Why Gen Z is Drinking Less and Millennial Women are Drinking More with Dr. Katherine Keyes

0:00Let me know. Welcome to That Can't Be True, a show that swords fat from fiction, especially on issues impacting our health. I'm Chelsea Clinton. For many people, alcohol is part of celebration, social occasions, winding down at the end of the day, part of dinner. And for decades, many of us heard some version of the same message that moderate drinking might be good for our health. That particularly a glass of red wine might be good for our hearts. But new research is challenging some of these long-held assumptions and understandings about the relationship between alcohol and health, including what moderate really means in this context and whether any amount of alcohol is entirely risk-free. So what does the new research say? What does the evidence tell us?

1:01What do we know when we think about the trade-offs between alcohol and THC, a question that increasingly Americans are asking themselves? To help us separate fat from fiction, I'm joined by Dr. Catherine Keys, a professor of epidemiology at Columbia University, who's led a lot of the research that is helping to catalyze these conversations and inform hopefully all of us as we think about choices in our lives. She studies changing patterns of alcohol use, substance use, health consequences of alcohol and substance use, and how different generations are making different choices. Hi. Hello. Thank you so much for your time this morning. Of course, thank you for the invitation. I have to ask this question and I'm excited to ask this question mentally because this was something I believe that I learned in preparing for this interview, which is that you were

2:02cited in last year's Make America Healthy Again report for a paper you had never written. Yes. Can we just talk about that experience if that really happened? Like, what was that like when you saw your name appear for an ephemeral, non-existent study? It was a really surreal experience. I got an email from a journalist and just said, I'm going through the reference. I didn't even know that I was cited in the Mahat report. And then a journalist emailed me and said, we're going through the citations in the Mahat report. Can you confirm that you wrote this paper? And I looked at the paper and I'm like, it was very surreal because it was authors that I had published with. And it was a journal that I had published in. And the topic was depression, anxiety, and youth that I'm like, well, I study that. And I know these people, but we've never published together. And so then I truly was confused. I looked up the journal. We were like, you're Googling. You're like, did it?

3:02You're like, did I do this? Right. I was Googling myself. And then I just see my back and I said, I did not publish that paper. Like, I don't know where this came from, but it wasn't mine. And then within the next 24 hours, it became like the national news, not just me, but there were other people who had been kind of fake sighted in the Mahat report. And I was on the subway going to my job at Columbia. And I, you know, how your cell phone kind of works in between stations. Yes. Yes. And I like opened up my cell phone and opened up my email. And it was like one of those things where like just the email started coming through from all these different news outlets saying, we want to interview you about being false sighted in the Mahat report. And I just thought, I do real research. I do, I do real scientific studies that I would love to talk to the Washington Post and the Wall Street Journal about, but they want to talk to me about a study that I didn't do. And that's going to be my claim to fame. And that's not what I got into this field to be so bizarre.

4:03It must have just been such a bizarre experience. Yeah. It really, it really was. And I mean, they changed the report. And I think that they removed the, I, you know, I'm not an expert, but what seemed to be hallucinated citations. And I, you know, never heard from the federal government about it at all. I want to start with you telling us like what psychiatric and substance use epidemiology is. And particularly how and why you're so interested in looking at how the questions you ask change across someone's life or even across generations. Yeah. Yeah. I mean, to start with, you know, most people now know what epidemiology is once we went through the COVID pandemic, you know, prior, prior to the pandemic, when I told people I was an epidemiologist, most people said, oh, so you study skin. Oh, wow. That was the most common response. But now I think most people understand that epidemiology as a field is interested in studying

5:07patterns, trends, and determinants of a wide variety of health outcomes. And many people, I think, understand epidemiology as part of kind of epidemicology. So trying to study how things like COVID, flu, HIV, how they get transmitted in populations and what we can do in terms of public health interventions to reduce them. But there are many areas of epidemiology and some of those include chronic disease, epidemiology, injury, epidemiology in my field of psychiatric and substance use epidemiology. But my field is interested in understanding how many people have certain conditions like substance use disorders, depression, schizophrenia. How do we know how many people have those disorders? Who's at most risk for the disorders? Are the disorders changing in incidents and prevalence over time? What are the causes of disorders? Are those changing over time? And therefore, informing kind of public health interventions that we can do to reduce psychiatric disorders and substance use, which are among the most common and disabling health conditions

