Has the WHO lost its way regarding alcohol?

As I am sure that most wine-related people have noticed, the World Health Organization (WHO) has recently (since early 2023) taken a very negative formal stance with regard to alcohol consumption (No level of alcohol consumption is safe for our health). This is quite a change of tune from its previous writings, which reported some protective associations of low to moderate alcohol consumption.

Other wine commenters have been doubtful about discussing either the science or the medicine behind the WHO (eg. What the debate about wine and health gets wrong; Yes, we are all doomed to die. But wine won’t do us in). Well, my professional background is in biological science, and so I will do so. It seems to me that the WHO’s current official stance is, in at least some ways, absurd. I will discuss this here, focusing specifically on wine as the source of alcohol. It is quite a long post, but please bear with me.

The WHO’s change of tune has actually been coming gradually over the past decade. However, this topic has come to the fore recently, at least partly because the U.S. federal government is currently revising its dietary guidelines (Alcohol policies in U.S. states, 1999–2018), and it has been made quite clear that these are likely to recommend a major reduction in alcohol use (Biden’s alcohol czar warns Americans could soon be told to limit themselves to just two beers per week under strict new booze guidelines). The wine industry has now woken up (The Barbarians are at the gate).

Well it seems to me that the WHO is attacking wine for no good science reason. Having read their documentation (cited above), their principal claim is that there is no acceptable proof of the health safety of any amount of alcohol. Therefore, they conclude that alcohol must be avoided.

This conclusion is arrant nonsense. Even if their premise is correct (no evidence), then their conclusion (avoid) does not necessarily follow. If there is almost no scientific “proof” one way or the other, as far as health is concerned, then given their own claims, the best that the WHO can do is be neutral on the matter.¹

The issue here is that there never could be any evidence that the WHO would find acceptable, because such experiments would be unethical (ie. the manipulation being performed in the experiment would never be allowed). The allegedly best scientific experiment (and experimental design is a subject that I professionally taught to university science students) is what is called a “double-blind treatment–control” experiment (or sometimes a “randomized controlled trial”, or RCT), as shown in the next picture. In this, we take a randomly chosen group of people, and separate them into two groups: those who drink alcohol and those who do not. We then assign half of each group at random to the now-drink-alcohol (“treatment”) group and half to the now-do-not-drink-alcohol (“control”) group. Then we follow the resulting four groups of people through time, and see what medical and psychological benefits and problems arise.

It should be obvious to everyone that this procedure cannot be done ethically, and so no-one has ever done it (even in the name of science!). Even worse, though, we should ideally do all of this in such a manner that the people involved do not know which of the four groups they are in, and nor do the people evaluating their behavior (this is what “double blind” means). Is this feasible? Of course not.

So, we will never have the best possible scientific evidence about the effects of alcohol on human health. The WHO is therefore correct in claiming that scientific evidence is lacking; but they are wrong in reaching any conclusions from this lack. This is certainly not how scientists proceed under these circumstances, anyway.

What the scientists do is the best that they ethically can. In this case, we follow large groups of drinkers and non-drinkers through time, and see how they get on — this is called an “observational” study rather than a “manipulative” one (as described above), of several types as listed in the next picture. In this type of study, health and behavior experts measure all of the consistent differences they can between the people, to see what matches their patterns of drinking and non-drinking. There have been several summary publications in the medical literature reporting on these types of experiments.² This is where all of the positive attitude towards consuming small amounts of alcohol came from, ten years ago.

So, all of the evidence regarding the effects of alcohol comes from experiments of the latter type. This type of rigorous analysis dates back to Raymond Pearl and his 1926 book Alcohol and Longevity (see: Raymond Pearl on alcohol and longevity). If you want to read further, then the World of Wine (by Erik Skovenborg) has several good posts, citing the pertinent literature.

Just as importantly for our purposes here, there is a difference between “hazard” and “risk”, and the WHO does not seem to acknowledge this anywhere in their writings about the alleged effects of alcohol.

