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Alcohol and Health in Canada: A Summary of Evidence and Guidelines for Low-Risk Drinking Authors Dr. Peter Butt College of Family Physicians of Canada Dr. Doug Beirness Canadian Centre on Substance Abuse
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Alcohol and Health in Canada: A Summary of Evidence and Guidelines for Low-Risk Drinking Authors Dr. Peter Butt College of Family Physicians of Canada Dr. Doug Beirness Canadian Centre on Substance Abuse Mr. Frank Cesa Health Canada Dr. Louis Gliksman Centre for Addiction and Mental Health Ms. Catherine Paradis Éduc alcool Dr. Tim Stockwell Centre for Addictions Research of B.C. Disclaimer: The views expressed in this document are those of the authors and do not imply any broader agreement or approval by their employing or host institutions. November 3, 2010 Acknowledgements The authors are indebted to the following organizations and individual for the valuable feedback received in response to an earlier consultation draft of this document: Alberta Health and Wellness Brewers Association of Canada British Columbia Ministry of Healthy Living and Sport Canadian Association of Chiefs of Police Canadian Association of Liquor Jurisdictions Canadian Centre on Substance Abuse Canadian Vintners Association Centre for Addiction and Mental Health Centre for Addictions Research of British Columbia Dr. Louise Nadeau Éduc'alcool Health Canada MADD Canada National Native Addiction Partnership Foundation Nova Scotia Department of Health Promotion and Protection Public Health Agency of Canada Spirits Canada Association of Canadian Distillers The Student Life Education Company Yukon Liquor Corporation The authors also wish to thank the Canadian Centre on Substance Abuse (CCSA) for providing travel costs, expenses, a venue and a first-class secretariat to support our work. Carolyn Franklin hosted the meetings on behalf of CCSA and single-handedly coordinated, facilitated and provided a secretariat to enable the work to take place over a period of several months. The authors owe her a huge debt of gratitude for making the process enjoyable, congenial and constructive. We thank our three expert peer reviewers, each drawn from different continents of the world and each sharing unique perspectives and special expertise in alcohol epidemiology, prevention and policy. The Working Group also acknowledges with thanks the help of Matilda Stockwell in the preparation and presentation of some of the tables in the report. November 2010 Page 2 Alcohol and Health in Canada: A Summary of Evidence and Guidelines for Low-Risk Drinking Executive Summary This document is intended for health professionals, policymakers, communication experts and members of the public who may wish to be informed about low-risk use of alcohol, whether for themselves or to advise others. The summary of evidence provided here and the proposed Canadian Guidelines for Low-Risk Drinking have both been developed by an independent expert working group with members drawn from Canadian addiction research agencies. The document has also been significantly strengthened by a process of international peer review conducted by three invited experts on alcohol epidemiology and feedback from concerned individuals and organizations. These Guidelines have been developed against a backdrop of: a 14 percent increase in per capita alcohol consumption in Canada since 1996; different advice provided by authorities in different Canadian provinces; a rapidly growing scientific literature that identifies both significant risks and some possible benefits from low levels of alcohol consumption; and a national strategy document, Reducing Alcohol-related Harm in Canada: Towards a Culture of Moderation - Recommendations for a National Alcohol Strategy (National Alcohol Strategy Working Group, 2007). The Guidelines are intended to provide a basis upon which to advise all Canadians on how to minimize risks from their own and others' drinking in this complex environment. The Guidelines also acknowledge and support personal choices made by many Canadians to not drink alcohol at all, whether for cultural, spiritual, health-related and/or other personal reasons. They are not intended to encourage individuals or communities who choose to abstain to take up drinking. High-risk groups and situations are also discussed in which either abstinence or extreme caution with alcohol intake is advised, including alcohol use during pregnancy, by youth, in association with high-risk activities (such as driving) and in combination with medication and/or other drugs. No separate guideline is provided for older Canadians, given that the major risk factors for this group (being physically unwell, using medication and reduced tolerance) are highlighted under November 2010 Page 3 other guidelines. While the Guidelines are intended for all Canadians, we recommend the need for consultation with Aboriginal groups for a more nuanced community- and population-specific approach in order to more fully address