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.
It will take a slow uphill campaign similar to that waged against tobacco to turn things around. It is cultural; alcohol came over on the Mayflower. Many recovering alcoholics will mention that they thought it must be okay because the government sells it in their own stores. Prevention is better than treatment. Many alcoholics started very young and as a consequence drank at their problems rather than facing and learning to stand and deal with them as the rest of society has to.
The following articles debunk the idea that alcohol sales are good for government coffers. The statistics are old and likely have only grown worse with COVID but the author came up with a deficit of $3.7 billion in the 2020 Report. Education and prevention have to be started as early as grade 7 when children are most vulnerable.
Canadian Substance Use Costs and Harms 2015-2017 – CSUCH Report 2020
in 2017, substance use cost Canadians almost $46.0 billion, led to over 275,000 hospitalizations and contributed to the loss of nearly 75,000 lives. This report presents the estimates of the costs of substance use in Canada from 2015 to 2017 using the most reliable, up-to-date data sources and methods according to the following categories:
• Cost type (healthcare costs, lost productivity costs, criminal justice costs and other direct costs);
• Substance (alcohol, tobacco, cannabis, opioids, other CNS depressants, cocaine, other CNS
stimulants and other drugs)
At-a-glance – The alcohol deficit: Canadian government revenue and societal costs from alcohol, Shrek A, Health Promotion and Chronic Disease Prevention in Canada, 40[5/6] 2020 May/June: https://doi.org/10.24095/hpcdp.40.5/6.02
Societal costs, including health care, economic loss of production, criminal justice and other direct costs, were substantially higher than government alcohol-related revenue in all provinces and territories in 2014. Nationally, government revenue of $10.9 billion is below the societal cost of $14.6 billion estimated by the CSUCH study, resulting in an annual, ongoing alcohol deficit of $3.7 billion. It is clear we are robbing Peter to pay Paul.
A few comments and thoughts.
1. I agree around the framing and marketing in the media of the guidelines being a shock to the general public. A few people I work with were upset by it and see it more as absurd than informative.
2. I have also heard many members of the general public within the “old” “low risk” drinking guidelines of under 14 per week for men and 10 per week for women be shocked by this data and reduce their use. As a society, we deserve to know the actual risks of substances just like cigarettes. The impact of the CCSA document suggest that the findings were a shock to the general public.
3. Addiction medicine has only taken off in the last 15-20 years in terms of anti craving medication, counseling for alcohol use, etc etc. Historically alcohol support has occurred outside of medicine. In medicine, these harm reduction conversations have only become more wide spread in the last 3-5 years. How many doctors will coach patients to move from non palatables to hard liquor to beer as they try to reduce the seizure risk? It is a process that is just starting.
They say it takes 17 years for evidence to become practice so all is not lost.
4. I agree different messaging is required for people who drink. Different coaching for health care providers so that can best serve the individual, where ever they are at.
Harm reduction is an essential part of any health care providers practice. And Public health has to do better than spreading a one size fits all approach for health care. I have patients and friends where some were shocked at the framing, and others took the “less is better” messaging to heart and have improved their individual health.
Thank you for your thoughtful, poignant and necessary article sharing the poor public impact of the CCSA document. This is certainly the case in my addiction medicine practice.
Maybe they need (or another organization needs) to create a document on “healthier drinking” or harm reduction for people who drinking more than the old low risk guidelines. In my clinical practice, I still share the old documents for those people.
Most importantly, I also hope people also have access to documents that share the accurate risks of all substances and at risk behaviors. (Eg cannabis, cocaine, injection drug use, obesity, sugar, crystal meth, opioids, exercise use or lack there of etc etc).
I believe the only way to come up with an approach more effective for society, an approach that also fosters trust in the health care system as a whole is to convey accurate risks. Skewed partial truths like “alcohol is legal” “Cannabis is safer than alcohol” or “any more than 2 drinks a week is bad” have unintended harms.
Regardless of how large organizations decide to frame their messaging, I hope they are able to create spaces for accurate risks to be shared.
As someone working with people who drugs for over a decade, this document was the first place I have ever seen the accurate risks of alcohol shared in one place comprehensively. Even as “clinical expert”, I had no idea the data was so strong. And these are all risks that the scientists doing research in field have known for decades.