For example, for skin cancer there is a difference between the hazard [the sun] and the risk [getting skin cancer]. In this case, we try to control the hazard by addressing the risk. That is, we limit sun exposure to our bare skin as much as we can, and this keeps us as healthy as possible.

To take a behavioral example, getting into a car is unsafe from the first moment we do so. However:

•   we give ourselves control of the car (eg. steering, braking)
•   we make using it as safe as we reasonably can (eg. seat belt, airbag)
•   and then we get on with it (eg. train people to drive safely).

Is there a hazard or a risk warning actually written on any car? No, because it is a societal issue, and we are all expected to know both the hazard and the risk. It seems to me that alcohol is much the same.

The WHO’s failure here tacitly assumes that alcohol is, in itself, the cause of all drinking problems, and that the amount of alcohol consumed determines the extent of any drinking problems (irrespective of the speed of drinking, the purpose of drinking, or the social environment involved). This is further discussed in: Anti-alcohol industry 101: the neo-temperance movement.

Now, this does not mean that we should be complacent about potential health risks.³ After all, Wikipedia shows an increase in per capita deaths recently in several countries, and alcohol is sometimes involved. So, we should all be cognizant of the health risks of consuming alcohol. After all, people should not drink alcohol because they actually believe that it is always healthy for them! (See: Pour one out; and The truth about drinking a glass of wine every day, according to health experts.)

One important recent research publication about the risks is: Alcohol consumption patterns and mortality among older adults with health-related or socioeconomic risk factors (2024 JAMA Network Open 7(8):e2424495). To quote from it:

While no associations were found for low- or moderate-risk drinking patterns vs occasional drinking among individuals without socioeconomic or health-related risk factors, low-risk drinking was associated with higher cancer mortality and moderate-risk drinking with higher all-cause and cancer mortality among those with health-related risk factors; low-risk and moderate-risk drinking patterns were associated with higher mortality from all causes and cancer among those with socioeconomic risk factors ... Wine preference (>80% of alcohol from wine) and drinking with meals showed small protective associations with mortality, especially from cancer, but only in drinkers with socioeconomic or health-related risk factors and was associated with attenuating the excess mortality associated with high-, moderate- and even low-risk drinking.

The work done here looks good, to me, and the authors and funding look “clean” from a conflict standpoint. Importantly, it addresses an apparent paradox, and comes to a fairly clear conclusion. This could turn out to be a key reference paper.

Equally importantly, we need to note that there is more to life than medicine (as shown in the picture above). That is, we need to weigh the relative benefits and risks of all of our health-related activities, together. This point was explicitly made in the editorial of the Lancet medical journal, replying to the WHO’s first publication of its new stance (Alcohol and health: all, none, or somewhere in-between?).

In particular, Robert Joseph has noted: “we need to promote the unique, historic qualities of wine that make it such a great convivial product and such a delicious partner to food.” That is, in the words of Erik Skovenborg, we need to note: Wine as part of a healthy lifestyle; and Drinking with friends: wine’s role as a social lubricant. If the wine label has to list the risks (as is being suggested for the new USA guidelines), should it also list the benefits? (eg. Should alcoholic beverages have cancer warning labels?; or Is wine the ‘2024 cigarette’?)

Even at my advanced age, I still well-remember going down to the pub with my mates on Friday nights (at only 17 years of age!). I was one of the designated drivers, and therefore I drank lemon-squash, but the other guys certainly enjoyed their beers. These people were not just part of my official life (as a school student) but a part of my private life (as a part of society), and our interactions were highly valued in both roles (eg. Couples who drink together live longer, study suggests; and Why social drinking is integral to a longer life). (See also: Rediscovering the fun in wine; and my own post: What are the current causes for optimism in the wine industry?)

In this sense, the new Drinks Insider’s Wine + Health series (by Felicity Carter) provides a podcast that is freely available. The first broadcast tackles: Anti-alcohol groups and drinking guidelines.

