Alcohol Guidelines - Science and Technology Committee Contents

Written evidence submitted by the International Scientific Forum on Alcohol Research and AIM, Alcohol in Moderation (AG 09)


Each year our understanding of the biological, physiological, psychological and social effects of drinking alcohol at different doses grows. In general, national guidelines reflect the medical findings of the j shape curve, that is, that approximately 20g a day consumption for women and 30g consumption a day for men is considered as "safe" or "low risk" for most healthy adults. Therefore we believe the current UK guidelines to be in accordance with the science base.

The science base for the health consequences of both alcohol misuse and moderate consumption, although important should not be the only factor considered by governments when producing guidelines as the purpose of recommendations is to encourage adults to drink within the responsible drinking guidelines. Hence, it is important to continue to promote a simple public health message that is likely to respected and regarded as realistic by consumers.

1.  What evidence are Government's guidelines on alcohol intake based on, and how regularly is the evidence base reviewed?

1.1 AIM, Alcohol in Moderation was one of many organisations that submitted a paper in 1995 to the sensible drinking guidelines review, drawing on evidence from eminent epidemiologists such as Sir Richard Doll, Professor Eric Rimm (USDA committee) and Professor R Curtis Ellison as well as cardiologists such as Professor Art Klatsky. In particular, the evidence base in the early 1990's showed the importance of a daily "little and often" guideline versus "saving up" units and drinking on one or two nights a week.

1.2 We are able to have "low risk" guidelines, rather than a message of "don't drink" due to the medical evidence base, which began with the publication by Professor Klatsky in 1974 of one of the first studies to suggest an inverse association between moderate alcohol consumption and coronary heart disease, This was followed in 1979 with St Leger in The Lancet finding that wine appeared to be protective against heart disease, independent of other risk factors. Since then, many hundreds of studies from 25 countries have confirmed and strengthened the association, with the protective effect, or what has become known as the J shaped curve for moderate alcohol consumption, applying predominantly to post menopausal women and men over 40.

1.3 The j shaped curve shows that light and moderate drinkers of any form of alcohol live longer than those who abstain or drink heavily. The relative risk of mortality is lowest among moderate consumers (at the lowest point of the J), greater among abstainers (on the left-hand side of the J), and much greater still among heavy drinkers (on the right-hand side of the J). In addition to longevity in general, the J-shaped relationship also exists for cardiovascular deaths, specifically for coronary heart disease and ischemic stroke.

1.4 Many factors influence the definition of safe alcohol consumption and include age, gender, body mass index, ethnicity, family history, genetic differences, mental and physical health, and concomitant medications. Consequently, it has not been possible to determine the exact inflection point in dose where a potentially beneficial, or harmless dose changes to a potentially harmful one, hence definitions of a drink and responsible drinking guidelines vary from country to country and governments usually use simple messages and recommendations that apply to the majority general population.

1.5 Moderate drinking is generally medically defined, however, as approximately 20g a day (one or two standard drinks) for women and 30g a day for men. Further, epidemiological studies have assessed the importance of drinking patterns including frequency and quantity. "Saving up" units for drinking on one or two occasions a week is not considered moderate drinking.


1.6 Evidence from these studies suggests that beneficial changes in High Density Lipoprotein cholesterol levels, clotting factors, insulin sensitivity, and markers of inflammation provide biological plausibility to the association. Coronary heart disease (CHD) is the leading cause of death throughout the developed world, accounting for 25-50% of all deaths. Studies consistently show that regularly consuming moderate amounts of alcohol reduces mortality from CHD and ischemic stroke by 25 -30%, mainly in men aged over 40 years and in postmenopausal women, when the risk factors for CHD and stroke significantly increase.

