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By the 20th century&#44; the regular consumption of wine&#44; beer&#44; liquor and other alcoholic beverages during meals and leisure activities had become a standard practice in the Western world&#46; It is not surprising that there are few religious&#44; social and occasionally academic celebrations that are not accompanied by alcoholic beverages&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">These habits have been endorsed in recent decades by the publication of epidemiological studies that have supported the hypothesis that there is a negative correlation between moderate alcohol consumption and cardiovascular disease &#40;CVD&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> a highly relevant fact given that CVD is the main cause of death in industrialized countries&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The hypothesis resulted from the French paradox&#44; a term that arose from the decreasing incidence of CVD in France&#44; despite being a country with a high consumption of saturated fats&#46; This phenomenon was attributed to the high consumption of wine by the French population due to the effect of some of its bioactive components such as polyphenols&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Others have argued that the result was probably a benefit shared with alcohol&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> A similar scenario was observed in countries of Southern Europe and was also related to the Mediterranean diet&#44; which has been shown to reduce CVD mortality<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and that initially included red wine along with other key constituents such as olive oil&#44; fruit&#44; fish&#44; vegetables and nuts&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Numerous mechanisms have been proposed to explain the possible benefit that moderate alcohol consumption can have on the heart&#44; including increased fibrinolysis and HDL cholesterol&#59; reduced plasma viscosity&#44; fibrinogen concentration&#44; platelet aggregation and inflammatory response&#59; and improved endothelial function and antioxidant effects&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Similarly&#44; a beneficial effect has been observed from the polyphenolic components of wine &#40;especially red wine&#41; on some types of cancer&#44; an effect analogous to that observed in CVD&#46; In breast cancer&#44; these polyphenols &#40;resveratrol&#44; quercetin and catechin&#41; have a structure similar to estrogens and can act as agonists and antagonists of the estrogen receptor<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and can in turn regulate the peripheral transformation of androgens to estrogens by acting on the aromatases&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Although they do not recommend drinking alcohol&#44; numerous scientific societies &#40;among them the European Society of Cardiology<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and the US Dietary Guidelines&#41;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> have therefore included as healthy the regular consumption of a moderate quantity of alcohol in the diet&#44; which they set at 20&#8239;g of alcohol per day for men &#40;2 small glasses of wine&#41; and 10&#8239;g for women&#44; due to their lower acetylation capacity&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> However&#44; a number of recent publications have since questioned this recommendation and the entire theory of moderate consumption&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Alcohol consumption</span><p id="par0035" class="elsevierStylePara elsevierViewall">There is considerable worldwide geographical variability in alcohol consumption&#46; The amount is usually measured in grams and depends on the volume of liquid and its proof&#46; To uniformly quantify the amount&#44; the standard drink unit &#40;SDU&#41; has been proposed in recent years and corresponds to 10&#8239;g of pure alcohol&#44; a figure that can vary in some countries&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the most common beverages in our community and their SDU equivalence&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">When we analyze the worldwide patterns of alcohol consumption&#44; we see that alcohol use is clearly higher among men than among women &#40;almost double&#41; and increases progressively with age&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Alcohol consumption is higher in countries with a high sociodemographic index and includes all Western countries&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The highest alcohol consumption rate is in Europe&#44; although in recent years the rate has dropped&#44; while in southeast Asia the rate has risen&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> In 2016&#44; 60&#8211;79&#37; of the Spanish male population were estimated to be regular drinkers &#40;mean consumption&#44; 5&#46;6&#8239;SDUs&#47;day&#41;&#44; while 40&#8211;60&#37; of the Spanish female population were considered regular drinkers &#40;mean consumption&#44; 2&#46;1&#8239;SDUs&#47;day&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The consumption has varied little in the past 15 years &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">A