Did James Bond's Drinks Shake Due to Alcohol Induced Tremor?
Did James Bond's Drinks Shake Due to Alcohol Induced Tremor?
We have shown that James Bond's alcohol consumption, while on his various missions for Her Majesty's Secret Service is, on average, between 65 and 92 units a week. There is only one indication of his alcohol consumption while not on a mission. During a medical assessment in Thunderball he is documented as drinking half a bottle of spirits a day, equivalent to 105 units a week. There are also occasional references to hangovers during non-mission times in the books. We therefore conclude that his drinking during missions is roughly comparable with his "office days."
Many studies have shown that people generally underestimate their alcohol consumption by around 30%, implying that Bond's could be as high as 130 units a week. It is unclear whether having a third party describing one's alcohol intake would make stated consumption more or less accurate. Recent research implies that half of all alcohol sold is not accounted for by health surveys, so actual consumption could even be double that claimed. We are unaware of any studies that have shown an overestimation of alcohol consumption. Similarly, when we had to estimate Bond's consumption (such as "visited a bar") we have been deliberately conservative. We are therefore confident that our estimates are at the lower end of the truth.
UK NHS recommendations for alcohol consumption state that an adult male should drink no more than 21 units a week, with no more than 4 units on any one day, and at least two alcohol free days a week. James Bond's drinking habits are well in excess of each of these three parameters. This level of consumption makes him a category 3 drinker (>60 g alcohol/day) and therefore in the highest risk group for malignancies, depression, hypertension, and cirrhosis. He is also at high risk of suffering from sexual dysfunction, which would considerably affect his womanising.
Data on the average life expectancy of real world secret agents are, not surprisingly, difficult to find. Although some secret service deaths are high profile, there are limited data on a robust denominator for this population. In Moonraker, Bond reflects that he would probably be killed before the age of 45 (the age of mandatory retirement from the "00" section of MI6). Should he not be “"killed in action," his risk of developing many serious pathologies is high.
Deaths from liver cirrhosis occur at a relatively young age in the UK; an average of 59 years, in stark contrast to the other major causes of mortality including respiratory and cardiovascular disease. Rehm and colleagues have shown a dose:response relation with alcohol and development of cirrhosis. Drinking between 65 and 92 units of alcohol a week equates to between 74 g and 105 g of alcohol a day, giving Bond a relative risk of developing liver cirrhosis of between 7 and 16 compared with a lifetime abstainer. Work by Hart and colleagues would suggest that his relative risk of all cause mortality is greater than 1.74 (95% confidence interval 1.47 to 2.06) and particularly from stroke (2.33, 1.31 to 4.14) and alcohol related causes (3.72, 98 to 7.00). Presuming survival despite the high risk nature of his profession, we anticipate that James Bond's life expectancy would be significantly reduced. In fact, the author Ian Fleming died aged 56 of heart disease after a life notable for alcohol and tobacco excess. We suspect that Bond's life expectancy would be similar.
High stress jobs are often associated with high alcohol intake, and it would therefore be logical to assume that these professions are also associated with a high alcohol related mortality. An analysis by the website businessinsider.com, however, showed that actually bartenders and shoe-machine operators had the highest alcohol related deaths. They identified that sailors were the sixth highest risk, with a relative risk of 1.75 for an alcohol related death. Bond was, first and foremost, a sailor, so his drinking habits might have their root in his original profession.
It is well recognised that alcohol increases the risk of driving related incidents, and this risk increases from blood alcohol level of 0.04%. The UK sets its limit at 0.08%, which is the same as the US, but higher than that of much of Europe and Australia. No such limits existed in the 1950s and throughout the books Bond is noted to have several drinks, enough to put him well over this limit and then drive. In Goldfinger, for example, he drinks 18 units while having drinks and dinner with Auric Goldfinger before then driving home. In Casino Royale he drinks over 39 units before engaging in a high speed car chase, losing control, and spending 14 days in hospital. We hope that this was a salutatory lesson.
