Canada’s Alcohol Consumption Guidance: A Roundtable Discussion

This transcript has been edited for clarity. Erik Greb: I'm Erik Greb, editor of Canada and global news and features for Medscape. With me is Dr Peter Butt, clinical associate professor in the Department of Family Medicine at the University of Saskatchewan in Saskatoon. He has served as a consultant in addiction medicine in the Saskatchewan Health Authority for more than 24 years. Also with me is Dr Jürgen Rehm, a professor at the University of Toronto and a senior scientist at the Centre for Addiction and Mental Health (CAMH). Dr Rehm analyzes the scientific data needed to inform clinicians and policymakers of strategies to reduce harm related to alcohol, tobacco, and other drugs.Today we're going to discuss Canada's alcohol consumption guidance. In 2023, the Canadian Centre on Substance Use and Addiction published new guidance on alcohol and health. Instead of providing numerical limits for weekly and daily alcohol use, the guidance recommended that people consider reducing their alcohol use. It described a continuum of risk associated with weekly consumption and asserted that each additional standard drink radically increases the risk for adverse consequences such as cancer, heart disease, or stroke. The guidance noted that all types of alcoholic beverages entailed risk and advised that no matter where you are on the continuum of risk, less alcohol is better for your health. Many health organizations applauded the guidance for reflecting the contemporary evidence on cancer risk, but industry and some sections of the public have criticized the guidance for being too strict and not establishing a safe consumption level. I'd like to begin by asking both of you a question: How has Canada's alcohol consumption historically compared with that of other nations?Jürgen Rehm, PhD: Canada’s alcohol consumption has, for the past decades, always been larger than the average alcohol consumption in the world. Canada has always been above global consumption, and not by being slightly above and statistically significant, but really above. And we are talking about at least 50% of global consumption. Peter R. Butt, MD: Dr Rehm is entirely correct, and it's well embedded in Canadian culture, unfortunately. We have a phenomenon like beer leagues: people who play recreational hockey, for example, and then retire for alcohol beverages. It's often a part of not only sports, but also other social activities. To have a shift in consumption, we need to be cognizant that this is a cultural shift, that this is a process. It's not an event, and we have to be thinking strategically about a series of messages and approaches that will help people to make change. That's why we framed our most recent report as a guidance rather than guidelines, because people told us they didn't want to be told what to do. Quite clearly, they were tired, during the time of COVID, of directives. What they wanted was clear messaging, keeping it simple, telling them why it's important, as well as giving them ways to make the recommendations actionable.This was included in the guidance as well, and it's unfortunate that people, in part through the media, but in general, latched on to the two standard drinks per week as if it were an edict. That was not the case. As you've identified, the primary message was that we recommended to Canadians that the best recommendation is for them to reduce their alcohol consumption. And from a public health point of view, this is important because, arguably, given the exponential nature of the curve of harms, people going from 16 or 20 standard drinks per week, reducing by four or six, are going to improve their health much more than someone going from eight to six. But any reduction is positive, and that's the message that we really wanted clinicians to pick up — to reinforce reduction, that any little bit would improve a person's health and well-being.Rehm: Let me just give you one more example of comparison. Canadians are still drinking like they were in the last century in Europe. Lots of European countries have now reduced their consumption. Look, for example, at Italy. Some 30 years ago, on average, Italians consumed more than twice what Canadians did. Now they're consuming 50% less than Canadians on average. Our picture of the culture of Italy is completely wrong. It is that they're drinking red wine day in, day out, every meal, meaning twice a day, etc. But we have forgotten that the world evolves. While there is a drinking culture, it doesn't mean at all that a culture is cast in stone and every son drinks as their father did and every daughter drinks as their mother did. That is absolutely incorrect. We've seen swings in countries, in cultures, that are dramatic, going to one fourth of what the parents had been drinking before. Italy is one of those examples. Greb: Yes, the cultural question is pertinent. Thank you both for bringing that up. I'd also like to ask, what is the scientific evidence on which the guidelines are based?Butt: In this case, we relied greatly on some of the work done by Dr Kevin Shield, who was in Dr Rehm's shop, if you will, at CAMH — an extremely good epidemiologist. He helped us with the relative risk curves that were generated based upon the best evidence we could find for approximately 50 conditions that are well established as being associated with alcohol. In addition to that, he helped in drawing the absolute risk lines for 1-in-100 and 1-in-1000 levels of risk. That gave us both the curves, in terms of relative risk, and the absolute thresholds that helped us to define the spectrum or continuum of risk. And if you would like me to elaborate on that further, what we found is that — perhaps I should step back. We need to talk about risk and perception of risk here because it's highly variable from one person to another, which is why it was important for us to use international standards.If we think of risk from a public health point of view, involuntary exposure generally has an acceptable risk level of 1 death in 1 million (this is regarding clean water, clean air, and that sort of thing). When it comes to voluntary exposure, such as unprotected sex and so on, people will typically accept a risk level of 1 death in 1000. Historically, purely for socioeconomic and cultural