quarter of all alcohol consumed worldwide is &#8220;not registered&#8221;&#44; i&#46;e&#46;&#44; unaccounted in the official statistics on taxes or alcohol sales&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> In Spain&#44; the maximum unregistered rate is estimated at 15&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Moreover&#44; almost half of all alcohol consumption recorded worldwide is in the form of spirits&#44; with beer and wine in second and third place&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> In Spain&#44; most alcohol consumption in terms of liters per capita is of beer &#40;54&#37;&#41;&#44; with a significant increase in recent decades&#44; followed by liquor &#40;28&#37;&#41; and wine &#40;18&#37;&#41;&#44; whose consumption has fallen drastically during the same period&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">The risks of alcohol</span><p id="par0050" class="elsevierStylePara elsevierViewall">In contrast to the possible benefit of moderate alcohol consumption&#44; the harmful use of alcohol has a significant social impact and is a risk factor for premature death and disability worldwide&#44; due not only to its direct toxic effects on the body resulting from its likely carcinogenic&#44; teratogenic&#44; myopathic&#44; myelotoxic and neurotoxic effects but also indirectly due to the increase in aggression&#44; accidents and greater susceptibility to other risks&#46; Alcoholic cardiomyopathy&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> cirrhosis and thiamine-deficiency diseases such as polyneuropathy and Wernicke&#8211;Korsakoff syndrome are well-known examples of the direct impact of alcohol&#46; The harmful use of alcohol is not only affected by the quantity of alcohol consumed but also by the patterns of consumption&#59; drunkenness and &#8220;binge drinking&#8221; &#40;extreme and uncontrolled drinking over a short period&#41;&#44; which is very common among young adults&#44; have a highly negative impact on health&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In Spain&#44; alcohol and drugs &#40;along with tobacco&#41; are the main risk factors leading to death and disability&#44; surpassing arterial hypertension&#44; a high body mass index&#44; hypercholesterolemia&#44; hyperglycemia and atmospheric pollution&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In 2010&#44; the World Health Organization &#40;WHO&#41; approved a number of strategies to achieve a relative reduction of 10&#37; in the harmful use of alcohol by 2025&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> These measures have been recently endorsed in the 2018 report that attempts to involve politicians&#44; states and societies &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Nations and communities have also adopted measures&#46; The Spanish Ministry of Health has published an extensive document in 2007<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> on preventing the problems resulting from alcohol use&#46; More recently&#44; Catalonia started the &#8220;Alcohol is Everyone&#8217;s Problem&#8221; campaign&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> The statistics are striking&#58; approximately 3 million deaths annually are attributed to alcohol use worldwide&#44; and 10&#37; of the deaths occur among those aged 15-49 years&#44; either due to accident or disease&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> In Catalonia&#44; a mean of 50 people daily are treated for alcohol poisoning&#44; and approximately 30&#37; of adolescents &#40;14&#8211;18 years&#41; stated having engaged in binge drinking at least once in the past month&#46; Alcohol is the substance that creates the greatest demand for treatment in drug addiction centers and that causes the most damage to third parties&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">It is therefore clear that the harmful use of alcohol constitutes a major social problem&#44; and measures aimed at controlling it are necessary and should involve all of society&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Scientific studies</span><p id="par0075" class="elsevierStylePara elsevierViewall">Numerous studies have analyzed the relationship between alcohol use and mortality&#46; In 2006&#44; a meta-analysis of 34 prospective studies that included more than 1 million participants and more than 90&#44;000 deaths described a J curve&#44; with reduced mortality in low consumption and a progressive increase in deaths with greater intake&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> The lowest mortality risk was observed with 6&#8239;g&#47;day &#40;approximately half a drink&#47;day&#41;&#46; However&#44; compared with no alcohol consumption&#44; the meta-analysis observed a risk reduction with up to 4&#8239;drinks&#47;day for men and 2&#8239;drinks&#47;day for women&#46; Subsequently&#44; the same group analyzed the mortality of patients who had already had a CVD event and reported that low-moderate consumption &#40;5&#8211;10&#8239;g&#47;day&#41; reduced total mortality and that up to 26&#8239;g&#47;day reduced cardiovascular mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> A national survey in the United States found similar results&#44; with a lower risk for fewer than 2 