In 438,442 U.S. veterans followed from 2011 to 2024 in the Million Veteran Program, moderate alcohol consumption (0.1–30 g/day) was associated with 14% lower all-cause mortality (HR 0.86) and 16% lower major adverse cardiovascular events (HR 0.84) compared with lifetime abstainers. Yet cancer risk followed an entirely different, linear trajectory: even moderate drinkers showed a trend toward elevated cancer incidence, rising to a 28% increased risk at ≥90 g/day. Smokers who also drank heavily faced a 5.7-fold elevated risk of head and neck cancers versus non-smoking abstainers.
This large, well-powered cohort adds important nuance to a debate that has intensified since the Global Burden of Disease consortium declared no safe alcohol level for cancer in 2018. The J-shaped cardiovascular finding is consistent with decades of prior epidemiology, but the persistent confounding problem looms large: lifetime abstainers include former heavy drinkers and those abstaining due to illness, artificially inflating the apparent benefit of moderate drinking. The veteran cohort skews heavily male and older, limiting generalisability. Critically, the split outcome pattern — cardioprotective vs. pro-carcinogenic — means individual risk calculus depends heavily on baseline cardiovascular versus cancer risk profiles. For adults already managing cardiovascular risk factors, this finding reinforces what clinicians should communicate: any alcohol benefit for the heart does not extend to cancer, and the two risks cannot be traded off simply.