I'm William Brangham and this is "Horizons."

From Portland's craft beer to Kentucky's bourbon, alcohol is a cultural staple across the country, woven into so many parts of our social lives.

And while everyone has heard the caveats about moderation, is any amount of alcohol truly safe?

A growing body of evidence says no.

Alcohol and our health, coming up next.

♪ Narrator: Support for "Horizons" has been provided by Steve and Marilyn Kerman and the Gordon and Betty Moore Foundation.

Additional support is provided by Friends of the News Hour.

♪ This program was made possible by contributions to your PBS station from viewers like you.

Thank you.

From the David M. Rubenstein Studio at WETA in Washington, here is William Brangham.

Welcome to "Horizons."

We're talking today about a product so tightly woven into our society that we struggle to see what it's really doing to us.

That product is alcohol, the drink that is central to so many holidays and celebrations and daily rituals, and yet one that takes a terrible toll on our health, our economy and on the lives of millions of people.

While drinking trends have been declining, according to data from 2024, Americans still spend well over 200 billion dollars every year on beer, wine and hard alcohol.

According to Pew, 18 percent of Americans drink alcohol daily or a few times a week.

Another 23 percent drink a few times every month.

And despite well-documented links between drinking alcohol and cancer, heart and liver disease, not to mention car crashes, accidents and addiction, well over half of all drinkers, 57 percent, think that their own consumption doesn't raise their risk for serious health problems.

So we want to look at these two distinct issues, what we know about what alcohol is doing to us and why we have such a hard time recognizing the public health crisis that's staring us right in the face.

For that, we turn to Lev Facher.

He's a journalist with the health news site Stat.

He co-authored a recent series about alcohol called "The Deadliest Drug."

And joining us from Atlanta is Marissa Esser.

Until recently, she ran the alcohol program at the Centers for Disease Control and Prevention.

She now runs her own private public health consulting firm.

And joining us from the Bay Area is epidemiologist Priscilla Martinez.

She's the deputy scientific director at the Alcohol Research Group, which studies alcohol and drinking patterns.

Thank you all so much for being here.

Really appreciate this.

Lev, to you first.

Your series in Stat was this all-encompassing look at alcohol's influence on our society, an incredible, powerful piece of journalism.

But in particular, I want to talk about the impacts that you document on our health.

You mentioned 500 Americans dying every day, that alcohol causes more deaths in a typical year than every infectious disease combined.

Can you just give us a little bit more detail about what your reporting showed about what alcohol does to us?

Absolutely, so the idea behind this series that I wrote with my colleague, Isabella Cueto, is to reframe alcohol as what it is, which is America's deadliest substance use crisis.

Imagine being an alien from outer space and arriving on Earth, and you start to study human behavior and American behavior.

And you're thinking about what is healthy for these animals and what is unhealthy.

Alcohol is going to go straight to the top of the list of behaviors that you can't quite fathom.

Brangham: "Why on Earth are they doing this?"

Absolutely, it's essentially a toxin and it's causing cancer, it's causing cardiovascular disease, it's causing liver disease.

And that's on top of the more obvious acute impacts that we all know about, like violence, car crashes, suicide, addiction.

So this is really an addiction crisis in the truest sense.

And it's not just an addiction crisis.

There are many, many health impacts from moderate and debatably even light drinking.

So it's not just people who are drinking in a way that people would consider to be ruinous, it's people who are drinking in ways that are very societally normalized and accepted.

And there are still these really, really significant health externalities.

And that's the framing of the series, that we want to approach alcohol as a leading cause of death and disease in this country.

Marissa, what would you add to that?

I mean, you, for many period of time worked at the CDC running the government, federal government's, one of its big alcohol programs.

When you think about alcohol's impact on public health, what would you add to what Lev is just adding?

Yes, I agree.

It's a really under recognized problem in this country.

You mentioned 500 deaths per day from alcohol related causes, and that yields about 178,000 deaths per year.

And if we think about that in other terms, that's about the size of enough people to fill two football stadiums roughly, and that's how many people we're losing every year.

But these deaths are often under recognized and not often discussed.

And then, in addition to the deaths, we also have... alcohol is a leading cause of chronic disease.

Lev mentioned cancer, it's also associated with liver disease, heart diseases.

So people often are more familiar with thinking about the risk of addiction, but it's really affecting this broad range of chronic diseases, as well as injuries.

It's involved in about 20% of suicides, for example.

So it's really the whole spectrum of harms from alcohol that's important to consider.

Brangham: And Priscilla, why...?

Do you have a good sense as to why we struggle to talk about it in these terms?

I mean, when we talk about, quote unquote, "drug problems" in America, we talk about opioids, we talk about marijuana.