drinks&#47;day&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> Another subsequent meta-analysis of 18 studies showed similar results&#44; with a reduced mortality risk by CVD with the consumption of 2&#46;5&#8211;14&#46;9&#8239;g&#47;day&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> However&#44; a study conducted in England&#44; based on health surveys in a population older than 50 years&#44; found that the benefits of moderate alcohol consumption were restricted to women older than 65 years&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> A cohort study of 47&#44;921 women aged 30&#8211;49 years living in Sweden and followed-up for 15 years revealed that&#44; compared with not drinking&#44; low to moderate alcohol consumption &#40;0&#46;1&#8211;19&#46;9&#8239;g&#47;day&#41; showed a statistically significant inverse association with overall mortality&#44; but the reduction in risk in these young women was limited to CVD and not to cancer&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> Similarly&#44; the epidemiological study PURE&#44; conducted in 12 countries and encompassing 114&#44;970 adults&#44; showed a limited benefit for moderate consumption&#46; The study showed that&#44; compared with nondrinkers&#44; the drinkers had lower myocardial infarction rates but greater rates of cancer and injuries&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> The intense drinkers had higher mortality&#44; while the moderate drinkers saw a benefit only in countries with high economic levels&#44; which suggests that other factors such as income-related lifestyles could be associated with the benefit of a moderate consumption pattern&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In light of these results&#44; it seems clear that&#44; with differential nuances&#44; there is evidence that moderate alcohol consumption reduces the risk of CVD&#46; However&#44; many of the studies on which this statement is based have been subject of criticism because&#44; in addition to lifelong abstainers&#44; the studies included sporadic drinkers and ex-drinkers in the no-alcohol group&#46; Ex-drinkers are a group with a poorer prognosis due to having other conditions that required them to abandon alcohol consumption&#46; A meta-analysis&#44; adjusted for the bias of abstemious patients and nondrinkers&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> and a randomized Medelian analysis<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> did not replicate the J curve&#46;</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Alcohol and cancer</span><p id="par0085" class="elsevierStylePara elsevierViewall">In parallel with the observation of the beneficial effect on CVD&#44; the impact of alcohol on the incidence of cancer has been the subject of debate&#46; Initial studies showed a protective effect conditioned by the weight of alcohol intake&#46; Thus&#44; a 2013 meta-analysis showed that alcohol increased the risk of cancer but that low doses &#40;&#60;25&#8239;g&#47;day&#41; in men could reduce this risk&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> A cohort study of 16&#44;320 participants conducted in South Korea showed higher mortality among the drinkers but with a J curve&#44; with lower overall mortality and cancer mortality in the population with low alcohol consumption &#40;&#60;90&#8239;g&#47;week&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> Similarly&#44; a case-controlled study comparing 250 patients with colorectal cancer against 250 healthy individuals concluded that the association between the amount of alcohol ingested and the presence of cancer also followed a J curve&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> While there was a deleterious effect with consuming large quantities of alcohol&#44; a moderate intake had a protective effect&#44; both in men and women&#44; which was possibly related to wine consumption&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Until recently and despite the proven association with the dose&#44; the threshold of consumption that determined a clinically significant risk was not exactly known&#46; Many of the previously mentioned studies have been criticized for the bias introduced by ex-drinkers&#46; A new analysis adjusted for the data from this population reported that alcohol increased the risk of cancer at any level of consumption&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> Similarly&#44; a new meta-analysis showed that alcohol&#44; at any dose&#44; increased the risk of oral&#44; pharyngeal&#44; esophageal&#44; laryngeal&#44; liver&#44; breast and colorectal cancer&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> It appears that the direct toxic effect at the cellular level of acetaldehyde could play an important role&#46; Therefore&#44; the American Association of Clinical Oncology issued an open warning regarding the association between alcohol and cancer and proposed control measures especially for the younger population&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> along the same line as the WHO &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Recent studies&#46; A change in paradigm&#63;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Highly relevant studies have been published in the past 2 years that have reconsidered the paradigm of alcohol