ABSTRACT
The discussions following presentations on alcohol and health sought to establish specific clinical guidelines for healthy drinking. Numerous complicating factors were noted, both individual and societal in nature. Nonetheless, speakers and commentators felt it was important for physicians to be educated about relationships between drinking and health.
Counseling people to start drinking. Arthur Klatsky was asked under what circumstances it might be appropriate to advise patients to drink. Klatsky emphasized that such recommendations must be made on a one-to-one basis, because so much depends on the individual's risk profile. The easiest case is the male patient who has had a coronary incident and who has “gone clean” by changing his health habits, including stopping light, daily drinking. This patient might be informed that he was mistaken in making this change. Another case in which a recommendation to increase drinking might be made is an Asian woman (a member of a group that traditionally drinks little) who asks whether it is all right to drink more than once a month. In this case, she might be given a guideline of up to three or four drinks weekly. Older patients who have no tendency to drink heavily would be a group that in general could be advised that drinking might not pose much or any risk.
Applying normative drinking research to cultures with norms of abstention. A participant pointed out that some developing nations have high levels of abstention, such as India (see Chapter 8), Sri Lanka, and Thailand, in which most of the female and about half of the male population were said to abstain. In these parts of the world, claims of the cardioprotective effects of alcohol are likely to be resisted. Although consumption levels have been rising in many such areas, their high abstinence rates cloud the epidemiological evidence supporting beneficial claims for drinking.
Ethnic differences in drinking and risk for coronary heart disease. In response to queries about ethnic differences, Klatsky reported that his studies at Kaiser Permanente involved a wide range of ethnic groups (including many people from Asian groups) and his research found that alcohol reduced coronary heart disease risk equally among these groups. This was particularly interesting because coronary heart disease rates are very low in Chinese Americans but high in South Asians.
Social status, economic differences, and coronary heart disease. Louise Nadeau reviewed the longitudinal Whitehall (United Kingdom) study, which found a gradient of cardiovascular (and other) diseases occurred in an inverse relationship to status in the bureaucracy, so that those in higher status positions lived longer (Smith, Shipley, & Rose, 1990). The relationship could be explained by differences in lifestyles of those at different status levels, or might simply be due to wealth itself. Control, self-efficacy, even pleasure (see Chapter 1) seem to be directly related to immunity. Thus, other psychosocial factors in addition to alcohol consumption, and even overall lifestyle, influence longevity and health.
Combining the harm reduction and the reduction of consumption models. Asked whether the introduction of harm-reduction techniques would change the optimal level of consumption in a society, Ole-J0rgen Skog answered that indeed changes in the risk parameters would change the optimum level of consumption.
Conflict between clinical advice and optimum social consumption. In response to a question about the impact of cautious individual recommendations such as those that Klatsky advocated, Skog indicated that “contagious change in consumption” has been observed in some societies. This refers to the diffusion of the impact of beneficial rises in drinking among lower drinking groups to higher, more risky, drinking in higher drinking groups.
Alcohol and breast cancer risk. Asked about the solidity of the evidence on breast-cancer risk and drinking, Carlos Camargo indicated that the Nurses' Health Study showed an overall reduction in mortality rate, along with a greater risk of breast cancer, at one drink daily (Fuchs et al., 1995). “If you accept one result from the study, you should accept the other.” Likewise, when a member of the audience questioned the significance of a relative risk of 1.5, because it could be a statistical artifact, Camargo said that if that argument were accepted, alcohol mortality benefits of 1.1 and 1.2 also would have to be dismissed. “You can't have it both ways.” Camargo then related his wife's personal experience, in which she drank intermittently during her recent pregnancy and moderately following the birth {after breast-feeding in the evening, so as not to pass on alcohol to the baby).
Primary care physicians giving advice on drinking. Asked whether it was realistic to expect primary care physicians to advise patients on drinking in an era of managed care, Camargo noted that physicians spend on average only 8 minutes per patient. Nonetheless he felt that physicians had a valuable role to play, and that they needed to be educated to provide sound information about alcohol. Currently, there is an unproductive exchange of sound bites—blithely optimisitic views on heart and mortality-rate benefits versus attempts to scare all women away from drinking.
The issue of underreporting of drinking levels. Klatsky inquired whether the underreporting of drinking might make the risk of breast cancer appear to occur at a lower level of drinking than it actually did. Nadeau indicated that other data, such as mortality rates, suggest little effect from underreporting. On the other hand, studies showed that heavy drinkers of both genders do un-derreport. Camargo agreed with Klatsky that underreporting of drinking tended to provide lower estimates of optimal levels of drinking, but he pointed out that questioning the applicability of “one drink per day” applied equally to both positive and negative results, so that both might actually occur at somewhat higher drinking levels. The point was made that sales data were needed to supplement self-reported drinking levels.
Sexism and guidelines for women's drinking. Christa Appel from the Forshungsgruppe Gesundheit und Sucht claimed that separate guidelines for women were paternalistic and sexist. In Germany, these tended to be ignored and people drank a lot because “they enjoy it and it tastes good.” Nadeau responded that women are not necessarily the equivalent of men in relation to food and alcohol consumption.
Age limits on women's drinking guidelines. A questioner asked whether research had been conducted with women older than 65 years of age and what advice could be given to those in this group. Camargo indicated that larger cohort studies included women of these ages, and that most recommendations applied across this age range.
How best to offer advice on healthy drinking levels. Speakers raised a number of issues about offering advice on drinking levels. For example, primary care physicians are themselves confused by conflicting information about alcohol's dangers. Moreover, even if information is given by physicians it is up to the individual consumer to make consumption decisions. In order to gain maximum adherence, advice should not be given as a dictum.