6:09that people face both in America and across the world. And so, Catherine, how many people in America do you think are or could be affected? So it's very interesting, traditionally in most of our psychiatric epidemiology studies, we would find about a third to almost a fourth of people would experience a psychiatric disorder. Now we've been doing kind of these long-term longitudinal studies where we're really following people across the life course. And what those studies are demonstrating is that's probably underestimated that in fact, most people will experience a disabling psychiatric disorder or substance use disorder during their lives. Like, these are not abnormal or rare. Most of us are going to go through periods of really destabilized mental health. It's more common in the early part of the life and adolescence and in young adulthood. But when you follow people over time, you find that this is part of the human condition

7:13is dealing with really not only negative emotions, but a real inability to cope and process with them. But I will say, you know, when I first started in the field, a lot of my work around substance use disorders was focused on alcohol and alcohol use disorders. And that's really been a dominant driver of a lot of the work that I do. Alcohol remains, you know, the substance that kills more Americans than anything else, including opioids. That said, I think over the last 20 years, two really emergent crises have changed the way that psychiatric and substance use epidemiologists have engaged with our work, one being the opioid crisis. And the other big change in the last 10 years has been young people in mental health, especially adolescence. We've just seen extraordinary increases in depression and anxiety and unfortunately, suicide among younger and younger cohorts of young people.

8:13I want to talk about that. I first though, do you want to talk about your work as relates to alcohol, which has gotten attention recently? And as a segue into that, I want to start with that. That can't be true segment where we'll play some tape from the internet of late and get your reaction and then go into the broader conversation around what your research and others have shown to be true and not true about alcohol use. So here's something we found on Bon Appetites Instagram page. Gen Z is drinking again, according to a new study, but is it enough to save the dying spirits industry? Open the open tab. Let's get to it. There's been a whole hull of blue this week because beverage insights company, IWSR, released a study finding that Gen Z's drinking rates are at 74% up from 66% three years ago. Part of the reason is just that more Gen Z people are of legal drinking age, but it does also suggest a cultural shift. This change comes after years of declines and drinking rates for younger populations. Those declines hit the spirits industry hard and spirits giants like Pernover Card and Diagio, their stock prices have been tanking. Okay, you heard it here first.

9:15Drinking is back. So Catherine, is that true? Like are people in that you're studying drinking more in Gen Z or are they drinking less? What is true and not true? No, that is not consistent with our data. I'm involved in a national study of middle school and high school students who we then follow into adulthood. And we've been conducting the study every single year since 1975. It's called monitoring the future. Oh, wow. We have many, many generations, including our generation. And we've been studying their drinking patterns and other substance use patterns. And we're able to then kind of really distinctly delineate drinking patterns across generations. Among young people, alcohol use has been going down for decades. The peak of binge drinking in high school seniors was in 1983. And it's really been declining thereafter. And there is an increase in drinking that occurs during the transition to adulthood after

10:20kids leave college, especially when they reach legal drinking ages was mentioned in that video. And the acceleration of alcohol use during that transition has gotten faster. So as adolescents are drinking less in high school, they're more rapidly accelerating their consumption during the transition to adulthood. So we'd have seen some increases in drinking in middle age groups. But in the last several years, our data as well as others showed that even that is now on the decline, even among middle age people, there has started to be a really rapid decline in alcohol use. And Catherine, why do you think that is? It's such an interesting question. So I mean, in terms of the decline in drinking that we've seen in just the last few years, there's a lot of speculation that doesn't have a lot of data to back it up. You know, everyone kind of has a theory. So what I'm going to say about this is that the way we're doing it, we're doing it as well as this kind of post pandemic, you know, people aren't going out as much work functions

