NHS Scotland has launched a new campaign to promote awareness of the recommended guidelines, whilst the journal Addiction has published a set of open access commentaries debating how drinking guidelines should be developed and communicated.
The new 'count 14' campaign follows several years of regular debate about alcohol health risks and their communication since the revised guidelines of 14 units per week, spread over three days or more, were announced by the Chief Medical Officer in 2016. Whilst based on epidemiological evidence indicating drinking at around the guideline level broadly reflects a 1% increased risk of dying from an alcohol-related condition over a lifetime, issues raised range from the interpretation of the available evidence itself through to how such messages should form policy or behaviour change approaches.
The ongoing media attention and debate appears to reflect the fundamental challenge of communicating a single consumption threshold to the public as a whole; as indeed some such as David Spiegelhalter have argued needs expanding upon. Other challenges include the low level of awareness of the guidelines and units, or the question marks over the commonly held belief regarding health benefits from moderate consumption and the 'j-curve'. Last year a large scale study suggested there was no overall beneficial effect on mortality risk when considering all conditions.
As such, some groups have been increasingly keen to highlight a 'no safe level' rather than a low risk message, particularly concerning cancer risks. NHS Scotland's new campaign however seems to acknowledge both by linking to further information with a low risk message whilst also stating that 'when it comes to drinking alcohol, almost all of us could do with cutting down'. As such, some may see a pragmatic approach in recognising a 'low risk' drinking guideline whilst still seeking to emphasise that degrees of risk rise in line with consumption, albeit with significant variation cross individuals and population groups.
Academics debate: science Vs pragmatism?
Such issues are explored in depth in a set of open access commentaries published in response to a debate piece published last year on 'How should we set consumption threshold for low risk drinking guidelines' by John Holmes and colleagues at the Sheffield Alcohol Research Group (SARG). The original commentary sought to identify how criticisms over the development of guidelines should be addressed, proposing a series of recommendations for future guidelines and their communication based on the experiences of several countries including the UK.
One response came from Sir Ian Gilmore, a long standing advocate of firmer policy to reduce alcohol related harms, who acknowledged the inherent challenges in such communication, for example, the individual difference in how people evaluate risk. Gilmore highlights people 'will accept more voluntary risk (driving their own car) than involuntary ones such as pollution', and as such for 'a legal psychoactive drug called alcohol that produces a "feel-good factor" on demand, they will probably accept even more risk.'
However in the 'post-truth' era of Brexit and 'fake news', Gilmore argues that 'scepticism of experts played into the hands of the drinks industry', sections of which sought to decry experts as 'anti-alcohol lobbyists', whilst the Portman Group declined to advise its members to include the guidelines on drinks labels. These and the many other challenges need recognition, but for Gilmore the key question is one of pragmatism: how can the guidelines can be meaningfully translated for their real world audience in the absence of further understanding about their acceptability to the public.
A response from Cucciare & Timko further explores the need to establish better understanding of the issues which are most important to the public, particularly concerning transparency about the source of the information, whilst ensuring it remains understandable.
Another response (Naimi) arguably triggers the more controversial aspect of the debate, suggesting the focus of guidelines ought to reflect the 'nadir of risk curves', which as the SARG authors note, may amount to a 'no safe level' message. Naimi highlights the issues with the available evidence about the health impacts of low level alcohol use, proposing the benefits of the j-curve may be a 'statistical illusion', as indeed others such as Spiegelhalter have previously suggested.
However, whilst suggesting decision making about 'acceptable risk is probably best left to individuals', Naimi concludes that the evidence suggests 'consuming less alcohol, either in total or on a per occasion basis, would probably improve health for most drinkers', and as such should be the focus of guideline related messages.
SARG's concluding response though argues that those behind developing or promoting health guidelines would be unlikely to support such an approach at present since 'it would not be seen as credible by the public and would erect a lightening rod for "nanny state" criticisms.' The SARG authors give further acknowledgement of the tension between the pure scientific implications of epidemiological data and how messages translate to the public, accepting the need for broader range of evidence on this issue.
Where next?
For some, such debates may seem somewhat academic whilst efforts to engage the public and change related policy continue. Policy attention of late has often been focused on labelling debates, most recently in the wake of the revised Portman code of practice and an apparent Government expectation that alcohol producers have until September this year to comply with the Department of Health's labelling guidance.
Policy debates are also likely to continue over who should be responsible for such messages, particularly following Public Health England's (PHE) partnership with Drinkaware for the 'drink free days' campaign last year, which faced significant criticism.
Several alcohol groups have already called for the government to follow Scotland's campaign, whilst messages along the lines of 'less is better at any level of drinking' may be increasingly form part of alcohol risk communication strategies. Others, for a variety of reasons, will no doubt argue against such an approach.
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