Time to stop condoning the drink: Why GPs should abandon alcohol neutrality

Thom Phillips is Chief Medical Officer at Forth, and a former NHS GP He has a clinical interest in performance and preventive medicine. He is on LinkedIN

There is an old joke, that often raises a wry smile from patients and colleagues: “You’re only an alcoholic if you drink more than your doctor.”

What once stood as a nod to alcohol fuelled medical school nights out – and possibly poorly developed coping skills – should now land as a confession of professional failure.

For millennia, alcohol occupied a rational place in human life. Fermented beverages emerged at least as far back as 7000 BCE, not primarily for pleasure but out of necessity. Contaminated water killed. Weak ale and diluted wine did not. Alcohol’s antimicrobial properties were a genuine public health technology. In medieval Europe, beer was safer than river water. In long ocean voyages, spirits preserved both liquid and sailor. The Sumerians, the Egyptians, the Romans all brewed because clean water was a luxury they could not reliably secure. Alcohol was, in its origins, a workaround for failed sanitation.

We no longer have that excuse. Clean drinking water is available to virtually everyone in the United Kingdom at the turn of a tap. The utilitarian justification for fermented beverages dissolved the moment we built functioning sewers and water treatment works. What remains is habit, culture, industry, and, critically, a medical profession that has for too long offered a tolerant shrug.

That shrug now contradicts the evidence we hold in our hands.

The 2018 Global Burden of Disease analysis, covering 195 countries, was unambiguous: the level of alcohol consumption that minimises overall health risk is zero grams per week.¹ The apparent cardioprotective signal from moderate drinking, which gave a generation of GPs cover for their reassurances, was largely an artefact of methodological bias, sick quitters and lifetime abstainers lumped together as the reference group.² A 2023 systematic review and meta-analysis of 107 cohort studies involving over 4.8 million participants found no significant reduction in all-cause mortality for those drinking under 25 g ethanol per day once these biases were corrected.³

Cancer risk is where the science is most damning. Alcohol is a Group 1 carcinogen. It causes at least seven cancer types, and crucially, the majority of alcohol-attributable breast cancers in the WHO European Region arise from light to moderate consumption; below 1.5 litres of wine per week.⁴ There is no threshold of safety. A 2024 comprehensive meta-analysis confirmed elevated risks of oesophageal, colorectal, laryngeal, and breast cancers even from light drinking.⁵ The brain is equally unspared: a landmark longitudinal BMJ study found that even moderate drinkers (within then-current guidelines) showed hippocampal atrophy and accelerated cognitive decline compared with abstainers.⁶

None of this is secret. The UK’s Chief Medical Officers acknowledged as much when they revised the guidelines in 2016, making explicit that the risk of cancer begins at any level of consumption.7 And yet the clinical encounter remains strangely relaxed. We ask about units, nod if the answer is below fourteen, and move on. We have normalised a Group 1 carcinogen.

The cultural moment is shifting, and younger patients are leading it. In 2022, 26% of 16-24 year olds in England reported not drinking at all in the previous twelve months, up from 19% in 2011.⁴ Gen-Z has largely concluded that alcohol is not worth it. They are not being puritanical. They are being rational, and they are arriving at that rationality without waiting for their doctors to catch up.

What would it mean to actually catch up? Not prohibition. Not moralising. It means GPs ceasing to implicitly condone alcohol by treating any consumption as medically acceptable. It means saying clearly: there is no safe amount, just as we say this about smoking. The historical reasons for drinking are gone. The medical reasons for restraint are overwhelming.

The joke about drinking more than your doctor was always a little too close to the truth. It is time we stopped being the punchline.

Deputy editor’s note: see also https://bjgplife.com/dont-pass-me-the-drink/

References

1. GBD 2016 Alcohol Collaborators. Alcohol use and burden for 195 countries and territories, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2018;392(10152):1015-105. DOI: 10.1016/S2215-0366(18)30337-7
2. Zhao J, Stockwell T, Naimi T, Churchill S, Clay J, Sherk A. Association between daily alcohol intake and risk of all-cause mortality: a systematic review and meta-analyses. JAMA Netwrk Open. 2023;6(3):e236185. DOI: 10.1001/jamanetworkopen.2023.6185
3. Stockwell T, Zhao J, Clay J, Gorski Findlay M, Chikritzhs T, Pare G, et al. Why do only some cohort studies find health benefits from low-volume alcohol use? A systematic review and meta-analysis of study characteristics that may bias mortality risk estimates. J Stud Alcohol Drugs. 2024;85(4):441-453.DOI: 10.15288/jsad.23-00283
4. World Health Organization Regional Office for Europe. No level of alcohol consumption is safe for our health [Internet]. Copenhagen: WHO; 2023 [cited 2025 May]. Available from: https://www.who.int/europe/news/item/04-01-2023-no-level-of-alcohol-consumption-is-safe-for-our-health [cited 2025 May]
5. Bae JH, Kim B, Yun EH, Park S, Lim MK, Oh JK. Cancer risk based on alcohol consumption levels: a comprehensive systematic review and meta-analysis. Epidemiology Health. 2023;45:e2023092. DOI: 10.4178/epih.e2023092
6. Topiwala A, Allan CL, Valkanova V, Zsoldos E, Filippini N, Sexton C, et al. Moderate alcohol consumption as risk factor for adverse brain outcomes and cognitive decline: longitudinal cohort study. BMJ. 2017;357:j2353. DOI: 10.1136/bmj.j2353
7. Case P, Ng Fat L, Shelton N. Exploring the characteristics of newly defined at-risk drinkers following the change to the UK low risk drinking guidelines: a retrospective analysis using Health Survey for England data. BMC Public Health. 2019;19:928.DOI: 10.1186/s12889-019-7240-0

Featured photo by Dylan de Jonge on Unsplash