Where Have All the Winos Gone?

Klatsky, Arthur L.


Division of Research, Kaiser Permanente Medical Care Program, Oakland, CA.

Address correspondence to: Arthur L. Klatsky, Senior Consultant in Cardiology and Adjunct Investigator, Division of Research, Kaiser Permanente Medical Care Program, 280 West MacArthur Boulevard, Oakland, CA 94611; hartmavn@pacbell.net or alk@dor.kaiser.org

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Definition:Wino: “U.S. slang. An excessive drinker or alcoholic who drinks the cheapest wine because with it he obtains the most alcohol for his money.”1

Some decades ago I was a House Officer at a busy city hospital in which many patients had alcohol-related problems. The teaching was that the above definition of “wino” (a pejorative term even then) applied to a large proportion of the alcoholics seen, and that the beverages consumed were usually fortified wine or jug wine. Anecdotal observation at the time seemed to confirm this. My more recent observations in northern California suggest that alcoholics who drink mostly wine are commonly seen, and that they are, perhaps, disproportionately women. It should be noted that organ damage from long-standing heavy drinking is probably related primarily to lifetime ethyl alcohol intake, not beverage choice; the evidence for this is clearest for alcoholic cirrhosis. 2 However, any traits that are related to predisposition to heavy drinking have obvious relevance to these risks.

The ability to accurately predict individual risk of developing a drinking problem would be a great boon, as problem drinking is probably the least disputed sequela of light/moderate alcohol intake. So far, individual risk can only be approximated; predictors include genetic and other internal factors, as well as an array of social, cultural, and other external environmental factors. 3 Even when these known predictors are taken into account, changes in drinking late in life may be related to unpredictable life events. 4 Methods that attempt to reduce or prevent problem drinking are also diverse, and include limiting the availability and increasing the cost. 3

In this context the report by Jensen et al5 in this issue that beer drinkers are more likely than wine drinkers to progress to heavier drinking is both interesting and potentially important. The analysis is well controlled for available confounders, although the authors rightly point out the strong possibility of residual uncontrolled confounders. The beer/wine relative risks for progression are modest, except among young men;ie, in general, people who prefer beer were only slightly more likely than those who prefer wine to progress to heavy intake. Possible explanations offered are that user traits of beer and wine drinkers may be involved or that some ingredient in beer encourages heavy drinking. Jensen et al5 rightly discard the latter as unlikely but do not raise the intriguing possibility that something in wine or about wine drinking might discourage heavy drinking.

Although some reports show no major differences, there has been much recent interest in differential health effects of alcoholic beverage choice. Those studies that do show disparate relations tend to indicate that wine is associated with more favorable health effects at light drinking levels and less harm at heavier drinking levels. 6 Some feel that possible favorable effects of light/moderate wine drinking largely have to do with possible nonalcohol ingredients in wine. With respect to benefit for atherothrombotic vascular disease, this unresolved issue 7,8 has little apparent relevance to risk of progression to heavy drinking and its consequences. Lower risk of wine drinkers for total mortality, 6 cancer, 9 and stroke 10 have been found in Denmark; as Jensen et al5 point out, these effects are more likely to be related to amount of drinking than to beverage choice.

User traits and drinking pattern are clearly implicated in these associations. In Denmark and the United States, reports show that wine drinkers have a healthier lifestyle. In a large California study, 11 individuals who preferred wine smoked less, had more education, and had more temperate drinking habits than those who preferred beer or liquor. In Denmark wine drinking, independent of educational status, was strongly associated with intake of a “healthy” diet, defined by intake of fruits, vegetables, fish, salads, and olive oil, 12 leading to the conclusion that these associations had “implications” for interpretation of lower mortality risk among those who prefer wine. Another report showed that wine drinkers had better perceptions of overall health. 13 The most recent pertinent analysis 14 compared young Danish wine and beer drinkers, showing that the wine drinkers were of higher socioeconomic status; had higher IQs; and, on a battery of tests, were more likely to demonstrate “optimal functioning.” Surely, all of these indicators of sociocultural advantages of wine drinkers over beer drinkers in Denmark are related to the lower risk not only of many illnesses but of progression to heavy drinking. Higher socioeconomic status is associated with more favorable health outcomes, and association of healthy habits is a general phenomenon creating difficulties in interpreting epidemiologic findings.

On the other hand, in countries with preponderant wine drinking, most heavy drinkers drink the prevalent, usually inexpensive, beverage. A few examples of resultant wine-induced pathologies include liver cirrhosis in many countries, 2 hypertension in France, 15 cardiomyopathy in Spain and France, 16,17 and peripheral neuropathy in Italy. 18 These facts suggest that, given the appropriate cultural milieu, some wine drinkers readily progress to heavy drinking. Even in countries where other beverages predominate, wine may be the “beverage of moderation” only in selected circumstances. 19

Beverage price influences the volume of sales of specific beverages, 3 but this may not influence heavy drinkers as much as light/moderate drinkers. 20 In the absence of current published data, I surveyed prices in several local northern California stores, with expert help from the manager of a large alcoholic beverage supermarket. I noted the lowest-priced beverages of each type, including “specials,” and I calculated the cost per 100 ml of ethyl alcohol. Acknowledging possible sampling bias and missed data, here are the results:

• For distilled spirits (identical for vodka, gin, and bourbon), $9.99 for 1,750 ml at 40% alcohol = $1.43 per 100 ml of ethyl alcohol;

• For beer, $2.99 for 2,160 ml at 5% alcohol = $2.77;

• For fortified wine (port), $5.99 for 1,750 ml at 18% alcohol = $1.87;

• For table wine, $6.99 for 4,000 ml at 12% alcohol = $1.67;

• For “peppermint liqueur”, $3.99 for 1750 ml at 20% alcohol = $0.87.

This limited survey suggests that wine does not provide the cheapest path to heavy alcohol intake. Another more important conclusion might be that cost is unlikely to deter anyone who wishes to drink heavily.

In recent years there has been a worldwide shift away from cheap wines to quality wines marketed to middle-class consumers. 21 This has helped to make table wine the more frequent choice of alcoholic beverage among the better-educated segments of society in Denmark, the United States, and some other countries. High cost might dampen proclivities toward heavy drinking among those who treat themselves to Chateau Lafitte or any “boutique” wine, yet some who can afford such wines might be unconcerned about price. But are there beverage characteristics other than cost that actually make it more difficult to drink wine in large amounts? Some wine aesthetes think so, but I know of no supporting data and it is unlikely that a satisfactory controlled experiment will be performed.

Cultural context, in the broadest sense, is a crucial factor in determining beverage preferences and a very important influence upon progression to heavy drinking. Unfortunately, the alcoholic who drinks mostly wine has not disappeared. It is unproven and unlikely that encouraging the potential heavy drinker to switch to wine would have the effect of precluding a later problem. In short, the answer to prevention of drinking problems will be found for the drinker, not in the drink.

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