shops of state-run alcohol monopoly Systembolaget can sell strong alcohol. With just one shop per town, which typically closes at 7pm on weekdays and 3pm on Saturdays, alcohol has become a planned rather than a spontaneous buy.

France, too, has radically cut intake, albeit from a shocking base. The French once practically lived off wine. In 1939 the average person consumed more than half a bottle a day. Many commentators blamed defeat by Hitler on “the fact France had a bar for every 80 persons, as compared to 270 in Germany, 430 in Britain, and 3,000 in Sweden”, writes Robert Paxton in Vichy France.

From 1950 to 1965, Frenchmen were about 70 times more likely than British men to die of alcohol-related causes, says the IAS. But gradually the French cut down. The shift from farms to offices shortened lunches and rewarded alertness. Governments encouraged the new habits. Mediocre vineyards closed. The average annual intake of pure alcohol for each French person aged 15 and over plummeted from 26 litres in 1961 to 11.7 litres in 2016 – still above British levels.

Further declines in drinking in western countries will probably have to happen without much help from governments. When I asked Musson if the drinks industry feared regulation, he replied: “I haven’t heard anybody scared of that.” Most states are so keen on short-term income from alcohol taxes that they are willing to take on the long-term costs of treating, policing and sometimes imprisoning drunks. In Britain, newspapers and TV have normalised alcohol, the drug of choice of their journalists, advertisers and audiences. A young person dying of an overdose is only news if the drug isn’t alcohol.

Yet the long-term trend in developed countries is probably towards further moderation. (Developing countries are still stuck in the loop where rising incomes mean increased drinking.) Look at the factors generally thought to have sobered up today’s younger generation. These people were raised by helicopter parents; they don’t want to be eternally vomiting in the gutter on friends’ Instagram feeds; they have unprecedentedly educated brains to protect; with the mating game now digital, they have less need to drink to reproduce; and for men, #MeToo has put a price on what used to be winkingly dismissed as “a drunken pass”. These factors increasingly affect older people, too.

But all through history, humans have consumed some mind-altering substance or other. If people stop drinking alcohol, most will seek an alternative – and the obvious candidate today is cannabis. Perhaps more significant than its legalisation in a few countries is its growing toleration by police. In France, where cannabis is illegal, 48 per cent of 17-year-olds in 2014 admitted to trying it, up from 21 per cent in 1993, writes pollster Jérôme Fourquet in L’archipel français (2019). He cites research suggesting 200,000 French people work as cannabis dealers – about 10 times as many as drive for car services such as Uber.

The perils of pot are now much debated. Some are only just being discovered, as legalisation encourages research. A paper in last month’s Journal of the American College of Cardiology noted that “smoking marijuana carries many of the same cardiovascular health hazards as smoking tobacco”.

No doubt there are other risks, too. However, it’s misleading to compare taking cannabis with avoiding drugs altogether. The relevant comparison is the harms of cannabis with the harms of the only legal drug in many countries, alcohol. Nutt thinks cannabis is safer.

I plan to keep drinking alcohol, doing my utmost to stay within limits. In moderation, any health risks appear negligible. I’m writing this the morning after two glasses of Malbec at my daughter’s birthday dinner, and I’ve concluded that the benefits are unquantifiable.

‘Now I find people my age are very accepting’: how not drinking became no big deal

Laura Gaynor, 25, a film-maker in Dublin, decided aged 10 that she wanted to be teetotal. “I was almost a bit friendless when I was 15 because alcohol was such a big thing. Some of my friends thought I was boring. Now I find people my age are very accepting.” She notes that her generation accepts a wide range of behaviour, from veganism to different sexual identities. It’s usually only older people who ask her, “Why don’t you drink?”

In pubs she orders tea, which almost always prompts a joke from the barman. Her nights out tend to end around midnight, when her friends are too drunk for proper conversation. But she has rarely witnessed drunken misbehaviour among her peers, perhaps because they are disciplined by #MeToo and social media. When she was 19 or 20, “a night out would be almost performative, with the whole thing going up on Facebook or something”. Photographing social life is rarer at 25, she adds.

She points to a big advantage of teetotalism: “I get so much out of the weekend. I’ll go out for a few hours, get home by midnight, and I can be up at 7am and do something really good.”

Ben Cooper, 21, a student at Vanderbilt University in Nashville, Tennessee, was one of the few people put off alcohol as a teenager by the famously unsuccessful Drug Abuse Resistance Education programme. “I didn’t like the idea of changing my personality just to make friends,” he says.

Arriving at Vanderbilt, he found that the social scene for freshmen largely revolved around bars. That alienated him, but drinking declined in upper years, and eventually he found a more coffee shop-based social life. He didn’t drink till he was 21, and now has one drink a week. In his circles, he says, drinking is “not a spontaneous thing”. It’s confined to the end of the week, or celebrations such as when a friend gets into law school.

When he interned at a company, the custom of collective drinking at happy hours shocked his peers. “It was a bit weird to be drinking with your bosses, we all felt.”

Many younger people complain that alcohol is still considered obligatory when socialising. Quazi Islam, 34, recently moved to Amsterdam from Bangkok. “Literally every social event I have been invited to has been centred around drinking,” he says, “be it whisky Wednesday or tequila Thursday or Friday night beers or weekend wine tastings . . . you reach the dreaded moment when someone says, ‘Why aren’t you drinking?’ Because hey, not drinking is abnormal.” Having to justify not drinking, he says, “only serves one purpose – to make you, the teetotaller, feel completely alienated and uncool. I wish we didn’t live in a world so focused around the consumption of alcohol to foster human connections.”