1.7 It is thought that alcohol itself accounts for 75% of the cardio-protective effects of alcoholic beverages. It favourably alters the balance of fats or lipids in the blood, by stimulating the liver to produce the "good" high-density lipoprotein cholesterol (HDL). HDL removes the "bad" low-density lipoprotein cholesterol (LDL) from arteries and veins for disposal via the bile, which is referred to as reverse cholesterol transport.Alcohol decreases blood clotting and/or the "stickiness" of blood platelets, which if untreated could form a clot to block blood flow in an artery to cause a heart attack or stroke. The message is little and often as the blood thinning effect of alcohol lasts for approximately 24 hours and one drink confers the benefit.

1.8 Drinking alcohol is not recommended if suffering from uncontrolled, high blood pressure. If someone has an existing heart condition, alcohol can generally be drunk in moderation, but only if alcohol use does not affect the medication, a doctor's advice should be sought. Binge drinking is seen to significantly increase systolic blood pressure, which increases the risk of a heart attack or stroke.

1.9 The many epidemiological studies that have shown an inverse relation between alcohol and cardiovascular disease have come from a great variety of nations and cultures. Despite great diversity in the populations, study size, diet and lifestyle factors and length of follow-up the consistency and similarity of outcomes provide further support to the robustness of the findings. Inverse associations have been documented in France, Japan, Denmark, Germany, Finland, Korea, Great Britain Australia, China, Italy, Puerto Rico, the Netherlands, Sweden, Yugoslavia and the US (see references).

1.10 More recent studies of alcohol and CHD have focused on subgroups defined by age or health status. Although alcohol in moderation will likely provide greater benefit for older populations where rates of CHD are highest, the etiology of CHD is such that moderate consumption in middle age also is beneficial. Several important risk factors for CHD, such as obesity and the prevalence of type 2 diabetes, both of which have been increasing in younger adults around the world, are consistently reported to be inversely associated with moderate alcohol consumption.


1.11 An important meta-analysis of 4235 studies on the association of alcohol consumption with selected cardiovascular disease outcomes was published in the BMJ in 2011: This meta-analysis provides a summary of current knowledge regarding alcohol associations with six meaningful clinical end points—cardiovascular disease mortality, coronary heart disease incidence and mortality, stroke incidence and mortality, and all cause mortality. Reflecting previous meta-analysis by Maclure in 1993 and by Corrao et al in 2000, the results demonstrate risk reductions for alcohol drinkers relative to non-drinkers of 25% for cardiovascular disease mortality, 29% for incident coronary heart disease, 25% for CHD mortality and 13 % for all cause mortality. The lowest risk of CHD mortality occurred with 1-2 drinks (15-30 grams of alcohol) per day is also in line with previous knowledge. (Paul E Ronksley, Barbara J Turner, Kenneth J Mukamal et al BMJ 2011;342:d671 doi:10.1136/bmj.d671 Effect of alcohol consumption on biological markers associated with risk of coronary heart disease: systematic review and meta-analysis of interventional studies Susan E Brien, Paul E Ronksley, Barbara J Turner, Kenneth J Mukamal, William A Ghali Cite this as: BMJ 2011;342:d636 doi:10.1136/bmj.d636).

1.12 Another recent paper set out to determine the extent to which potential "errors" in many early epidemiologic studies led to erroneous conclusions about an inverse association between moderate drinking and coronary heart disease (CHD). Based on prospective data for more than 124,000 persons Fuller concludes that the so-called "errors" have not led to erroneous results, and that there is a strong protective effect of moderate drinking on CHD and all-cause mortality. (Fuller TD. Moderate alcohol consumption and the risk of mortality. Demography 2011. DOI 10.1007/s13524-011-0035-2).


1.13 Research is increasingly showing the importance of drinking at meal times, this is known as the "post prandial state". This not only decreases the effect of alcohol (drinking on an empty stomach), but helps us counter damaging free radicals. Rich foods increase the state of "oxidative stress" in the body. Research shows that drinking above 30g a day outside of meal times or abstinence increases the risk of blood pressure and all cause mortality significantly.