reasons, the low-risk level for alcohol has been set much, much higher than that: 1 in 100. That risk threshold for alcohol for low-risk drinking has been used repeatedly, not based on health impacts, but rather because it's a special commodity. People look at it differently than they do other substances. And we end up in this bizarre situation where we have a Class 1 carcinogen that's intended to be ingested and has absolutely no warning labels on it and no sense of accountability since the 1980s, letting people know that they're putting themselves at risk regarding cancer. In addition, there are myths about the cardioprotective effects of alcohol, and the World Heart Federation has come out with a policy statement saying that alcohol is not good for the heart, period. So, there needed to be some way to address some of this mythology around alcohol and inform the consumer. Fundamentally, the consumer has a right to know. Once they're equipped with this information, the decision they make on how much they drink is entirely up to them. We respect that. If they choose to reduce, we'll help them. But it's important that they be informed, and this includes clinicians being aware that alcohol is a carcinogen. Alcohol is toxic not only to the liver, but also to the heart and other systems. The modeling was important in being able to define what the risk curves were and what the thresholds were. We use the years of life lost by both male and female sex. We use 1 in 1000 years of life lost to define low risk. It's equivalent to a voluntary level of exposure. This is a rational approach to alcohol. That was at two standard drinks per week. That's how we got the two standard drinks per week as low risk. And then we looked at the 1-in-100, that more traditional approach to risk-level acceptance with alcohol, and that came out at six standard drinks per week. What was interesting with that is that when we compared that amount of alcohol in Canadian standard drinks with what the Australians had determined to be low-risk drinking at the equivalent to six or seven standard drinks per week (they use different measures for a standard drink), it was fairly close. It was interesting. Really, one of the approaches was to revisit the strong evidence that has been there historically with a lens that was much more focused on the health impacts of alcohol, so that people were going to be better informed about the effect of alcohol on their health and well-being. Rehm: I'll give a little bit more explanation on what this approach entails in lay terms. Basically, we simulate a life and then we take a population of Canadians where we have already subtracted all the damage caused by alcohol. In that cohort of Canadians without alcohol, we simulate what would happen if they drank one glass, or one standard drink, every year. Then we look at how many people die of alcohol-attributable deaths, meaning deaths caused by alcohol — not only associated with alcohol, but also caused by alcohol. The counterfactual scenario is that without alcohol, these people wouldn't have died in this year. And then we can basically let the computer run. What happens if somebody drinks one glass per week, two standard drinks per week, three standard drinks per week, etc.? For the guidance, we had to finish after a few standard drinks per week because the probability of dying in a lifetime was already so high that you end up with those relatively low numbers. But the whole process is a simulation, a mathematical simulation incorporating all our knowledge about relative risks, and then the rest is done by the computer. That's a completely different approach than low-risk drinking guidelines had in the past. In the past, there was a number of gray-haired men (sorry, it was usually men) who sat around a table and said, "Oh, this is too much. This is not enough." And then they discussed, and there was no objective criterion for what risk is acceptable or what risk is not acceptable. It was what people thought was acceptable to the public, sort of a paternalistic view of the public. This type of guideline is what the Australians did, the Americans have done (that's a little bit more complicated, but they have done the same), and what some European countries have done.We have just done it for the Finns. You take the known risks of a country, the known mortality of a country, and add in models about what we know about the relationship between alcohol and risk. No more judgments by scientists, except they have to select the meta-analysis (because for most disease outcomes, you have different meta-analyses that they put into this model). But that is much less dependent on judgment than the prior way to deal with it. Greb: Yes, a more objective approach, rather than subjective.Rehm: Yes. Greb: What kind of social or industry resistance have the guidelines encountered? Butt: It has been significant. The industry resistance was well organized and significant at different levels. They would wind up “academics” to speak against them. The International Scientific Forum on Alcohol Research is funded by the industry. It has academics who research different aspects of alcohol. It is heavily biased in the favor of the industry and is frequently used as a reference point to debunk the findings. These are individuals who are not published in peer-reviewed journals because their research is funded by the industry, so it's not seen to be credible. It wouldn't pass peer review. But it comes out in the media, and so it creates confusion. It's a form of disinformation. This group has been exposed. There have been documentaries internationally, including one in France, regarding how they function and how they're funded. They invite each other to different symposia. They reference each other's work and so on. This is a very organized approach by the alcohol industry that is similar to the tobacco playbook that we experienced with cigarette smoking. It follows a pattern. The other aspect to the interference has been at the government level. Although Canada's Guidance on Alcohol and Health was funded by Health Canada, they have yet to formally endorse it or post the whole report on their website. It's best to go to the Canadian Centre on Substance Use and Addiction to get all the reports that are publicly available. This is where one sees