How much alcohol is actually safe? with Prof. David Nutt

Dry January often raises big questions: how much alcohol is actually safe, and do you need to stop drinking altogether to protect your health?

In this episode, world-leading alcohol expert Professor David Nutt explains why alcohol ranks as one of the most harmful drugs to society, how even “normal” drinking can affect your health, and what the science really says about cutting back without giving it up completely.

David, a neuropsychopharmacologist and former UK government drug adviser, explains why alcohol was ranked the most harmful drug overall in a landmark comparison of 20 drugs, how harm rises sharply as drinking increases, and unpacks common beliefs like red wine being “good for you”.

The conversation also covers the social benefits of alcohol and why the goal isn’t necessarily to stop drinking, but to drink with awareness.

If you’re pausing and reflecting this dry January, what might change when you start drinking again? And which habits are worth leaving behind for good?

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Transcript

Jonathan: David, thank you for joining me today. We always start these shows with a rapid fire Q and A with questions from our listeners and we have some very strict rules. You can say yes or no or, if you have to, a one sentence answer. Yes. You got it already. Alright. Is alcohol more harmful than the drug ecstasy?

David: Yes.

Jonathan: Can reducing alcohol intake improve your sleep?

David: Yes.

Jonathan: Should the government ban alcohol?

David: No.

Jonathan: If I’m only drinking a glass or two of alcohol a night, could it still be affecting my mental health?

David: Depends on the size of the glass. So yes.

Jonathan: Do I need to cut out alcohol completely in order to improve my health?

David: No.

Jonathan: And finally, what’s the biggest misconception that people have about alcohol?

David: That middle-aged men benefit from drinking red wine.

Jonathan: Alcohol is so pervasive in the world. I’ve never really thought about the fact that at some point in the past, our ancestors must have discovered how to make it. And if I guessed, I would’ve assumed this was like two or three thousand years ago. But I understand you told our research team that our ancestors have actually had a love affair with alcohol for a really long time.

David: We don’t know when humans first started manufacturing alcohol, but they almost certainly met alcohol through rotting fruit, and they would’ve been fascinated by why other animals were foraging around trees, fruit trees, plum trees, etc, where the stuff had fallen on the ground fermented.

They would’ve eaten that and they would’ve found it was psychoactive. The first sort of recorded evidence of producing alcohol is mead, produced from fermenting honey, possibly 40,000 years ago.

Jonathan: 40,000 years ago.

David: Yes. It was suggested in the African Rift Valley that the very early hominids actually worked out that you could ferment honey to get better intoxication.

And then in terms of the modern human era, we’ve got evidence of people brewing in China four to five thousand years ago.

Jonathan: So basically it sounds like our ancestors learned how to make fire, make a sharp stick, and then proceeded to figure out how to make beer.

David: Yeah, so there’s an interesting tension in the field of paleoanthropology between a man called Yuval Harari, who wrote the book Sapiens, and he postulates it.

Human civilization developed because people discovered how to turn wheat into bread, and therefore they had to plant wheat seeds and then wait for the seeds to grow and make sure that their goats didn’t eat them. So while they were sitting around waiting for the wheat to grow, they discovered things like mathematics and language and all sorts of cultural developments.

But there’s another guy called Edward Slingerland who said, no. Yes, wheat was the original crop, but they were growing wheat to make beer.

Jonathan: We’re sitting in England today. And so I guess I think about really ancient monuments in England and Stonehenge, and I understand you have some views about this as well.

David: Well, Slingerland believes it’s these great monolithic temples which scatter around most of the world, in fact, were not necessarily to do with astronomy, but were gathering places where the small human tribes who were quite disparate and have rather limited genetic variation would come together when alcohol was available.

That would be in the autumn to have massive parties in which people would meet others. And therefore you could spread the gene pool because you would actually have some sort of sex outwith your tribe. And that was great for genetic variation.

Jonathan: Wow. So these were like the original raves.

David: Correct. But possibly on a slightly larger scale than we do today and probably a bit less violent.

Jonathan: You are painting a picture of alcohol as something that we have coexisted with really for as long as there’s been human societies. You’re making some jokes, but it’s really interesting that you’re suggesting this is deeply intermingled with what it is to be human.

David: And I think the reason for that is that humans are a very successful species.

We obviously are the dominant species on the planet, and that’s because we work together in groups, and we pool intellect and strength. We’re actually not very good at socialising. Most of us are slightly anxious in social situations, and it kind of makes sense when you’re meeting a stranger, you need to know whether they’re on side or not.

So there’s always going to be a bit of anxiety, but alcohol reduces that. And that’s why we drink in social situations. Alcohol facilitates social communication and makes us essentially the social animals that we aspire to be. And then when we’re social, we all do all sorts of interesting things.

We don’t just make babies. We actually build teams and sell boats and build armies, etc.

Jonathan: So it’s interesting because I think about alcohol as being like, why does it make me feel good? But it sounds like your first point you’re talking about is that actually, it’s almost like a lubricant of a group or a society.