1.14 Research also emphasizes regular moderate versus episodic or binge drinking . An important prospective study shows that regular moderate drinking is associated with lower risk of MI, but episodic or binge drinking increases the risk. Lifetime abstinence has a similar adverse relation to CHD. Reference: Ruidavets J-B, Ducimetièere P et al Patterns of alcohol consumption and ischaemic heart disease in culturally divergent countries: the Prospective Epidemiological Study of Myocardial Infarction (PRIME). BMJ 2010;341:c6077 doi:10.1136/bmj.c6077.


1.15 There is no doubt that the prolonged excessive consumption of alcohol, especially when combined with smoking, leads to an increased incidence of many cancers (mouth, throat, larynx, oesophagus, breast and liver). A growing body of epidemiological studies show evidence for a positive association, even at moderate levels for breast cancer risk,(estimated lifetime increased risk of 6% per daily drink). Lifestyle factors such as diet and adequate folate intake may weaken the positive association, but this is an area still under study. The risk of breast cancer from alcohol consumption is additive with other risks such as: lifestyle; family history; medical history; nulliparity; endogenous/exogenous hormones (such as hormone replacement therapy); body mass index; and environmental exposure to carcinogens.

1.16 Cancer risk should not be considered in isolation from the risk of other factors for mortality, as regards responsible drinking guidelines. As regards all cause mortality, the current daily guidelines reflect the scientific findings well in recommending safe or low risk guidelines for alcohol consumption for healthy adults.


1.17 It has been suggested that the inverse association between alcohol and all cause mortality may not be causal but because moderate drinkers may be better off, more likely to eat better, exercise more, and live a healthier life. Most studies from the last decade account for potential con-founders of the effect of moderate drinking - such as education, occupation, social status, physical activity, diet, and changes in alcohol consumption during lifetime. Although most prospective studies of alcohol and cardiovascular risk are observational, trials have been conducted to study changes in markers of CHD such as HDL cholesterol, triglycerides, glycemic control, and clotting factors and support the conclusions of the observational studies.

1.18 Klatsky and Udaltsova (2007) reworked previously published data to address the purported confounding and potential over-estimation of a health benefit from moderate alcohol consumption claimed by Fillmore et al (2006, 2007), and showed a shallower but still significant J-shaped relationship between alcohol consumption and all-cause mortality risk. The data was of 21,535 deaths and follow-up included 2,618,523 person-years of observation (average 20.6 years). Their re-analysis reconfirmed the relationship previously published with an increased risk for individuals consuming more than three (14 g) drinks per day and a reduced risk at three or less drinks per day, almost always due to a reduced risk of death from cardiovascular disease. Former consumers were observed to be at increased risk of death from non-cardiovascular disease and occasional consumers were observed to have a risk similar to lifelong abstainers.

1.19 Another study by Mukamal et al (2006) on older adults separated lifetime abstainers from former drinkers, and occasional drinkers from regular light drinkers It demonstrated reductions in the risk of a variety of cardiovascular outcomes from moderate consumption. Another study on older people by Tolvanen (2005) separating ex-drinkers were from lifetime abstainers, total mortality was highest in the ex-drinkers and labstainers, and 30?40% lower in current consumers.


1.20 There have been suggestions that the elderly should reduce their alcohol consumption to below daily drinking guidelines. This is based on the fact that they have less body water than younger adults. However, moderate, regular consumption, within the guidelines helps protect against cardiovascular disease, cognitive decline and all cause mortality, especially among post menopausal women and men over 40, hence the US dietary guidelines 2010 cite:

In most Western countries where chronic diseases such as CHD, cancer, stroke and diabetes are the primary causes of death, results from large epidemiological studies consistently show that alcohol has a favorable association with total mortality especially among middle age and older men and women ….