their sometimes diverse and complex circumstances. The Guidelines identify three distinct types of risk from drinking: situations and individual circumstances that are particularly hazardous (e.g., women who are pregnant or planning to become pregnant, teenagers, persons on medication) and for which abstinence or only occasional light intake is advised; increased long-term risk of serious diseases caused by the consumption of alcohol over a number of years (e.g., liver disease, some cancers); and increased short-term risk of injury or acute illness due to the overconsumption of alcohol on a single occasion. There are different ways to establish recommended low-risk drinking guidelines for those who choose to drink. A complication with assessing a low-risk level of alcohol consumption for the long-term risk of serious diseases is that there is also evidence of health benefits in relation to diabetes and some cardiac diseases. The approach employed here was to identify a level of average daily consumption where overall net risk of premature death is the same as that of a lifetime abstainer because potential health risks and benefits from drinking exactly cancel each other out. While there are non-fatal health and social problems associated with drinking, the level of consumption for the risk of these has been less well quantified and so only studies on risk of death from all causes presently provide a means of balancing costs versus benefits for individual drinkers. Relative rather than absolute risks of adverse outcomes were assessed (i.e., the focus was on whether risk increased for individuals because of their drinking rather than whether they were already at high or low risk before drinking due to other characteristics). In relation to short-term harms that can happen during or after a particular drinking occasion, an emphasis is placed on reducing risk by using good judgement about settings and associated activities that are consistent with low-risk drinking, as well as restricting the amount consumed per occasion. November 2010 Page 4 Average long-term consumption levels as low as one or two drinks per day have been causally linked with significant increases in the risk of at least eight types of cancer (mouth, pharynx, larynx, esophagus, liver, breast, colon and rectum) and numerous other serious medical conditions (e.g. epilepsy, pancreatitis, low birthweight, hemorrhagic stroke, dysrythmias, liver cirrhosis and hypertension). Risk of these individual medical conditions increases with every increase in average daily alcohol consumption over the long term. In addition, there are a number of serious medical conditions caused entirely by hazardous alcohol use, including alcohol dependence syndrome, alcoholic psychosis, nervous system degeneration, alcoholic polyneuropathy, alcoholic myopathy, alcoholic cardiomyopathy, alcoholic gastritis, alcoholic liver diseases and hepatitis, alcohol induced pancreatitis, fetal alcohol syndrome, and alcohol toxicity and poisoning. Low levels of consumption have also been associated with health benefits resulting in lower risks of illness and premature death, notably from ischemic heart disease, ischemic stroke and diabetes. Systematic reviews and meta-analyses that estimated risk of death from all causes were identified to help define a balance point of average daily consumption where the likelihood of harms and benefits exactly cancel each other out. A review by et al (2006) indicated that maximum health benefits from drinking could be obtained with an average daily consumption of between a half and one standard drink per day. This meta-analysis was singled out as having made significant efforts to define the comparison group as comprising lifetime abstainers. The zero-net-risk point compared with lifetime abstainers at which the risks and benefits balanced each other out was two drinks on average per day for women and three for men. Reviews of emergency room studies that quantified the relative risk of injury as a result of consumption within the previous six hours were also examined. However, there are some methodological problems with these studies. It was evident that risk of injury was significant at low levels of consumption when the context of drinking was not controlled (i.e., the place, company and activity). Because drinking context adds a great deal to the risk of injury on a given drinking occasion, it was considered that most of these studies did not provide accurate estimates of the risk from alcohol consumption. November 2010 Page 5 Recommended Guidelines for Low-Risk Drinking Note: These Guidelines are not intended to encourage people who choose to abstain for cultural, spiritual or other reasons to drink, nor are they intended to encourage people to commence drinking to achieve health benefits. People of low bodyweight or who are not accustomed to alcohol are advised to consume below these maximum limits. Guideline 1 Do not drink in these situations: Guideline 2 If you drink, reduce longterm health risks by staying within these average