Alcohol is often not in that conversation.

Why do you think that is?

Yeah, that's a really important question.

Because it really is the most popular psychoactive substance that the world uses and that Americans use.

And I think it's just how it's been normalized in our society.

It's like you noted, it's part of our rituals and traditions.

It's everywhere.

You can get alcohol pretty much wherever you want, gas stations, liquor stores, grocery markets.

There's some variation by state.

But overall, you can get alcohol anytime you want in a lot of places.

So it's very normalized.

And I think that has made it hard for us to think of it as something that's bad for us.

How would we allow something that is bad be everywhere, so omnipresent and part of our daily lives?

Brangham: I mean, Lev, do you think that part of it is also the language that we use to talk about it?

I mean, alcohol is related to happy hour.

It's you have a glass of bubbly when you want to celebrate something.

It's how we characterize a guy who I'd like to have a beer with.

Like it's so associated with positive recreational things that it makes it tough to say, by the way, this also really is a toxin.

I would also even note that a lot of us were raised in religious traditions where alcohol plays a really pivotal role.

So if you have your priest or your rabbi offering you wine, that's an authority figure.

That's a figure who's supposed to provide a sense of morality and spirituality.

And if alcohol is central there, obviously it's going to be approved of.

There's not stigma.

And stigma gets complicated when you talk about substances, because there are a lot of ways that it can hold us back from pursuing evidence-based life-saving policies.

But absolutely, the language and more broadly, the culture surrounding alcohol, the idea that people need alcohol just to have vibrant social lives, there's a lot of inertia there.

And human beings can be awkward.

Alcohol is really kind of an expected component for a lot of people of a first date or just a night out with friends.

Brangham: It's a social lubricant.

We all know this.

Facher: Exactly.

And to be clear, the series that Isabella and I wrote is not advocating for prohibition, because we can really quickly get into that territory where any time someone starts advocating for evidence-based alcohol policy, you get accused of wanting to ban alcohol and return to the days of prohibition.

And there are not really serious policy thinkers out there who are advocating for that.

But there are ways that we could substantially reduce the harm associated with moderate and heavy drinking, and then, of course, drinking that rises to the level of an addictive behavior.

And because of the language and the culture that you're describing, it's really, really hard to get the ball rolling forward on those policies and those initiatives.

Brangham: Marissa, please.

Esser: Yeah, I just wanted to also add that you mentioned about it being a social lubricant, but that's also because of how our society has been designed and messaged by the alcohol industry in part.

So why is alcohol offered at hair salons, at children's birthday parties, at some movie theaters?

Sports events are plastered with alcohol marketing.

These are all ways that the alcohol industry has been working alcohol to be embedded in the society in this way by influencing local, state, and federal policies for expanding the availability of alcohol so that we feel like alcohol is normalized in all of those different settings.

Brangham: And, Priscilla, it's also the argument that you hear from the industry is, "We get it.

"We know that this is something "that we don't want everyone "to just drinking to intoxication."

You often hear this term, "Drink responsibly, drink in moderation."

What do you make of that message overall?

Martinez: There is some good evidence that the "drink responsibly" messaging doesn't have any real effect on people's drinking.

And it's "drink responsibly, drink in moderation."

It's vague.

What does that mean?

It's going to mean different things to different people.

So I think it's, you know, said plainly, I think it is a cop-out for what the impacts of even moderate drinking are.

And I think that we are in a paradigm shift in our understanding of what alcohol's health impacts are.

Like it's been noted that, yes, we know about addiction and drunk driving and violence, gun violence, domestic violence, but people don't often think about cancer from having a couple of drinks a day or cardiovascular disease.

And we don't also think necessarily about the harms to other people that come from drinking.

It's not just violence, but having a parent who has an alcohol use disorder is really detrimental for children or in schools.

So I think the message of moderation isn't very clear and doesn't adequately convey alcohol's problems for society.

Facher: And, William, if I could add to Priscilla, it's one thing to get alcohol manufacturers and the beverage industry to say, "drink responsibly," but it's also, once you do that, incumbent on us as a society and our leaders and government figures to actually put that into policy and practice.

And that's an entirely different ballgame, obviously.

So if you get them to say it, great, but that's just the first of many, many, many steps.

And we would want to put in place many demand reduction and harm reduction policies that would help reduce the disease burden and death burden of alcohol.

And that's currently not the case.

So as Priscilla is saying, it really doesn't do that much to get alcohol manufacturers to say, "drink responsibly."

You actually have to help people do that, tell them what it means, and institute policies that are going to lead to moderation and harm reduction.

Brangham: Right, in fact, Marissa, I want to go back to you about this question.