David: Totally. It’s a social lubricant. That is why it exists in almost all cultures. Except for those Islamic cultures that deny it. And even there, of course, it’s widely used by the individuals who can get access to it. It is the ultimate social lubricant, and I believe that’s why it has survived through many, many millennia and also through periods where it has been banned.

Like prohibition in the States that failed because humans, frankly, prefer or even need the social lubrication of alcohol. And they were prepared to put that above the health benefits of stopping.

Jonathan: Could you spend a minute more to help us understand, I guess, that social benefit? You talked about us being a bit anxious, but could you just expand a little bit on that?

David: Alcohol boosts your natural, relaxing, calming transmitter. And that means you can engage with people without anxiety, and that means you're basically more confident. You look them in the eye more, you smile more, you engage with them more. You feel less threatened, you share more. That builds rapport.

Rapport and camaraderie and conviviality. And then, wow, the party gets going.

Jonathan: We know that, you know, human groups are as likely to kill each other when they meet, perhaps as to go and party. Does it actually reduce the violence?

David: I think they came to party because they wanted to meet and mate.

But you do make an interesting point. Alcohol has also been used to fuel violence, but more through reducing the pain of violence. So the Viking berserker was supposedly definitely alcohol related. They also put some magic mushrooms and other herbs in. So you can use alcohol to change the way you face fear, but usually that’s much larger doses of alcohol.

Jonathan: David, you’re a world expert on what’s actually going on with alcohol, what’s actually going on in my brain, and it sounds like what I have with maybe my first glass of wine or beer might be different than from what’s going on as I drink more. What? What’s happening?

David: That’s exactly right. There’s a sort of ladder effect of alcohol. It’s likely that alcohol affects every single neurotransmitter in your brain. So neurotransmitters are the chemicals which communicate between brain cells, but what we know is that the first dose of alcohol, the first glass of wine, first pint of beer, enhances this calming neurotransmitter called GABA.

But then if you double the dose, you begin to interact with other neurotransmitters. One of them is called dopamine. Now most people have heard of dopamine. It’s a sort of energising, get up and go transmitter. That’s when people start to get loud and possibly a bit aggressive, but certainly outgoing and challenging.

And then if you take more, then you begin to release endorphins. Endorphins are the brain’s natural opiates. And that also relaxes you, that deadens pain. Which is why alcohol was used before we had better forms of anaesthesia and pain control.

But both dopamine and opiates also cause addiction. So the addictive properties of alcohol are mediated through those.

And then if you keep on drinking, you get to a point where you start to lose your memory, you get blackouts, and that’s because alcohol then blocks the major transmitter in the brain that keeps you awake. It’s called glutamate.

And every single memory you lay down, everything you learn or remember from this podcast, is laid down by glutamate, working on particular receptors in the brain to lay down memories. Alcohol blocks glutamate receptors. You can’t lay down memories. You have amnesia, and of course if you keep on drinking, then you need glutamate to keep you breathing and you stop breathing and you die.

Jonathan: If you’re starting with blackouts, you’re really on the pathway to then not even breathing, is what you’re saying.

David: Yes. If you’ve had alcoholic blackouts, then you have definitely put yourself at high risk, not just from death, from poisoning with alcohol, which of course three or four people every week in Britain die of alcohol poisoning, but also probably lost quite a lot of judgement. And people don’t know where they are and they go the wrong, you know, I mean, they get into trouble through basically being so intoxicated. They make themselves vulnerable.

Jonathan: There’s sort of these different effects as I am drinking. So the first one you talked about, this GABA neurotransmitter, and that just sort of relaxes you, lets you socialise, then you’re drinking a bit more and you’re getting the dopamine, which I often hear people talk about, like when you go to the gym or you go running or something like that.

And at that point, that’s when I’m getting louder, more outgoing, but potentially more aggressive. You said as well, in some people, I feel I fall asleep, actually. But the next point is endorphins, which again, in my mind is a bit similar to dopamine. And you’re saying this is like my body’s own opium. Reduces my pain, but it’s also what causes a new addiction. Then you’re getting to the point where you’re blocking this major neurotransmitter, you say glutamate. And then actually, literally, I can’t store things in my brain, and if I keep getting worse, this is actually going to switch off the thing that tells my body to breathe.

There’s this sort of pathway from what you’re describing, is this really nice relaxation through to at the other end death. Correct. Which, I guess, is why we have this very complicated relationship with this drug.

David: It’s clearly dose-related. And for most people in Western societies, about 80% of adults drink alcohol at some point in their lives.

And probably of those, 65, 70% don’t get into problems. It’s a smallest proportion between 10 and 15% of drinkers who get into problems. And those are the ones who either are genetically vulnerable to the effects of alcohol in terms of addiction, or who drink so much that they turn on the addiction cycles of dopamine and endorphins, and then find that they can’t stop drinking.

Jonathan: And when you say get into trouble here, you are talking about it affecting them in a very profound way. ’Cause I think one of the things we will talk about, I think, through the rest of the podcast is whether even at more moderate doses, like on balance is a good or a bad thing.

David: Yes, that’s right. So there are two aspects to the harms of alcohol.

