The future of alcohol

0:00This is Stanford Engineering's The Future of Everything, and I'm your host Russ Altman. I thought it would be good to revisit the original intent of this show. In 2017, when we started, we wanted to create a forum to dive into and discuss the motivations and the research that my colleagues do across the campus in science, technology, engineering, medicine, and other topics. Stanford University and all universities, for the most part, have a long history of doing important work that impacts the world. and it's a joy to share with you how this work is motivated by humans who are working hard to create a better future for everybody.

0:37In that spirit, I hope you will walk away from every episode with a deeper understanding of the work that's in progress here and that you'll share it with your friends, family, neighbors, co-workers as well. When we put everything together, we do see that alcohol has a harm. Now, I want to be honest here. That degree of harm at low levels of alcohol intake is pretty small. And nonetheless, it remains true that any drink is probably harmful. And the idea that there's a safe level of alcohol use is probably mythology.

1:21This is Stanford Engineering's The Future of Everything, and I'm your host, Russ Altman. You know, we always ask you to follow the show in whatever app you're listening to. Why do we do that? Well, first of all, for your benefit, you'll get told about all the new episodes so you won't miss anything. It also benefits us because we have to feed the beast. The algorithms like it when people are following a specific show and they push our show up higher in the recommendations. So, frankly, it helps us grow our audience. So thanks for considering that. Today, Randall Stafford will tell us that from a health perspective, there really are no benefits to alcohol.

1:55So if you're going to drink it, you have to drink it for some other reason, not for your health. It's the future of alcohol. Today, we're continuing our feature, The Future in a Minute, where I will ask Randall a few rapid fire questions, and he'll give me some quick answers about alcohol in the end. And before we get started, please remember what I just said a few minutes ago. Following us in the app is great. It helps you, we think, and it definitely helps the show.

2:25so humans have been drinking alcohol for thousands of years most of us are pretty familiar with its effects effects in small amounts i get chatty that might not surprise you and at larger doses it has the traditional effects of being drunk and everything in between but for thousands of years you would think we would be very aware of exactly what it does on our health. And yet, for years, it's been an up and down in terms of benefits and costs of alcohol and a very fuzzy signal to the public about are there health benefits or not. This is an important question. There are benefits to alcohol, you could argue, that have nothing to do with health in terms of having a nice evening on a veranda, eating a nice meal and having a glass of wine.

3:11Some people really enjoy that and that's a benefit to them. But what about their health? That's different to consider the health benefits versus other potential benefits. Well, Randall Stafford is a professor of medicine at Stanford University and an expert on the health influences of alcohol. He'll tell us that alcohol right now does not have many actual benefits. Randall, alcohol has been used for thousands of years by humans. Why has it been so difficult to assess the health impacts and pin it down? Well, I think that one of the problems is that it's something we enjoy consuming. And I think our emotional attachment to what we enjoy sometimes does get in the way of science.

3:56So now, in my lifetime, I've seen an ebb and flow of public health advice about alcohol. As I'm sure you're well aware. It was small amounts are actually beneficial. There's been some changes. Can you give us a little abbreviated history of our understanding of the health impacts of alcohol? Yeah, I think that for a long time, there was really very little scrutiny about alcohol. And then once there was, I think quite a bit of the research was tainted by the idea that, You know, we really kind of want to show that alcohol is good or at least not bad for us. So as I map out kind of what's happened over the last 50 years, we have plenty of information that suggests that there are some harms with alcohol.

4:47And a lot of the focus of research has been on physical health, somewhat leaving out the mental health aspects that go along with alcohol use. But just in terms of physical problems with alcohol, I think what we've seen is that very early on, some data that suggests that for some conditions, there may be some benefit. So, for instance, if one looks at coronary artery disease, the problem that causes people to have heart attacks, there is some evidence that low levels of alcohol may actually be beneficial in terms of preventing bad outcomes from that particular disease. And we've worked out some of the mechanism as to why that might happen.