and health&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">On one hand&#44; a new broad study was published that reinforced the benefit of moderate alcohol consumption&#46; In 2017&#44; Xi et al&#46; published the analysis of 13 serial surveys from the US National Health Interview Survey &#40;NHIS&#41; that encompassed 333&#44;247 participants categorized into 6 groups&#58; abstainers&#44; occasional drinkers&#44; ex-drinkers and currently light&#44; moderate and heavy drinkers&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> The results showed that heavy drinkers &#40;&#62;14&#8239;drinks&#47;week&#41; and binge drinkers &#40;&#8805;1&#8239;binge drinking&#47;week&#41; had a higher cancer mortality and all-cause mortality risk&#46; The light or moderate drinkers &#40;&#8804;14&#8239;drinks&#47;week for men and &#8804;7&#8239;drinks&#47;week for women&#41; had a lower cardiovascular and all-cause mortality risk&#44; reproducing the known J curve&#46; An analysis by other researchers of the drinking patterns from the same NHIS database&#44; comparing them with those of 93&#44;653 individuals from the US Veterans Administration&#44; showed that&#44; if one considered the intake of 1&#8211;2 drinks on each occasion&#44; the greatest benefit was achieved by drinking 3 times&#47;week&#44; given that daily consumption slightly increased the risk compared with this level&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Another study published the same year and conducted in South Korea with a smaller sample &#40;8333&#8239;participants&#41; and a 10-year follow-up also showed that low-moderate alcohol consumption &#40;&#60;15&#8239;g&#47;day&#41; reduced the risk of myocardial infarction and coronary artery disease but also showed that the reduction was not significant when occasional drinkers were added to the reference group&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> The authors found demographic similarities between light and occasional drinkers&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">On the other hand&#44; we have the published report from the Global Burden of Disease &#40;GBD&#41; on the effects of alcohol and health&#46; The GBD is a regional and global research program that evaluates mortality and disability caused by the main diseases&#44; injuries and risk factors worldwide&#46; The GBD was founded in 1990 and has worked closely with the Institute of Health Metrics and Evaluation of the University of Washington and with the WHO&#46; The program currently has 1800 researchers in 127 countries&#46; The latest global report published in 2017<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> presented the factors that most influenced what the program defines as disability-adjusted life years or years lost due to disability or premature death &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The GBD estimated that alcohol was the seventh primary component of DALY risk worldwide in 2016 and was the factor that had risen the most in importance&#44; affecting men the most&#46; Alcohol was the main risk factor for the 15&#8211;49-year age group&#46; The GBD found that alcohol consumption had increased in countries with low to medium economic levels&#46; Therefore&#44; a year later&#44; the program published the specific data from the analysis of alcohol&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> with extensive supplemental material&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The authors remarked that their analysis had provided a methodological improvement in terms of estimating alcohol consumption based on several aspects such as analyzing 694 individual and populational data sources&#44; including the alcohol consumption of tourists and of unrecorded alcohol and performing a meta-analysis with a new analytical method of relative and individual risk on 23 health results associated with dose-response&#46; The study showed that&#44; at the global level&#44; alcohol increased the risk of a number of diseases without there being a benefit to low doses&#44; except for diabetes&#44; ischemic heart disease and ischemic stroke&#44; which decreased the risk&#46; However&#44; there were also a number of diseases for which low doses did not raise or lower the risk &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">A highly relevant study published in 2018 by Wood et al&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> analyzed 599&#44;912 alcohol drinkers from 83 studies&#44; encompassing 19 countries with high economic levels&#46; The study revealed that there was a positive curvilinear relationship with all-cause mortality and that the lowest risk level was an intake of &#8804;100&#8239;g&#47;week&#44; which corresponded to the flat part of the curve &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; As in previous studies&#44; the study found a negative relationship with CVD at low doses&#44; especially with myocardial infarction&#44; which decreased with any level of alcohol consumption&#46; However&#44; there was a positive almost linear relationship for the incidence of stroke&#44; another type of CVD&#44; hypertensive heart disease&#44; aortic aneurysm and even heart failure&#44; the latter of which contradicted a recent study called Atherosclerosis Risk in Communities&#44; which reported