There’s the harms which come from addiction. And then there are the other harms which we are beginning to learn more about, which are essentially metabolic harms, harms in other organ systems rather than the brain, or also the brain to some extent, which can occur below the level of being addicted, but above the level of socialisation.

Jonathan: I know you’ve done a sort of groundbreaking study on the harms of alcohol, and so I’d love for you actually to tell us about it and what you found, because I think what you’re just saying now is fascinating. I think when I was growing up, all the risks of alcohol were really focused on becoming addicted to alcohol and the dangers of drinking so much that you might die. I remember being told about this, you know, as a teenager you’ve got to be really careful to not drink so much that you don’t pass out and choke on your own vomit. But I didn’t think anyone was talking about the idea that at a lower level it could be doing any harm at all. But I think that your research paints a more complicated picture.

David: So the study you are referring to was a very famous study now, where we looked at the comparative harms of 20 different drugs published in The Lancet in 2010, the scale of harms.

It turns out there are 16 ways in which drugs can harm you. There are nine harms to the user, and there are seven harms to society.

And when you aggregate all those, the harms to the user, the harms to society, it turns out that alcohol is overall the most harmful drug in the UK. Alcohol is the most harmful drug, and that’s been replicated in Europe. It’s been replicated by experts in Australia, in New Zealand, and also in Canada that’s not yet published.

So we’ve now got five sort of Western jurisdictions where alcohol is freely available, where alcohol is the most harmful drug. And the reason for that is that it is the most harmful drug to society, to other people. And that’s because so many people drink that there are problems from the drinking. There are problems in terms of social disorder. There are problems in terms of health. Actually the biggest cost of alcohol is lost productivity from hangovers.

Jonathan: Could you tell me a bit more about the harms to you as an individual. What is going on when I start drinking?

David: So the harms of alcohol come from the fact that alcohol is toxic.

So when you are about to have an injection, you rub alcohol on your skin to kill bugs. Now bugs are pretty tough. They’ve got shells, cell membranes, which actually it’s why they exist. Living out there in the world, it’s pretty challenging. So if alcohol can kill those, it can kill cells in your body, which have got much less good surface protection.

So alcohol is intrinsically toxic and people who drink start damaging the cells in their mouth. So alcohol’s associated with mouth cancer. Cells in your gullet, in your oesophagus, are associated with oesophageal cancer. In your stomach, where not only associated with cancer, but also associated with ulcers.

So there’s a toxicity to alcohol. That’s the first thing. And of course, the most obvious manifestation of that is the toxicity to the liver.

So there’s the toxicity of alcohol and there’s the fact that alcohol itself is broken down into a metabolite called acetaldehyde. And acetaldehyde is one carbon atom longer than formaldehyde, and most people know formaldehyde is a preservative. Dead bodies are put into formaldehyde to stop them dissolving. And acetaldehyde is also a pickling agent. So acetaldehyde contributes to the pickling of your body, in particular, your liver and your brain. Not a good thing.

The area that perhaps people haven’t understood as much as they should is you begin to damage the surface of blood vessels, so they become stiff, and then you get the cholesterol deposits.

So you get the plaques laid down, and then the plaques, of course, give you stenosis of the heart, so you get less blood flow to the heart. So you have angina or heart attacks, but also the same, you get blockages of blood flow to the brain. So alcohol contributes to both heart disease and also, to basically stroke.

Jonathan: It’s actually quite surprising, I think, what you’re describing to understand that the alcohol is doing things that I think many of us think about food doing. So as you’re describing blockages in my arteries, in my brain, this has come up a lot on podcasts here at ZOE, but people are talking about red meats and saturated fats and things like that. Ultra processed foods. And it sounds like you’re saying that actually alcohol, which isn’t any of those things, and I wouldn’t have thought would be doing anything to my blood vessels, it was doing something similar.

David: Yes. So I mean, a saturated fat is an oxidised fat, and what alcohol does is produce free radicals, which oxidises the fat more and oxidises the surface of cells, oxidises more of the cholesterol that’s being deposited.

And that’s, you know, oxidised proteins are basically dysfunctional proteins and oxidised fats are less functional fats.

Jonathan: So what is the body doing in response to this? Why does that lead to these increased risks you’re describing?

David: Well, because you begin to fur up your arteries. Alcohol has two big effects on the cardiovascular system.

The first is it furries it up by encouraging the deposition of cholesterol and the hardening of cholesterol. And secondly, if you then do have a problem, if you have a bleed, you get excessive bleeding because alcohol damages the clotting factors as well.

Jonathan: You’re saying first it furries you up, and then if you do have some sort of bleed inside you, it stops you clotting that

David: Yeah. Excessive alcohol intake. And we’ll maybe talk in a minute about what that means is probably the easiest, most tractable target for lowering blood pressure. The advice we give is if you are hypertensive, you should explore cutting down your alcohol intake because that, in many cases, will reduce your blood pressure significantly.

And the reason the blood pressure goes up with alcohol is because of this stiffening of the arteries, because of these free radicals that alcohol produces and the laying down of cholesterol.

When you do have your health checks, the doctors are supposed to ask you about your drinking, and it’s best if you’re honest because hiding your drinking is actually, you know, you are hiding the truth from yourself.

