A new study on alcohol consumption risk levels based on almost 600,000 drinkers has been published in the Lancet, reporting the risk of early death from drinking begins to rise at a level above 100g of alcohol per week (12.5 units).
The findings, which cover 19 countries, can be seen to add weight to the Chief Medical Officer's recommended guideline of not regularly drinking more than 14 units per week, revised in 2016 and since subject to ongoing debate. The issue for many in the alcohol field though remains how best to communicate drinking guidelines and associated risks. Whilst most ultimately support the goal of informed decision making, the real world complexity of alcohol harms and how drinkers take note of - or indeed dismiss - alcohol-related messages leaves many ongoing questions over how to make use of such evidence.
Widespread media reporting of the latest study again revealed some such issues, for instance some articles assuming 'a glass of wine' to be a set number of units, or inferring guidelines thresholds as a hard and fast cut off. The research though confirmed 'as expected, the more alcohol someone drinks, the greater the increased risk of early death', Prof Tim Chico explained as one of a number of expert reactions published by the Science Media Centre. Prof David Spiegelhalter said that 'above two units a day, the death rates steadily climb', adding 'of course it’s up to individuals whether they think this is worthwhile'.
Many of the media reports though embraced the study's calculations on life expectancy effects. A 40 year old drinking 12.5 to 25 units a week would be likely to live 6 months less compared to drinking within 12.5 units per week, whilst a 40 year old drinking 25 to 44 units was likely to live 1 to 2 years less. Drinking more than 44 units would lead to live 4 to 5 years less. It also calculated that the risk of death rises more than 30% for those drinking above 37 units a week.
Settling the score on 'health benefits'?
Notably the study also provides valuable insight on the much debated question of whether drinking has protective effects for heart disease. Whilst indeed identifying a 'J-shaped curve' indicating a small positive impact of moderate drinking on cardiovascular mortality, there was no overall beneficial effect on mortality risk when considering all conditions. As Prof Tim Chico described, 'although non-fatal heart attacks are less likely in people who drink, this benefit is swamped by the increased risk of other forms of heart disease including fatal heart attacks and stroke', and as such the study 'makes clear that on balance there are no health benefits from drinking alcohol'.
The key finding is in this graph: that *within drinkers*, there is a J-shaped curve for cardiovascular mortality risk (i.e. a protective effect), but there is no overall protective effect, and risk increases for drinkers consuming >100g/week (12.5 units) pic.twitter.com/lSTTrzYn9Z
— Colin Angus (@VictimOfMaths) April 13, 2018
Where next for risk communication messages?
Health groups though may hope that the study moves debate on from recurring questions over the exact recommended guideline towards what they hope may be a more suitable communication of the health risks given the still low level of awareness. Some see the starting point for this as mandatory labelling of alcohol units and the inclusion of the guidelines on all alcoholic products, though for the near future there seems little chance of any change here. Others may be more concerned with how drinking attitudes and consumption may be more effectively shifted by national alcohol policy levers, particularly when considering the limitations of awareness raising or education based initiatives in isolation.
However it seems the very existence of a single 'threshold' guideline will be likely to continue to cause debate. Whilst few alcohol leads disagree with the need for its existence, its implications as a 'risk message' to be communicated to drinkers raises various issues. For one, there is of course wide variation on health outcomes for drinkers across income groups, regions and many other variables. These differences aside, individual motivations for drinking are also widely varied, with obvious implications for how messages or interventions may have an effect. Brief interventions in part may be effective because of their potential for personalisation of a 'risk' messages, which general guidelines communications may struggle to match.
Previous attempts have also been made to communicate several risk thresholds such as the 'traffic light' approach as seen in the former ''Your Drinking and You' NHS booklet [pdf].
Indeed at the 2017 Public Health England conference, David Spiegelhalter argued that we should 'treat people with respect' and adopt messages that more explicitly acknowledge people's ability to decide what risk they are happy with, arguing the current guidelines may be seen by most as a 'broadly acceptable risk', whilst higher risk levels might be considered 'unacceptable'.
Several notable academics seem to agree. As John Holmes has previously argued, public health groups should exercise caution over simplified or 'no safe level' messages and be mindful of the implications in terms of public credibility, further exploring such issues in an editorial on risk in addiction science, policy and debate.
Current Government policy on seeking to inform drinkers of the health risks may be seen as mainly relying on the industry funded charity Drinkaware, and only advising what they would voluntarily like to see included on alcohol labels. For 2018, minimum pricing will no doubt remain the headline alcohol policy issue, but 'risky' drinking and its communication also looks set to remain a popular topic.
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