levels: Guideline 3 If you drink, reduce shortterm risks by choosing safe situations and restricting your alcohol intake: Guideline 4 When pregnant or planning to be pregnant: Guideline 5 Alcohol and young people: When operating any kind of vehicle, tools or machinery; using medications or other drugs that interact with alcohol; engaging in sports or other potentially dangerous physical activities; working; making important decisions; if pregnant or planning to be pregnant; before breastfeeding; while responsible for the care or supervision of others; if suffering from serious physical illness, mental illness or alcohol dependence. Women Men 0 2 standard drinks* per day 0 3 standard drinks* per day No more than 10 standard drinks No more than 15 standard per week drinks per week Always have some non-drinking days per week to minimize tolerance and habit formation. Do not increase drinking to the upper limits as health benefits are greatest at up to one drink per day. Do not exceed the daily limits specified in Guideline 3. Risk of injury increases with each additional drink in many situations. For both health and safety reasons, it is important not to drink more than: Three standard drinks* in one day for a woman Four standard drinks* in one day for a man Drinking at these upper levels should only happen occasionally and always be consistent with the weekly limits specified in Guideline 2. It is especially important on these occasions to drink with meals and not on an empty stomach; to have no more than two standard drinks in any three-hour period; to alternate with caffeine-free, non-alcoholic drinks; and to avoid risky situations and activities. Individuals with reduced tolerance, whether due to low bodyweight, being under the age of 25 or over 65 years old, are advised to never exceed Guideline 2 upper levels. The safest option during pregnancy or when planning to become pregnant is to not drink alcohol at all. Alcohol in the mother's bloodstream can harm the developing fetus. While the risk from light consumption during pregnancy appears very low, there is no threshold of alcohol use in pregnancy that has been definitively proven to be safe. Alcohol can harm healthy physical and mental development of children and adolescents. Uptake of drinking by youth should be delayed at least until the late teens and be consistent with local legal drinking age laws. Once a decision to start drinking is made, drinking should occur in a safe environment, under parental guidance and at low levels (i.e., one or two standard drinks* once or twice per week). From legal drinking age to 24 years, it is recommended women never exceed two drinks per day and men never exceed three drinks in one day. * A standard drink is equal to a 341 ml (12 oz.) bottle of 5% strength beer, cider or cooler; a 142 ml (5 oz.) glass of 12% strength wine; or a 43 ml (1.5 oz.) shot of 40% strength spirits (NB: 1 November 2010 Page 6 Canadian standard drink = ml or g of ethanol)a summary of the Canadian Guidelines for Low Risk Drinking recommended by the expert working group is provided above. Recommendations are also made for improving the knowledge base from which drinking guidelines can be developed. A comprehensive set of communications strategies is suggested to promote low-risk drinking in Canada, including the use of interactive Internet technology, brief interventions by health professionals and consideration of the introduction of standard drink labels on alcohol containers. Were all Canadian drinkers to consume within the proposed Guidelines, it is estimated that alcohol-related deaths would be reduced by approximately 4,600 per year. A substantial proportion of all alcohol consumed in Canada (i.e., at least half) is presently consumed in excess of low-risk drinking guidelines similar to those recommended in this document (Stockwell et al, 2009). It is unrealistic to expect that the provision of drinking guidelines alone will have any significant effect if implemented in isolation. Low-risk alcohol guidelines can, however, support the implementation of other evidence-based regulatory and preventative interventions (Loxley et al, 2004; Babor et al, 2010). November 2010 Page 7 Table of Contents Introduction 10 Underlying Philosophy and Purpose of the Guidelines 10 Definitions of Key Terms Used in the Guidelines 12 Drinking Patterns 14 Figure 1. Dimensions of alcohol use and related harms 15 When Complete Abstinence is Usually Recommended 17 Alcohol use, pregnancy and breastfeeding 17 Alcohol and driving 19 Alcohol use and youth 19 Other high-risk activities 20 Alcohol use and medication 21 Alcohol use and other psychoactive substances 22 Alcohol dependence 23 Harms and Benefits of Alcohol Use 24 Alcohol Consumption and the Risk of Serious Medical Conditions 25 Table 1. Percentage change in long-term relative risk by average standard drinks per day for 12 illnesses that are similar for men and women aged below 70 years 26 Table 2. Percentage change in long-term relative risk by average standard drinks per day for five illnesses