Observational data suggest that moderate alcohol consumption is associated with reduced all-cause mortality compared with that associated with either abstinence or heavy drinking. Alcohol consumption reduces cardiovascular disease risk primarily by increasing production of high-density lipoprotein cholesterol, and possibly by increasing plasminogen, tissue plasminogen activator, and endothelial function, and decreasing platelet aggregability, fibrinogen, and lipoprotein(a). Red wine, containing antioxidants, has been purported to be especially cardioprotective. However, red wine consumption is not associated with reduced all-cause mortality in European countries, and American studies have found no relationship between the type of alcohol consumed and cardiovascular risk. Alcohol appears to be more cardioprotective if consumed with meals (possibly owing to protection against postprandial endothelial protection) and in moderation daily (as opposed to binge drinking). Despite the wealth of observational data, it is not absolutely clear that alcohol reduces cardiovascular risk, because no randomized controlled trials have been performed. Alcohol should never be recommended to patients to reduce cardiovascular risk as a substitute for the well-proven alternatives of appropriate diet, exercise, and drugs. Alcohol remains the number three cause of preventable premature death in this country, and the risk of alcohol habituation, abuse, and adverse effects must be considered in any patient counseling.