The question of moderate drinking and health returned to the headlines with a vengeance following the publications of a major study in the Lancet using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016.
The review, which used 592 studies including 28 million people worldwide to study the health risks associated with alcohol, concludes that any possible protective effects of moderate drinking are outweighed by its adverse effects on other aspects of health, particularly cancers.
As such, some will hope the study will put to bed claims that drinking in moderation can be described as good for the health when considering the net effects, but the actual risks of low levels of drinking raise further questions about public messaging. Whilst some health groups have supported the use of a 'no safe level' message, others have pointed out the actual increased risks when within the guidelines as so small that they do not warrant public health warnings. Dr James Nicholls pointed out on an Alcohol Concern blog, 'if you’re drinking between 0-14 units a week, the best advice is probably to not worry about this issue at all.' However, he notes 'the science is complex, and the choice is yours. Guidelines are not personalised advice; your risk will be different to mine, and my risk today will be different to what is was ten years ago'.
Spiegelhalter: the voice of reason?
David Spiegelhalter, a Professor on risk and evidence communication, has written a blog 'The risks of alcohol (again)' in response to the study in which he raises a number of points. Firstly, Spiegelhalter questions the paper for not reporting on absolute risks such that 'readers couldn’t tell how dangerous drinking alcohol really was for them'. However he credits the Lancet press team who insisted on absolute risk measures, publishing the following explainer:
'Specifically, comparing no drinks with one drink a day the risk of developing one of the 23 alcohol-related health problems was 0.5% higher — meaning 914 in 100,000 15–95 year olds would develop a condition in one year if they did not drink, but 918 people in 100,000 who drank one alcoholic drink a day would develop an alcohol-related health problem in a year.
This increased to 7% in people who drank two drinks a day (for one year, 977 people in 100,000 who drank two alcoholic drinks a day would develop an alcohol-related health problem) and 37% in people who drank five drinks every day (for one year, 1252 people in 100,000 who drank five alcoholic drinks a day would develop an alcohol-related health problem).'
Spiegelhalter further looks at what actual amounts of consumption and subsequent numbers of additional health problems, suggesting the numbers are very small even at 2.5 units a day. As such, he argues that the 'analysis supports the current UK guidelines as being low-risk, but perhaps would better be described as ‘very low-risk’'. Next, whether there be 'no safe level' justifies an argument of abstention is explored, in which he suggests:
'There is no safe level of driving, but government do not recommend that people avoid driving... Come to think of it, there is no safe level of living, but nobody would recommend abstention. Presumably people who choose to drink alcohol moderately get some pleasure from it, and any risk needs to be traded off against this enjoyment.'
Next Spiegelhalter explores the issue of apparently contradictory studies, including a major study released earlier this year which as well as appearing to add support for the level of 14 units as a guideline, also appeared to show 'clear harms to non-drinkers, even when ex-drinkers are excluded, in direct contrast to the IHME paper'. Spiegelhalter suggests this may be in part down to methodological issues, but in conclusion states 'this suggests some of those who choose not to drink are just different, and not because they are ex-drinkers... Maybe choosing to avoid alcohol is not so much a cause of ill-health as, at least for some, a sign of potential ill-health.'
Another well-known researcher in the alcohol field, Dr John Holmes, also weighed in with a Twitter thread explaining 6 reasons he dislikes the no safe level messaging in light of the new study. Holmes argues that it focuses the issue on 'the presence of risk, not the scale of risk', and that even the UK guidelines do not refer to 'no safe level'. As such he asks what the goal of a no safe level message is in public health terms, for instance whether population wide abstinence is actually desirable or ethically justified.
Where next?
For most the key question may be how to communicate consumption related messages to those who are drinking above the guidelines. This opens up a range of issues including how accurately people actually gauge consumption, how to engage those who may wilfully disregard health information, or how it may be relevant to those with more severe alcohol problems such as dependency.
For many, as Spiegelhalter has argued, alcohol health messages need refinement such that the actual level of risk can be better determined by individuals, rather than a single one size fits all threshold of 14 units. A starting point has been suggested as the use of several risk thresholds or 'traffic light' approaches to different levels of drinking. Others may note the limitations to any health messaging strategies and wish to focus alcohol debates on policy levers such as pricing or advertising controls. With a new alcohol strategy expected next year, efforts to capture the ears of policy makers on all such issues will no doubt be under way.
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