The long awaited revised recommended guidelines for alcohol consumption have been released, confirming a lower limit for men of 14 units per week - the same amount as advised for women. In addition to the weekly guideline for regular drinkers, advice on limiting 'single occasion' drinking also highlights the risk of accidents and injuries in particular.
The announcement resulted in wide-scale media coverage and articles ranging from the expected accusations of 'nanny-statism', to analysis of the evidence and context of guidelines in public health terms. A Government consultation document [pdf] seeks views on various components of the new advice.
The basis for the new lower level is on 'significant new, good quality evidence available on the effects of alcohol consumption on health, which was not available at the time of the 1995 review' - summarised here.
In particular, the expert group say 'stronger evidence has emerged that the risk of a range of cancers, especially breast cancer, increases directly in line with consumption of any amount of alcohol'. Cancer risks start from any level of regular drinking and rise with the amount being drunk, and as such the new guidelines have been set at a level to keep the risk of mortality from cancers or other diseases low.
Those that do drink 'as much as 14 units per week' are advised to spread this evenly over 3 days or more. Having several alcohol free days week are also advised, although a number of alcohol free days is not specified.
An end to 'binge' drinking?
To keep the short term health risks low the advice on single episode drinking includes 'limiting the total amount of alcohol drunk on any one occasion', and 'drinking more slowly, with food and alternating with water'. However a specific number of units for daily or single occasion drinking is no longer offered. Binge drinking had previously been defined as twice the daily guideline on a single occasion, though owing to the disconnect between many people's ideas of binge drinking as planned drunkenness, this definition had been much maligned.
Pregnancy, benefits and risk...
The guidelines for pregnant women are that no level of alcohol is safe to drink in pregnancy. This advise is 'precautionary guidance' based on recent evidence indicating a range of risks to infants which increase above regular consumption of 1-2 units.
The review group also concluded that the evidence supporting protective effects of alcohol on ischaemic heart disease (IHD) is now weaker than it was at the time of the 1995 report. As such 'there is no justification for recommending drinking on health grounds, nor for starting drinking for health reasons'. Furthermore the report finds the benefits of alcohol for heart health only apply for women aged 55 and over, with the greatest benefit seen for women who limit their intake to around 5 units a week.
Chief Medical Officer for England Dame Sally Davies said “drinking any level of alcohol regularly carries a health risk", but limiting intake to no more than 14 units a week "keeps the risk of illness like cancer and liver disease low". The report states regular drinking increases the risks of long term health effects arising over time - typically over 10 to 20 years or more. However the advice is based on evidence that:
"...if people did drink at or above the low risk level advised, overall any protective effect from alcohol on deaths is overridden, and the risk of dying from an alcohol-related condition would be expected to be around, or a little under, 1% over a lifetime. This level of risk is comparable to risks from some other regular or routine activities, such as driving."
Will the guidelines help public health efforts?
As identified in Alcohol Research UK's explanation of the review, there is 'no research evidence to demonstrate that safe drinking guidelines change behaviours', and that there are risks from promoting messages that feel unrealistic to drinkers. Simple unit guidelines may also fail to resonate with drinker's social motivations, attitudes and approaches to calculating risk. Whilst overall improvements in knowledge of alcohol and associated harms may have contributed to recent declines in consumption, there is no clear research to back this up and unit knowledge still remains sketchy.
However as a potentially dangerous but legal drug, alcohol guidelines are arguably deemed necessary from a public health perspective even if their existence alone doesn't impact behaviour. Despite this, calls for the 'state to butt out of Britain's drinking habits' claimed a share of the media coverage, whilst other articles emphasised the guidelines as exactly that - a means to help informed decision making rather than instruct people what to do. Dr Suzi Gage neatly outlined the key principles behind the guidelines, summarising:
"...whether we like it or not, there is a risk to our health from consuming alcohol. It seems that any amount of alcohol will increase our risk of ill health, and it’s not the case that 14 units a week is safe, while 15 will be harmful. The risk to our health increases as consumption increases. Of course, how we weigh up that risk is up to ourselves as individuals."
The guidelines though may be considered an important basis for other activity. If ultimately the public health goal is to maximise the number of adults who drink to do so at 'low risk' levels, then 'lower risk' needs to be as clearly and accurately defined as possible. Brief interventions, treatment outcomes or indeed goal setting for those undertaking self-help approaches are all underpinned by an understanding of consumption in relation to risk. That there are many variables on an individual level - and as such a 'one size fits all' guideline may feel rather blunt - is an inconvenient truth for those promoting low risk drinking. However 'neither of the expert groups felt there was adequate justification for having separate guidelines for different age or social groups'.
For many drinkers, reducing or managing risk from their alcohol consumption may not mean drinking within the new guidelines, but it is clearly the intention of the revised message to promote understanding of the principle that frequency and volume of consumption are critical factors. How and whether the revised guidelines facilitate more effective alcohol interventions, messages or policy measures in the future will be hard to assess. Research - and the debates over how to interpret and implement it - will go on.