The initial hypothesis and evidence that moderate alcohol consumption reduces the overall mortality rate through its protective effect against cardiovascular disease are now broadly known and accepted (see Chapters 12 and 13). This evidence continues to accumulate, most recently in a study of nearly a half a million middle-aged and elderly people in the United States (Thun et al., 1997). Yet notwithstanding these findings-along with many long-held cultural beliefs that drinking improves health-most people consume alcohol for experiential rather than health reasons (Hall, 1996; Lowe, 1994b; see Chapters 18 and 20 and the Introduction). The critical role of pleasure not only as a motivation for drinking but also as a potential cause or indicator of positive health outcomes is attracting medical attention. As an editorial in the British Medical Journal noted, "Public health campaigns have often ignored people's requirement for pleasure" (Cleare & Wessely, 1997, p. 1637). However, clinical medicine has begun to identify global quality of life and level of general functioning as essential dimensions of health outcomes (Wilson & Cleary, 1995; see Chapter 23). Taking into account the psychosocial as well as medical benefits of moderate drinking balances the heretofore exclusively negative public health emphasis on
Baum-Baicker's (1985) earlier review identified five areas of psychosocial benefits from alcohol consumption: (a) stress reduction; (b) mood enhancement; (c) cognitive performance; (d) reduced clinical symptoms, primarily of depression; and (e) improved functioning in the elderly. Taking off from this and the more limited reviews that have appeared in recent years (Midanik, 1995; Pittman, 1996; Poikolainen, 1994), the present authors have updated and expanded Baum-Baicker's framework to include additional areas of benefit, drawing from ethnographic, psychological, and epidemiological research (Peele & Brodsky, 1998). This chapter summarizes these data as an invitation to take stock of their significance. Among the issues to be assessed are:
• Whether and which of these benefits assume the J-shaped and U-shaped curves regularly found in mortality rate studies, in which moderate drinkers have better outcomes than either abstainers or heavy drinkers
• The explanatory power for health outcomes of such psychosocial benefits associated with moderate alcohol consumption
METHODOLOGICAL ISSUES What Constitutes Moderate Drinking? The definition of optimal drinking for health purposes has been fairly well accepted in the United States and United Kingdom as one or two drinks daily and at the lower end of the range for women (Department of Health and Social Security, 1995; U.S. Department of Agriculture/Department of Health and Human Services, 1995). Going farther afield, however, this range may expand. Gr!llnbrek et al. ( 1995) found mortality-rate gains for men and women up to three to five drinks of wine daily in Denmark, as did Fuchs et al. (1995) with a sample of women in the United States. Doll ( 1997) summarized various factors contributing to the relativity of both reported and optimal unit consumption across national boundaries, including extremely different definitions of what constitutes a standard drinking unit and the common underreporting of alcohol consumption. Thus, in Poikolainen 's ( 1995) cross-cultural review, minimum mortality rate was associated with consumption levels ranging from one to five drinks
daily. In the current review, which includes ethnographic as well as epidemiologic data and covers a range of cultural settings beyond those involved in typical epidemiologic studies, moderation is an even more variable ideal.