1.21 This message has been further strengthened this month by the findings of the nurses health study( Alcohol Consumption at Midlife and Successful Ageing in Women: A Prospective Cohort Analysis in the Nurses' Health Study) following 14,000 older women for 16 years. Those who consumed between 15g and 30g of alcohol regularly had a 28% better chance of "successful ageing versus abstainers or light occasional drinkers (

1.22 Another recent paper finds that after adjusting for former problem drinking status, health and social-behavioural factors, moderate drinking was associated with considerably lower risk of all-cause mortality. In comparison with "moderate drinkers" (subjects reporting up to 3 drinks/day), abstainers had 51 % higher mortality risk and heavy drinkers had 45% higher risk. (Holahan CJ et al. Late-Life Alcohol Consumption and 20-Year Mortality. Alcoholism: Clinical and Experimental Research 2010;34).


1.23 There is no question that heavy alcohol consumption is a key factor in the development of Laennec's cirrhosis, and that almost all studies show that women may be at greater risk than men for a specified level of intake. The key question for public health officials is whether or not there is a threshold level of drinking associated with increased risk of cirrhosis.

A recent meta-analysis supports the theory that there is a threshold of drinking above which the risk is increased. The study reported that for morbidity from cirrhosis, both men and women consuming up to one drink per day had a lower risk than that of lifetime abstainers. Women had a significantly increased risk above 24 grams/day and men above 36 grams/day. This suggests that there may a threshold effect of alcohol on the risk of cirrhosis in line with current guidelines. (Rehm J, Alcohol as a risk factor for liver cirrhosis: A systematic review and meta-analysis. Drug and Alcohol Review 2010,29,437-445. DOI: 10.1111/j.1465-3362.2009.00153.x).


1.24 There are physiological gender differences in body size and the distribution of fat and water, as well as in alcohol metabolism that determine that for a given amount of alcohol, the resultant BAC is greater in women than in men. The maximal BAC may be approximately 10-16% greater in women compared to men. In addition it should also be stated that women's organs and tissues are more susceptible to the toxic effects of alcohol and its metabolite such that harmful effects of regular heavy drinking are observed earlier in women. Hence the current lower guidelines for women are correct and balanced.


1.25 Both NICE and The Royal College of Obstetricians and Gynaecologists have reviewed the extensive evidence base and the current guidelines are in line with their findings.


1.26 There are significant economic, medical and social consequences from irresponsible or high risk alcohol consumption. Heavy or hazardous drinking ( more than twice the moderation guidelines), inappropriate drinking ( drinking to drunkenness), and binge drinking ( more than five drinks in quick succession) have no health benefits and are associated with both acute and chronic harms to health, both short and long term.

Drinking at all in some circumstances is hazardous, such as when pregnant, on certain medications, when driving, suffering from some illnesses, working with machinery or at heights.

2.  Could the evidence base and sources of scientific advice to Government on alcohol be improved?

2.1 You will find forwarded separately examples of how the Canadian and US Government's conduct their responsible drinking guideline reviews, with an experienced panel of predominantly MEDICAL specialists and epidemiologists and nutrition lists reviewing the evidence collated reporting to a BALANCED panel of expertise.

2.2 The US guidelines are reviewed every five years. Australia and Canada more sporadically. You will find a recent review of common themes in country guidelines under separate cover.

2.3 It is very important that the evidence base is not based on a few individual papers but on a comprehensive database of studies and meta- analyses from different disciplines, please see the bibliography for the US and Canadian reviews.

2.4 There is a feeling among the 40 scientists and medical doctors that contribute comment to The International Scientific Forum on Alcohol Research (unpaid) and AIM who are directly involved in alcohol and health research that there is an unhealthy reliance on non medically qualified public health statisticians and use of mathematical modelling - such as the use of alcohol attributable fractions for example rather than analysing the hard science.

2.5 Evidence needs to take account of cardiology, hepatology, oncology, all cause mortality, epidemiology, pattern of drinking and put alcohol in context with other lifestyle factors such as BMI, smoking, exercise and diet. NICE may be the best body to bring together such a panel.

4.  How do the UK Government's guidelines compare to those provided in other countries?

4.1 The UK definition of a unit is the smallest at 8g. Unit definition varies from 10g ( Australia, France, Austria, Ireland, The Netherlands, New Zealand) 12g (Denmark, Italy), 13.6-14g (Canada and US) and 19.75 (Japan).