Such behaviour is typical of Bond. Despite his alcohol consumption, he is still described as being able to carry out highly complicated tasks and function at an extraordinarily high level. This is likely to be pure fiction.
It was noted that Bond's intake decreased in the middle part of his career but increased again towards the latter years. Consistently high but variable levels of drinking have already been documented in heavy drinkers, but one potential reason for the increase in the later books could be the death of his new wife in On Her Majesty's Secret Service in 1963. This could explain the peak of his drinking in 1964, as he tried to find a quantum of solace in alcohol, before returning to his more usual level of consumption in 1965 when he was pitted against Francisco Scaramanga. It would also match the findings of Eigenbrodt and colleagues that in all ethnicities together alcohol intake will slightly decrease with age, but in white men it will actually increase, at least up until the age of 60.
A commonly used screening tool to identify alcohol dependence is the "CAGE" questionnaire, where two yes responses should prompt further investigation:
Applying these to Bond, the authors would score him 3 out of 4. In Thunderball he recognises his high alcohol intake and that he feels better drinking less. He also admits to having an eye opener on some mornings (the "Prairie Oyster"). Also in Thunderball, together with the Living Daylights, he becomes annoyed when challenged about his drinking by his boss "M". It is likely that an international spy and assassin cannot spend too much time worrying about remorse, so we are not surprised that there are no documented instances of alcohol associated guilt.
The most common cause of tremor is essential tremor. This is typically postural and will most commonly affect the upper limbs, although lower limb involvement is recognised. The role of alcohol is somewhat uncertain, with some evidence that in lower doses it can be beneficial in essential tremor, while others propose that those with high alcohol consumption are four times more likely to suffer with essential tremor.
Cerebellar lesions are well known to cause an intention tremor and cerebellar tremor is considered a distinct clinical entity. While strokes are a more common cause of cerebellar lesions (of which Bond is at increased risk), chronic exposure to toxins, such as alcohol, that cause more generalised damage to the cerebellum can also cause a cerebellar tremor. We have shown that Bond's alcohol intake is of sufficiently high frequency and duration to cause such cerebellar damage.
Ideally each of the authors would have read all of the books and reached their own total for Bond's alcohol consumption, allowing a κ statistic to be calculated and a consensus amount for each book. Unfortunately limited resources and other clinical, social, intellectual, and cultural commitments meant a more pragmatic approach had to be taken, and seven books each were allocated over the six month study period.
On several occasions estimates of consumption have had to be used as Mr Fleming was not precise with his writing. The authors have taken reasonable measures to ensure that, when necessary, conservative estimates have been made. Of the total 1,150 units drunk, only 190 units (16.5%) were accounted for by these terms, therefore if the estimations were inaccurate this would make a minimal change to the total. Similarly, when it was mentioned that drinks were shared, we thought it appropriate to assume an equal share of the drinks, regardless of who he was sharing with.
One of the study authors was familiar with the books and had read them before the study period. While it was noted at that time that the consumption of alcohol was an important part of Bond's life, detailed notes on the magnitude of his consumption were not taken. It did, however, inform the original study idea.
James Bond's weekly alcohol intake is over four times the advisable maximum alcohol consumption for an adult male. He is at considerable risk of developing alcoholic liver disease, cirrhosis, impotence, and other alcohol related health problems, together with being at serious risk of injury or death because of his drinking. Although we appreciate the societal pressures to consume alcohol when working with international terrorists and high stakes gamblers, we would advise Bond be referred for further assessment of his alcohol intake and reduce his intake to safe levels.
We conclude that James Bond was unlikely to be able to stir his drinks, even if he would have wanted to, because of likely alcohol induced tremor.
(Enlarge Image)
Figure 2.