a reduction in the incidence of heart failure with an intake of &#60;7&#8239;drinks&#47;week&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> In the study by Wood et al&#46;&#44; an intake &#62;100&#8239;g&#47;week reduced life expectancy the younger the population and the greater the intake&#46; The authors concluded that the recommended limit for alcohol consumption should be reduced to 100&#8239;g&#47;week and that for other CVD &#40;except for myocardial infarction&#41;&#44; there is no safe level of consumption&#46; It is worth indicating that in this study the risk of all-cause hypertensive heart disease and stroke increased in the drinkers&#44; in contrast with the data from the GBD that indicated a reduction in ischemic stroke and a neutral effect on hypertensive heart disease in the light drinkers&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">It is also worth noting that these results only included individuals who drink&#46; When nondrinkers &#40;53&#44;851&#41; and ex-drinkers &#40;29&#44;726&#41; were included &#40;data published in the supplemental material&#41;&#44; both groups had a greater risk of overall mortality &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; The data were even more striking when analyzing cardiovascular events&#46; Although it is a well-known fact that ex-drinkers are a population at greater risk&#44; the data from the nondrinkers are surprising and were highlighted in the editorial comments&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> This subgroup had a higher proportion of individuals with diabetes and a lower educational level &#40;34&#46;9&#37; of the non-drinkers were university educated&#44; compared with 37&#46;2&#37; of the ex-drinkers and 51&#37; of the drinkers&#41; but had an increased risk despite the higher proportion of women &#40;70&#37; among non-drinkers&#44; compared with 51&#37; and 44&#37; for ex-drinkers and drinkers&#44; respectively&#41; and performed more moderately intense physical activity &#40;75&#46;7&#37; vs&#46; 62&#46;8&#37; and 50&#37;&#44; respectively&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Moreover&#44; a recent study conducted in London provided another argument for proponents of moderate alcohol consumption&#46; The Whitehall II study analyzed a cohort of 9087 middle-aged individuals &#40;35&#8211;55 years&#41; followed-up for 23&#8239;years and reported that there was an increased risk of dementia in the abstainers and drinkers of &#62;14 units&#47;week&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Lastly&#44; a recently published study &#40;April 2019&#41; in China reinforced the threshold of consumption of 100&#8239;g&#47;week&#46; The study analyzed a population of 500&#44;000 individuals&#44; mostly men &#40;98&#37;&#41;&#44; who were followed-up for 10 years&#46; Of these&#44; 161&#44;498 were genotyped for 2 variants that change alcohol metabolism and determine the pattern of consumption&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> The conventional epidemiological analysis reproduced the U curve for myocardial infarction&#44; stroke and intracerebral hemorrhage&#44; with a maximum level of risk reduction with a consumption of 100&#8239;g&#47;week&#46; However&#44; the mean alcohol intake predicted by the genotype &#40;ignoring the drinking patterns and in a Mendelian randomization&#41; did not result in this U curve&#46; The study found that alcohol increased systolic pressure&#44; stroke and hemorrhage and was neutral for myocardial infarction&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Considerations regarding moderate alcohol consumption</span><p id="par0135" class="elsevierStylePara elsevierViewall">Although epidemiological studies have shown high levels of association between alcohol consumption and numerous diseases&#44; there have been no randomized trials that have revealed a causality&#46; The Moderate Alcohol and Cardiovascular Health trial&#44; a multicenter trial sponsored by the National Institutes of Health and the National Institute of Alcohol Abuse and Alcoholism&#44; is the only randomized trial to date that has analyzed the impact of moderate alcohol consumption &#40;15&#8239;g&#47;day&#41; on cardiovascular disease and type 2 diabetes&#46; However&#44; the trial was prematurely interrupted in May 2018 after including 105 patients&#44; due to conflicts of interest created by the private funding &#40;more than 70&#37;&#41; from industrial alcohol manufacturers&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> We can therefore conclude that the level of evidence on the impact of a moderate consumption on health is not high&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">However&#44; recent studies have indicated that any alcohol consumption can increase the risk of various neoplasias &#40;especially in the gastrointestinal tract and breasts&#41;&#44; atrial fibrillation and hypertension&#46; This finding is counteracted by the evidence that moderate consumption reduces the risk of CVD &#40;especially myocardial infarction and diabetes&#41; and dementia&#44; effects that are more significant in countries in the industrialized world&#44; which have greater alcohol consumption and a specific drinking pattern&#46; Therefore&#44; the decision to consume alcohol is individual and should be