Jonathan: I think the thing that at least I’m surprised about, and I think many listeners might be, is not that drinking lots is bad for you. I think that’s a well understood public health message. It’s you’re linking it to having high cholesterol and how you might affect it. And I guess my question is, if you were drinking quite a lot and have high cholesterol and you stop drinking, would you expect that to actually reduce your cholesterol levels?

David: Yes. It would go down, yes. And your blood pressure would go down. Real health generally would improve. Absolutely.

And I think this is quite a critical point. And the reason I think many people would be surprised by that is because of what we used to call the French paradox. There was this idea that if you drank particularly red wine, you might have some kind of cardiovascular protective effect. And there was this possibility that there was a little benefit to alcohol in middle-aged men.

That turns out probably not to be true unless you just happen to live in Provence and have all the benefits of that along with your red wine.

Jonathan: So help me to unpack the French paradox.

Jonathan: I think I have heard of this. This is idea that the French are healthier than you would expect them to be because they have, you know, all of this butter and cream in their diet and they drink red wine. So why aren’t they having as many heart attacks as Americans? And I remember this is the sort of thing that’s in the press all the time, is like it’s because they’re drinking red wine every day. You don’t think this is true?

David: Well, it’s very hard to pin it down on the red wine, let’s put it that way. A lot of people have thought, oh great, if I drink red wine, that’ll override all the other problems, and it’s not true.

So we know that alcohol consumption itself in most of the rest of the world has very negative effects, even on cardiovascular function.

So if you really want to get the benefits of red wine, there are two messages I’m going to give you. The first is no more than a hundred millilitres of red wine a day, a very small glass. That’s the optimal benefit if there is a benefit at all.

And the second is move to Provence and get all the other benefits, which is a diet high in polyunsaturates, a lovely sunny climate, so your vitamin D levels are high, and a nice, wide-ranging fresh vegetable, fresh fruit diet. The Mediterranean diet is definitely a healthier diet, and we know that because if you impose Mediterranean diets on middle America, then they do get healthier.

Jonathan: I think my takeaway from this is if you’re going to drink a glass of something, red wine might be better than something else. It might be better not to have the red wine at all.

David: Well, that’s the question, isn’t it? The key question is whether it’s better just to take the polyphenols. Does the ethanol in the wine offset the benefit of the polyphenols? I would suggest it probably does, but that hasn’t been formally tested.

Jonathan: I guess the other thing in this is how you feel about the benefits. Like I think if my wife was here, she’d say, like a small glass of wine at the end of the day after a really stressful day makes her feel really good. So she would view that as quite a high benefit to then balance, I guess, against everything else.

David: Totally agree with you. And I’m not anti wine, I’m not anti alcohol.

I’m in favour of a rational use of it. So if you can clearly experience, as your wife does, that a small or medium glass of red wine at the end of the day benefits you in terms of your ability to recover from the stress of the day, in terms of interacting with your kids and your husband, then use it.

But make sure you have balanced out the benefits and risks. Be aware that there are some risks, minor risks from that amount of wine, but potentially there are. Make sure you don’t ever drink more than what you should.

Jonathan: Well, I’d like to talk about that because I think there’s an increasing view that any level of alcohol is just bad for you. And, you know, you’ve talked, I guess, about how bad it is if you’re drinking a lot, and I think that’s very clear. What about if you are drinking less? Is all alcohol bad?

David: So in terms of physical health, probably. In terms of social health, probably not.

Most of us drink to socialise. Socialising is hugely beneficial to mental health and to some extent probably to physical health as well. So drinking within the current recommended limits, for most people, it probably has a net benefit in terms of social interaction.

The only exceptions might be people who are at a very high risk of some cancer, particularly breast cancer. If you’ve got the BR gene and you may be at high risk of breast cancer, then even small amounts of alcohol might increase that risk, but sticking within the limits, provided also that you don’t drink all the weekly allowance in one go, don’t get drunk, the risks of having health harms from alcohol are pretty low.

Jonathan: What is one unit? What does that mean?

David: So that’s 10mls of alcohol. So one unit is a small glass of wine or half a pint of beer.

Jonathan: So if you’re drinking maybe at that level a day or maybe a little bit more. What is the evidence about how that impacts your long-term health and how does that tie up to this increasing visibility that it seems like there’s some stuff going on around, you know, things that you can measure even at that level.

David: So within the sort of current UK recommendations, it’s two units a day, so 14 a week. And the other recommendation is to have a couple of days a week when you don’t drink, and maybe you can go up to three units or so one of the days, and have a couple of days free because that gives your liver a chance to recover within that limit.

Then you are at low risk of having liver disease, cardiovascular disease, brain inflammation, etc.

If you drink three units one night, you’ll probably notice your sleep is different from the night you don’t drink. I think that’s quite a common experience, and that’s largely because even with three units, you’re going into a little bit of withdrawal overnight, and withdrawal is activating your noradrenaline, your sympathetic nervous system, which is why your heart rate variability goes down and why you wake up a bit early.