11:20and stuff, people aren't getting together as much. That's one thing. Others have suggested that, you know, is this really because people are transitioning to cannabis use or alternative products that are also now rapidly available at lower price and now real awakening for a lot of people into the health risks associated with alcohol. There's more and more information. You know, we just had a Surgeon General's report a couple years ago highlighting the cancer risk with alcohol use. You do see a lot more sober, curious movements, mocktails, you know, people who are making choices to reduce or even eliminate alcohol from their lives as part of a healthy lifestyle that I don't think has been part of a national conversation before. So I like to think that at least part of the decline is because public health messaging has been effective and that alcohol is, there's no safe level of alcohol for your health and that people are choosing to reduce for that reason. But again, that has very little data to back it up either. Well, but Catherine, you and your team, like Columbia recently published a study that said

12:20new research links even low alcohol consumption to cancer heart disease and premature death. It's quite striking headline. What did you find that we didn't already know or we just find being more evidence to flesh out what we have known? You know, it's so interesting because that study did get a lot of attention and I do think I was surprised because it is stuff that we know. So this study that we did was part of a study called the Alcohol and Health Study that we, I worked on with a lot of different colleagues. The purpose of the study was to use US data to try to directly model the impact of each drinking level on these health risks. So 0 versus 1 drink, 1 versus 2 drinks, 2 versus 3. You know, really trying to get a fine-grained estimate of your future health risks at these pretty specific drinking levels. And what we found which was again, not surprising to us is that the increases in risks begin

13:23at very low levels of alcohol consumption. You know, there are some health outcomes that you don't start to have an acceleration of risk until later in the drinking continuum. But there are a lot of health outcomes where it's pretty early in the drinking continuum that you start to see increases in risk, including risk to your liver. And so when kind of taken together the conclusion from the study, which again is something that is for most alcohol researchers was not news, is that the dose makes the poison. And at low levels there is a small increase in risk but present and that there's no protective benefit of alcohol use at moderate levels to your health. Which I think is counter to often what we have heard that a glass of wine a day, a glass of red wine a day can be really good for your health. And you're saying even if maybe there might be a benefit, I don't know if that's what you're saying, but even if that were to be true, it's outweighed by the risk. That's exactly right. You know, there are some specific health outcomes where we do see some slight decline in mortality

14:27at low levels of alcohol consumption, but there are enough health outcomes where you see an increase in risk at low levels of consumption that on balance when we're thinking about public health guidance, it's not like you want to pick which health outcome you want to avoid or increase your risk for, right? But yeah, no, this is counter to a lot of the traditional literature which found, you know, what we used to call it a J-shaped curve that for people who didn't consume any alcohol, they had higher risks of mortality than people who consumed low amounts of alcohol and then there was like this kind of escalating risk that occurred at higher levels of alcohol. But what we know now from really good epidemiological studies as well as some what we call quasi-experimental studies is that a lot of that was just confounding. People who drink low levels of red wine every day are wealthier, they're more likely to exercise, they have all kinds of health benefits that outweigh, you know, the impact of that alcohol use. And so on balance, there's just simply no good evidence anymore that there's a health benefit to drinking small amounts of alcohol.

15:33And Katherine, what do you find if people either stopped drinking or maybe they were higher on the continuum and now are more moderate? Is there a health reset? And I'm thinking admittedly, you know, in the context of what we've heard for so long about smoking, that if you quit smoking, like your lungs really do recover, like your body really does. Yeah. Yes, like, you know, bear a memory of that, but really also can recover itself. Is that true here as well? Absolutely. Yeah, reducing or eliminating alcohol use really, you start to see benefits very quickly after the cessation of use. Across a number of different systems, you know, in terms of oxidative stress repair and other types of mechanisms, there's no time like the present to reduce alcohol consumption. You know, I also know that this, I think this research, but possibly, you know, other research as well was expected to inform the federal dietary guidelines and then didn't.

