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Health warnings on bottles and new advice on alcohol and pregnancy

‘Sensible drinking‘ messages on bottles by the end of 2008 and new advice to avoid alcohol when pregnant or seeking to become pregnant are two key components of the new Alcohol Strategy. Both ideas immediately ran into controversy, the Government being accused of either going too far or not far enough. Interestingly, one accusation that might have been made but was not was that the Government has in effect now raised the ‘sensible drinking‘ limits. Despite this, and for entirely different reasons, some drinks companies were reported as threatening not to co-operate with the new labelling initiative.

There was also criticism of the new advice on pregnancy for going beyond the scientific evidence. However, the British Medical Association (BMA) supported the Government‘s new message. The BMA said that while it was true that there is currently no conclusive evidence that drinking one or two units of alcohol per week is harmful to the developing child in the womb, evidence is continuing to emerge of possible risks of prenatal alcohol exposure at low to moderate levels. The BMA agreed, therefore, that “Given the current uncertainty regarding the level of risk to the developing foetus, and the lack of clear guidelines, the only safe sensible drinking message is not to drink any alcohol during pregnancy."

Sensible drinking message on labels On ‘sensible drinking‘ the Department of Health said that by the end of 2008 it expected all alcoholic drinks labels to include alcohol unit information, following what it described as a ground breaking agreement between Government and the drinks industry.

It stated that labels will include:

  • The drink‘s unit content and the recommended Government ‘safe drinking’ guidelines.
  • UK Health Departments recommend men do not regularly exceed 3-4 units daily and women 2-3 units daily.

The label may also refer the consumer to the alcohol-industry funded charity ‘Drinkaware’ for further advice.

In addition, the Government is also encouraging the alcohol industry to include ‘sensible drinking’ information for pregnant women on labels.Avoid alcohol if pregnant or trying to conceive is the shortened form of the Government advice announced on 25 May 2007.

Public Health Minister Caroline Flint said; “This landmark, voluntary agreement will help people calculate, at a glance, how much they are drinking and whether they are staying within sensible drinking guidelines.We want to make it as simple as possible for people to keep an eye on how much they are drinking and help them take the responsibility for lessening the impact excess alcohol can have on their health. Although most spirits and beer labels for sale in the UK market and many supermarkets’ own brands of beers, wines and spirits, do carry some information on unit content people can miscalculate and lose track of how much they are drinking. Unit information combined with sensible drinking guidelines on the new labels will make it simpler for people to calculate how many units they are drinking and make it easier for them to stick to the recommended limits.”

But have the limits been raised?
Until 1995, the recommended ‘sensible limits’ of regular consumption were no more than 21 units of alcohol per week for men and no more than 14 units per week for women. There was also guidance on hazardous and definitely harmful levels of consumption.

In December 1995, following a Government review of the ‘sensible drinking’ message, the guidance was changed from weekly to daily limits - no more than 3-4 units per day for men, and no more than 2-3 units per day for women, but with the qualification that consistently drinking 4 units a day for men and 3 units for women was not recommended on health grounds. There was also advice to have two alcohol-free days following an ‘excessive drinking episode’.

While the advice to have two alcohol free days after a heavy drinking episode is retained in the small print of the Government’s revised Alcohol Strategy, it appears to be omitted from the new warning to be placed on labels. And as the advice no longer warns against drinking up to the maximum recommended amount every day, and there are seven days a week, it seems that the weekly guidelines are now 21 and 28 units for women and men respectively, rather than the previously recommended 14 and 21 units.

No new evidence to justify raising the limits has been produced, and no official statement confirming the limits have been raised has been made. However, on the face of it, the new advice cannot be interpreted in any other way. As the new limits represent a 50% increase in the recommended maximum consumption for women this might be considered worthy of note, particularly at a time when there is considerable medical and public concern about increased female consumption and the consequences of the ‘binge drinking’ epidemic

Alcohol industry ambivalence
However, despite the apparent raising of the drinking limits, the press reported considerable misgivings on the part of the alcohol industry about the new initiatives. The Daily Telegraph reported that “Plans to put detailed health warnings on bottles of alcohol have been undermined by disagreements between drinks companies and the Department of Health”. The newspaper went on to report that while most in the industry supported the principle of better labeling,many had reservations about what to put on their bottles and objected to being forced to follow a Government template. Advising pregnant women to avoid all alcohol was another cause of unhappiness in industry circles.