Discussion
We have shown that James Bond's alcohol consumption, while on his various missions for Her Majesty's Secret Service is, on average, between 65 and 92 units a week. There is only one indication of his alcohol consumption while not on a mission. During a medical assessment in Thunderball he is documented as drinking half a bottle of spirits a day, equivalent to 105 units a week. There are also occasional references to hangovers during non-mission times in the books. We therefore conclude that his drinking during missions is roughly comparable with his "office days."
Many studies have shown that people generally underestimate their alcohol consumption by around 30%, implying that Bond's could be as high as 130 units a week. It is unclear whether having a third party describing one's alcohol intake would make stated consumption more or less accurate. Recent research implies that half of all alcohol sold is not accounted for by health surveys, so actual consumption could even be double that claimed. We are unaware of any studies that have shown an overestimation of alcohol consumption. Similarly, when we had to estimate Bond's consumption (such as "visited a bar") we have been deliberately conservative. We are therefore confident that our estimates are at the lower end of the truth.
UK NHS recommendations for alcohol consumption state that an adult male should drink no more than 21 units a week, with no more than 4 units on any one day, and at least two alcohol free days a week. James Bond's drinking habits are well in excess of each of these three parameters. This level of consumption makes him a category 3 drinker (>60 g alcohol/day) and therefore in the highest risk group for malignancies, depression, hypertension, and cirrhosis. He is also at high risk of suffering from sexual dysfunction, which would considerably affect his womanising.
Data on the average life expectancy of real world secret agents are, not surprisingly, difficult to find. Although some secret service deaths are high profile, there are limited data on a robust denominator for this population. In Moonraker, Bond reflects that he would probably be killed before the age of 45 (the age of mandatory retirement from the "00" section of MI6). Should he not be “"killed in action," his risk of developing many serious pathologies is high.
Deaths from liver cirrhosis occur at a relatively young age in the UK; an average of 59 years, in stark contrast to the other major causes of mortality including respiratory and cardiovascular disease. Rehm and colleagues have shown a dose:response relation with alcohol and development of cirrhosis. Drinking between 65 and 92 units of alcohol a week equates to between 74 g and 105 g of alcohol a day, giving Bond a relative risk of developing liver cirrhosis of between 7 and 16 compared with a lifetime abstainer. Work by Hart and colleagues would suggest that his relative risk of all cause mortality is greater than 1.74 (95% confidence interval 1.47 to 2.06) and particularly from stroke (2.33, 1.31 to 4.14) and alcohol related causes (3.72, 98 to 7.00). Presuming survival despite the high risk nature of his profession, we anticipate that James Bond's life expectancy would be significantly reduced. In fact, the author Ian Fleming died aged 56 of heart disease after a life notable for alcohol and tobacco excess. We suspect that Bond's life expectancy would be similar.
High stress jobs are often associated with high alcohol intake, and it would therefore be logical to assume that these professions are also associated with a high alcohol related mortality. An analysis by the website businessinsider.com, however, showed that actually bartenders and shoe-machine operators had the highest alcohol related deaths. They identified that sailors were the sixth highest risk, with a relative risk of 1.75 for an alcohol related death. Bond was, first and foremost, a sailor, so his drinking habits might have their root in his original profession.
It is well recognised that alcohol increases the risk of driving related incidents, and this risk increases from blood alcohol level of 0.04%. The UK sets its limit at 0.08%, which is the same as the US, but higher than that of much of Europe and Australia. No such limits existed in the 1950s and throughout the books Bond is noted to have several drinks, enough to put him well over this limit and then drive. In Goldfinger, for example, he drinks 18 units while having drinks and dinner with Auric Goldfinger before then driving home. In Casino Royale he drinks over 39 units before engaging in a high speed car chase, losing control, and spending 14 days in hospital. We hope that this was a salutatory lesson.
Such behaviour is typical of Bond. Despite his alcohol consumption, he is still described as being able to carry out highly complicated tasks and function at an extraordinarily high level. This is likely to be pure fiction.