16:37What happened, like why weren't your findings more incorporated? And what do you think the federal government should be telling Americans about alcohol based on your and your colleagues work? Yes, I can tell you what I, what I experienced was that this study, the alcohol and health study was commissioned to be part of the materials that would be considered in developing the federal dietary guidelines. Simultaneously, there was another report commission from a separate group on a similar topic, alcohol and health. The findings from the two reports were published and they used very different methodologies, but the other report did not demonstrate the kind of increase in risk that low levels of drinking. They didn't, you know, estimate risk at each level of drinking like we did. So it's not necessarily surprising that they didn't find that. But the headline was, you know, two studies find very different findings and one preserved the kind of moderate drinking benefit or at least not demonstrating an increase in risk at low levels.

17:39Subsequently, I don't know what happened behind the scenes, but that was the only report that was submitted as part of the of what was to be reviewed by the federal dietary guidelines. And so what do you think the federal government should be saying? So this is the thing that was interesting to me about the whole process is that then when the federal, the new federal dietary guidelines came out, the guideline that they came out with was really consistent with our report, which is drinking less is better for your health. And it didn't provide any kind of cut points, you know, the previous dietary guidelines were a little bit confusing and it was no more than 14 drinks per week of your man and seven drinks per week of your woman and no instances of five or more drinks if you're a man and four or more drinks if you're a woman. And that's hard to keep in your brain, even I think for those of us that you want to be responsible and healthy and simple is generally better. Exactly. Exactly. And they simplify the guidelines to just say drinking less is better for your health.

18:39Which is exactly what our report demonstrated right like if it's the dose makes the poison then at any point where you're drinking drinking less would be better for your health and drinking more now is the guideline drinking less is better for your health. A great public health message. This is something that is currently being debated in my opinion. It's unclear drinking less than who drinking less than what well how many drinks per week am I allowed can I drink what if I what if I drink a glass of wine a day is that that or good, you know, simple is good but but not too simple. Yeah, I think that that's a good way of putting in. And you mentioned the kind of different guidelines that we have had historically around women and men and I know that you've looked at to alcohol use and women's health and kind of the ways in which we might be affected differently. I wonder what you can share about that are we more vulnerable as women does that shift over our lifetimes.

19:40Yeah, the available evidence does indicate the women are more vulnerable to the effects of alcohol compared with men typically on average women have smaller body size than men and so at the same level of consumption women are going to have a higher blood alcohol content. And so there's just going to be more damage to the body at the same level of consumption. We also have unique health risks that are more concentrated in women like breast cancer and other reproductive cancers and so we bear those risks as well compared to men. So for all of those reasons, you know, we know that at the same level of consumption there's just a greater effect on a female body than on the male body and that is more towards the kind of chronic health outcomes that we see in alcohol use like liver damage, cardiovascular disease stroke and, you know, as I mentioned these different cancer sites. One thing that the epidemiological data has been very clear about is that when you look across the last 20 years. Among adolescents, alcohol use has been going down among adults. We see kind of stability and or increases.

20:43It's very clear that there's one group that has been increasing drinking and binge drinking and that is women. A middle-aged adult women across the last 15 years is where we have seen increases in alcohol consumption. And so I do think that is very concerning for a whole host of public health reasons. And we've looked into a lot of the reasons why that was my next question like why do you why do you think this is happening and what should we know. So when you look at among the group of middle-aged women, the women where you see concentrated increases in alcohol consumption and binge drinking are the women with the highest levels of education, college education or above, the highest levels of family income and the highest levels of occupational prestige. You see some increases in drinking among other groups of women, but not nearly as much as you see in these kind of highest, highest socioeconomic status groups. And Katherine, how does that relate to the fact that that group too often isn't having children until later in life or is that not connected?

21:49It is absolutely connected. Thank you for raising that. So we looked at all the demographic shifts in what we call the kind of big five social roles or that's what the term that's used in developmental psychology. So the big five social roles that we typically talk about are these markers of different markers of kind of transition to adulthood and they are attending college, residential independence, so not living with your parents getting married, having kids and full time employment. And when we look across the last really 40 years, there have been real shifts in occupying these social roles and it has been quite gendered. So for women in particular, exactly as you said, there's a delay and sometimes not having children altogether, but on average women are having children later and later and there's a higher prevalence of women who are not having children at all. There's also declines in marriage. If your women are getting married and if they do get married, they wait until later to get married.