When you go beyond that, one of the problems with alcohol is that it has a nonlinear relationship with harm. So if you go from, say, 14 units a week to 28, you actually triple the harms, and then if you double again to 56, you will more than quadruple the harm. So this is a very non-linear, it’s an exponential curve.

And drinking more than a bottle of wine a day is definitely something you shouldn’t do. At that level, you are probably reducing your life expectancy by between about five and seven years.

Jonathan: I’ve just turned 50. I’m not a regular drinker, but I do drink occasionally, and I often notice that even if I have one glass of wine, it affects how I sleep.

Jonathan: I feel the difference. And when I was younger, I absolutely didn’t. So I can’t cope with it in the same way. We all know now that we live these long periods of quite poor quality health at the end of our life. And my wife also says I can be a hypochondriac. So what’s the reality here?

David: Well, worrying too much about sleep is hypochondria, yes. So don’t worry too much. But alcohol is strange, honestly, because it actually promotes sleep for most people. It helps you get off to sleep, but it distorts sleep in two ways. ’Cause it brings on deep sleep early in the night. It shortens the period of sleep.

Now, whether losing 15, 20 minutes of sleep at the end of the night is seriously problematic to your health over time, I don’t think we know the answer to that, but it’s unlikely to be good. It might be neutral.

If you get benefits from drinking, you know, better social life, then don’t get hung up on the poor sleep. But if sleep is a problem, then definitely explore whether cutting down alcohol will help your sleep.

Jonathan: And are there very personalised responses to this?

David: Yeah, there are, absolutely, there are. I mean, but it’s complicated by what we call tolerance. One of the reasons alcohol is such a challenging drug is because people get tolerant to it so they can drink more and more. So there will be people who say, well, I know what you’re talking about. You know, I drink a bottle of wine at lunch and a bottle of wine in evening and fine. Well, you may be fine, but you know, your liver probably isn’t.

But the perception of the impact of alcohol is obviously extremely determined by how much you actually have drunk and how much your brain has adapted.

Jonathan: Could you explain for a minute what’s going on there?

David: So when you change your brain in any way, and certainly when you change your brain with alcohol, once you get over about second drink, your brain is thinking, hang on, something is going on here. This is different.

And your brain is quite smart, ’cause it kind of knows that you may not know what you are going to do next. You know, it’s probably met a time when you actually did drink more than you wanted to, you know, maybe you got really drunk.

So your brain is always thinking he’s going to have another one. I’m going to start protecting him against that. So you start to dial down the brain so that you don’t get as intoxicated as you would.

Now that dialling down mechanisms are complicated, but basically it’s a counteracting. So alcohol’s sedating you, the brain’s turning on to un-sedate you, and then when the alcohol disappears, you’re in a state of less sedation. Your brain is in the un-sedated state, the activated state, and that’s what a hangover is, and that disrupts your sleep.

Jonathan: Why do I get a hangover?

David: So hangovers are comprised two separate features. There’s this subjective psychological effect, and the sleep disruption, which is due to this increased excitation in the brain, the counteracting the sleepiness.

I’ve told you, you get relaxed and sleepy on alcohol. Your brain is saying, well, you know, this guy’s got to do things. You know, he’s got to get up and look after his kids. So it doesn’t want you to be anaesthetised.

Alcohol blocks glutamate, and the glutamate system then increases its function to offset the alcohol.

But hangovers are also compounded by the fact that alcohol is inflammatory and alcohol and acetaldehyde release inflammatory substances in the brain. Interleukins, different sorts, which are inflammatory to nerve cells, which are inflammatory to glial cells. They’re inflammatory to blood vessels. They’re inflammatory all over.

And that’s part of the process of toxicity of alcohol, this general inflammation in the body. Inflammation in the brain is painful, and so you’re awake. Lights are too bright because your glutamate system’s overactive. Your brain’s inflamed, and that’s a hangover.

Jonathan: If I’m feeling hungover, my brain is inflamed. And when I think about inflamed, that’s like, you know, my finger is inflamed if I hit it with a hammer, you’re saying basically I’ve sort of done the equivalent of hitting my brain with a hammer. It’s physically inflamed in my head the following morning. It is from drinking,

David:. It is. And one of the theories as to why alcohol shrinks the brain over time, which it does, and we’ll talk about that in a minute, is that the inflammation damages the neurons and also the protective glial cells in the brain.

Jonathan: It sounds terrible.

David: Well, it’s not good. One of the problems with the brain is, of all the organs in the body, possible exception of the heart, the brain is least able to manufacture new cells, to restore cells that have been damaged. So it’s best if you don’t inflame your brain.

And there are two big implications for this.

The first is in young people. So we know that young people who binge maybe on a Friday or Saturday night, they have more evidence of brain damage in their teens, in their early twenties, than those who don’t binge. So you can begin to measure a negative impact of heavy drinking on the brain early on.

But then there’s the other side of the coin, and it is people like you who drink sensibly over a lifetime. But some maybe drink one glass a night and some maybe drink two and some maybe drink three or four.

