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Low-risk alcohol guidance sparks debate as drinkers start examining habits, evidence

New guidance is more like a dial rather than a light switch
An alcoholic beverage is seen in a drinking establishment in Halifax on Wednesday, Aug. 1, 2018. Canada’s new guidance on alcohol is sparking plenty of debate, and while some experts say it could lead to frank conversations with health providers to help drinkers make informed choices, others are questioning the advice to imbibe fewer than two drinks per week. THE CANADIAN PRESS/Andrew Vaughan

Canada’s new guidance on alcohol is sparking plenty of debate, and while some experts say it could lead to frank conversations with health providers to help drinkers make informed choices, others are questioning the advice to imbibe fewer than two drinks per week.

Heidi Tworek, associate professor of public policy at the University of British Columbia, said the guidance aimed at changing people’s behaviour to reduce their risk of alcohol-related cancer or heart disease should be accompanied by other strategies that help them assess their own situation based on family history or alcohol-use disorder, for example.

The Canadian Centre on Substance Use and Addiction said in a report released last week that no amount of alcohol is safe and those who consume up to two standard drinks per week face a low health risk. This increases to moderate risk for three to six weekly drinks, and is high beyond that.

The guidance is more like a dial rather than a light switch that some people will find helpful as they monitor their consumption, said Tworek, a Canada Research Chair in health communication.

“The guidance will reach some people, but there are a lot of people for whom this isn’t going to resonate or they’re never going to hear about it in the first place,” she said.

The CCSA updated its advice from 2011, when it said 15 drinks per week for men and 10 drinks per week for women was considered low risk. The new recommendations were based on the latest research into risk of cancers including of the breast and colon, as well as risk of injuries, accidents and violence.

It also called for governments to mandate warning labels on alcohol bottles and cans so people know how many standard drinks they contain, the health risks involved and guidance on consumption.

However, conveying information about people’s individual risk will be a challenge without broader conversations about the evidence that justified the updated guidance, Tworek said.

“This has been difficult in science communication in general, like during the pandemic: how do you communicate around uncertainty and why your guidelines are changing? It will take a lot of time and multiple modes of communication to reach people,” she said.

Tworek said the guidance should also be translated into different languages to serve various communities as federal and provincial governments do their part through education campaigns and public health policies.

The office of federal Addictions Minister Carolyn Bennett said Health Canada “will continue to engage Canadians on the CCSA’s recommendations” to reduce alcohol-related harms.

Canada’s guidance is stricter than in other countries including France, the United Kingdom and Australia.

Compared with Canada, guidelines in Australia, for instance, suggest 10 drinks per week pose a low risk.

However, standard drinks in Canada are about one-third stronger because they’re based on 13.45 grams of ethanol versus 10 grams of ethanol in Australia, said Dr. Peter Butt, who co-chaired the CCSA’s guidance project.

“Their 10 drinks is really about seven of our standard drinks,” said Butt, who is also an associate professor of family medicine at the University of Saskatchewan. “What we have in terms of the moderate risk range is three to six drinks. So the difference is one standard drink per week based on the Australian analysis of the data and what we took from Australia and updated.”

“We’re not promoting abstinence,” he said. “We are actually encouraging Canadians to be better educated with regards to beverage alcohol, reflect on their use and situate themselves with regards to the risks and harms and make an informed decision,” he said, adding Canada’s guidance is in keeping with a recent statement by the World Health Organization on alcohol-related harms about no safe level of consumption.

The CCSA’s recommendations mean one to two standard drinks per week represent a one in 1,000 level risk of death, consistent with other voluntary activity such as unprotected sex as per international standards. The risk of dying rises to one in 100 if six standard drinks a week are consumed, it said.

“We’re not presenting the relative risk, we’re presenting the absolute risk,” Butt said, adding the advice is based on population health studies.

The guidelines have spurred some people to rethink their alcohol consumption.

Lisa Scotland, who was enjoying a glass of wine with her sister during lunch at a restaurant in Vancouver, said seeing warning labels on containers of alcohol could make some people consider their choices.

“I don’t think the (guidance) will necessarily change my behaviour but I will think about it every time I have a drink,” she said.

“I don’t think a lot of people think about cancer risks so a label would be a good idea. If it could help, wouldn’t it be worth it? If it can destroy your liver, shouldn’t there be a warning?”

Scotland noted the risks of smoking were well-known long before warning labels were placed on cigarette packages but said text and graphic images about health risks helped many people kick the habit.

Her sister, Dianna Reimer, said warning labels on alcohol may be more effective for younger people compared with those who are set in their ways when it comes to the amount they drink.

“I understand the risks but sometimes you have the worst day ever and you have a few glasses of wine,” she said.

Dan Malleck, a medical historian on alcohol policy at Brock University in St. Catharines, Ont., called the guidance “fearmongering” that ignores the social benefits some people gain from gathering to enjoy a few drinks.

“There’s a certain ideological perspective in this, which is the perspective that alcohol is no good, has no benefits, only harms. And we just need to chart how much harm you should be aware of.”

“I see the language of temperance, of moral judgment. And I think that’s a problem,” he said.

People who have an illness that may put them at greater risk of harm from alcohol are better off monitoring how much they drink, but “everyday people” should not be stigmatized for having more than two drinks at a sitting, Malleck said.

The CCSA could discredit itself by “going too far in one direction,” with its guidance, he said.

Malleck also challenged the methodology used for the guidance, but Butt said it’s based on international standards and the “best evidence,” which makes the risks “more transparent” so people can make their own choices.

Dr. Eric Cadesky, a family physician in Vancouver, said he will be asking patients about their alcohol intake during periodic health examinations and when discussing concerns such as sleep problems.

“It’s an opportunity to check in on their alcohol use and to inform them on what we know now,” he said, adding nurses, social workers and mental-health professionals could also be trusted sources on the recommendations.

“Trust is such an important commodity today and there are many people who can deliver that message. Unfortunately, we know about 20 per cent of the population throughout Canada does not have a family doctor. And those who have a family doctor do not have ready access.”

—Camille Bains, The Canadian Press

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