A brief history of the UK’s low risk drinking guidelines

Summary

• The current low risk drinking guidelines were introduced in 2016, set at 14 units
• The current guidelines replaced a set of recommendations derived from evidence dating back to the 1980s
• The move to update the drinking guidelines stems from an inquiry calling for a review of new evidence that had emerged on the health risks associated with drinking, and also on levels of public understanding of the guidelines

Introduction

The current low risk drinking guidelines were introduced in 2016, the product of an inquiry initiated by the House of Commons Science and Technology Committee plus years of discussion between the UK’s Chief Medical Officers and three independent groups of experts.

Set at 14 units, the regular drinking guidelines brought parity between male and female recommended low risk consumption levels. However, the UK’s history of drinking guidelines stretches back more than 30 years.

This briefing provides an overview of how the guidelines came to be, and their evolution over time.

What are the current guidelines?

In 2016, the Chief Medical Officers for the UK regions published a new set of alcohol consumption guidelines, split into three main categories: 1) regular drinking; 2) single drinking episodes; and 3) drinking in pregnancy [1].

The official UK alcohol consumption guidelines – on regular drinking

This applies to adults who drink regularly or frequently i.e. most weeks. The Chief Medical Officers’ guideline for both men and women is that:

• To keep health risks from alcohol to a low level it is safest not to drink more than 14 units a week on a regular basis.
• If you regularly drink as much as 14 units per week, it is best to spread your drinking evenly over 3 or more days. If you have one or two heavy drinking episodes a week, you increase your risks of death from long term illness and from accidents and injuries.
• The risk of developing a range of health problems (including cancers of the mouth, throat and breast) increases the more you drink on a regular basis.
• If you wish to cut down the amount you drink, a good way to help achieve this is to have several drink-free days each week.

UK Chief Medical Officers’ Low Risk Drinking Guidelines

The official UK alcohol consumption guidelines – on single drinking episodes

This applies to drinking on any single occasion (not regular drinking, which is covered by the weekly guideline). The Chief Medical Officers’ advice for men and women who wish to keep their short term health risks from single occasion drinking episodes to a low level is to reduce them by:

• limiting the total amount of alcohol you drink on any single occasion
• drinking more slowly, drinking with food, and alternating with water
• planning ahead to avoid problems e.g. by making sure you can get home safely or that you have people you trust with you.

The sorts of things that are more likely to happen if you do not understand and judge correctly the risks of drinking too much on a single occasion can include:

• accidents resulting in injury, causing death in some cases
• misjudging risky situations, and
• losing self-control (e.g. engaging in unprotected sex).

Some groups of people are more likely to be affected by alcohol and should be more careful of their level of drinking on any one occasion for example those at risk of falls, those on medication that may interact with alcohol or where it may exacerbate pre-existing physical and mental health problems.

If you are a regular weekly drinker and you wish to keep both your short and long-term health risks from drinking low, this single episode drinking advice is also relevant for you.

UK Chief Medical Officers’ Low Risk Drinking Guidelines

The official UK alcohol consumption guidelines – on pregnancy

The Chief Medical Officers’ guideline is that:

• If you are pregnant or think you could become pregnant, the safest approach is not to drink alcohol at all, to keep risks to your baby to a minimum.
• Drinking in pregnancy can lead to long-term harm to the baby, with the more
  you drink the greater the risk.

The risk of harm to the baby is likely to be low if you have drunk only small amounts of alcohol before you knew you were pregnant or during pregnancy.

If you find out you are pregnant after you have drunk alcohol during early pregnancy, you should avoid further drinking. You should be aware that it is unlikely in most cases that your baby has been affected. If you are worried about alcohol use during pregnancy do talk to your doctor or midwife.

UK Chief Medical Officers’ Low Risk Drinking Guidelines

Past guidelines

The current guidelines replaced a set of recommendations that were originally based on evidence submitted in a report by the Royal College of Physicians (RCP) to the UK government in 1987, in turn based on guidelines written by the Health Education Council. This report acknowledged that there was ‘insufficient evidence to make completely confident statements about how much alcohol is safe’ [2]. However, in making the judgement that the public needed to be informed about the risks associated with drinking, it suggested the following guidelines for ‘sensible limits’ of drinking [3]:

• Men – no more than 21 units per week
• Women – no more than 14 units per week
• Both men and women should have two or three alcohol-free days
• The total number of weekly units should not be drunk in one or two bouts

These guidelines were based on the underlying assumption that they did not apply to children and adolescents, to adults who had particular health problems or a family history of alcohol problems or to women during pregnancy.