And there’s this wonderful study, the Whitehall study, which has looked at civil servants, hundreds, maybe tens of thousands of civil servants, over decades, and they’ve recently published data on brain volume in relation to alcohol consumption. The more you drink overall, the more your brain shrinks.

So brains shrink as you get older, and that shrinkage is accelerated in people who drink. And it’s a kind of linear, the more you drink, the more your brain shrinks.

Jonathan: You’re probably the world’s expert on this. What would your estimate be at the point of drinking that you would start to see any of these effects cut in? Is it zero or is it a higher number than that?

David: Well, it’s a difficult question to answer because the odd binge might be much worse than drinking the same amount more regularly.

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Avoiding hangovers is a good thing because, as I’ve said, hangovers are inflammatory, so try to avoid hangovers. My own view is that if you can stick within the current guidelines, spread it out over a week with a couple of days gap, then you’re probably all right. You know your brain’s going to shrink anyway.

Jonathan: David, I’m not an expert at all, but somehow brain shrinking sounds bad.

David: Your brain has to shrink when you’re a teenager, you know, your brains are really big when you’re 11 or 12, and it’s got to shrink to the optimal. The optimal brain is not the biggest brain. The optimal brain is a brain that’s functioning optimally.

So I don’t want to scare people because there may well be benefits to socialisation. We know that. If you don’t socialise, you lose the skills of social interaction, you become more isolated, you begin to lose confidence. I mean, socialisation is a significant part of what humans do and are.

So yeah. So if not drinking at all didn’t impede the rest of your life, then I wouldn’t drink, if you really want to maximise your brain power. But on the other hand, if you actually want to be a social human being and drinking socially means that you get more out of life, then drinking moderately probably is fine.

Jonathan: It sounds like you’re saying if you are not getting any benefits out of drinking, then zero is the best place to be. Yes. But if you are, for example, you described you feel anxious or stressed by the day and you have a glass of wine and you feel much better and you’re more social and you get all those other benefits, you’re saying potentially, actually all of those benefits are real from that social interaction and that could actually outweigh what are quite small harms at, you know, one to two glasses of wine a day. This is your sort of two units. If you are going beyond that, like the harms start to explode and if you’re suddenly like my age, you probably weren’t told the full picture of just like how harmful alcohol can be.

David: Correct. As you know, I’ve written a book called Drink?, and in there there’s a chapter on how you look at your own drinking, and one of the key messages, which I think we might come to later, is never drink a drink that doesn’t, in hindsight, give you a benefit.

For most people, that’s probably half of what you drink, so get rid of those and then you’ll be fine.

Jonathan: I’m immediately thinking about the really terrible like ouzo shots you get served when you’re on holiday in Greece that you know you don’t want. And so you’re telling me now I have an excuse to say I’m just not going to have it.

David: Absolutely.

Jonathan: Given how harmful alcohol is, why is it still legal? Is this just an accident of history? Should it be banned?

David: No, it shouldn’t be banned because we know what happens if you ban it. People go underground. Why is that? Because most people enjoy drinking and they’re not addicted. Alcohol is part of the human condition.

In many ways, it has helped forge humanity. It’s helped bring tribes together, bring families together. We use alcohol to celebrate birth, wedding, and death, or at least to commiserate in a wake. So it has a huge social role.

What we need to do is not ban it, but replace it with something that’s less harmful, which is of course what I’ve been trying to do for the last 20 years.

Jonathan: Now, you wrote a science paper about the risks of something called— which I think ties into this whole question of what we should permit and banning. Could you explain what that is?

David: Yeah, so I was trying to get people to think about why we make decisions about banning things or not banning things. And I wrote a paper called Equity: A New Addiction with Important Health Implications.

And it’s actually my most ever downloaded paper. Equity stands for equine addiction syndrome. It’s people who can’t stop riding horses despite the fact that they have broken their necks, their backs, their legs, their arms, their head, etc.

And it’s quite common. I’m a psychiatrist. One of the colleagues I trained with, she’d fallen off a horse, broken her neck three times. Why’d you do it? I just love it.

And so I thought, well, hang on. We don’t ban horse riding, so why would we ban something that is less harmful than horse riding?

If you horse ride and you jump, then I think it’s like one in every 300 hours or something of that, you’re going to have a serious, serious accident.

Jonathan: Wow. And so your point is you don’t think that we should be banning that? Is that right?

David: People should look at comparative harms and make decisions about them. I mean, we shouldn’t ban alcohol for the reasons I said. Whether we should ban jumping over fences with horses, it depends a bit on whether you like jumping and you like watching it or whether you’re on the side of the horse. ’Cause the horses don’t do very well out of it.

I’m neutral on horse riding. I got so attacked by that paper. I don’t mind. I mean, I think the horses probably enjoy it too, but just be honest about it. Don’t pretend that there aren’t risks to many activities.

Jonathan: Got it. And so your point being that we don’t think logically necessarily about these drugs in the same way that we might think about horse riding or skiing or all these other activities where we know we’re taking physical risk also.

David: Absolutely. Hang gliding. We allow hang gliding. I don’t know. I mean, there aren’t many people who hang glide who haven’t had some injury, but we don’t stop it.

