In the pit of the pandemic, with no one to see and nowhere to go, and horrors unfolding daily outside the front door, there was for many a reliable bright spot: the 5 p.m. drink that would mark the end of the workday.
Drinking, which was already on the rise before 2020, became a coping mechanism for overburdened parents, burnt-out workers, the traumatized, and the bored. There was a beer, wine, spirit, or seltzer for every occasion: game nights, weddings and birthdays over Zoom, socially distanced happy hours, and too many nights on the couch watching a TV show about tigers.
When people went back to the streets, there were even more drinks to be found, thanks to alcohol regulations that had been rolled back in many states during the pandemic. A bottle of booze could be delivered to the front door.
Alcohol sales per capita went up more from 2019 to 2021 than in any two-year period since 1969, according to estimates from the National Institute on Alcohol Abuse and Alcoholism. Deaths from excessive alcohol use are also rising, as are deaths where the underlying cause of death was alcohol-related. And it’s not just liver disease. Alcohol has been linked with over 200 conditions, impacting basically every single organ system.
As scientific information emerges, experts are becoming increasingly concerned about Americans’ drinking patterns, and how best to talk to the public about its potential risks.
“The alcohol situation was exacerbated by the pandemic. And we realized: We really need to change the conversation about alcohol in the United States,” said NIAAA Director George Koob. “There’s so many people that need help, for alcohol use disorder or alcohol misuse, and it really has such a major impact on health care at all levels — I mean at all different diseases and conditions.”
Experts are currently evaluating the scientific evidence on alcohol’s health effects. The 2025 Dietary Guidelines for Americans are due at the end of next year, and could change what people in the U.S. are told about drinking. But controversy has surrounded the guidelines process for decades, and this time around is no different when it comes to alcohol.
The once-popular, appealing idea that alcohol might be good for health has been tempered by years of research findings that suggest the opposite. Some studies still support the idea that low-to-moderate drinking could decrease risk of cardiovascular disease, dementia, or diabetes. However, those potential benefits must be balanced against evidence that alcohol consumption increases the risk of many other conditions. Because of these conflicting reports — and the influence of a rich and powerful beverage industry — there is still debate over what drinking advice officials should give the public.
Think of the last time you had alcohol. How much did you have? What about the time before that? How many ounces? Did you have drinks over the course of a week, or stacked on the weekend?
Like all patterns of consumption, drinking is tricky to track. It’s a tool of diversion, relaxation, and celebration, and one served in inconsistent portions. Happy hour prices are made loud and eye-catching, while alcohol content is just a small number on a bottle or menu.
But other numbers — data from study after study — give a more clear-eyed view of Americans’ drinking lives and the ripple effects.
Drinking habits
Who drinks?
Picture six American adults. In the past month, half of them did not drink alcohol, according to federal data. One drank in moderation, and the remaining two drank excessively. This is roughly the spread of drinkers in the American population at any given time.
When zooming out to alcohol consumption in the past year, over 60% of U.S. adults said they drank, according to the 2022 National Survey on Drug Use and Health. And nearly 80% of people over age 11 reported having drunk at some point in their lives.
Alcohol use is most prevalent among people in their early-to-mid-20s, and tends to decrease slightly as people age. Underage drinking has greatly declined through the years, but heavy drinking in the 20s and 30s is a lingering problem. Over 60% of 26-to-44-year-olds drink, and 55% percent of adults 45 to 64 years old drink. Rates of alcohol use generally go up with income and educational attainment.
Adult women on the whole drink less alcohol than men and have lower rates of alcohol-related disease and death. However, studies show women’s rates of drinking and binge drinking have increased over time, narrowing the gap between the sexes. Since women are more susceptible to certain alcohol-related harms — in part due to having bodies that absorb alcohol well and take longer to process it — they are also increasingly facing the consequences of heavy drinking.
Among women who are pregnant, up to 14% report currently drinking, according to CDC data. That number has slightly increased since the early 2010s. Some studies have found that LGBTQ+ people have higher rates of alcohol use, and are at higher risk of developing an alcohol use disorder.
How much do drinkers consume?
When Americans do drink, they typically consume more alcohol than is recommended by the Dietary Guidelines for Americans, which suggest a maximum of one drink per day for women and two for men.
