hemorrhagic stroke (Donahue et al., 1986), and certain cancers (International Agency for Research on Cancer, 1988). Alcohol is listed as one of the top identifiable contributors to death in the United States (McGinnis and Foege, 1993), after tobacco and diet and activity patterns; and of all the threats to human health, alcohol probably causes the widest range of diseases and injuries (Rose, 1992).

In 1990, approximately 5 percent of all deaths (about 100,000 deaths) were attributable to alcohol consumption, as were 15 percent of potential years of life lost before age 65 (Rose, 1992). The consequences of alcohol consumption extend beyond death rates. Alcohol affects nerve cells in the brain and impairs cognitive function, both temporarily and permanently, over the long term (Meyer, Terayama et al., 1998), and it contributes to the destruction of personal and social relationships (Brookoff et al., 1997). An estimated 18 million people in the United States suffer from alcohol dependence, and an estimated 76 million people are affected by the consequences of alcohol abuse through either their own habit or that of someone close to them (McGinnis and Foege, 1993). Nearly a third of all U.S. adults engage in risky drinking patterns and thus need some kind of intervention, whether it is advice to cut down or referral for further evaluation and treatment for suspected abuse or dependence (Dawson, 2002).

In contrast to these harmful effects, however, there is substantial evidence for a beneficial effect of the consumption of moderate amounts of alcohol on the risk of coronary heart disease and thrombotic stroke. The risk of death from these cardiovascular causes is reduced, on average, by about 20 to 40 percent by the consumption of moderate amounts of alcohol (Doll, 1997; Thun et al., 1997). Because cardiovascular disease is the leading cause of death among those of middle and old ages, a reduction in the risk of mortality from cardiovascular disease with moderate alcohol use will translate into a reduction in the total risk of mortality in many populations. Clearly, there is a need to balance the many risks and benefits of alcohol use.

The Impact of Alcohol on Cancer Incidence

Because alcohol use tends to be associated with cigarette use and other high-risk behaviors, its independent effects on cancer have long been questioned. However, in 1988, on the basis of abundant epidemiological evidence, the International Agency for Research on Cancer concluded that alcohol is, in fact, a Group A carcinogen and an independent risk factor for cancers of the upper aerodigestive tract and liver (World Cancer Research Fund and American Institute for Cancer Research, 1997). Since publication of that report, a large body of evidence has confirmed that alcohol use also increases the risk of breast cancer (Longnecker et al., 1988; Willett et al., 2000) and, probably, colon cancer (Tomeo et al., 1999) (Table 3.10).

Although numerous studies have compared the effects of beer, wine,



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