4.2 In spite of this, daily drinking guidelines where they exist , are broadly in line—suggesting an average intake of 20g a day for women and 30g for men.

4.3 The lowest guidelines for women are Poland at 10g and 14g a day from the US, with an average of 20g (WHO guidelines, France, Australia, New Zealand, Sweden, Switzerland). Some of the highest are from Canada (27.2g). the UK sits comfortably in the evidence zone of suggesting 16-24g as a daily guide.

4.4 The lowest guidelines for men are 20g in Poland, Sweden and Australia (up to 40g on occasions), rising to 28g in the US, 30g in France, New Zealand and WHO, and 40g in Spain, hence the UK guide of 24-32g is in balance.

4.5 For the many countries where there are no official Government guidelines, such as Belgium, China, Germany, Hungary, India or Russia, it is recommended that the WHO low risk responsible drinking guidelines are followed. Which are:

(2)  Women should not drink more than two drinks (10g) a day on average.

(3)  For men, not more than three drinks (10g) a day on average.

(4)  Try not to exceed four drinks on any one occasion:

(0)  Don't drink alcohol in some situations, such as when driving, if pregnant or in certain work situations and abstain from drinking at least once a week.

Men or women who consistently drink more than these recommended levels may increase risks to their health.


4.6 Reflecting an acknowledgement that people celebrate and party, several guidelines now have an "upper limit":

—  US guidelines: No more than three drinks in any single day for women (42g) and for men no more than four drinks (56g) in any single day for men.

—  WHO - no more than 4 drinks on one occasion (40g).

—  Australia's 2008 guidelines: up to 40 g of ethanol on occasional days for men and women.

4.7  Protection for older populations

Canadian guidelines: "men and women consuming up to 14 and 9 standard drinks (13.6g) per week respectively, have a lower risk of early death than abstainers."

UK guidance: "The health benefits are more evident from regular daily drinking." Specifically, men over age 40 and postmenopausal women are emphasized as recipients of a "significant health benefit in terms of reduced coronary heart disease mortality and morbidity." Middle aged or elderly non-drinkers or infrequent drinkers and especially those at risk for heart disease "may wish to consider the possibility that light drinking may be of benefit to their overall health and life expectancy."

US revised guidelines 2010: "In most Western countries where chronic diseases such as CHD, cancer, stroke and diabetes are the primary causes of death, results from large epidemiological studies consistently show that alcohol has a favourable association with total mortality especially among middle age and older men and women".

4.8  Balance between harms and benefits

These are reflected well in the US guideline conclusions:

"The hazards of heavy alcohol (ethanol) intake have been known for centuries. Heavy drinking increases the risk of liver cirrhosis, hypertension, cancers of the upper gastrointestinal tract, injury, and violence. An average daily intake of one to two alcoholic beverages is associated with the lowest all-cause mortality and a low risk of diabetes and CHD among middle-aged and older adults. Despite this overall benefit of moderate alcohol consumption, the evidence for a positive association between alcohol consumption and risk of unintentional injuries and breast and colon cancer should be taken into consideration. The DGAC recommends that if alcohol is consumed, it should be consumed in moderation, and only by adults. "Reference:".

So, to conclude, The International Scientific Forum on Alcohol Research and the social Scientific and Medical Council of Alcohol in Moderation believe the current guidelines reflect the current scientific evidence base regarding alcohol and health and definitions of safe or low risk drinking well. It may be wise, as is the case with the USDA guidelines, to review the evidence base every 5 years to ensure that emerging research is accounted for.