Consumer data from 71,500 American households found national alcohol sales went up by almost $2.5 billion (34.4%) — up to $9.55 billion — in the first few months of the pandemic compared to the same time period in 2019. The biggest increases in sales were for liquor. Households with higher incomes had larger relative increases in alcohol purchases during the pandemic, but buying went up across geographic areas and demographic groups. And while alcohol purchasing seemed to slow down a bit in 2023, sales of “ready-to-drink” cocktails continued to increase — more than doubling since 2019, up to $10.7 billion.
Binge drinking
Research suggests nearly half of people who drink engage in binge drinking, defined as having four or more drinks in the span of a couple hours for women, or five or more drinks in two hours for men. It’s estimated 17% of adults binge drink, and about a quarter of those reported binge drinking multiple times per month.
The American Public Health Association says binge drinking is more common among men, 18-to-34-year-olds, and people with household incomes of $75,000 or more.
Among U.S. veterans, high-risk alcohol use increased between 2019 and 2023, according to self-reports captured in VA health data. Nearly 15% of veterans had documented, high-risk alcohol use between 2022 and 2023. And the problem grew worse for women who had served: The proportion reporting excessive drinking now surpasses the proportion of men. Veterans between the ages of 18 and 39 engaged in the highest rates of risky alcohol use, with 27% of American Indian/Alaska Natives and nearly 17% of Asian Pacific Islanders reporting high-risk use.
What are people drinking?
Standard drink sizes in the U.S. are: one 12-ounce serving of 5% ABV beer, a 5-ounce serving of 12% ABV wine, 8-10 ounces of 7% ABV hard seltzer, or 1.5 ounces of 40% ABV liquor.
However, some data suggest men drink an average of 3.5 servings of beer or 1.8 servings of wine on days when they drink beer and wine. Women drink an average of 2.2 servings of beer or two servings of wine. And at least one study found the average alcohol content of beer, wine, and spirits increased between 2003 and 2016, packing more of a punch per serving.
Sales of ready-to-drink beverages, such as hard seltzers, alcoholic teas, and canned cocktails or wines, have boomed in the last several years. Sales of spirits outcompeted beer and wine in 2023.
Potential harms are many
Alcohol use disorder
It’s estimated 11% of the U.S. population has a diagnosable alcohol use disorder. Overall, about 1 in 5 people who start drinking will develop an alcohol use disorder at some point in their lives. Anywhere from 20% to 40% of people with anxiety and mood disorders have an alcohol use disorder, and up to 60% of people who seek out AUD treatment have post-traumatic stress disorder, according to the scientific literature.
Cancer
Alcohol is a toxic product. It has been considered a carcinogen by the World Health Organization and the U.S. government for years, and is considered the third leading preventable cause of cancer, after obesity and smoking tobacco.
Studies consistently report that alcohol accounts for over 75,000 U.S. cancer cases and 20,000 cancer deaths each year. Risk increases the more people drink, but mounting evidence suggests even low levels of alcohol (within the 1-2 drinks per day range recommended by U.S. dietary guidelines) could lead to certain cancers because of how the substance damages DNA as it courses through the body.
In women, breast cancer is the kind of malignancy most driven by alcohol. Just one drink per day can increase women’s risk of breast cancer by up to 15%, studies have found. Reduced drinking (going from heavy drinking to moderate or mild drinking) is associated with decreased cancer risk.
Beyond the breast, alcohol is associated with at least half a dozen types of cancer. About 4% of all cancer deaths in the U.S. are believed to be caused by alcohol. That’s not new information: A decade ago, researchers in the U.S. found that almost half of oral cavity and pharynx cancers in men and about 28% of both esophageal and oral cavity/pharynx cancers in women were associated with alcohol. The largest burden was for female breast cancer — 39,060 cases attributable to alcohol.
More recent research by the Canadian Institute for Substance Use Research suggests that in 2022, alcohol was to blame for 9,500 cancer cases and 3,800 cancer deaths in Canada. Baseline estimates presented at a conference last month blame alcohol for over a third of esophageal cancers (mostly squamous cell carcinoma) and oral cavity and pharynx cancers, and a quarter of liver cancer cases. Nearly 20% of laryngeal cancers, 15% of colorectal cancers, and over 7% of both breast and pancreatic cancers were pinned on drinking.
