WHEN it comes to alcohol consumption, there’s a simple message to convey to patients: less is better. It’s an important message that clinicians need to share positively, by using the context of improving health and avoiding long term outcomes.

That’s the message from the guideline summary of the National Health and Medical Research Council (NHMRC) 2020 Australian guidelines to reduce health risks from drinking alcohol, published in the MJA.

The 2020 guidelines aim to be less ambiguous than those of previous decades. The recommendations are:

  • Healthy men and women are advised to drink no more than 10 standard drinks per week and no more than four standard drinks per day. This has been revised down from 14 drinks per week in the 2009 guidelines.
  • People under 18 years of age are advised not to drink at all.
  • Women who are pregnant or planning a pregnancy are also advised not to drink. The guidelines also advise that not drinking is safest for a woman who is breastfeeding her baby.

Although the guidelines were released a year ago, according to one of the summary’s authors, Professor Mark Harris, this guideline review is timely for GPs.

“It’s not the sort of thing that’s easy to deal with in telehealth, it really is something that’s better dealt with face to face,” said Professor Harris, from the Centre for Primary Health Care and Equity at the University of New South Wales.

Evidence on alcohol and health has changed significantly since the NHMRC last released guidelines in 2009.

“Evidence linking alcohol to cancer risk has strengthened, particularly at lower levels of consumption. Alcohol is classed as a Group 1 carcinogen by the International Agency for Research on Cancer, with strong evidence of increased risk of seven types of cancer: breast, colon and rectum, pancreas, liver, oesophagus, mouth, and throat and pharynx,” the authors wrote in the guideline summary.

Countries are revising their guidelines down, with the UK and France currently recommending no more than 10 or 11 standard drinks per week.

To reduce confusion, the guidelines also don’t discriminate between men and women.

“The amount of harm from drinking at somewhat higher levels is a bit different between males and females. But at these lower levels, there isn’t much difference. So, we tried to keep the message clear and simple. Same message for everyone,” Professor Harris explained.

It’s important to note that the guidelines aren’t about recommending abstaining.

“We are not saying that people should never drink. We’re saying that lower alcohol consumption is less risky,” Professor Harris said.

According to Professor Michael Farrell, Director of the National Drug and Alcohol Research Centre, it all comes down to the risks people are willing to take.

“The big challenge we have is the gap between what we assess as risks and what the population perceives to be a risk. There’s a huge gap,” he said.

For involuntary environmental toxins, there are tight guidelines to keep the risk of dying at no more one in a million.

However, as the new guideline summary states, people choose to drink alcohol despite knowing the risk.

“The 2009 guidelines … used drinking thresholds that would limit lifetime (absolute) risk of dying from an alcohol-related cause to less than one in 100 — similar to the lifetime level of risk of driving a car (data from the United States),” they wrote.

The 2020 guidelines have a similar goal.

“The committee retained the aim to ascertain the upper level of drinking that would limit lifetime (absolute) risk of dying from an alcohol-related cause to less than one in 100,” the authors stated.

When it comes to higher levels of alcohol consumption, there is more likelihood of acute harms such as liver injury and heart rhythm problems. However, it can be harder to relate to the risks for lower level drinking. Although there are some statistics from the guideline review that might help doctors have the conversation with their patients.

“For example, the risk of breast cancer in women increases by 12% per additional standard drink (10 g ethanol) per day, with elevated risks apparent from an average of one standard drink per day,” the authors wrote.

When clinicians are educating patients with this information, it helps to relate it to a condition they have.

“There are very clear messages around alcohol consumption and raised blood pressure. There are aspects of health that are very clear and unambiguous. Clinicians often try not to go in broadly, but they try to focus and have a link through a stated condition,” Professor Farrell advised.

Professor Harris hopes these new clearer guidelines will make it easier for GPs to communicate with their patients.

