The Alcohol Preventive Paradox

Unhealthy Alcohol Use and the Preventive Paradox

People who drink the heaviest amounts have the highest risk of harm from alcohol. People who consume less, however, accrue most of the harm because they, as a group, are much larger.

  • To examine whether the distribution of alcohol-related problems, deaths, and hospital admissions supports this preventive paradox, researchers pooled data from 4 Finnish population surveys. They compared self-reported problems (n=5558) and alcohol-related hospital admissions and deaths (n=6726) in the 10% of the population who drank the most* with the 90% who drank less (excluding abstainers).
  • The 90% of men consuming less experienced 70% of the self-reported problems, 70% of the alcohol-related hospitalizations, 64% of the alcohol-related deaths, and 64% of the premature life-years lost.
  • The 90% of women consuming less experienced 64% of the self-reported problems, 60% of the alcohol-related hospitalizations, 93% of the alcohol-related deaths, and 98% of the premature life-years lost.
  • Drinking ≥5 drinks, versus less, on an occasion in the past year was generally related to more harm.


The preventive paradox suggests efforts to reduce the population harms of alcohol use must reach the majority of drinkers rather than the smaller proportion of heavy drinkers. These findings support this paradox and NIAAA** recommendations to use the screening question, “How many times in the past year have you had 5 or more drinks in a day (4 or more for women)?” If screening and brief interventions can produce even modest reductions in heavy drinking episodes among otherwise nonproblem drinkers, the public health will most likely benefit.

Peter D. Friedmann, MD, MPH

*At least 753 drinks per year for men and at least 213 drinks per year for women
**National Institute on Alcohol Abuse and Alcoholism

Research References: Poikolainen K, Paljärvi T, Mäkelä P. Alcohol and the preventive paradox: serious harms and drinking patterns. Addiction. 2007;102(4):571–578.


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