Other data has found drinking is associated with a decreased risk of certain cancers, including kidney, non-Hodgkin lymphoma, and thyroid cancer. Some polyphenols in red wine have antioxidant and anti-inflammatory qualities that could help prevent tumors. However, the amount of alcohol — and the amount of pure ethanol people drink — seems to have a bigger impact on cancer risk than the type of alcohol consumed. And every potential benefit also carries a potential harm.
Chronic disease
Studies have reported low levels of drinking may be protective against some conditions: cognitive impairment, dementia, atherosclerosis, coronary heart disease, heart failure, hypertension, or ischemic stroke. However, the more a person drinks, the faster potential benefits vanish and are replaced by a litany of possible bad outcomes. High average levels of consumption and binge drinking are associated with increased risk of coronary heart disease, stroke, congestive heart failure, atrial fibrillation, dementia and hypertension.
Alcohol use also is a risk factor for pancreatitis, gastritis, gastro-esophageal reflux disease and peptic ulcer disease, as well as a potential aggravator of mental and behavioral disorders. When drinking is combined with tobacco use, risks go up across the board.
Liver disease
From 2020 to 2021, age-adjusted death rates increased 9% for chronic liver disease and cirrhosis (13.3 to 14.5) — a bigger jump than stroke, diabetes, and kidney disease. There were about 5,000 more deaths from alcohol-associated liver disease in 2020 than in 2019 — a 22% change.
Half of liver disease deaths in the U.S. are caused by alcohol, according to the National Institute on Alcohol Abuse and Alcoholism. Alcohol-associated liver disease kills about 22,000 people in the U.S. every year — roughly 347,000 deaths over the past 20 years. In 1999, three in 100,000 people died of alcohol-associated liver disease. By the first year of the pandemic, 8 in 100,000 were killed by the condition.
During the pandemic, specialists watched as alcohol-related illness soared. Hospitalizations went up, rates of alcohol-associated hepatitis — a severe form of liver injury that can happen in a shorter time frame of heavy drinking — and demand for liver transplants increased. And more young people and more women started showing up to their clinics. A decade ago, more than 6,000 adult liver transplants were performed in the U.S., but only about 20% of those were for people with alcohol-associate liver disease. After the pandemic, alcohol-related liver disease now accounts for 40% of all liver transplants in North America.
Certain groups are being hit hard. Rates of alcohol-associated hepatitis continued to rise sharply in U.S. military veterans. Between 2010 and 2023, rates increased from 31.6 to 392.6 cases per 100,000 people per year. And chronic liver disease, including from alcohol, is highest in American Indians and Alaska Natives.
Deaths
Alcohol-related deaths are on the rise, and experts are particularly concerned by an increase among young people and women. The U.S. saw a 25.5% spike in alcohol-related deaths between 2019 and 2020 — accounting for 3% of all deaths in the first year of the pandemic. The largest increases in alcohol-related deaths were among people 25 to 24 and 35 to 44 years old; deaths in both groups increased by over 37%. Mortality from alcohol-associated liver disease is rising most rapidly in those ages 25-34. Women have seen large annual increases in alcohol-related mortality for years.
Opioid overdose deaths that involved alcohol as a contributing cause went up by 41% (and by nearly 60% in cases where people overdosed on synthetic opioids such as fentanyl) in 2020.
One in five deaths — about 45,000 deaths per year — among people 20 to 49 years old is attributable to alcohol, CDC data show. Binge drinking is responsible for more than 40% of deaths.
Is there a safe zone?
Researchers are still trying to figure out how low-to-moderate alcohol use (at or below the dietary guidelines levels) affects health, and whether there is a threshold — short of total abstinence — that would reasonably protect people from serious risk of disease or death. Is that one drink per week? Or five? Alcohol’s pleasurable effects are also indubitably valuable to many people’s lives. But many of alcohol’s negative impacts can be altered by personal genetics, underlying disease and other factors, which makes tailoring drinking recommendations to individual people really difficult.
Still, there are some widely agreed-upon guidelines — drinking thresholds above which a person’s risk of developing a disease or shaving time off their life significantly increases, according to the data.
Many people who drink wade into this territory, going past the zone of unknown risk and into more dangerous drinking behaviors. And they might not know it.
STAT’s coverage of chronic health issues is supported by a grant from Bloomberg Philanthropies. Our financial supporters are not involved in any decisions about our journalism.