‘Alcohol can kill’
In contrast, the British Liver Trust criticized the Government’s proposed messages for not going far enough. While the Trust welcomed the move towards universal unit labelling on alcoholic drinks, it said that the Department of Health, in suggesting that the industry puts a sensible drinking message for pregnant women on labels, was missing the key point - that almost every sector of the UK population drinks excessively. Alison Rogers,Chief Executive of the British Liver Trust said: “We have a rising rate of cirrhosis and alcohol-related deaths in the UK. The government’s own figures show that 22,000 people die prematurely each year as a result of alcohol.The Trust has previously suggested to the Department of Health that unit labels should include messages such as ‘Alcohol can kill’. This is a softer version of cigarette packets’ message that ‘Smoking kills’, but nonetheless a fair reflection of the harm that alcohol wreaks on the UK population.”

Ms Rogers said that this was backed up by the recent scientific review which placed alcohol as fifth up the list of harmful drugs - far above many that are classed as illegal substances such as cannabis and ecstasy. “If we continue to adopt a very ‘softly softly’ approach to the whole issue of alcohol” she said, “it will be at a horrendous health, social and economic cost to the UK. Cheap and accessible booze coupled with the UK’s ‘anytime anywhere anyplace’ mentality is costing us all very dear, and far too many are literally paying with their lives.”

Alcohol in pregnancy

The revised Department of Health advice says:

  • Pregnant women or women trying to conceive should avoid drinking alcohol.
  • If they do choose to drink, to minimise the risk to the baby, they should not drink more than one to two units of alcohol once or twice a week and should not get drunk.

The Department of Health explained that the new guidance had been introduced to provide stronger, consistent advice for the whole of the UK. It was not the result of new scientific evidence, but it was consistent with the current evidence. The Government had revised the advice to make it easier to understand and to provide consistent advice across the UK.

Deputy Chief Medical Officer Dr Fiona Adshead said; “We have strengthened our advice to women to help ensure that noone underestimates the risk to the developing foetus of drinking above the recommended safe levels. Our advice is simple: avoid alcohol if pregnant or trying to conceive. This advice could also be included on alcohol packaging or labels.

“The advice now reflects the fact the many women give up drinking alcohol completely during pregnancy. It is now straightforward and stresses that it is better to avoid drinking alcohol altogether.”

The National Organisation on Foetal Alcohol Syndrome estimates for the UK as a whole that there are more than 6,000 children born each year with Foetal Alcohol Spectrum Disorder.

Excessive alcohol can cause damage to the unborn baby at all stages in pregnancy and of course many women don‘t confirm they are pregnant until a number of weeks into the pregnancy. Therefore, for women who are planning to conceive it makes sense to avoid alcohol or limit their consumption to no more than 1-2 units once or twice a week.

Dr Sheila Shribman, the National Clinical Director for Children,Young People and Maternity Services said: “Alcohol and pregnancy advice is now consistent across the UK.

“Our last survey of pregnant women showed that nine per cent were still drinking above the recommended levels. It is vital that we alert pregnant women and women hoping to conceive about the potential dangers of excessive alcohol consumption during pregnancy.

“Although there is still scientific uncertainty about the precise impact of excess alcohol on unborn babies we believe the time is right to introduce a strong consistent approach across the whole of the UK. This revised advice has been agreed by the four Chief Medical Officers across the UK.”

The previous advice in England was: pregnant women or women trying to conceive should not drink more than one to two units of alcohol once or twice a week and should avoid getting drunk.