In this latter regard, we may well ask how so many temperance groups get to be advisors to the WHO (since 2018) (How neo-prohibitionists came to shape alcohol policy). Their presence (especially Movendi International, a heavily funded umbrella organization for the neo-prohibition movement) is repeatedly noted in commentary on the current WHO attitude towards alcohol, and the bias that it generates seriously concerns me. This also leads to all sorts of accusations against researchers of alcohol effects (see: The fight over moderate drinking: why studies on effects are unlikely to happen).

Let’s face it, we have been making wine for at least the past 6,000 years (Ancient winery found in Armenia), so it cannot be all bad for us, given how much our species has developed during that time. There are not many other creative things we have actual evidence of doing for that long. Surely, we would have dropped it, just like we have done for a lot of other things, if there was a major problem.⁴

However, even if the WHO does succeed with its current campaign (compare Gen Z continues shift away from alcohol with Why today’s reds are higher in alcohol), this does not mean that the wine industry must fade away. After all, we do have methods for reducing the alcohol content of wines, and we can even start to make alcohol-free wines worth tasting (Why alcohol-free wine is in the ascendant) — but that is a subject for another post (see also my previous post: Fruit wine and alcohol-free wines really are also wines).

---

¹ For example: Aaron E. Carroll, who teaches at the Indiana University School of Medicine, wrote, in an assessment of alcohol science, that: “15 desserts a day would be bad for you. This could lead to assertions that ‘there’s no safe amount of dessert.’ But it doesn’t mean you should never, ever eat dessert.”

² For example:

• Alcohol dosing and total mortality in men and women: an updated meta-analysis of 34 prospective studies. 2006. Archives of Internal Medicine 166(22):2437-2445.
  
• Association of alcohol consumption with selected cardiovascular disease outcomes: a systematic review and meta-analysis. 2011. British Medical Journal 342:d671.
  
• Alcohol consumption over time and risk of death: a systematic review and meta-analysis. 2014. American Journal of Epidemiology 179(9):1049-1059.
  

³ For example, there is no doubt that heavy alcohol consumption damages your liver. The standard sort of disclaimer is something like this: “There are health risks associated with heavy alcohol consumption; and individuals with known health issues related to alcohol consumption, depression, or a family history of alcohol abuse, may not have any safe level of alcohol consumption.”

⁴ As Esther Mobley wrote: “I know that sugar, in high doses, is awful for me. But that doesn’t stop me from enjoying dessert after dinner a couple of times a week. There’s no question in my mind that the deliciousness of a piece of cake is worth whatever health trade-off I’ve made.”

How many drinks are there in a bottle of wine?

How much wine you drink on any given occasion is a serious issue, not just for your own health, but for the happiness of those around you. Even more seriously, the most dangerous place you can be after a drink or two is behind the wheel of a car — there is a borderline between fun and danger.

For this decision to be practical, you need to be able to estimate how much you have consumed, at least roughly. We have been told that drinkers commonly under-estimate the amount of alcohol they imbibe, thinking that a “standard drink” is of greater volume than it is (ie. people often pour more than 1 standard drink as their usual glass of alcoholic beverages). This is the topic that I will address here.

One issue that we need to get out of the way first is: How much alcohol is too much for a driver? It has been suggested, for example, that the U.S. drunk-driving BAC (blood alcohol concentration) limit is too high. Utah is apparently the only state with a 0.05% BAC limit when driving, and everywhere else in the U.S.A. it is 0.08%.

When I was young, Australia brought in that same 0.08 limit, but later lowered it to 0.05, which is therefore what I find “normal” — one serious drink is all you can safely have. I now live in Sweden, where the limit is 0.02 — you can’t safely drink at all, if you are the designated driver for your outing group. Apparently, there are more than 30 other countries with similar low limits (Drunk driving law by country).

There are a number of web pages that provide data for blood alcohol percentage, for both males and females, based on body weight and the number of standard drinks consumed; for example: BAC facts: impairment starts at the first drink; and Blood alcohol level chart.

So, what is this “standard drink”? Sadly, there is no accepted international definition for how a standard drink is defined in terms of the amount of pure alcohol (ie. ethanol), and so it can potentially vary from country to country. However, according to the U.S. National Institute on Alcohol Abuse and Alcoholism, a standard drink is defined as containing 14 grams (0.6 ounces) of pure alcohol, which is a widely accepted version.