Jonathan: David, I think you’ve painted a very clear picture that in a way this is quite a tricky thing because you are suggesting that everybody shouldn’t go to zero usage, and yet you’re also saying that it can be very dangerous if you have too much. I think many people listening are going to be the same. I think I probably am drinking more than I want to be. If someone is in that situation, what’s the actionable advice that you would give? And many of them at this time of year and then new year are saying, oh, I’m just going to go cold turkey from tomorrow for a month. Is that the right place to start?

David: It’s not a bad place to start because we know for most people, unless you’re addicted, going cold turkey won’t be a huge issue.

If you start to have withdrawal, then obviously you need to think through that quite carefully. And if you’re starting hallucinating, getting delirious, then please don’t do that.

Jonathan: What’s the amount of alcohol that is separating the yes, go and cut it off tomorrow from saying you should do something different?

David: If you’re drinking more than a bottle of wine a day, then I think I would cut it down to half a bottle for a few days and then stop. I wouldn’t stop from levels that high or higher because you could have quite bad withdrawal.

But for most people, stopping suddenly, yeah, you’ll probably have a couple of nights of not very good sleep, bit of anxiety, but then you’ll recover over a week or so.

And then there’s another important message here. When you restart, don’t go back to the level you were drinking before because you’ve lost tolerance.

Some of you may have heard of Amy Winehouse. Some of you may not know. She died of alcohol poisoning. She stopped drinking ’cause she was an alcoholic. She stopped drinking for I think about six weeks. She was also a heroin addict, and you know what killed her was alcohol in the end because when she relapsed, she went out and bought a litre of vodka, drank a litre of vodka, and died with a blood alcohol level that wouldn’t have killed her if she’d carried on drinking.

Abstinence from alcohol makes you more vulnerable if you relapse to drinking, so just be aware of that. If you have an alcohol problem, don’t jump back in if you’ve been dry for a month.

But for most people, interestingly, the evidence is now if you’ve managed to stay dry for a month, you actually don’t resume at the level you were before. There’s a sort of overall net benefit of reduction, which can last for several months after dry January. So it’s worth trying. That’s the first thing.

And also then you can properly evaluate what alcohol was giving you, what benefits it was giving, which is really the next critical question.

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So there are several things each individual should think about in terms of their drinking. The first I’ve already mentioned is never drink a drink that, in hindsight, you couldn’t say that gave me value.

Another useful tip for couples, when you are drinking wine with a meal, never open a second bottle. Because by the time you’ve opened the second bottle, your brain has said, I’m really enjoying this, the dopamine flowing. And you often finish the second bottle and that puts you into a level of consumption which will be harmful.

The third thing is try to keep a diary. Have a look back at each week at how much you did drink, and that helps you work out whether you got benefits from drinking or not.

One of the things I would say to everyone really is that how much you drink should be a fact that you hold in your mind alongside other facts, like what your weight is, what your blood pressure is, what your cholesterol is, what your waist circumference is. These are key measures of you. And for most of those, you should be trying to restrict them and reduce them.

So actually, know what you are drinking. Take it seriously. It is a drug.

I mean, we haven’t talked about this, but if alcohol was invented today as a food additive, the maximum recommended consumption per year is 150mls of absolute alcohol. So that’s sort of five glasses of wine per year.

Jonathan: If someone discovered it today, they’d say you’re allowed five glasses of wine over the year. Anything else would be too dangerous because of the cancer and everything else.

David: Exactly. Another really important message: if in middle age someone has ever criticised you for drinking or doing something silly when you are drinking, take them very seriously. Don’t get angry. Don’t be defensive. Reflect on the fact that they’ve probably observed something in you that you are not observing and act on that.

Always try to have a couple of days a week when you don’t drink at all. That is particularly to help your liver recover.

Jonathan: The having a couple of days off, is that only about letting your liver recover or is that also something to do with the behaviour, like breaking the habit?

David: That’s a good point. I hadn’t thought about that, but no, I think you’re right. It shows that you can, and also it helps your brain recover as well.

Your audience obviously is very interested in health, interested in gut health, and eat very well and eat very sensibly. Many of them will almost certainly be drinking more than they should.

And one of the most frightening statistics was from Nick Sheron. He was a professor of hepatology at Southampton University, and he did studies over decades of people coming in with liver disease. A third of them were middle-class people who were just drinking normally. They never had an alcohol problem at all.

A third of the people with alcohol cirrhosis were just drinking as they said, well, just drink normally. You know, we just drink a bottle of wine between the two of us a day. That’s too much. That will lead initially to inflammation, fatty liver, and eventually for some people lead to cirrhosis. So it is important that people understand that.

The current way of drinking can be as harmful as eating the wrong food and drinking the wrong amount of alcohol. Both have insidious effects and they’re normalised.

Jonathan: So if you are sharing a bottle of wine with your partner and drinking that every night, you are drinking much too much and you have got serious risk of ending up with liver failure.

David: Absolutely. You’re drinking too much, but what you are doing has become completely normalised.

