January 8, 2016

expert reaction to new Alcohol Guidelines Review from the Chief Medical Officers

The UK chief medical officer, working alongside a group of experts, has made recommendations about how lower risks to health from drinking alcohol. The group looked at the evidence about the levels and types of health harm that alcohol can cause, depending on how much and how often people drink, and recommended that both men and women limit their weekly intake to a maximum of 14 units.

Prof. Sir David Spiegelhalter, Winton Professor of the Public Understanding of Risk, University of Cambridge, said:

“These guidelines define ‘low-risk’ drinking as giving you less than a 1% chance of dying from an alcohol-related condition. So should we feel OK about risks of this level? An hour of TV watching a day, or a bacon sandwich a couple of times a week, is more dangerous to your long-term health. In contrast, an average driver faces much less than this lifetime risk from a car accident. It all seems to come down to what pleasure you get from moderate drinking.”

Prof. Alan Cameron, Vice President of Clinical Quality for the Royal College of Obstetricians and Gynaecologists (RCOG), said:

“The Royal College of Obstetricians and Gynaecologists reiterates that women should be well informed about the risks of alcohol consumption during pregnancy. Consistent with our advice, abstinence from alcohol is the safest option, in particular for women trying to conceive or during the first three months of pregnancy.

“There is no proven safe amount of alcohol a woman can drink during pregnancy. We know that heavy drinking can cause fetal alcohol spectrum disorders and has also been linked with an increased risk of miscarriage. Although the available evidence on low-level drinking has not yet been found to be harmful to women or their babies after 12 weeks of pregnancy, we cannot rule out the risks altogether.

“It is our responsibility as healthcare professionals to be open and honest with women, explaining both the potential risks of consuming alcohol during pregnancy and the limitations of the science, and supporting them in coming to a decision for themselves. We all deal with uncertainty in our lives on a daily basis; pregnant women are no less capable of doing so.”

Prof. Peter Anderson, Professor of Substance Use, Policy and Practice, Newcastle University, said:

“The scientific basis for the guidelines is correct and revision of the drinking guidelines was long overdue. It is correct to say that the overall risks of death from alcohol, including injuries and long term health problems, are similar for men and women. It is also correct to say that alcohol is a carcinogen, and a cause of a range of cancers. As a carcinogen, there is no level of alcohol consumption that is risk free. It is appropriate to set the guidelines at the equivalent of 14 UK drinks a week. This will seem low to many people, but the level reflects the scientific evidence. At this level, the evidence shows that the lifetime risk of dying from an alcohol-related condition is about 1 in 100.

“Unfortunately, the text of the guideline (as in the summary of the proposed new guidelines) itself is long, vague and difficult to understand. The text is likely to confuse most people, and most healthcare professionals. And, because of that, the guidelines run the risk of being ignored. Getting the text simple and easy to understand is a missed opportunity.

“The logic of going to a weekly guideline does not make sense to me. It is very difficult to monitor how much you drink on a weekly basis – whereas it is much easier on a daily or occasion basis. It is a pity, also, that the guidelines did not take the jump and move away from the very confusing unit concept to grams of alcohol. On beverage and food labelling, we are not given units of salt or units of sugar, but are given grams of salt and grams of sugar. Alcohol should be treated in the same way in my opinion.

“For the regular drinking guidelines, I would have simply stated: “The lifetime risk of harm from drinking alcohol increases with the amount consumed. For healthy men and women, it is safer not to drink more than 20 grams of alcohol (about two drinks) on any day.” For the single drinking episode guidelines, I would have simply stated: “The risk of injury from drinking alcohol increases with the amount consumed on any one occasion. For healthy men and women, it is safer not to drink more than 40 grams of alcohol (about four drinks) on any occasion.” Thus, before the guidelines are released for public use, a lot of work needs to be done to translate the scientific evidence into simple short messages.  It is therefore good that now the content of the guidelines have been finalised, they are open for public consultation to explore their clarity and usability.

“The public also need much better information on about how important this all is in relation to other lifestyle factors. Risks should always be presented as absolute risks and not relative risks. People need to know what their absolute risk of dying or getting cancer is from their level of drinking, and how this compares with other things that they do.”

Dr James Nicholls, Director of Research and Policy Development, Alcohol Research UK, said:

“The new CMO guidelines on low-risk drinking are strongly informed by recent research showing an association between alcohol consumption and a number of cancers. They also take a conservative view of the possible protective effects of moderate alcohol consumption on heart disease and stroke.

