Richard Smith: Battling over safe alcohol limits

Richard SmithAdvice on smoking is simple: don’t smoke. But what should be the advice on alcohol? It can’t be “don’t drink,” nor can it be “drink less.” Doctors and governments think that they need to give guidance to people on alcohol—and mostly they do that by suggesting “safe limits” based on units of alcohol. But is this advice scientifically sound and beneficial? These were the issues debated with considerable feeling at the recent Battle of Ideas meeting in London.

I was a member of the Royal College of Physician’s working party that in the early 80s proposed safe limits for the United Kingdom of 21 units a week for men and 14 for women with one unit being 8 grams of alcohol. We advised that a unit was half a pint of beer or a standard glass of wine. I achieved some notoriety about five years ago for telling a journalist that these limits were “plucked out of the air.” Now whenever there is a debate about the validity of the safe limits—as there often is—I’m rung by journalists for a quote. My clumsy statement has not made me popular with the Royal College of Physicians.

Many of the thinkers attending the Battle of Ideas, a good few of them libertarians, don’t like being “told what to drink” by doctors and governments. Dolan Cummings, associate fellow of the Institute of Ideas and editor of Culture Wars, argued that the safe limits are scientifically weak, few people use them, most of those who drink alcohol drink more than the safe limits, and there is a level of “healthy, responsible, controlled” drinking that is well above the limits. “Children,” he said, “are being lied to” about what’s safe, and “unit drinking is not a healthy way to drink” just as calorie counting is not a healthy way to eat. Drinking alcohol is a social not a medical issue, and society not  doctors and governments should decide what is responsible drinking.

Kristin Wolfe, head of alcohol policy at SAB Miller, one of the world’s largest brewers, said that 80-90% of people are responsible drinkers and that the harm results from the other 10-20%. She accepted that people should be given information on safe limits, but she pointed out that there is considerable variation in advice around the world: in Australia the advised limit is 20 grams a day, whereas in Portugal its 37 grams; in the US a unit  is 14 grams, contrasting with the 8 grams in Britain.

I agreed that it’s difficult to set safe limits. I remember the debate at the working party nearly 30 years ago when the epidemiologist said it was impossible to set limits because the evidence was poor. Then there are the problems that the possible consequences of alcohol are hugely varied, including both social and medical problems, people are all different in size, body composition, and responses to alcohol, and the amount of alcohol even within the same category of drinks (beer, wine, or spirits) varies considerably. Despite these difficulties the working party agreed that it was better to offer some advice rather than none and that it needed to be simple. Although there is variation among countries on what they advise they are all, said Ray Tallis, physician, philosopher, and writer, “in the same ballpark.” People are unlikely to come to much harm drinking below the safe limits.

More than a quarter of men (28%) and nearly a fifth of women in England (19%) drink more than the recommended limits in an average week, and more than a third of men (38%) drink more than four units in one day and nearly a third of women (29%) drink more than three units in one night—making them binge drinkers by one definition. Most of those at the meeting liked to think that these drinkers, although above recommended limits, are “responsible” or “healthy” drinkers. In reality many of these people are likely to damage themselves or their families because the risk of medical and social damage rises steadily with consumption and because alcohol is an addictive substance, meaning people tend to increase consumption and find it steadily more difficult to cut down.

We did debate providing people with much more complex information that gives data on the risk of various consequences as consumption increases—perhaps through a smart phone and combined with information on how any given individual reacts to alcohol. There was scepticism, however, that more than a handful of people would use the information. Many people, including possibly me, prefer to fool themselves that their drinking is not harming them.

My main argument, which led to sharper disagreement than over units, was that it was best to respond to alcohol through public health rather than individual measures. Overwhelming data shows that the more alcohol a country or community consumes the more harm it will experience, and we know that increasing price will reduce consumption. So a steady increase in the price of alcohol is the best way to reduce harm—just as with smoking. This is a message that is very unattractive to the drink trade and to many of those at the Battle of Ideas. I left understanding more clearly how politically difficult it can be to do what seems sensible and obvious to doctors.

Competing interest: RS was speaking at the meeting and was offered expenses, but as he cycled there and back he didn’t have any. He did, however, get a free cup of (not very good) coffee.

RS was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.