determined by personal factors&#44; family history and social context&#46; In any case and based on current data&#44; the accepted limits of 140&#8211;200&#8239;g of alcohol&#47;week for men and 70&#8211;100&#8239;g for women should be reduced to 100&#8239;g&#47;week or less &#40;equivalent to 7&#8211;10 drinks weekly&#41;&#44; given that it appears that these levels do not increase all-cause mortality&#46; Based on the premise that alcohol consumption should not be started for health purposes and in contrast to total abstention with the social burden that represents&#44; these levels of alcohol consumption might be acceptable for middle-aged and elderly individuals but should exclude&#44; in line with a recent consensus document&#44;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> young adults&#44; pregnant women&#44; individuals with addiction&#44; those with arrhythmias&#44; liver or pancreatic diseases and those at risk of gastrointestinal or breast cancer&#46; Moreover&#44; all measures proposed by the WHO to fight excessive consumption and prevent binge drinking should be implemented&#46; In this respect&#44; the Mediterranean diet&#44; with moderate alcohol consumption combined with meals&#44; could be a recommended example of a healthy drinking pattern&#46; Although wine &#40;especially red wine&#41; has a high polyphenol content &#40;hydrolysable tannins&#44; resveratrol&#44; etc&#46;&#41; that has been confirmed to have beneficial health effects in numerous experimental studies&#44; a clear superiority over other alcoholic drinks has not been demonstrated&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Nevertheless&#44; the recent study by Wood et al&#46; found that there was a lower risk for those who predominantly drank wine compared with those who predominantly drank liquor or beer &#40;Fig&#46; 4&#8239;C&#41;&#46; Other studies<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">49&#44;50</span></a> have also found that wine drinkers had greater protection than non-drinkers or those who did not drink wine&#59; however&#44; there are also studies that have found advantages with beer and even with liquor&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;51</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0145" class="elsevierStylePara elsevierViewall">JM and JRGL are members of the scientific committee of the Research Foundation on Wine and Nutrition&#46;</p></span></span>"
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          "titulo" => "Alcohol consumption"
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          "identificador" => "sec0015"
          "titulo" => "The risks of alcohol"
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              "titulo" => "Scientific studies"
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              "identificador" => "sec0030"
              "titulo" => "Recent studies&#46; A change in paradigm&#63;"
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          "identificador" => "sec0035"
          "titulo" => "Considerations regarding moderate alcohol consumption"
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    "fechaRecibido" => "2019-03-18"
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          "clase" => "keyword"
          "titulo" => "Keywords"
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          "palabras" => array:8 [
            0 => "Alcohol"
            1 => "Wine"
            2 => "Health"
            3 => "Cardiovascular disease"
            4 => "Cancer"
            5 => "Moderate consumption"
            6 => "Harmful consumption"
            7 => "Binge drinking"
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          "titulo" => "Palabras clave"
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          "palabras" => array:8 [
            0 => "Alcohol"
            1 => "Vino"
            2 => "Salud"
            3 => "Enfermedad cardiovascular"
            4 => "C&#225;ncer"
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            6 => "Consumo nocivo"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Recent epidemiological studies have shown that alcohol consumption can increase the risk of arterial hypertension&#44; atrial fibrillation and gastrointestinal and breast cancer&#46; Various sectors are therefore promoting abstinence from alcohol&#46; However&#44; light alcohol consumption has once again been shown to reduce the risk of myocardial infarction and diabetes but with an unclear effect on cerebrovascular disease&#46; The decision to consume alcohol should therefore be an individual one based on personal factors&#46; A level of consumption &#60;100&#8239;g&#47;week for men &#40;less for women&#41; appears not to increase all-cause mortality&#44; while high consumption or binge drinking significantly increases mortality risk&#46; All measures to prevent this type of consumption&#44; especially among the younger population&#44; should therefore be applied&#46; There are data indicating an advantage of wine over other beverages&#44; but they are not conclusive&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Estudios epidemiol&#243;gicos recientes han demostrado que el consumo de alcohol puede aumentar el riesgo de hipertensi&#243;n arterial&#44; fibrilaci&#243;n auricular y de c&#225;ncer