“We need to try to keep the message as clear and simple for our patients. The most important message is about the long term effects. On the balance of evidence, keeping your consumption to 10 drinks a week or less is the way to achieve that,” he concluded.

Also online first at mja.com.au

Research: Incidence and causes of early unplanned re-admission after hospitalisation with peripheral arterial disease in Australia and New Zealand
Woelk et al; doi: 10.5694/mja2.51329 … FREE ACCESS permanently.

Perspective: What doctors should consider before prescribing e-liquids for e-cigarettes
Ween et al; doi: 10.5694/mja2.51351 … FREE ACCESS for 1 week.

Podcast: Associate Professor James Branley and Associate Professor Lucy Morgan from Nepean Hospital, talking about how to save lives in the early days of COVID-19 symptoms … FREE ACCESS permanently.


The new guidelines make it simpler to talk with patients about alcohol harms
  • Agree (45%, 13 Votes)
  • Neutral (21%, 6 Votes)
  • Strongly agree (17%, 5 Votes)
  • Disagree (14%, 4 Votes)
  • Strongly disagree (3%, 1 Votes)

Total Voters: 29

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5 thoughts on “Talking about the booze: keep it simple. Less is safer.

  1. Dr Malcolm De Silva says:

    The pleasures of life are all to be enjoyed in moderation the “middle way/path”.Many great religious leaders have through their own experiences realised the futility of abstinence and ascetism.One has only to look around look around to see that those who have survived happily to a ripe old age are those who have enjoyed the pleasures of life alcohol,tobacco,sex ,air travel ,fast cars and women all in moderation.

  2. Sue Ieraci says:

    One of the difficulties with giving evidence-based advice in this area is that there are few studies looking at very low/occasional use of alcohol. This paper in BMJ open attempts to examine the issue in pregnancy : Low alcohol consumption and pregnancy and childhood outcomes: time to change guidelines indicating apparently ‘safe’ levels of alcohol during pregnancy? A systematic review and meta-analyses (https://bmjopen.bmj.com/content/7/7/e015410). The authors noted that “Evidence of the effects of drinking ≤32 g/week in pregnancy is sparse. As there was some evidence that even light prenatal alcohol consumption is associated with being SGA and preterm delivery, guidance could advise abstention as a precautionary principle but should explain the paucity of evidence.”

    The suggestion to “drink no more than 10 standard drinks per week and no more than four standard drinks per day” can have limited use, if the question is “can I have a small glass of wine once or twice a week (or a month) without endangering myself or my foetus. The “it’s best to abstain altogether” answer is paternalistic – we should be able to say “there is no sound evidence that less than ten grams per week is harmful.”

    It makes no sense to say that there is “no safe level” of carcinogens because there are few – if any – areas of life that carry zero% risk. Even breathing and eating are not 100% safe.

  3. Anonymous says:

    Actually it is not our job to tell people how to live their lives. Happy to pick up the pieces of bad decisions. That’s what we trained for. We should not make moral decisions about people get sick. Our job is to care for them not to judge them.

  4. Anonymous says:

    10 drinks a week is too much
    4 drinks a day is too much
    People don’t understand what a std drink is.
    A “glass of wine” is usually filled to the top.
    Keeping it simple ?

  5. Dr Colin Mendelsohn says:

    Very sensible and reasonable guidelines for alcohol harm reduction. There are strong parallels with tobacco harm reduction (THR) but perversely THR is not supported by the NHMRC or AMA although smoking kills far more people.

    – Abstaining from the drug (alcohol-nicotine) is not required
    – ‘There are clear health benefits’ for both
    – People choose to drink (vape) despite knowing the risks’
    – ‘lower alcohol consumption (vaping) is not risk-free but is less risky’

    One difference is that alcohol is a class 1 carcinogen, but nicotine is not carcinogenic.

    The scientific evidence does not support this double standard. Tobacco harm reduction and alcohol harm reduction both reduce risks and save lives. But one is supported and the other is not. Why?

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