5:33For instance, alcohol does have a favorable effect on our cholesterol and our lipids in our bloodstream. So there's kind of a rationale for why alcohol might have some benefits in certain conditions. On the other hand, we've never really looked at alcohol in a very holistic way. As I mentioned, often we kind of discount the mental health aspects of alcohol's harm. And even looking at just physical aspects, we often don't bundle everything together. So I think what we've seen over the last 20 or 30 years is increasing evidence that when we put everything together, we do see that alcohol has a harm.

6:20Now, I want to be honest here. That degree of harm at low levels of alcohol intake is pretty small. And nonetheless, it remains true that any drink is probably harmful. And the idea that there's a safe level of alcohol use is probably mythology. And I think that's one of the things I want to stress during our talk is that I'm not only interested in kind of what is the epidemiology, what's the public health impact of alcohol, but how did we get into this situation of essentially ignoring a lot of information and convincing ourselves that low-level alcohol use was beneficial? It clearly isn't. And I think we have lots of information, even available 30 years ago, that would have said that the evidence has accumulated more and more over the last few decades to the point where I don't think there's any doubt.

7:20Now, one of the conundrums, one of the difficulties here is that alcohol is something that can come and go from people's lives. And when we look at populations, we need to be very careful about why people may have reduced their alcohol intake. So if we look at a study that looks at everybody in a population, what we may see are that former drinkers may have some health problems that are greater than those people who are drinking. But what we need to understand is how those people got in that situation and whether perhaps their health issues contributed to their decision to stop drinking. Now, ideally, we might look at this through a randomized clinical trial.

8:14We might randomize people in the population to drink nothing, drink a little bit, and then drink a little bit more for a third part of the population. Unfortunately, we can't do that. It's really unethical. And the logistical barriers to actually having people adhere to that particular assignment would be problematic. So we really are left in this situation where we need to use what's called observational information. And clearly that's not the ideal type of information. It would be much better to have the randomized clinical trial, but we simply can't do that. So one of the problems, as I said, is that people who have stopped drinking may have behaviors and may have other health problems that cause them to look like their lack of alcohol in some senses caused their problems.

9:09When in fact, it may be just the opposite. So let me, I do want to get into the recent understanding of especially the mental health things, which you mentioned, but also affects broadly on life and lifestyle and social implications. But you made a point earlier that one of the challenges I'm guessing that you face is what are people rooting for? Like this is a, this is different kind of epidemiology, like for then from other diseases where everybody agrees, I don't want to get that disease and anything you can tell me about how to avoid it. But I think one and I think one of the dynamics going on here is there's a strong feeling in the population that like I enjoy my glass of wine or my drink of whiskey on a Friday night or a Saturday night.

9:50Hopefully not every night, but we'll get to that. And therefore, society is not just a what would you call it? They're not just a neutral listener to the to the findings. They have opinions, and in fact, they have their own data from their own lifestyle and their own enjoyment or lack of enjoyment, which kind of affects how they interpret. And then I know you've also written about this is an industry and there's a lot of money at stake here. So before we go into what the latest findings are, tell me about that dynamic of when you're working in a field where everybody has an opinion and a primary data from their own life and there's a lot of money at stake.

10:29Yeah. And I think this is part of the human condition is that the way we see the world does have certain biases. And one of our biases is that those things we enjoy doing, we want to be at least neutral, if not beneficial for our lives. I really like the analogy between alcohol use and driving. So in some sense, driving is part of our culture. Alcohol is part of our culture. But we should realize that there are different ways to drive. There are different ways to drink. And also that any driving really does carry with it some risk of injury. And that unless we recognize that, we're not going to take care of ourselves in the most appropriate way.

11:18So, you know, I'm not making an argument here that everybody should stop drinking. But I think what's really important is that even low levels of alcohol do carry some risk and that those risks magnify as we increase the amount of alcohol that people are taking in. In other words, their dosage and that certain types of drinking, particularly multiple drinks in a single episode are particularly harmful. So I want to just put this in the context of other sorts of behaviors and really say there is no benefit of alcohol use. the harm at low levels of use may be small, but for some people who are particularly susceptible to certain diseases, it may be enough to cause some real problems in people's lives.