“The evidence on cancer has become stronger in recent years and shows that some cancer risks start to increase with any amount of alcohol consumption – though those risks are usually low to start with. Acknowledging these associations is important and to be welcomed; hopefully, the publication of the guidelines will encourage an informed, but not scare-mongering, debate on this issue.

“The CMO report broadly rejects the claim that alcohol has a protective effect on the heart. This question is still unresolved in the research and there is not much detail on how the claim that moderate drinking only reduces risk of heart disease among women over 55 remains was arrived at. However, the guidelines do reflect the fact that any protective effect is likely to be cancelled out by any heavy drinking – even on a single occasion – and that the possible protective effects among older drinkers need to be balanced against the new evidence on cancer risks, which are spread more widely across the population.

“On pregnancy, the CMO has adopted an explicitly precautionary approach. The report acknowledges that there is little evidence showing significant risks from low levels of consumption during pregnancy. However, it advises against drinking on the basis that a zero-risk message is easier to communicate and avoids creating grey areas. While it is vital that women do not drink at risky levels while pregnant, it is also important that women who have drunk small amounts during pregnancy – perhaps unknowingly – do not now worry excessively.

“14 units a week may seem low, and we know that the existing guidelines are either ignored or seen as not credible by many drinkers. 14 units a week is not a magical break point: it is the point at which the CMO estimates that the overall risk of dying from an alcohol-related cause reaches 1 in 100. It will be a challenge to communicate this message in ways that are workable and effective. However, the guidance provides an important reminder that all alcohol consumption comes with some degree of risk, as do many other activities, and that drinking within these levels will reduce many of those risks to a very low level. The decision on what level of risk is acceptable is, however, for individuals to make: these guidelines provide a benchmark, but an informed and considered public debate on how we think about risk in relation to drinking would be very welcome in the months ahead.”

Prof .Naveed Sattar, Professor of Metabolic Medicine, University of Glasgow, said:

“I am pleased to see this new advice. Alcohol excess causes many problems in society but paradoxically is now easier to buy in more outlets and much cheaper than ever. For years, many have been seduced into drinking more than they should in the belief that alcohol protects them from heart disease. However, this apparent ‘protection’ is now open to question and with the other evidence demonstrating even small amounts increase other health risks including but not limited to weight gain and cancers, then it’s clear that for many the less alcohol drunk the better. Hopefully these new messages will be a wake-up call for many and motivate them to moderate their intakes, with resulting improvement in health.”

Prof. Matt Field, Professor of Addiction, University of Liverpool (part of the UK Centre for Tobacco and Alcohol Studies), said:

“The UK Government last issued guidance on sensible drinking in 1995, and since then a lot more evidence has accumulated regarding what constitutes a ‘safe’ level of alcohol consumption. Almost every day a story appears in the media about the harmful or beneficial effects of alcohol consumption, and this has led to confusion about the relative risks (e.g. increased risk of liver disease) and possible benefits (e.g. reduced risk of heart disease) of drinking. Therefore, the issue of this new guidance from the Chief Medical Officer is timely and it will help people to make an informed choice about the amount of alcohol that they consume.

“One of the most important changes is that there is no ‘safe’ level of alcohol consumption: any amount of drinking is associated with increased risk of a number of diseases; the often-reported ‘protective’ effects will not apply to the majority of people and where they do apply, they refer to very low levels of drinking. So, any amount of alcohol consumption carries some risk. However, it is important to bear in mind that most activities that people undertake on a daily basis (e.g. driving to work) carry some risk, and people need to make informed choices about the level of risk that they are prepared to accept. For example, information published along with the CMO guidelines demonstrates that, among men, approximately 8 in 1000 non-drinkers or drinkers who stick to the weekly limit (no more than 14 units per week) are at risk of developing liver cancer, but this rate rises to 11 in 1000 for men who drink between 14 and 35 units per week. But for cancer of the oesophagus, the rates are increased for men who drink even within the weekly guideline (13 in 1000) compared to those who abstain completely (6 in 1000), and further increased for those who exceed the guideline (25 per 1000 in men who drink between 14 and 35 units per week).

“It is also important to emphasise why this advice is being issued. This is not about telling people what to do. Instead, people have a right to accurate information about alcohol and its health risks so that they can make informed decisions about their drinking behaviour.

“Finally, it is debatable whether this will make much difference to people’s drinking habits, which are very sensitive to environmental and social influences such as social norms and the wide availability of cheap alcohol, which can over-ride the best of intentions. However, this does not undermine the importance of providing people with accurate information about the health risks associated with alcohol consumption.”

