A news clip from a local Hamilton TV station went viral on social media recently when a St. Catharines, Ont., man was asked on air what he thought of Canada’s Guidance on Alcohol and Health, a new set of guidelines focusing on safer alcohol consumption. The man, identified only as Dino in subsequent reporting, described the guidelines as “heartbreaking” after learning the definition of “low-risk” would be two drinks per week. “Two drinks a week? What’s that gonna do for you?” he rhetorically posed.
Dino, speaking outside of a Beer Store location, shared that he had just bought 12 beers and that he generally drinks six beers a day.
Canada’s new guidelines state that any further consumption increases the risk of head and neck, liver, breast and colorectal cancers. A standard drink, defined as 17 mL of pure alcohol, is equivalent to a bottle of beer, a glass of wine or a shot of spirit (Table 1). This guidance replaces guidelines from 2011, which stated 10 standard drinks for women and 15 drinks for men per week was low risk.
Guidelines such as these are documents published by governments, non-governmental organizations, medical associations and professional organizations that compile academic literature and expert opinion on topics of interest to clinicians and the public, providing a trusted, peer-reviewed source for the latest in medical treatments and counselling. Canada’s Low-Risk Alcohol Drinking Guidelines (LRDGs), funded by Health Canada, began in July 2020 and was published by the Canadian Centre on Substance Use and Addiction. It includes national experts in addictions medicine, public health and preventative medicine, epidemiology and internal medicine.
After sharing his shock at the new guidance, Dino was asked what he believed should be the recommendations. “Two drinks a week? … That doesn’t even get you through a day … You’re at home, you should be able to have four beers. That’s just two more. I mean, I’ll have six but four is a fair number,” he exclaimed, inadvertently demonstrating a common theme in medicine. Dino’s personal “guidelines” illustrate a concept taught to medical students – patients often underestimate their substance use. Medical students are taught to be skeptical of patient self-reports of alcohol use.
Dino, on learning that the recommendations include alcohol consumption in all locations, shared his anger at being told what to do: “Why are there guidelines anyway? Why are they gonna tell me how much I can drink at home?”
Patients do welcome screening about alcohol use, so long as it is done non-judgmentally.
The disconnect between Dino’s understanding of what is “recommended” versus what experts believe will result in a lower disease burden based on the latest evidence presents a challenge for patients and their care providers, contributing to underreporting of substance use.
Existing literature has shown that patients underreport their substance use due primarily to stigma around alcohol use. Family and friend reports of an individual’s alcohol use tend to be more accurate. Research indicates that on average, however, patients do welcome screening about alcohol use, so long as it is done non-judgmentally.
Reading further into the guidelines, the authors advocate for a harm-reduction approach to alcohol use. They emphasize that “any reduction in alcohol use can be beneficial,” wrote Alexander Caudarella, Chief Executive Officer of the CCSA, in the report.
Harm reduction is a philosophy of care emphasizing that patients should make their own medical decisions in collaboration with their health-care team. It is an approach to patient encounters respecting patients’ abilities and desires to make lifestyle changes, encouraging patients to make healthier choices while respecting their right to make individual choices. It originated in reducing spread of HIV in intravenous drug users, and is an approach applied to many areas of medical recommendations, including safer sexual practices, diet and physical activity.
Highlighting the harm-reduction aspects of the guidelines would clearly go a long way to helping Dino understand how to make safer choices for his health. Clinicians must understand the reasons patients provide inaccurate self-reporting of substance use and use evidence-based strategies to make a non-judgmental space for patients to share. Understanding the factors that bring patients to hear two beers a week as “being told what to do” can help build bridges between clinicians and patients, contributing to a healthier lifestyle.