Using this definition yields the above graph, showing how the number of standard drinks relates to the alcohol content of the wine, which can vary greatly (wine typically ranges from 9% to 16% alcohol by volume, ABV). That is, the higher the alcohol content then the greater is the number of standard drinks that the bottle contains, and the smaller volume is the size of the standard drink that can be taken from it.

For example, as shown in the graph, there are roughly 5 standard drinks in a bottle of 12% ABV wine, or a standard drink of wine taken from that bottle is 5 fl.oz (150 ml). Alternatively, there are 5.5 glasses in a bottle of 13% wine, and 6 glasses in a 14% wine bottle, and the glass volumes are correspondingly smaller.

Obviously, then, for each bottle of wine we are getting ready to consume (either alone of with others!) we need to check the ABV (always on the label), and then we will know how many “glasses of wine” it contains. This will give us an idea of what situation we are now in.

When we are judging this in real life, however, the shape of the wine glass and its volume can affect our judgement. This is illustrated in the next picture, which shows what a 5 fl.oz pour looks like in five different glasses. Note that wider glasses typically receive inordinately larger pours. It has even been reported that the amount of wine poured can be affected by whether the glass is held in the hand or stands on a table, and whether the wine is white versus red (whites typically get bigger pours); and, of course, it is reported that: Risky drinkers underestimate their own alcohol consumption.

Returning to the initial topic, we also need to consider: How quickly does the alcohol disappear from the body and can you sober up faster? Apparently, the liver breaks down alcohol into other substances at a rate of about one drink per hour, although there are big differences between individuals. Sadly, alcohol and its byproducts can continue to be detected in your system, so that you could fail a breath test several hours later.

The current dietary guidelines for healthy alcohol consumption by adults in the United States differ between sexes:
 — women should consume no more than 1 standard drink per day and a maximum of 7 drinks per week
 — men should consume no more than 2 standard drinks per day and a maximum of 14 drinks per week.

In comparison, in Australia and New Zealand the guidelines are that:
 — a woman should have no more than 2 standard drinks daily, no more than 10 per week, and no more than 4 at once
 — a man should have no more than 3 standard drinks daily, no more than 15 per week, and no more than 5 at once.

It is for these reasons, as well as simply general health concerns, that sales of low- and no-alcohol wines have been growing briskly in recent years, as wine drinkers now pay more attention to what goes into their bodies (Why major players are investing big in wine with little, no alcohol).

The latter is a tricky business. There are two main ways to produce lower-alcohol wines — harvest grapes at lower sugar levels, and remove the alcohol after fermentation. This is a topic for another post.

The effect of background music on the taste of wine

Some people seem to like pairing a bit of music with their wine consumption, but it actually goes much further than this. There is experimental evidence that music has an effect on how we taste wine, so that different music produces different taste sensations in our brains. This seems to me to be an important and interesting topic, and yet it seems not to have been covered much in the wine literature. So, let’s have a look at it here. *

One of the earliest publications on this topic dates back only a dozen years:
Adrian C. North. (2012) The effect of background music on the taste of wine. British Journal of Psychology 103: 293–301. The author, then at the Heriot Watt University, Edinburgh, but now at Curtin University, Perth, Australia, summarized his work like this:

Research concerning cross-modal influences on perception has neglected auditory [sound] influences on perceptions of non-auditory objects, although a small number of studies indicate that auditory stimuli can influence perceptions of the freshness of foodstuffs. Consistent with this, the results reported here indicate that independent groups’ ratings of the taste of the wine reflected the emotional connotations of the background music played while they drank it. These results indicate that the symbolic function of auditory stimuli (in this case music) may influence perception in other modalities (in this case gustation); and are discussed in terms of possible future research that might investigate those aspects of music that induce such effects in a particular manner, and how such effects might be influenced by participants’ pre-existing knowledge and expertise with regard to the target object in question.

