Research debates and politics aside, the fundamental purpose of a guideline is to help drinkers evaluate how their own drinking levels might affect their chances of alcohol-related harms. But how many 'at risk' drinkers really consider themselves as such?
The first point to note of course is that the guidelines are simply that, and any 'one size fits all' message is subject to a wide range of individual variables. As such assessment questionnaires such the gold standard AUDIT give a far more accurate indication of individual risk by taking into account a number of important predictors. Regardless, seeking to understand how many at risk drinkers may contemplate their drinking in such a way - or not - has important implications for policy and interventions. Here we will be using 'at risk' drinkers to describe either those regularly drinking above the guidelines, or scoring in any category above low risk on the AUDIT.
Starting with the highest estimation of the proportion of 'unaware' at risk drinkers (or at least unwilling to accept being categorised as such), '83% of people who regularly drink above the guidelines don’t think their drinking is putting their long-term health at risk' according to the Department of Health. However the figure appears to originate from 'qualitative proposition research' referenced in 2011 national social marketing strategy, but with further details seemingly unavailable.
Department of Health verdict: 83% of people who regularly drink above the guidelines don’t think their drinking is putting their long-term health at risk'
More recently, Drinkaware's 2015 Monitor survey assessed people's AUDIT scores and a range beliefs about alcohol and their drinking. Of those classified as above low risk (scoring 8+) on the AUDIT, just 55% chose a statement that described their drinking as above a safe level.
The majority of these drinkers (37% of those scoring above low risk) chose the statement 'I don't drink to excess but I probably drink a little more than is really good for me', with just 18% choosing the statement 'I frequently drink quite a bit more than what is supposed to be "safe".
Monitor verdict: 45% of alcohol misusers do not consider themselves to be drinking at a level above 'safe'
Perhaps the most detailed exploration of this issue can be found in a paper on the findings from the Global Drug Survey (GDS), completed by over 100,000 people in 2015. Of course whilst not a UK data set, and a self selecting survey on drug use, the analysis still gives an interesting insight into the issue of 'moral ambivalence' amongst drug and alcohol users alike.
GDS identified 77% per cent of those who were at some risk from their alcohol (based on AUDIT scores 8+) felt they were drinking at 'low or average levels'. Whilst this was a measure of perception compared to drinking norms rather than in reference to any drinking guidelines, the results did show that higher AUDIT scores were associated with a lower likelihood of believing they were drinking at low levels, but the greater the overall degree of underestimation. The proportions who considered their drinking 'low or average' was broken down to two-thirds (64%) of those drinking at harmful (higher risk) levels; and two-fifths (39%) of those drinking at a level of probable dependence.
Approximately two-thirds (68%) of all GDS respondents were drinking at risky levels or above (AUDIT score 8+), with around a fifth drinking at the two highest ‘risk levels’ (11% harmful and 7% probable dependence). In total 83% of GDS respondents felt they were drinking at low or average levels.
This 'normative misperception' though was found across all substances, although alcohol and tobacco were rated more negatively than most illegal drugs. Across all substances, heavier users and those who saw themselves as such were more likely to want to reduce their consumption, with 36% of all respondents wanting to drink less alcohol. The GDS is linked to DrinksMeter and DrugsMeter, which provide normative feedback and advice.
GDS verdict: 77% of all at risk drinkers believed they drank at 'low or average' levels, but must be noted as a self selecting international sample.
So what - everybody 'lies' about their drinking?
Based on the above data, it could be suggested that anywhere close to half to two thirds of 'risky' drinkers do not consider their alcohol use to be placing their health at risk. The reasons behind this are most likely varied; perhaps more commonly amongst those drinking at the lower end of the at risk spectrum, it may be a simple lack of awareness of their own consumption or the guidelines themselves, as indicated by other health survey findings. For others, reflecting on their alcohol use may simply be something they have little internal or external motivation to do, particularly where they see no evidence of harms.
Many such drinkers may however have a significant degree of 'ambivalence' - thoughts or reasons they may be able to identify in support of change, alongside their positive reasons for drinking. Indeed the paper exploring GDS findings concludes that ambivalence is evident through a number responses to offset drinking pleasure from the reality of its potential harms. For example, under-estimating one's consumption may help to avoid potential stigmatisation, or the need to think about changing a behaviour they do not feel they wish to.
Understanding how many at risk drinkers do not consider themselves to be, and the reasons behind this, can be considered important from policy and practitioner perspectives. Interventions tend only to be effective where they appreciate the drinker's beliefs and motivations; brief intervention approaches may sometimes 'work' because they initiate awareness of risk in the first instance, or for others because they help a person to resolve 'ambivalence' and enhance motivation. Identifying trends in the proportions of drinkers who identify their actual level of risk may also give insight into wider changes in drinking patterns and associated cultures.