So I don’t know if any of you have watched Big Little Lies, female targeted programme. All the protagonists were women. They’re all living on the coast of California. They’ve all got beautiful homes and every meal except breakfast, they drink wine and they drink a schooner, up to 200, 250 mls. That has become completely normalised in middle class women’s drinking, and that is very dangerous.

So, in fact, another tip: my recommendation to those who drink wine with meals is never drink wine with a meal. ’Cause actually, the taste of the food changes the taste of the wine. Drink the wine after the meal, so you can really appreciate it.

Jonathan: You’ve given a set of tips that assume that it’s fairly straightforward to decide to take two nights off or stop, but I think there are a lot of people for whom dry January is hard. Like, or the idea of stopping is hard because actually this is the pattern that they’re used to and they’ve done for so long. If someone is listening to this and saying, well, I would like to do something about my drinking, but actually I don’t know that I can easily follow these tips, what would your advice be?

David: Well, the first thing I would say is, though I’m in favour of Stoptober and dry January, they’re not the solution. The solution, frankly, is to drink responsibly all the year round.

That’s the first thing to say, to drink sensibly.

So what I do now, being even older than you and even more affected by alcohol, I’ve invented this drink called Sentia, which is basically a horrible alternative to alcohol. And I drink that in the week, and I just reserve a bottle of wine for the weekends and try to split that over two nights.

Jonathan: Brilliant. And if someone feels like they think they do have an addiction problem with alcohol, what would you advise them? If they say, I’m not confident I can solve this on my own.

David: Well, you must go and see your doctor. Before you go to your doctor, have a diary, have a couple of week diary of what you’re drinking, then you can have a sensible discussion with them about whether it’s too much.

There are treatments. There are treatments that help people get abstinent. And obviously if you’re very heavily drinking, you might need something to help you through withdrawal. And there are treatments which can help you stay sober if you have problems with relapse.

Jonathan: Just to wrap up, if someone’s listened to all of this and they’re saying, you know what, I would like to cut down on alcohol today, what is the one tip that you would say to them is like the most effective thing that they could just start using today, this week?

David: Write down every drink you drink, and then next week eliminate the ones that didn’t give you an obvious benefit, and ask your partner as well. You’ve got someone else to sort of hone in on that, you might get the better answer.

Jonathan: Brilliant. David, thank you so much. I’m going to try and do a summary. We covered a lot today.

The thing that comes first is this idea that alcohol is toxic. I rub it on my skin to kill the bugs, and I’m thinking about, you know, when you get your injection or something, and I never really thought about it, that that’s what it’s also going to do inside my body, which does reframe what it is.

The second thing is when I have a hangover, my brain is inflamed in the same way that my finger is when I’ve like caught it in the car door. That is bad. And if you do it often, your brain shrinks. So really you want to avoid being hungover. You want to avoid binge drinking. That when you drink alcohol, it’s having many different negative effects in my body.

So you mentioned that it increases my risk of cancer from like mouth and stomach cancer and breast cancer. That over time, you know, it damages my liver and if I do it too much, it ends up killing my liver. But also something I hadn’t understood is that it’s acting on all my arteries in the same way that thinking about fatty red meat and things like this, that it’s actually going to fur them up. And so amazingly, if my cholesterol is high, if I were to cut out alcohol, my cholesterol will fall and indeed my blood pressure will fall. So it’s really having this extraordinary set of effects so that then paints this extraordinarily bad picture.

What is then interesting is you don’t therefore say everyone should just stop. And I think what you’re saying is two things. Firstly, if you’re drinking small amounts, probably these harms are not very significant. And you were saying, you know, one to two units a day is probably not having very significant impact for most people if you’re not feeling it.

But probably more important, you are saying the social benefits of alcohol have been very significant throughout human history. And so if actually a glass of wine is what means that you are happy to be out with other people and interacting with them rather than not, or it really relaxes you and allows you to interact and feel happier, there’s a lot of benefit there. And so when you balance this out, and also when you look at the data as you did in this Lancet study, it’s not clear that at this level this is bad. Am I playing that back right?

David: Correct. Correct.

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Jonathan: But the amounts of alcohol that are okay are a lot less than many people think. And certainly if you are, you know, my age or older, ’cause it’s very different from my kids. Like my kids really think about alcohol as generally just being a bad thing. Yes. But I was brought up that, well, you know, half a bottle of wine, that’s not really that bad. You’re saying half a bottle of wine a night is a real problem and you should start to think about what you can do about it today.

Jonathan: And so then you came and talked about these different tips, which I think the core thing was to say, start first of all with a diary. Just understand what you are drinking and say, are there a bunch of drinks in there that aren’t even really giving me a lot of pleasure? Could I take those out?

Jonathan: Try and take a couple of days a week without drinking. That resets things completely and that if you are thinking about having a dry January, like this is a good idea. Like you are interested, you’re saying taking the month off is powerful and even if you were to go back to how you’re drinking before, it’s already a benefit, but the science suggests that often you will reduce what you’re drinking afterwards.

Jonathan: We tend not to believe in diets and short-term impacts in general around food, but you’re saying that for alcohol, actually, that’s a reset that you would be very supportive of.

David: Very well summarised.