This is fascinating, I think — sound influences taste. Since then, there have been a number of similar articles, and some follow-up ones, as listed by Pubmed.

One of these subsequent articles, with a theoretical discussion of the topic, is:
Charles Spence & Qian Janice Wang (2015) Wine and music (III): so what if music influences the taste of the wine? Flavour 4: 36. The authors summarized their ideas like this:

A growing body of evidence, both anecdotal and scientifically rigorous, now points to the fact that what people taste when evaluating a wine, not to mention how much they enjoy the experience, can be influenced by the specifics of any music that happens to be playing at the same time. The question that we wish to address here is ‘So what?’ Why should anyone care that music (or, for that matter, specially composed soundscapes) exert(s) a cross-modal influence over the wine-tasting experience? ‘Why not just drink great wine and forget about the music?’ a sceptic might ask. Here, we outline a number of the uses that such research findings have been put to in the marketplace, in experiential events, in artistic performances, and in terms of furthering our theoretical understanding of those factors that influence the tasting experience. We also highlight how the latest in technology (think: sensory apps and hyper-directional loudspeakers, not to mention digitally augmented glassware) augurs well for those wanting to deliver the most stimulating, the most memorable, and certainly the most multi-sensory of tasting experiences in the years to come. Demonstrations of sound’s influence on wine perception will most likely be applicable to a variety of other drinks and foods too. Ultimately, the argument is put forward that there are many reasons, both theoretical and applied, as to why we should all care about the fact that what we listen to can change the sensory-discriminative, the descriptive, and the hedonic attributes of what we taste.

This is more of a reasoned argument, rather than an experiment, of course, although the authors’ conclusions and suggestions are important. A more recent article with an actual experiment is:
Q.J. Wang, M. Frank B. Houge, C. Spence & K.A. LaTour (2019) The influence of music on the perception of oaked wines — a tasting room case study in the U.S. Finger Lakes Region. Journal of Wine Research 30: 312–321. These authors summarized their work like this:

Innovative wine makers and marketers increasingly see the consumers’ multi-sensory experience in the tasting room as a means of differentiating themselves from the competition. With recent research demonstrating the influence of music on the wine-tasting experience, the present study introduced music as a unique aspect of a VIP tasting room experience at a family-owned Finger Lakes winery. A convenience sample of 46 participants tasted four oaked still wines (2 white, 2 red) both in silence and with a complementary soundtrack, and rated the fruitiness, spiciness, and smoothness of each wine in both sound conditions. Undisclosed to the participants, the soundtrack had been designed to bring to mind woody/spiced elements of oak ageing. It was hypothesised that listening to the oak soundtrack would alter the evaluation of the wines to be smoother and spicier. The results revealed that those wines tasted while the soundtrack were playing in the background were rated as significantly fruitier and smoother than the same wines when tasted in silence. These results are discussed in terms of the literature on cross-modal correspondences and the emotional mediation account. Moreover, the positive feedback from the attendees showcases music as a viable component of a multi-sensory experience when visiting a winery.

Given these results (the authors got the changes they predicted), I am sure that we will hear more about this topic. Wine tasting is not just about the taste and smell sensations — it involves all of our minds, and the sensory inputs during the tasting experience. Professional tasters need to be aware of this; and we amateurs need to take it into account as well.

Taste wine in the right atmosphere, and it will taste at its best.

---

* I let the authors speak in their own words, so please excuse their academic background!

Wine ratings involve both the accuracy and bias of the raters

Even a quick glance at the wine industry will convince everyone that putting scores on wines is big business, whether the scores vary from 80—100, 10—20, or 1—5 stars. I am not a big fan of actually doing this myself, but I do use the information when it is available, especially in relation to the price of the wines (ie. evaluating value for money). And I have written about this topic a number of times in this blog (see the link Wine scores) to the right.

Recently, a couple of papers have appeared in the academic literature evaluating the procedures for rating wines, and I thought that I might briefly summarize one of them here.