When the USDA put out recent guidelines about food and alcohol, and it encouraged people to drink less, but took this moderate stance, the Distilled Spirits Council, which is this consortium of alcohol industries, put out a statement, and they said, this was responding to those guidelines, it said, quote, "The dietary guidelines' "longstanding overarching advice "is that if alcohol is consumed, "it should be done in moderation.

"These updated guidelines, "underpinned by the preponderance "of scientific evidence "reaffirm this important guidance."

What do you make of that?

As someone who worked in the federal government, trying to urge us as a nation to be healthier, what do you make of this argument of moderation?

Yes, so the dietary guidelines for Americans that are put out every five years by the Department of Health and Human Services and the U.S.

Department of Agriculture are a very politicized document, and federal officials who were working on the alcohol section were removed from the process.

The alcohol program at CDC was shut down before the dietary guidelines process was complete.

And so the alcohol industry has been involved for many years in shaping and influencing their view on outcomes of what they would think of as a positive outcome for the dietary guidelines.

And so these vague guidelines that are now in place don't refer to any specific cut points or levels of drinking.

So it really doesn't give Americans a sense of where their risks begin for when they use alcohol.

It has a vague suggestion about drinking less for overall health, which is a true message that is critically important for people to understand, that the less you drink, that is better for your health.

But then there's important information that's also needed for people to understand, "Well, how much less drinking would actually improve my health or where do my risks begin?"

And so, for example, there are certain cancers that begin at just one drink per day, but the dietary guidelines don't have any information to give people a sense of whether they're still okay drinking five or six drinks a day as long as that's drinking less.

And so the alcohol industry has been very active in influencing policymakers and federal officials in the ultimate outcome of the dietary guidelines.

Brangham: Priscilla, do you think that there's also, that the binary that we have created societally between people who are just, you're either an alcoholic who should be in a treatment program versus the vast majority of the rest of society, which are people who drink a couple of drinks a week or maybe more, that that chasm helps us think, "Oh, well, I don't have a problem "because I'm not demonstrably an alcoholic."

That complicates this messaging too.

Martinez: It really does.

And in the alcohol research field, we don't use the term alcoholic anymore because of the stigma attached to it and because it's so polarizing and so binary.

And yeah, you will often hear people say, "Well, I'm okay because I don't have "a problem with drinking.

"I don't drink that much."

It's important to note that the definition of an alcohol use disorder is not defined by how much or how often you drink.

It's defined by the problems that it causes you and some of the physical symptoms you might have from that.

But even still, you're right that there is this dichotomy that means that people can say, "Well, I'm not that one thing, so therefore I'm okay."

And I think it's this new realization that even at lower levels of use, like Marisa just pointed out, there are increases in risk for serious diseases like a variety of cancers.

And my hope is that by having an improved understanding of alcohol's health effects at these low and moderate levels of use, that will reduce some of the stigma associated with somebody trying to reduce their drinking or somebody trying to quit.

I've heard several stories.

This is anecdotal, but nonetheless valid, that people say, "Well, I told people I stopped drinking "and everybody said, 'I didn't know you had a problem with alcohol.'"

And they said, "No, I just want to be healthier."

Brangham: Right.

Facher: And, William, if you think about it, the paradigm for thinking and talking about alcohol is so different from the way we talk about other things in our lives that we know are potentially okay in moderation and then unhealthy when used to excess.

So think about processed meats.

Think about a hot dog.

This is something that's also a known carcinogen, but no one would ever suggest, "Oh, you have to have had a heart attack" or "You have to meet the threshold for obesity "to want to cut back "on your processed meat consumption."

It's the kind of thing where you have a little bit, it's obviously not going to kill you immediately and directly.

And if you have a ton, it becomes very unhealthy.

And people with their diet, with food, often understand that these things exist on a spectrum.

But with alcohol, as you say, as Priscilla says, there's this gulf where either you are doing it in an unhealthy way and that's obvious to everyone around you or you're probably fine.

And that's not the case.

And the idea here is just to help people make more informed choices as opposed to forcing them into this binary where they're okay or they're not.

They need to drastically change their behavior or they don't.

All these things exist somewhere on that continuum.

Brangham: Right.

Marissa, what are the known levers that we can pull to help people move in a healthier direction with regards to alcohol consumption?

Esser: Yes, there are a lot of known and proven strategies available that are really not being used to the full potential in states and throughout our country.

The most effective policy solutions are those that increase the price of alcohol.

And so when we think about these strategies, we're thinking about increasing the taxation on alcohol or raising the price of the lowest cost products called minimum pricing policies.

And these strategies exist to help people purchase less and consume less.