R Curtis Ellison, MD, Section of Preventive Medicine/Epidemiology, Boston University School of Medicine, Boston, MA, USA (Co-Director)

Helena Conibear, Alcohol in Moderation, Bath, UK (Co-Director)


Alan Crozier, PhD, Plant Biochemistry and Human Nutrition, University of Glasgow, Scotland, UK

Alun Evans, MD, Centre for Public Health, The Queen's University of Belfast, Belfast, UK

David Vauzour, PhD, Senior Research Associate, Department of Nutrition, Norwich Medical School, University of East Anglia, Norwich, UK

Oliver James, MD, Head of Medicine, University of Newcastle, UK

Jeremy P E Spencer, PhD, Reader in Biochemistry, The University of Reading, UK

Alberto Bertelli, MD, PhD, Institute of Human Anatomy, University of Milan, Italy

Dee Blackhurst, PhD, Lipid Laboratory, University of Cape Town, Cape Town, South Africa

Giorgio Calabrese, MD, Docente di Dietetica e Nutrizione, Umana Università Cattolica del S. Cuore, Piacenza, Italy

Maria Isabel Covas, DPharm, PhD, Cardiovascular Risk and Nutrition Research Group, Institut Municipal d´Investigació Mèdica, Barcelona, Spain

Giovanni de Gaetano, MD, PhD, Research Laboratories, Catholic University, Campobasso, Italy

Luc Djoussé, MD, DSc, Dept. of Medicine, Division of Aging, Brigham & Women's Hospital and Harvard Medical School, Boston, MA, USA

Harvey Finkel, MD, Hematology/Oncology, Boston University Medical Center, Boston, MA, USA

Tedd Goldfinger, DO, FACC, Desert Cardiology of Tucson Heart Center, University of Arizona School of Medicine, Tucson, AZ, USA

Lynn Gretkowski, MD, Obstetrics/Gynecology, Mountainview, CA, Stanford University, Stanford, CA, USA

Dwight Heath, PhD, Dept. of Anthropology, Brown University, Providence, RI, USA

Ulrich Keil, MD, Institute of Epidemiology & Social Medicine, University of Muenster, Germany

Arthur Klatsky, MD, Dept. of Cardiology, Kaiser Permanente Medical Center, Oakland, CA, USA

Maritha J Kotze, PhD, Human Genetics, Dept of Pathology, University of Stellenbosch, Tygerberg, South Africa.

Dominique Lanzmann-Petithory,MD, PhD, Nutrition/Cardiology, Praticien Hospitalier Hôpital Emile Roux, Paris, France

Federico Leighton, MD, Laboratorio de Nutricion Molecular, Facultad de Ciencias Biologicas, Universidad Catolica de Chile, Santiago, Chile

Ross McCormick, PhD, MSc, MBChB, Associate Dean, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand

Francesco Orlandi, MD, Dept. of Gastroenterology, Università degli Studi di Ancona. Italy

Lynda H Powell, MEd, PhD, Chair, Dept. of Preventive Medicine, Rush University Medical School, Chicago, IL, USA

Ian Puddey, MD, Dean, Faculty of Medicine, Dentistry & Health Sciences, University of Western Australia, Nedlands, Australia

Erik Skovenborg, MD, specialized in family medicine, member of the Scandinavian Medical Alcohol Board, Aarhus, Denmark

Jan Snel, PhD, Social and Behavioral Sciences, University of Amsterdam, Amsterdam, Holland

Arne Svilaas, MD, PhD, general practice and lipidology, Oslo University Hospital, Oslo, Norway

Pierre-Louis Teissedre, PhD, Faculty of Oenology-ISVV, University Victor Segalen Bordeaux 2, Bordeaux, France

Gordon Troup, MSc, DSc, School of Physics, Monash University, Victoria, Australia

Fulvio Ursini, MD, Dept. of Biological Chemistry, University of Padova, Padova, Italy

David Van Velden, MD, Dept. of Pathology, Stellenbosch University, Stellenbosch, South Africa

Andrew L Waterhouse, PhD, Marvin Sands Professor, Department of Viticulture and Enology, University of California, Davis.

Yuqing Zhang, MD, DSc, Clinical Epidemiology, Boston University School of Medicine, Boston, MA, USA


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