12:11And perhaps there is a subpopulation who really shouldn't be drinking at all. Right. Very good. And then when you say there is no benefit, I think, is it fair to say we have to decorate that a little bit with there is no health benefit because people may say, well, it made my Friday night at the Italian restaurant very lovely. And that's a different kind of benefit, which we're kind of taking that off the table, I think, because we're doctors. We're thinking about health benefits and negatives. And that's what we're kind of paid to think about. So there are lots of factors that might play into whether somebody drinks and how much.

12:45But I think just the idea is to put that in as something that's real, something that isn't a benefit, although clearly we as humans wish there were a benefit. Some of this is similar to when we start talking about dark chocolate and its antioxidants. Please let it be healthy. In that case, I think we have the accumulated information that if it's certainly doing no harm and maybe doing some benefit through some of the compounds, the phytochemicals that are in cocoa and chocolate. But I think we need to kind of step back and just say, if we were designing the most appropriate life, we probably would put in alcohol as one thing we need to moderate.

13:37Right. Okay. So let's go a little bit into the recent findings. You said something very intriguing early on about the, people have been studying the physical effects of alcohol, but maybe over the last several decades haven't been focusing on the mental health issues. And I know from just from seeing friends and family, it is very clear that when people suffer from depression, it's clear to me, and you can tell me if this is supported by the data, people who suffer from depression, especially if they're not getting adequate healthcare, often kind of what we call self-medicate with alcohol. And it's very obvious and you see it and you can kind of see it happening in real time before you.

14:18What is the state of our understanding of the interactions between mental health? You know, you could say the alcohol is there because of the depression or the depression is resulting from the alcohol. How do you untangle that as an epidemiologist? Yeah. So this issue of bidirectional causing or causality. So we actually do know that alcohol consumption will lead to depression, will lead to worsening depression. At the same time, part of human behavior is this process of self-medication. So at the same time as we say that alcohol has a causal effect of causing depression, we can also say that depression itself and the symptoms that go along with it cause alcohol use.

15:04So this has been very carefully looked at. And it's really clear that both of these directions are working, which makes it fairly difficult to disentangle kind of what is the causal effect of alcohol on people's mental health. But we do have good studies that look longitudinally and find that increases in alcohol use seem to predate people having episodes of depression. Now, whether that applies to every single person in the population, not clear. But depression is an incredibly common problem in our population, one that really is not recognized and not given enough emphasis, in my opinion. And any correlation between alcohol use and depression, I think is problematic, but even more so when we have evidence that alcohol can be a causative effect in depression.

16:11And I would say this issue of causes and bidirectional causality is one thing that's problematic in looking at alcohol use. You know, we could look at things like suicidality in some of the same way that, you know, depression is going to lead to suicidality. Alcohol is often a proximal cause of people's attempted suicides. Now, that doesn't mean that alcohol is the only thing that's contributing to a person's mental health and the attempt at suicide, but there is a strong link between alcohol use and suicidal behavior. And suicide, likewise, is one of those problems that I think is under-recognized.

17:09We don't talk about it enough, but it's very common and really is one of the more common causes of death in young people. And we ought to face up to that and look at that from multiple angles. And of course, in some sense, alcohol is only one of those angles. But we need to think about these social problems in a much more comprehensive and whole person sort of way. So in addition to depression, which is a big one, I know, are there other aspects of mental health where we're seeing alcohol have these complex relationships? Yeah, certainly in bipolar affective disorder, we see some of the same bidirectional mechanisms at work, both a episode of mania will cause alcohol, but also on the other hand, alcohol use preceding an episode is quite common.

18:08So, you know, we have this complex kind of web of causality, and we know that alcohol kind of sits in the middle of this, both as a cause and as something that's caused by various mental conditions. One area that I think has not yet been studied enough are some of the other social dynamics of alcohol use. And we see, if we look carefully, and this isn't nearly as well researched as health effects, but we see this same bi-directional kind of pattern with unemployment. So people who are unemployed, yes, that is a cause of increased alcohol consumption. But on the other hand, we have data suggesting that increased alcohol consumption precedes many people's difficulties with employment.