And then when we take something like taxation, it also can generate more revenue for states and governments to be able to use and potentially use some of that revenue for designing health and wellness programming or put it towards alcohol use disorder treatment programs.

And so that extra revenue can really be good, put to good use to improve for their public health outcomes.

And in addition to pricing policies, we also know that reducing the availability of alcohol, it can help to change the environment in which people are living, where we don't want to make alcohol so available by default.

And so these are things like reducing the number and concentration of these stores and places that are selling alcohol.

And those types of things can help to redesign the communities.

We can make space for other types of stores that are not putting our communities at risk for these alcohol-related problems.

So there are a number of these policy strategies that we know are available and can be used, but policymakers haven't been actively using these, in recent years.

Brangham: Marissa, anyone that has either traveled to Europe or any of our European viewers will know that if you buy a pack of cigarettes in Europe, they come with these gruesome images that show throat cancer, tongue cancer, mouth cancer.

You cannot escape purchasing a pack of cigarettes without a glaring demonstration of what this product could do to you.

Do you think we should find some way to put a warning label on alcohol?

Maybe not that gruesome, but do you think that that's a good idea, Priscilla?

Martinez: I think warning labels are a very good idea.

The Surgeon General came out in January with the U.S.

Advisory on Alcohol and Cancer, and that called for warning labels to be updated to include cancer warnings, most specifically about breast cancer and colon cancer.

And warning labels are known to raise awareness of a certain behavior's health effects.

And you brought up the classic example of tobacco.

So I think warning labels would go far.

Even in California, we have Proposition 65, which requires point of sale to have a sign about various carcinogens, and alcohol is one of them.

And so you see it at alcohol outlets, not always in the most obvious places, but they are there.

And so you have higher levels of awareness that alcohol is a carcinogen in California relative to other states.

We've seen that in some surveys.

So yes, I think warning labels would be a very good idea.

The challenge is that it is literally an act of Congress and would require immense political will.

Brangham: Lev, in your reporting, one of the things I know you touched on is the difficulty that doctors have to talk about this, because they would be an obvious natural conduit to talk to their patients.

Talk a little bit about that, the difficulty that the medical community has in communicating what seems so evident.

There are two problems, really.

One is that many doctors are not particularly comfortable asking their patients about their alcohol consumption.

A lot of people are probably familiar with the experience of going in for a checkup, for a physical.

Your doctor asks you about your drinking, and you say something like, "Oh, a couple a week," or "I drink socially."

And that's the end of the conversation.

And even if your answer is ambiguous, even if there's really a wide range of potential behavior that your answer could imply, the doctor is likely to just move on.

And there are a couple reasons for that.

One, it's just uncomfortable.

Another, there's some training about alcohol and addiction medicine in general in medical school, but I think there's not enough.

But the other side of this problem is that even if a doctor were to implement the screening tools that we have, and there are a number of tools and surveys that are helpful in determining someone's drinking level and whether it's harmful, even if a doctor were to have that conversation in a productive way, there aren't necessarily amazing resources to give people, especially if they exist somewhere along the spectrum that we've been talking about where you want to reduce your drinking, but you're not a candidate for an inpatient rehab program, you're not interested in Alcoholics Anonymous, you're not someone who wants or necessarily even needs to reduce your drinking to zero.

So there are two problems.

There's the information intake and whether doctors are good at that and willing to participate.

But then even if they did, do we as a country have the infrastructure to help people moderate and to help get people with more serious, more harmful drinking behavior into some type of treatment program that would be helpful to them?

Brangham: Marissa, last point to you, we have just about 30 seconds left.

What would you like, again, people know what you did professionally, if they say to you, "How do I start to act "a little bit more healthily with regards to alcohol?"

What's your quick counsel to them?

Esser: Some quick tips would be to just generally start counting your drinks and get a better understanding of how much you're drinking throughout the week.

Oftentimes people don't realize that their number of drinks has been creeping up and they might not even have a sense of that.

So once you start beginning to understand how much you're drinking and get that awareness, then you can start setting goals for how much less you want to drink per week or per occasion and try to find a way to hold yourself accountable by telling your friends or someone in your family or write it down and set yourself a goal that you can check back in with yourself later on.

Brangham: All right, that is Marissa Esser, Priscilla Martinez and Lev Facher.

Thank you all so much for being here.

Really wonderful conversation.

Thank you.

And that is it for this episode of "Horizons."

Thank you so much for watching.

We'll see you next week.

Narrator: Support for "Horizons" has been provided by Steve and Marilyn Kerman and the Gordon and Betty Moore Foundation.

Additional support is provided by Friends of the News Hour.

♪ This program was made possible by contributions to your PBS station from viewers like you.

Thank you.

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