22:51And those shifts mediate the increases in drinking that we're seeing among middle aged women. So if we are married, if we have children, if we have full time employment, if we don't live with our parents, we're less likely to be heavy drinkers. That's right. In general, in general, but it's really marriage and children that really drive a lot of at least significantly mediate kind of the cohort differences that we're seeing in this middle age drinking trends. They don't mediate all of it, certainly that doesn't explain anything. And I don't think the public health implication is to get women to get married and have children earlier. That's not the solution, but it does indicate that this period of your 20s and your 30s, women increasingly have a lot of discretionary income. They don't have a lot of family responsibilities tying them down. And I don't think that they have been delivered effectively the message that alcohol use really comes with some serious health risks.

23:55In fact, we did another study where we were looking at generational trends in why people report that they drink, you know, to drink to cope with negative feelings. Do you drink for, you know, we have a whole battery of reasons why people drink. And by far, the motivation to drink that is increasing among women in this group who are increasing their consumption is drinking to have fun and socialize. So it's not that women in this age group are, you know, are are drinking to cope with negative feelings. They're drinking because they don't have that many adult responsibilities and they have high education and high paying jobs and they're buying alcohol with that money. I want to spend a little time talking about something you mentioned at the top of our conversation, which is the rise of mental health challenges and crises and young people. And what you think we may not be paying enough attention to where you do think we still need additional research kind of what those of us who are parents, you know, really need to be mindful of what we know and what we don't know.

25:07Yes, thank you so much for asking. I mean, I think the biggest kind of research topic over the past 10 years with depression anxiety and young people has been the role of digital technology and social media. And certainly we're seeing that play out legally right now and in these kind of high profile elements and court cases that have been going on. You know, the research on social media and mental health indicates very limited association when you look at metrics like how much time you're spending on social media or how many platforms you're on or how much time you're spending a digital technology. That's not strongly related to youth mental health. So I think the issue that we need to get away from is that it's about time. Then a lot of time your kid is on the iPad is not impacting their mental health. What's impacting their mental health is what they're doing online in my opinion, where we have a much stronger signal for an association with mental health problems is kids who are engaging with material that's related to self harm. Kids who are experiencing mental health crises using the internet to find dangerous information on lethal means, for example, is an area where I've done quite a bit of work and it's really troubling what we see.

26:14Kids who are exposed to cyber bullying and kids who report that they're really distressed about their experiences online. We have a much stronger signal for an association with mental health problems. So I think my message is for parents, especially is I don't think it's bad to set screen time limits, you know, all of that is fine. I think not having a phone in school. It makes total sense. But really it's about engaging with your adolescent about media literacy, digital literacy. What are they looking at online? What's okay? What's not okay? What's dangerous? What should they be wary of? When we look at increases in fatal suicide, we're starting to see real signals of things like sex torsion, being increasingly reported in youth fatal suicide. And so I think also communicating to young people that look, whatever's going on, you won't be judged. Just come to me, you know, if something happens online that you're scared of or you're worried about, this is a safe space where you will be taking care of and you will be listened to.

27:17I think those are the really important messages to get across to kids rather than get off your phone and go outside, which is probably true as well. But when where we see the real rest is in the content that kids are consuming online. And just that sense of you can tell me anything, right? You can tell me anything. We can talk about anything. Like there's nothing that is taboo. Exactly. Exactly. Catherine, before we move to our Factor Fiction segment, where I'll kind of throw out some claims that relate to what we've talked about today and you'll either put a finer point on them and say Factor Fiction or nuance. Is there anything else in your work that we haven't discussed that you think we should be paying more attention to? You know, the only thing I would just make sure that we highlight is, you know, if we look at opioid overdose, the last years, the first year that we've seen declines, major declines in opioid overdoses in the last 20 years. And so I just want to highlight that that, you know, that is a real bright spot for those of us in public health. You know, this has just been a devastating epidemic that's affected so many families.