interference at the political level. Of course, that has resonance here in Canada. Certainly, in Quebec, it was seen as an Anglo conspiracy against their culture. There are different ways of framing this. At that time, the Trudeau government was vulnerable. They needed the Quebec vote, so they were not going to do anything to disrupt that relationship with the voters in that province. It's nuanced. At that same time, we found that some ministers of health were willing to roll back some of the increases that were already scheduled on taxes for beer simply to gain political favor. There are ways that politicians will use alcohol to leverage votes that are patently unhealthy regarding the impact on the population. The lobby is very well placed. It's extremely well funded. It's one of the most sophisticated lobby groups in Canada. And they were active.But fortunately, we were able to get allies, such as some of the cancer societies, to come out quickly with ads and so on, building on the evidence that was being provided in the Canadian guidance regarding alcohol and cancer or other substances. This was gratifying because these people were completely unrelated to the project, read the evidence, reviewed it closely, and came out with campaigns. One of them was The Proof, an alcohol and cancer campaign that was brought out fairly quickly by BC Cancer. Rehm: I can give you two more examples. One was with the US guidelines. It became part of the political battle between Republicans and the prior government. There was a process by which the state agency said they would like to have guidelines using the same methodology as the Canadian guidelines. Obviously, the American mortality database is different from the Canadian one. They have more deaths of despair and more alcohol-related deaths, so it makes sense to do it based on the American data. For that reason, they charged a group, including Kevin Shield, who has been the main statistician for the Canadian guidelines (I was part of that group as well) to come up with the same modeling to inform the American dietary guidelines. What happened was that at that point, they already had enough lobbying in Congress, so Congress, even though this was the state trying to develop those guidelines, ended up charging a second group that did not check whether the panel had any conflict of interest. Some of those scientists had been working for the industry quite a lot. They said, "We want this from the National Academy, a second kind of guidelines, because Canadians like Dr Shield and Dr Rehm cannot make America great again, and this group is too close to abstinence." They couldn't find any conflicts of interest in our curriculum vitae regarding alcohol, so they charged us with accusations like, "They have worked in collaboration with the World Health Organization." That was in the official documents, and these official documents of the government were taken verbatim from two industry publications. So, we know that the official statement of the government was just taken from the industry. The second example I want to give is Canadian, and that has to do with the information. The idea of a guidance is to give people the information necessary to make their own decisions. If people choose to drink four drinks per day, so be it, but they should know what it entails. They should know how much of their life, in the end, they risk. That may not be a concern when you're 19 or 20, but at least we can warn them, and at least we can say, "Please consider this." The same idea was in a study done in the Yukon, where there was information on bottles, indicating that alcohol can cause cancer. Some of the Canadian guidelines of the time were also on bottles — nothing that was not information, just simple information. Nobody would deny that alcohol can cause cancer, not even the industry. But the pressure of the industry on the Yukon government was so big, and there was an official public threat of a lawsuit involving much more money than the budget of the Yukon, that the government said, "Okay, we’re going to take back this scientific study." It was a controlled scientific study. "We do not want to know those results. It risks too much of our state budget, so we have to take it back." That was, of course, not the best public relations for the alcohol industry, because they suffered quite a lot of image loss as a part of it. But it shows you how much the industry goes against even information, which entails no recommendations or anything — just the information that alcohol can cause cancer, which unfortunately most Canadians at that time didn't know was enough to stop a scientific study. Nothing else. That gives you an impression of how sensitive the industry is to anything that could hurt their profit model.Greb: Thank you very much for this contextual information. This is important to discuss, and I appreciate the contributions. So, how can general practitioners incorporate the guidelines into their daily practice? Rehm: A Canadian group was convened to make official guidelines for how doctors, particularly primary care physicians, should handle alcohol in their practices. This is to prevent alcohol use disorders. Obviously, alcohol causes a lot of damage other than alcohol use disorders, but alcohol use disorders are some of the risks that are considered. These guidelines came out 2 years ago, and at that time, the guidance document was fresh. The guideline process was 2 years long. There was a group of about 40 psychiatrists, family care physicians, and other healthcare professionals in this process. I was one of the chairs of this group, and we came up with this. We didn't want to change exactly when the new information or the guidance came out. So, once the guidelines for physicians were taken, we clearly saw that the guidance was at odds with those guidelines. As a group, we reconstituted ourselves and indicated that we would like to rewrite the guidelines, taking into consideration the new guidance. That came out last month in the Canadian Medical Association Journal. Basically, the recommendation is as follows: You should come up with a general statement like, "As a physician, I inform all of my patients about alcohol and I ask about alcohol. Would you be willing to talk about alcohol now?" Then, of course, the patient has a choice. If it is yes, then