19:00So, you know, this is beyond kind of the health realm and getting into kind of a, you know, one of the social problems that we really ought to be looking at because unemployment itself is then linked to depression and other social harms. This is the Future of Everything with Russ Altman. We'll have more with Randall Stafford next.

19:34Welcome back to the Future of Everything. I'm Russ Altman, and I'm speaking with Randall Stafford from Stanford University. In the first segment, we discussed alcohol and what is the evidence, and why is it so hard to get evidence about whether alcohol is good for us or not. The current evidence shows that with very few exceptions, it's mostly not good. In this segment, I'm going to ask Randall why we get so confused about alcohol, and And what can we do on a personal level to assess whether alcohol is helping or hurting us? Don't forget, we will end this segment with a future in a minute where I'll ask Randall a few rapid fire questions and he's going to give me his quick answers.

20:12In this segment, I want to ask you, Randall, how did we get here? How did we get to this position of kind of trying to grapple with all of these issues of alcohol, the mythologies about it being good for us? What's your assessment? Well, I think we got here for a few good reasons. I think as we've talked about, as humans, you know, we want to believe that what we're doing is okay. And information that contradicts that tends to be dismissed. And I think we have some of that happening in the area of the science of alcohol's effect on health. I think that some of the teasing apart, these bi-directional causing and alcohol being at the middle of some of these things is difficult.

20:56But I think what I would say is that we stuck with very simplistic analyses for a long time before we kind of got to the point of saying, well, maybe we need to account for this bidirectional causation. So I think that part of this is wishful thinking. Part of it is stopping research in simple ways and using simple results. I think also there's a certain amount of cherry picking. So, for instance, when we think about heart disease, yes, there may be a benefit of low levels of alcohol use for coronary artery disease. But when we expand that category to all heart disease, there clearly is a harm.

21:41Alcohol is quite involved with the causation of atrial fibrillation and with heart failure. And those are two very serious problems in our nation. And while heart attacks are the most common heart disease, if we take heart disease as a whole, alcohol has a negative effect. And if we look at other health conditions, there are very few health conditions where you would say that health is not negatively impacted. One of the areas where we have a lot of new information is on cancer. And part of this is the International Agency for Research on Cancer, a part of the WHO. And they found very good evidence that even moderate levels of alcohol are implicated in the causation of cancer.

22:33And this is particularly true for breast cancer. So this is something that I think people suspected for a long time, but it's really been proven and solidified over the last decade. You've referred to it as a mythology, which I find intriguing because it really stresses that this is a highly social. It's almost like a viral phenomenon. People talk. You can spread both truth and untruths through social media, through conversations with your friends. Is there an educational component and are you optimistic about educating? Should we should be discussing this with youth or is they are is this just not the right age and the right time for them to understand these issues?

23:15How do you think about that? Well, I'm very encouraged. I think there is a lot more discussion about kind of alcohol and what role it should have. I think it's no longer taken for granted as something that every person needs to do. And I'm very intrigued by particularly among young people, you know, the idea of taking a break from alcohol. And this is something that I would recommend for everybody. I think that having our own kind of capabilities of experimenting, seeing what life is without alcohol, looking at differences and, you know, perhaps deciding that maybe I don't need alcohol as much as I thought I did.

23:57Now, I enjoy alcohol, you know, but my intake has gone from somewhere around seven drinks per week to maybe two or three. And that's on the basis of these data. But, you know, I had trouble doing that and found, however, that in the end, it's beneficial. I actually think that I'm healthier and not drinking as much. and that very low level of alcohol, I think, presents a harm that's fairly negligible. Yes, it may be harmful, but only minimally so. So I really encourage people to look at their own alcohol use, think about it in the way they think about driving, and think about whether they want to kind of make some changes and go slow on those changes.