for men aged below 70 years 27 Table 3. Percentage change in long-term relative risk by average standard drinks per day for five illnesses for women aged below 70 years 28 All-Cause Mortality Studies: Balancing Risks and Benefits of Drinking 29 Table 4. Risk thresholds in Canadian standard drinks estimated for men and women compared with lifetime abstainers 29 Alcohol Consumption and Risk of Injury and Acute Illnesses 30 Table 5. Relative risks by number of Canadian standard drinks consumed three hours before an injury 32 Alcohol Consumption and Risk of Social Harm 33 Limits for Daily Low-Risk Consumption: Issues to Consider 35 Limitations of the Research Evidence 37 Underreporting of personal alcohol consumption 37 Failure to take account of heavy drinking episodes 38 Misclassification of former and occasional drinkers as lifetime abstainers 38 Failure to control for confounding effects of personality and lifestyle factors independent of alcohol 39 Importance of Drinking Frequency 40 Recommended Guidelines for Low-Risk Drinking 41 Guideline 1: Do not drink in these situations 41 Guideline 2: If you drink, reduce long-term health risks by staying within these average levels 42 Guideline 3: If you drink, reduce short-term risks by choosing safe situations and restricting your alcohol intake 42 Guideline 4: When pregnant or planning to be pregnant 42 Guideline 5: Alcohol and young people 43 November 2010 Page 8 Table of Contents (continued) Towards a Culture of Moderation 43 Comparisons with other Low-Risk Drinking Guidelines 44 Recommendations for Future Research 46 Recommendations for the Communication of the Guidelines 46 References 48 Appendices 61 Appendix 1: Members of Canadian Low-Risk Alcohol Guidelines Expert Advisory Panel 61 Appendix 2: Provincial Drinking Guidelines in Canada 62 Appendix 3: Details of the Quantitative Meta-Analysis from which the Information on the Dose-Response Relationships was Extracted 63 Appendix 4: Risk of Premature Mortality and Level of Average Alcohol Consumption Estimated with and without Stricter Definition of Lifetime Abstainer 64 November 2010 Page 9 Introduction Every week new research is published and discussed in the media that reports either positive or negative health consequences from drinking alcohol. In order to support Canadians who wish to make healthy choices about their own drinking and who might wish to give sound advice to others, the Canadian Guidelines for Low-Risk Drinking attempt to make sense of this new research and give balanced advice. The Guidelines have been developed by an independent expert working group with members drawn from addiction research agencies from across Canada (see Appendix 1 for list of members). The establishment and support for the expert working group was provided by the Canadian Centre on Substance Abuse (CCSA) as part of a core recommendation of the National Alcohol Strategy Working Group Report (2007), a policy framework developed under the joint leadership of CCSA, Health Canada and the Alberta Drug and Alcohol Abuse Commission. The Guidelines were informed by work commissioned by CCSA and undertaken by Dr. Jürgen Rehm, Senior Scientist, and colleagues at the Centre for Addiction and Mental Health and University of Toronto. Members of the expert committee also contributed independent systematic reviews and analyses on selected topics. It is hoped that health professionals, policymakers, educators, communications experts and concerned members of the public will use this document to inform a variety of clinical and health promotion activities intended to reduce alcohol-related harm. Underlying Philosophy and Purpose of the Guidelines Examples of guidelines for the low-risk use of alcohol can be found across millennia representing different perspectives and concerns. The Greek philosopher Eubulus provided one of the more colourful examples in 375 BC (cited by Ball et al, 2007): Three cups do I mix for the temperate; one to health, which they empty first, the second to love and pleasure, the third to sleep. When this bowl is drunk up, wise guests go home. The fourth bowl is ours no longer, but belongs to violence; the fifth to uproar, the sixth to drunken revel, the seventh to black eyes, the eighth is the policeman s, the ninth belongs to biliousness, and the tenth to insanity and the hurling of furniture. November 2010 Page 10 In the sixth century AD, Saint Benedict (as cited by Verheyen, 1949) recommended that members of his order restrict themselves to one hemina of wine per day (about half a litre of wine with a lower alcohol content than is usual today). In modern times, guidelines for low-risk drinking have been published by different authorities in a number of countries and make a variety of recommendations. There is some evidence of a trend towards lower recommended limits over time (National Health and Medical Research Council, 2008). In Canada, there has also been diversity in the levels recommended between provinces, perhaps reflecting different cu
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