The basic issue with any score or rating system is that each individual reviewer varies in what we might refer to as their “accuracy” (closeness to some underlying wine quality) and their “bias” (personal preferences) relative to other people’s decisions. Therefore, the rest of us do not really know how to interpret any given individual score or rating. This is an inherent limitation on every scoring system.

An example commenting on this issue from within the wine industry itself is: Why the hell don’t you ever see a 100 point Chablis? (Part 1, Part 2). This is definitely worth reading. In Part 2, the essential subjective component of all scores is put simply by Patrick Piuze:

Here is the recipe [for a perfect Chablis]: be in a very good mood with people you love and that are ready to open themselves to a great moment. Then and only then do the wines come into play. Right place, right people, right wine.

It therefore comes as no surprise whatsoever that the academic world has also had a look at this topic. One of the recent publications (May 2024) to which I referred above is:

Finding the wise and the wisdom in a crowd: estimating underlying qualities of reviewers and items; by Nicolas Carayol & Matthew O. Jackson, The Economic Journal ueae045.

This paper has been quite some time coming — the earliest reference I can find online is from September 2019, with a slightly different title, and with revisions online elsewhere in 2020. I interpret this as meaning that someone somewhere was not too happy with it, possibly the reference to a re-evaluation of the 1976 Judgment of Paris wine tasting, or the evaluation of 19 experts’ ratings of “en primeur” Bordeaux wines — people are named.

The formal summary of the paper reads like this:

Consumers, businesses and organisations rely on others’ ratings of items when making choices. However, individual reviewers vary in their accuracy and some are biased — either systematically over- or under-rating items relative to others’ tastes, or even deliberately distorting a rating. We describe how to process ratings by a group of reviewers over a set of items and evaluate the individual reviewers’ accuracies and biases, in a way that yields unbiased and consistent estimates of the items’ true qualities. We provide Monte Carlo simulations that showcase the added value of our technique even with small data sets, and we show that this improvement increases as the number of items increases. Revisiting the famous 1976 wine tasting that compared Californian and Bordeaux wines, accounting for the substantial variation in reviewers’ biases and accuracies results in a ranking that differs from the original average rating. We also illustrate the power of this methodology with an application to more than 45,000 ratings of ‘en primeur’ Bordeaux fine wines by expert critics. Those data show that our estimated wine qualities significantly predict prices when controlling for prominent experts’ ratings and numerous fixed effects. We also find that the elasticity of a wine price in an expert’s ratings increases with that expert’s accuracy.

If we take the Judgment of Paris wine tasting, and look at what the authors come up with for their new quality estimate (ie. addressing the potential problems with accuracy and bias), it looks like the following graph. Horizontally is the original (average) score of the taster scores, and each point represents one of the 10 wines. The new score is shown vertically. Note that seven of the points lie on a straight line, which indicates that the authors’ revised (new) score does not differ in interpretation from the original tasters’ score (ie. accuracy and bias were not a problem). However, three of the wines change their ranking in the quality order, as shown by the labels: Château Montrose and Mayacamas move up the ranking (with Montrose becoming the new “winner”), and Clos du Val moves down. This is why the authors conclude that there was “substantial variation in the reviewers’ biases and accuracies” in this famous assessment (well, for three of the ten wines, anyway).

I am not going to take sides here, but I will say that the authors do present a strong case.

The authors actually spend most of their paper on an analysis of the Bordeaux en primeur wines (based on >45,000 expert ratings of Bordeaux wines of vintages from 1998 to 2015), highlighting which experts show a measurable bias for the Right Bank wines (eg. Robert Parker, Jeff Leve, James Suckling, Chris Kissack, Wine Spectator, Yves Beck) and which for the Left Bank (eg. Jancis Robinson, Decanter, Jacques Dupont, La Revue du Vin de France, Wine Enthusiast). This does, of course, explain a lot of the disagreements between the scores produced by different review sources.

It has, however, been suggested that these days in the wine industry we are mostly just Talking to ourselves. Nevertheless, if you want a set of scores, then there is this one:
            The Official 2024 Wine Vintage Chart
Alternatively, you could focus on value for money, in which case there is:
            The best value bargain en primeur Bordeauxs.