Table 1. Temperance and Nontemperance Western Countries: Alcohol Consumption, Alcoholics Anonymous (AA) Groups, and Deaths from Heart Diseases
  Temperance Countriesa (n=9) Nontemperance European Countriesb (n=11)
Consumption, 1984, liters per capitac,d 8.7 14.1
% alcohol consumed as spirits, 1984c,e 33.3 17.1
% alcohol consumed as wine, 1974c,e 13.2 43.3
AA groups per million population, 1991f,g 167.1 40.9
Heart disease death rate, men aged 55-64, 1972d,h 775 410
a United States, Canada, Great Britain, Australia, New Zealand, Finland, Sweden, Norway, Iceland.
b Austria, Belgium, Denmark, France, Ireland, Itlay, the Netherlands, Portugal, Spain, Switzerland, West Germany.
c Data are teken from Levine, 14 whose data did not include the percentage of alcohol consumed as wine in 1984.
d Significance levels by t-test <.001.
e Significance levels are <.01.
f 1991 AA membership is based on a mimeographed form provided by Alcoholics Anonymous World Headquarters in New York City, and 1991 population estimates are from the 1993 World Almanac.
g The AA groups comparison is not significant despite the large difference in means because of large within-group variance (temperance group SD = 238). The highest ratio of AA groups in 1991 was in Iceland (784 per million people), but the next highest was for Ireland (201 per million). Although Ireland is listed as a nontemperance country, it is the Catholic nation that could most easily be called a temperance culture, with its history of antidrinking campaigns and the lowest alcohol consumption and percentage wine consumption among Western Catholic nations. The lowest per capita AA group ratio in 1991 was for Portugal (.6 AA groups per million people); the lowest ratio for a temperance country was in Norway (28 AA groups per million).
h The 1972 heart disease death rate is from LaPorte et al.15 and does not include Iceland.

Indeed, the "red wine paradox" — noted in France, where much red wine is drunk and French men have a substantially lower death rate from heart disease than do American men — has been the most popular version of the positive effects of alcohol, particularly since 60 Minutes featured a segment on this phenomenon in 1991. However, Protestant-Catholic, Northern-Southern European, dietary and other differences correspond with red wine consumption and confuse efforts to account for specific differences in disease rates. Furthermore, epidemiological studies have not found that the form of alcoholic beverage affects heart disease rates.

Does Alcohol Prevent Cardiovascular Disease? If So, at What Levels of Drinking?

The depth of American antialcohol feeling is expressed in the controversy over alcohol's protective effect against coronary artery and heart disease (both terms, which have the same meaning, are used by the authors discussed in this article). In a comprehensive 1986 review, Moore and Pearson16 concluded, "The strength of existing evidence makes new and expensive population-based studies of the association of alcohol consumption and CAD [coronary artery disease] unnecessary." Nonetheless, in a 1990 article on the negative effects of alcohol for the cardiovascular system based primarily on alcoholic drinking, Regan17 declared "a preventive effect of mild to moderate drinking on coronary artery disease is, at present, equivocal, largely due to the question of appropriate controls." The primary justification for this doubt has been the British Regional Heart study, in which Shaper et al.18 found that non-drinkers were at minimal risk for coronary artery disease (as opposed to ex-drinkers, who were older and who may have quit drinking due to health problems).

Nearly one of two people in the United States dies of cardiac causes. Two thirds of these deaths are due to coronary artery disease, which is caused by the fatty deposits in the blood vessels characteristic of atherosclerosis. The less common forms of cardiovascular disease include cardiomyopathy and ischemic (or occlusive) stroke and hemorrhagic stroke. Ischemic (occlusive) stroke behaves like coronary artery disease in response to drinking.19,20 Nonetheless, all other sources of cardiovascular mortality taken together increase at lower levels of drinking than does coronary artery disease.20 The most likely mechanism in alcohol's positive effect on coronary artery disease is that it increases high-density lipoprotein (HDL) levels.21