28:25So to start to see declines has been so heartening overdoses are still much higher than they were even 10, 20 years ago. So there's still a lot of work that needs to be done. But I do think I hope that in the next few years, we continue seeing these declines. And just so people know that opioid use still really is an important health driver in this country. And so they have people in their lives who are experiencing opioid use disorder that there are a lot of safe and available and non invasive treatments that people can get engaged with. And that thankfully we've had a real movement away from shame and stigma and still more work to do. But I do think thankfully there are much more open conversations about substance use disorder partly because Catherine of the available treatments that you just referenced. Yes, I certainly hope so. Yeah. All right. So as mentioned, we end each episode with a factor fiction segment. And some of this we've already talked about, but want us to kind of underline and some of it we haven't.

29:28I'm ready. All right. A glass of red wine a day can be good for your heart factor fiction. Fiction. If you only drink on weekends, you're healthier than someone who has one drink every night factor fiction. New wants it would depend on how much you're drinking on the weekend. It's the total ethanol exposure that matters. So if you only have one drink on the weekend, then that's better than drinking every day on the weekdays. Beer wine and liquor or hard alcohol are basically interchangeable when it comes to long term health risk factor fiction. Fact with nuance that it is, you know, the ABV, it's the amount of alcohol that you take in that matters and so drinks have different drink sizes. So what matters is the amount of ethanol that you're taking into your body. Beer wine and hard liquor have different amounts of ethanol in them. And so it's your total ethanol exposure that that matters. If you stop drinking after years of periodic or regular drinking, you can undo the damage that the alcohols down to your body factor fiction.

30:35I would say nuance. There are some damages that can be undone. And again, it would kind of depend on how much you've been drinking for how long in terms of whether those health effects are totally reversible or not. But many of the health effects of alcohol get better very quickly after cessation. So mostly fact, mostly fact, replacing alcohol with a low dose THC beverage can be better for your health factor fiction. I would say we don't really know. I can't answer that from a pure scientific standpoint. In general, I would say given how much we know about alcohol's harmful impact on health, I would say generally I would recommend that people would have a low THC beverage over an alcoholic beverage for their health. Cannabis or THC broadly are not addictive fact or fiction fiction. Do you want to talk more about that? Sure. No cannabis dependence is a diagnosis. And in the DSM is diagnosable. And it's increasing in the population.

31:36People who use high levels of cannabis experience withdrawal symptoms when they try to stop. Those withdrawal symptoms can be really difficult to deal with. And you have the same kind of classic symptoms of addiction with cannabis that you do with other kinds of addictive products. People who neglect roles in order to use people who spend a lot of time using people who spend a lot of time recovering from using all of those kind of craving all those kinds of classic addiction symptoms you see in cannabis as well. And so it's not an addictive free product. There is a danger of addiction and using cannabis. And there are currently no FDA approved treatments for cannabis use disorder or fact or fiction fact. Yeah. So that's another area of research that would be good. So move forward with. Heather, and thank you so much. I think that you're one of our hopes with this podcast is to certainly debunk things that may have stubbornly kind of held place in public discourse or imagination, but also really to empower each of us to make what we think are the right choices for us.

32:42Even if those have risk associated with them, you know, a glass of wine a night, but to know what we all should know. So really thank you so much for all you're doing and for your time today. Yeah, I appreciate you covering these topics. You know, I do think they're really important and their information people want to know. And so getting the information out there is empowering as you say. Well, thank you so much, Catherine and look forward to hopefully chatting again. Thank you. Dr. Catherine Keys is the director of the Susan Lasker Brody Center for Population Mental Health at Columbia University. Thanks for listening. Talk to you next week. That can't be true is a production of Lemonada Media and the Clinton Foundation. The show is produced by Catherine Barnes, Mix and Sound Design by Johnny Venn Sevens. Kristen Lapor is Senior Director of New Content and Jackie Danziger is VP of Narrative and Production. Maggie Crow Shore is our managing director of partnerships. Executive producers are Jessica Cordova Kramer, Stephanie Widdle's Wax and me, Chelsea Clinton. Special thanks to Erica Goodmanson, Sarah Horowitz, Francesca Ernst Kahn, Caroline Lewis, Sage Spalter, Barry Larry Westberg, Emily Young and the entire team at the Clinton Foundation.

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