Alcohol is the most widely used legal drug. Its use has been sanctioned by long-standing use and efforts to ban it have been largely unsuccessful, as the Prohibition movement found out during the years 1920-1933 when the production, importation, transportation, and sale of alcoholic beverages was completely banned in the US, after the 18th Amendment to the US constitution was easily passed in 1919. While private ownership and consumption of alcohol were not made illegal federally, some local jurisdiction did make those illegal too.

The legacy of prohibition is mixed.

The overall effects of Prohibition on society are disputed and hard to pin down. Some research indicates that alcohol consumption declined substantially due to Prohibition, while other research indicates that Prohibition did not reduce alcohol consumption in the long term. Americans who wanted to continue drinking alcohol found loopholes in Prohibition laws or used illegal methods to obtain alcohol, resulting in the emergence of black markets and crime syndicates dedicated to distributing alcohol. By contrast, rates of liver cirrhosis, alcoholic psychosis, and infant mortality declined during Prohibition. Because of the lack of uniform national statistics gathered about crime prior to 1930, it is difficult to draw conclusions about Prohibition’s effect on crime at the national level. Support for Prohibition diminished steadily throughout its duration, including among former supporters of Prohibition.

The 18th Amendment was repealed by the 21st Amendment passed in 1933, ending that experiment.

That drinking alcohol causes or exacerbates problems is clear, with men being the key drivers.

Even at lower levels of drinking, men are more likely to engage in impaired driving, commit violence or experience drownings and falls, scientists have found.

“Men drink more, binge-drink more and generally do dumber things when impaired,” said Tim Naimi, director of the Canadian Institute for Substance Use Research and another author of the alcohol report.

Men account for roughly three-quarters of alcohol-attributable deaths in the United States and Canada, Dr. Naimi continued, and they are responsible for a majority of “secondhand harms.”

Men have almost triple the number of emergency department visits for alcohol-specific diagnoses than women, according to national figures released on Thursday, with nearly four million visits each year on average in 2021 and 2022. The figure for women is 1.37 million emergency room visits.

Among men, the risk of dying from something related to drinking starts to exceed 1 in 1,000 at six and a half drinks a week, Dr. Rehm and his colleagues found. Among women, the threshold is roughly the same, more than seven drinks a week.

At eight and a half drinks a week, the risk exceeds 1 in 100 for both men and women.

“For low levels of use, at the same level of use, men are at a similar risk of health harms from alcohol use compared to women,” according to the internal H.H.S. document.

The overall death toll from alcohol, for both men and women, far exceeds that from drug overdoses. According to the Centers for Disease Control and Prevention, more than 178,000 U.S. deaths in 2020-21 were attributable to alcohol.

The figure includes deaths immediately linked to drinking — including those caused by alcohol poisoning and motor vehicle accidents — as well as those resulting from cancer and suicides.

Alcohol causes 8 percent of breast cancer deaths, for example, and nearly half of deaths in men who develop a certain type of esophageal cancer.

But what to do about alcohol consumption remains problematic to this day, with questions such as how much alcohol consumption (if any) can be considered ‘safe’ and what guidelines should be recommended to the public. While some recommendations, such as that pregnant women should not drink any alcohol at all, seem to be firm, what limits should recommended for others has fluctuated. Trump’s HHS secretary has nixed proposed changes to the existing recommendations that would have recommended more stringent limits, that both men and women limit themselves to one drink per day, and he has made even the existing ones vaguer.

Federal dietary guidelines long recommended limits on alcohol consumption for Americans: one drink daily for women, two for men. But last spring, health officials seriously considered a dramatic redefinition of moderate drinking for men, according to two people with knowledge of the process who spoke anonymously because they feared reprisals.

The officials proposed lowering the cap for men to one drink a day, the recommended limit for women.
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When Robert F. Kennedy Jr., the health secretary, and other officials unveiled the new guidelines earlier this month, they included a vague directive telling Americans only to “limit” alcohol. Even the long-established caps for men and women were gone.

The alcohol industry opposes any reduction in the limits and pointed to some studies that suggested that moderate levels of drinking led to lower all-cause mortality and lower cardiovascular mortality. But while people invoke many reasons to drink alcohol, Dr. Ned Calonge, an epidemiologist at the University of Colorado Anschutz Medical Campus who led the NASEM panel on alcohol, said “There are a lot of reasons people drink alcohol. …What we’re saying is health shouldn’t be one of them. Doctors should not recommend that people drink alcohol for any reason.”

Beliefs about gender also complicate the picture.

In the 1980s, the dietary guidelines said all adults could have one to two servings of alcohol a day, except during pregnancy. The separate recommendations for men and women, introduced in 1990, were based on the fact that men and women are biologically different.

But the idea that men could drink more was never rooted in solid scientific evidence, some experts have said, and it may have been influenced in part by paternalistic attitudes toward women.

The biological differences are real enough: Men are taller and heavier than women on average, and women metabolize alcohol differently because they have both a higher percentage of body fat (alcohol is water-soluble) and lower levels of a liver enzyme that’s responsible for metabolizing alcohol.

But men are more likely to engage in risky behaviors when drinking, and they have higher rates of habits, like smoking, that compound the harms of alcohol, scientists say.

The social pressures to drink alcohol begin early. It is associated with being an adult and popular culture sees drinking as something sophisticated people routinely do. The culture of bars as popular meeting places add to the pressure. But the problem is that many people do not stop at one drink or even two but go further. The resulting loss of inhibitions and control can lead to dangerous behavior. Asking such people to just ‘drink less’, without specific guidelines such as one drink per day, would likely be useless since drinkers very likely tend to have an inflated opinion of how much they can drink without becoming impaired, like car drivers who all think they are ‘above average’ in driving ability.