It was noted that Bond's intake decreased in the middle part of his career but increased again towards the latter years. Consistently high but variable levels of drinking have already been documented in heavy drinkers, but one potential reason for the increase in the later books could be the death of his new wife in On Her Majesty's Secret Service in 1963. This could explain the peak of his drinking in 1964, as he tried to find a quantum of solace in alcohol, before returning to his more usual level of consumption in 1965 when he was pitted against Francisco Scaramanga. It would also match the findings of Eigenbrodt and colleagues that in all ethnicities together alcohol intake will slightly decrease with age, but in white men it will actually increase, at least up until the age of 60.
Connoisseur or Alcoholic?
A commonly used screening tool to identify alcohol dependence is the "CAGE" questionnaire, where two yes responses should prompt further investigation:
Have you ever felt you needed to Cut down on your drinking?
Have people Annoyed you by criticising your drinking?
Have you ever felt Guilty about drinking?
Have you ever felt you needed a drink first thing in the morning (Eye opener) to steady your nerves or to get rid of a hangover?
Applying these to Bond, the authors would score him 3 out of 4. In Thunderball he recognises his high alcohol intake and that he feels better drinking less. He also admits to having an eye opener on some mornings (the "Prairie Oyster"). Also in Thunderball, together with the Living Daylights, he becomes annoyed when challenged about his drinking by his boss "M". It is likely that an international spy and assassin cannot spend too much time worrying about remorse, so we are not surprised that there are no documented instances of alcohol associated guilt.
The most common cause of tremor is essential tremor. This is typically postural and will most commonly affect the upper limbs, although lower limb involvement is recognised. The role of alcohol is somewhat uncertain, with some evidence that in lower doses it can be beneficial in essential tremor, while others propose that those with high alcohol consumption are four times more likely to suffer with essential tremor.
Cerebellar lesions are well known to cause an intention tremor and cerebellar tremor is considered a distinct clinical entity. While strokes are a more common cause of cerebellar lesions (of which Bond is at increased risk), chronic exposure to toxins, such as alcohol, that cause more generalised damage to the cerebellum can also cause a cerebellar tremor. We have shown that Bond's alcohol intake is of sufficiently high frequency and duration to cause such cerebellar damage.
Limitations
Ideally each of the authors would have read all of the books and reached their own total for Bond's alcohol consumption, allowing a κ statistic to be calculated and a consensus amount for each book. Unfortunately limited resources and other clinical, social, intellectual, and cultural commitments meant a more pragmatic approach had to be taken, and seven books each were allocated over the six month study period.
On several occasions estimates of consumption have had to be used as Mr Fleming was not precise with his writing. The authors have taken reasonable measures to ensure that, when necessary, conservative estimates have been made. Of the total 1,150 units drunk, only 190 units (16.5%) were accounted for by these terms, therefore if the estimations were inaccurate this would make a minimal change to the total. Similarly, when it was mentioned that drinks were shared, we thought it appropriate to assume an equal share of the drinks, regardless of who he was sharing with.
One of the study authors was familiar with the books and had read them before the study period. While it was noted at that time that the consumption of alcohol was an important part of Bond's life, detailed notes on the magnitude of his consumption were not taken. It did, however, inform the original study idea.
Conclusions
James Bond's weekly alcohol intake is over four times the advisable maximum alcohol consumption for an adult male. He is at considerable risk of developing alcoholic liver disease, cirrhosis, impotence, and other alcohol related health problems, together with being at serious risk of injury or death because of his drinking. Although we appreciate the societal pressures to consume alcohol when working with international terrorists and high stakes gamblers, we would advise Bond be referred for further assessment of his alcohol intake and reduce his intake to safe levels.
We conclude that James Bond was unlikely to be able to stir his drinks, even if he would have wanted to, because of likely alcohol induced tremor.
(Enlarge Image)
Figure 2.