24:46And I do think my understanding, and just being a consumer, the amount of, for example, non-alcoholic beer, non-alcoholic, even non-alcoholic champagne and other spirits has been stunning because in my life, this was not a thing until the last few years. You must take some heart in that. And there must be a movement separate from the science. People must be kind of voting with their feet and must be sensing the benefits of these. Are you aware of why this NA, non-alcoholic beer, NA spirits, where did this movement come from? Did it come from you? I'm not sure of its origin, but what I have noticed is just culturally, there are more skeptical, there's more skepticism in the media about alcohol.

25:34And I think that's a reasonable skepticism. I think we all should be very skeptical of the messages that we get from advertisements, for instance, and that we ought to think more deeply about the sort of behaviors that we engage in. So one of the very traditional things, I think if you ask people what's wrong with alcohol, I think it's generally understood in the population that impacts on your liver, especially with heavy alcohol use. So let's just talk about the liver for a minute. So of course, it's well known that if you have heavy, heavy alcohol use, you're going to have liver disease. But there are a lot of other liver diseases other than heavy alcohol use.

26:12There's hepatitis. There's various syndromes associated with fatty liver. What's the status of our understanding of the effects of alcohol on the liver when it's not just from huge amounts of alcohol intake, perhaps? Yeah. So what we know is that even moderate amounts can contribute to cirrhosis. In other words, scarring of the liver. It's less common than in people with very high levels of alcohol consumption. But we also know that when different situations induce the liver to be irritated, there's this additive effect. So many people do have metabolic liver disease on the basis of having prediabetes or diabetes.

27:00Unrelated to alcohol. Unrelated to alcohol. But when we add alcohol into that mix, we have even worsening liver disease. Okay. And is that true for things like hepatitis? Does it make a hepatitis worse? There is some evidence there, but the amount of effect that, let's say, alcohol use has in progression of hepatitis C seems to be relatively minimal. Okay. And so the final thing I want to ask you just as we wrap up in the last minute is you've already mentioned and encourage people to experiment with alcohol, but I would like to hear more about what could somebody who's sitting, listening to our conversation saying, hey, I might want to change.

27:43Are there any tips that you can give them about how to modify their alcohol use or even how to track their alcohol use? People might not be very intentional about even realizing how many drinks a week am I taking? Yeah. Well, I think it does make sense to track, to actually write down your alcohol consumption. One point that we hadn't mentioned before is that I believe the guidelines around alcohol consumption are going to be changing. Right now, we have in the United States this idea that men can drink up to two drinks per day, women one drink per day. That's way more than I think we ought to be drinking, particularly for men.

28:20So I see those guidelines changing, maybe to the level of three to five drinks per week. Now, in terms of what you can do, I think avoiding those instances where you drink more than two drinks at a time, I think is very wise. We know that binge drinking causes particular harms. So that's where I would start. And then I think trying to think about, well, what are the reasons why I drink? And perhaps limiting alcohol to those situations where there's social alcohol use with other people. I think we often don't think enough about the situations in which we're consuming alcohol. Yes. I'm also struck that with all of these devices, you know, the watches and the rings and the things that can track your sleep, it's very easy to see if something that you're doing is messing with your sleep because the data, even if it's not totally perfect, often shows you that the things you think are benign, like caffeine at night or alcohol at night, are actually affecting the quality of your sleep.

29:24Yeah, I agree. Thank you very much. And if it's okay, I'd like to move to our new feature, The Future in a Minute, where I ask you a few rapid fire questions and we get your rapid fire answers. Are you ready to go? Shoot. Okay, great. What is one thing that gives you the most hope about the future? I think it's seeing young people experimenting with stopping alcohol, having an alcohol-free month or an alcohol-free week. What's one thing you want people to walk away from this episode remembering? That there's no safe level of alcohol use. Aside from money, what is the one thing you need to succeed in your research?

30:04The thing I need is for people to believe the science and to really take away from science the fact that we have insights about behavior that we ought to be paying attention to. If all goes well, what does the future look like? Well, I think that we will have much more conscious or mindful use of alcohol. I don't expect that it's going to be zero, but I think we'll have less binging and we'll have levels of use which get us into the point of kind of negligible harm, at least for most people. And I think that we will have people who need to stop drinking entirely. If you were starting all over again and you needed to get your degree or your certification in a different discipline, what would that be?