Pregnancy and alcohol – a dangerous cocktail, says a new BMA report
Learning and physical disabilities and behavioural problems are part of foetal alcohol spectrum disorders [FASD]. These lifelong conditions can drastically impact on the lives of the individuals and those around them. A new BMA report says the reality is that these conditions are completely preventable by not drinking any alcohol during pregnancy.

The report, ‘Fetal alcohol spectrum disorders’, highlights how difficult it can be to detect FASD and how healthcare professionals need more guidance to help them diagnose and treat children suffering from the disorder.

The BMA report says the advice can be misinterpreted, as individuals may not clearly understand how many units correspond to what they are drinking. The alcoholic strengths of different beers and wines, and the considerable variation of standard measures used in bars and restaurants and in the home, can make it difficult for women to tell how many units they are consuming.

The new advice from the English government was disputed by some medical experts and the BMA is now calling for clear, evidence-based guidelines on alcohol consumption during pregnancy and for women who are planning a pregnancy.

Dr Vivienne Nathanson, Head of BMA Science and Ethics, said today: “The UK has one of the highest levels of binge-drinking in Europe and the highest rate of teenage pregnancies in Western Europe. Many women will not know they are pregnant during the early part of pregnancy, during which time they may continue to drink in their pre-pregnancy fashion with no awareness of the risk to their unborn child.”

There is proven risk that heavy drinking by pregnant women can cause these disorders in their children, says the BMA. The report states that evidence is continuing to emerge on the effects of low or moderate prenatal alcohol exposure and until there is clarification the only message is that it is not safe to drink any alcohol during pregnancy or when planning a pregnancy.

Dr Nathanson, added: “What is clear is that this is a complex concern and there is still so much that we do not know about this issue. It‘s important that women who drank alcohol before realising they were pregnant do not panic. But pregnant women should try to reduce their alcohol intake, or better still give up completely. If they are anxious they should talk to their doctor or midwife at their next antenatal appointment.

“We need to raise awareness of the emerging evidence on FASD among healthcare professionals. They need training and guidance on how to identify these disorders so that children are diagnosed quickly and get the help they need. Early intervention is crucial in decreasing the risk of additional problems commonly found in individuals affected by these disorders. These include mental health problems, disrupted school experience, alcohol and drug addictions. The lack of awareness and research in the UK on this subject, together with the complexity of the syndrome itself is leading to delays in diagnosis and referral.

“Healthcare professionals also need to get the message across to expectant mothers that consuming alcohol can cause irreversible harm to their unborn child. It‘s about giving people the right information so that they can act responsibly - and save children from completely preventable life-long disabilities.”

Recommendations in the report include:

  • There is an urgent need for further UK and international research on FASD.
  • Research should be undertaken to examine the relationship between different levels of prenatal exposure and the range of conditions associated with FASD.
  • The UK health departments should implement guidance and training programmes for healthcare professionals on the prevention, diagnosis and management of FASD.
  • Women who are pregnant, or who are considering a pregnancy, should be advised not to consume any alcohol.
  • Research should be undertaken to identify the most effective ways to educate the public about FASD and to alter drinking behaviour. This requires systematic studies that compare various universal strategies and their impacts across the different social groups.
  • All healthcare professionals should provide clear and coherent advice for expectant mothers and anyone planning a pregnancy on the risks of maternal alcohol consumption. This should be provided by GPs as part of routine clinical care and targeted at women of childbearing age. Members of the antenatal care team should provide continued advice and support to expectant mothers throughout pregnancy.
  • Any woman who is pregnant, or who is planning a pregnancy, and who has a suspected or confirmed history of alcohol consumption at low-to-moderate levels should be offered brief intervention counselling to help them stop drinking. This should occur at the earliest possible stage in a pregnancy and be considered as part of routine antenatal care where required.
  • Any woman who is identified as being at high-risk of prenatal alcohol exposure should be offered referral to specialist alcohol services for appropriate treatment. Any referral should be followed up and assessed at regular intervals.