Dr Niamh Fitzgerald, Lecturer in Alcohol Studies, University of Stirling (part of the UK Centre for Tobacco and Alcohol Studies), said:

“The purpose of these new guidelines is to provide the public with the latest accurate information on how they can reduce health risks from alcohol, if they choose to drink. Most people are aware of the links between smoking and cancer, but far fewer are aware of evidence linking alcohol consumption with an increased risk of future health problems, in particular cancers of the mouth, intestines and breast cancer in women. The new alcohol guidelines have been developed following a detailed consideration of this recent and strong evidence.

“The public have a right to expect clear information on the risks of alcohol from the government, which these guidelines provide. It is important that alcohol products are labelled clearly with the new guidelines, as well as other information on content such as calories and alcohol units. Together these measures will not only help people to make choices about their own drinking, but may also increase public support for the most effective regulatory measures on alcohol advertising and the cheapest alcohol products.

“This is not a crackdown on alcohol, it is about supporting people to make up their own minds. It would also be wrong to present it as an example of advice changing all the time, as Government advice on alcohol has not changed since 1995. While individual scientific studies about specific risks and suggested benefits of alcohol consumption are reported (and sometimes misrepresented) frequently, the new guidance takes a broad and detailed look at all of the evidence including new studies, and represents a strong scientific and health professional consensus on the risks from drinking alcohol.”

Dr John Holmes, Senior Research Fellow, Sheffield Alcohol Research Group, School of Health and Related Research, University of Sheffield, said:

“To inform the decision-making of the Chief Medical Officers and their advisory group in reviewing the existing lower-risk drinking guidelines, the University of Sheffield’s Alcohol Research Group was commissioned by Public Health England to provide an analysis of the evidence on health risks associated with different levels and patterns of drinking.  In the context of that analysis, we make the following points:

“The new guidelines are informed by a systematic and rigorous consideration of the evidence on the health risks of alcohol consumption.

“The CMOs’ new drinking guideline, which recommends drinking no more than 14 units per week, is consistent with our evidence and reflects the definitions of ‘low-risk drinking’ which we examined.  These definitions took account of potential health benefits from moderate drinking and also of the risks people appear to consider acceptable in other areas of life such as driving.

“Having the same guidelines for men and women reflects that there are only very minor differences in alcohol-related health risk between the sexes at this level of consumption (i.e. up to 14 units per week). At higher levels of consumption, health risks from the same level of drinking are greater for women than for men.

“While many scientific studies suggest moderate drinking can be good for your heart, researchers are increasingly concerned that problems with those studies mean any protective health effects which alcohol may provide have been substantially overestimated. Those problems include but are not limited to: (a) moderate drinkers with health problems being excluded from studies when recruiting participants, (b) non-drinkers appearing unhealthier than moderate drinkers because some non-drinkers have quit alcohol due to health problems and (c) inadequately accounting for influences on health other than alcohol (e.g. smoking and diet).

“Our analyses did take evidence of protective health effects at face value but still found that, after accounting for the health risks of drinking, any remaining protective effect was small, associated with very low levels of alcohol consumption and only likely to benefit specific groups in the population even if it was genuine.”

‘Alcohol Guidelines Review – Report from the Guidelines development group to the UK Chief Medical Officers’ published by the Department of Health on Friday 8 January 2016. 

Declared interests

Prof. Sir David Spiegelhalter: DJS contributed to the discussions of the expert group that drew up the guidelines.

Prof. Alan Cameron: No conflicts of interest to note.

Prof. Peter Anderson: “There are no relevant interests to declare.”

Dr James Nicholls: “I haven’t got any conflicts of interest to declare.”

Prof. Naveed Sattar: “I was a co-author on a paper which suggested alcohol intake increase heart disease, BMI and blood pressure.”

Prof. Matt Field: “I have received funding from the Medical Research Council, Wellcome Trust, Economic and Social Research Council, and Alcohol Research UK. I have no other conflicts of interest.”

Dr Niamh Fitzgerald: “I have no conflicts of interest to declare and have had no involvement in the development of the new guidelines.”

Dr John Holmes was a member of the Guidelines Development Group for this report until September 2014.  To inform the decision-making of the Chief Medical Officer and her advisory group in reviewing the existing lower-risk drinking guidelines, the University of Sheffield’s Alcohol Research Group was commissioned by Public Health England to provide an analysis of the evidence on health risks associated with different levels and patterns of drinking.