In 1995, the recommendations were reviewed by an inter-departmental government working group, following the publication of scientific evidence stating that small amounts of alcohol may have a protective effect against coronary heart disease. Despite this finding, leading health experts – including the British Medical Association (BMA) [4] and the RCP – came to the conclusion that the 1987 guidelines were still the most appropriate means of communicating to the public the risks associated with drinking [5].

Furthermore, it was agreed that clauses should be added to take account of short term episodes of heavy drinking which was argued to ‘often correlate strongly with both medical and social harm’. The Sensible Drinking report called for the establishment of daily benchmarks to help individuals ‘decide how much to drink on single occasions and to avoid excessive drinking with its attendant health and social risks’ [6].

These guidelines recommended that regular consumption of three to four units of alcohol a day for men and two to three units for women ‘accrue significant health risk’, and advised against the consumption of alcohol for at least 48 hours after an episode of heavy drinking, in order to allow affected parts of the body to recover fully.

The transition from weekly to daily guidelines effectively increased the weekly limit for men by 33% and women 50%, exceeding the previous threshold for low risk drinking as presented by the medical profession. These changes were met with concern by members of the health community, as they contradicted the evidence base and seemingly recommended ‘safe’ levels of drinking that were in fact over and above what was deemed a ‘low risk’ threshold [7].

The categorisation of weekly alcohol units consumed into low / moderate and high risk levels became part of the recommended guidelines.

How the current guidelines were made

In December 2011, the House of Commons Science and Technology Committee launched an inquiry into the current UK drinking guidelines, calling for a review of the evidence that had emerged since 1995 on the health risks associated with drinking, and also on levels of public understanding of the guidelines. The Committee received evidence from a number of organisations, including public health interest groups and the alcohol industry.

The Science and Technology Committee report, published in January 2012, concluded:

There are sufficient concerns about the current drinking guidelines to suggest that a thorough review of the evidence concerning alcohol and health risks is due. The Department of Health and devolved health departments should establish a working group to review the evidence and advise whether the guidelines should be changed. In the meantime, the evidence suggests that (i) in the context of the current daily guidelines, the public should be advised to take at least two alcohol-free days a week; and (ii) the sensible drinking limits should not be increased [8].

The Coalition Government’s Alcohol Strategy, published in March 2012, accepted a need to improve the UK public’s poor understanding of and adherence to the current drinking guidelines, with around a third of adult men and a fifth of adult women drinking above the recommended limits. In order to tackle this problem, the government tasked the UK’s Chief Medical Officers with overseeing a review of the drinking guidelines, with the mission of:

… tak[ing] account of available science on how we can best communicate the risks from alcohol, improving the public’s understanding of both personal risks and societal harms. This will include whether separate advice is desirable for the maximum amount of alcohol to be drunk in one occasion and for people over 65. This could complement the existing guidelines for young people and women who are pregnant or trying to conceive [9].

After two-and-a-half years of discussion led by the UK CMOs, involving three independent groups of experts considering the evidence on the health effects of alcohol, the new guidelines were published in January 2016 [10].

It was recommended that the guidelines should revert to a weekly, rather than a daily, recommended limit. A weekly format was seen to be an easier benchmark for people (most of the population) who do not drink alcohol daily.

The most notable change from the 1995 guidelines was the reduction in men’s weekly recommended alcohol units to that of women, 14 units per week. Part of the reasoning for this decision was that:

… when drinking within the low risk guidelines, overall levels of risk are broadly similar for men and women; although the risks of immediate harms such as deaths from accidents are greater for men; longer term harms from illness are greater for women [11].

The new evidence also indicated the following [12]:

• The benefits for heart health of drinking alcohol are less and apply to a smaller group of the population than previously thought. The only group with potential to have an overall significant reduction in risk of death in the UK is women over the age of 55 (especially if drinking around five units a week or less);

• There are adverse effects from drinking alcohol on a range of cancers – this was not fully understood in 1995 – and these risks start from any level of regular drinking and then rise with the amounts of alcohol being drunk.

The expert groups stated that their advice on regular drinking “is based on the evidence that if people did drink at or above the low risk level advised, overall any protective effect from alcohol on deaths is overridden, and the risk of dying from an alcohol-related condition would be expected to be around, or a little under, 1% over a lifetime”, comparable to risks from other everyday activities, such as driving [13].