digestivo y de mama&#44; por lo que diversos estamentos est&#225;n promoviendo la abstinencia&#46; Sin embargo&#44; tambi&#233;n han vuelto a confirmar que el consumo ligero de alcohol puede reducir el riesgo de infarto de miocardio y de diabetes&#44; no quedando claro el efecto en la enfermedad cerebrovascular&#46; Por ello&#44; la decisi&#243;n del consumo de alcohol debe ser individual y basada en factores personales&#46; Un nivel de consumo &#60;100&#8239;gr&#47;semana en hombres &#40;menor en mujeres&#41;&#44; parece que no aumenta la mortalidad por cualquier causa&#44; mientras que consumos elevados o en forma de atrac&#243;n &#40;&#8220;binge&#8221;&#41;&#44; incrementan significativamente el riesgo de mortalidad&#44; por lo cual deben aplicarse todas las medidas para prevenir este tipo de consumo&#44; especialmente en la poblaci&#243;n m&#225;s joven&#46; Hay datos que apuntan una ventaja del vino frente a las otras bebidas pero no son concluyentes&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as&#58; Masip J and Germ&#224; Lluch JR&#46; Alcohol&#44; salud y enfermedad cardiovascular&#46; Rev Clin Esp&#46; 2021&#59;221&#58;359&#8211;368&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Equivalence of alcoholic drinks&#46; The first row shows the approximate volume equivalent to 1&#8239;SDU of the most common drinks according to their proof&#46; The bottom row shows an approximation of the most common quantities or &#8220;portions&#8221; of alcohol consumption&#46; Alcohol content of a beverage&#8239;&#61;&#8239;volume &#40;dL&#41;&#8239;&#215;&#8239;proof&#8239;&#215;&#8239;0&#46;79&#42; &#40;&#42;conversion factor&#41;&#46; SDU&#58; standard drink unit&#8239;&#61;&#8239;10&#8239;g of alcohol&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">American Association of Clinical Oncology<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Maintain limits on days and hours of sale&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Enhance enforcement of laws prohibiting sales to minors&#46;&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Proposed measures for reducing harm alcohol consumption&#46;</p>"
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                    0 => array:2 [
                      "titulo" => "Wine and cardiovascular health&#46; A comprehensive review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "S&#46; Haseeb"
                            1 => "B&#46; Alexander"
                            2 => "A&#46; Baranchuk"
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                    0 => array:2 [
                      "doi" => "10.1161/CIRCULATIONAHA.117.030387"
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                        "tituloSerie" => "Circulation"
                        "fecha" => "2017"
                        "volumen" => "136"
                        "paginaInicial" => "1434"
                        "paginaFinal" => "1448"
                        "link" => array:1 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28993373"
                            "web" => "Medline"
                          ]
                        ]
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                  ]
                ]
              ]
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prospective study of alcohol consumption and risk of coronary disease in men"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "E&#46;B&#46; Rimm"
                            1 => "E&#46;L&#46; Giovannucci"
                            2 => "W&#46;C&#46; Willett"
                            3 => "G&#46;A&#46; Colditz"
                            4 => "A&#46; Ascherio"
                            5 => "B&#46; Rosner"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/0140-6736(91)90542-w"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "1991"
                        "volumen" => "338"
                        "paginaInicial" => "464"
                        "paginaFinal" => "468"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1678444"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Factors associated with cardiac mortality in developed countries with particular reference to the consumption of wine"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "A&#46;S&#46; St Leger"
                            1 => "A&#46;L&#46; Cochrane"
                            2 => "F&#46; Moore"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/s0140-6736(89)92659-7"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "1979"
                        "volumen" => "1"
                        "paginaInicial" => "1017"
                        "paginaFinal" => "1020"
                        "link" => array:1 [
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Review
Alcohol, health and cardiovascular disease
Alcohol, salud y enfermedad cardiovascular
J. Masipa,b,c,
Corresponding author
jmasip@ub.edu

Corresponding author.
, J.R. Germà Lluchc,d,e
a Servei de Medicina Intensiva, Consorci Sanitari Integral, Barcelona, Spain
b Servicio de Cardiología, Hospital CIMA Sanitas, Barcelona, Spain
c Universidad de Barcelona, Barcelona, Spain
d Institut Català d’Oncologia (ICO), Barcelona, Spain
e Institut d’Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain

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