you ask, "How many standard drinks do you drink per week?" If that's above or below the guidelines, you make recommendations. That is a standard approach. If you go to the physician 10 times a year, you would not want to be screened every time about alcohol. But if you go to a physician once a year, you should be screened about alcohol, and these kind of talks would be a nice entry. The problem is that we know from surveys that most physicians do not really talk about alcohol, not enough, and a lot of physicians are not knowledgeable about this guidance. By making it part of the official guidelines, we hope to change the habits of Canadian physicians as well. That's the formal thing, but Peter probably has more experience as a physician and can tell you exactly how he thinks it can be done from his own practice. Butt: Thank you for the background, Jürgen. It's true; many patients and clinicians see this discussion about alcohol as an imposition. People come in with a particular problem they want to have addressed. Unless we move screening for lifestyle conditions and this sort of thing into the waiting room, with direct input into an electronic medical record, and bypass this clinical interface, it's going to be hard to bring this forward on a regular basis because it's not what people want. And clinicians are busy. Although screening and brief intervention evidence is strong in research settings, that's because it's structured and motivated. In the typical busy clinical setting, it tends to fall off. I think a triaged approach is important outside of doing more screening in the waiting room. Frankly, I get more screening in the waiting room at my dentist than I do at my family physician. He's very good, but it's simply the way the clinic is structured. A triaged approach would be to recognize that people's risk is highly variable. We have to start where people are at in a destigmatized approach.To provoke reflection, generally, we want people to reduce [their alcohol consumption]. We can ask about quantity and frequency. That's important. We can even screen for binge drinking because binge drinking is engaged in by all people who have an alcohol use disorder. But not everyone who binge drinks has an alcohol use disorder. A single question about that can be used to help decide whether one needs to be concerned about the presence of an alcohol use disorder. More broadly, however, we know that alcohol is probably having an impact on the individual's health and well-being. In general, we want people to reduce. Less is better. If they're drinking in that high-risk zone, both male and female, at the level of seven or more standard drinks per week, we would encourage them to reduce to a moderate risk zone of three to six standard drinks per week. That's a relatively low level of reduction for many people.Some won't be interested in it, however, and this is where it's important to link some of the risks that they have — whether it's a family history of breast cancer, a history of cardiovascular disease, or hypertension — to the fact that this is alcohol-associated. By reducing their alcohol consumption, they may be reducing their risk for this condition and the need for intervention.It's interesting because a woman might feel highly motivated to reduce her alcohol consumption knowing that it's associated with breast cancer, even without a family history. That information can be powerful. Whereas somebody who has high blood pressure may not be inclined to reduce their alcohol consumption much at all, given that they're already on medication, and it seems to be stable. They'll say, "Why should I bother with this? I'm okay," not, perhaps, appreciating that it's not just high blood pressure but other aspects of heart disease that are impacted by alcohol. This is where the education of clinicians so that they can properly inform patients is important. If they have a risk for an alcohol-associated condition, they should reduce to that low-risk zone. If they already have a condition that is potentially affected by or associated with alcohol, then we would recommend zero alcohol as an option: further reduction, with a goal of zero. We also need to be thinking about the benefits of alcohol reduction. It isn't just about making suggestions that people are going to find unpalatable, if I can use that word, but rather about thinking about the benefits that they get from a health point of view. With decreased alcohol, there's going to be decreased caloric consumption and weight loss. There'll be improved sleep and more energy. It'll improve cognition and memory. It'll improve mood. It decreases blood pressure, decreases blood sugar, decreases triglyceride levels, decreases liver fat, improves sex life. What's wrong with this list of improvements? It improves immune function, decreases cancer risk, decreases the risk for accidents and injuries, improves relationships, and there's financial savings. We should not be purveyors of doom and gloom and constrained lifestyles. This is a very positive message that we can convey to consumers, and that's something that we need to bring out. It helps to not only give clinicians information, but also to provide a positive approach to alcohol reduction. We don't want finger-wagging. We want them to say, "You know, you get a better life from this. There's something to celebrate here." And just as Europeans tend to have a more mature relationship with alcohol, we don't have to be stuck in adolescence. We can develop a more mature relationship as well, in time. Harm-reduction strategies and concrete approaches are important to provide as suggestions to help people to make these changes. Keeping track of how many drinks they have per week is important. What's the quantity? What's the frequency? What's this associated with? Why are they drinking? Why do they have this pattern? If they have a weekly drinking target to reduce to, the next challenge is to stick to the limit. If they can't stick to the limit, why is that? Is it more of an issue than they appreciated before? Are they subject to more social pressures? These things are important to unpack and support in a nonjudgmental way, because what we're asking them to do is change the nature of their relationship with alcohol. With any problematic relationship, we can only control what we do ourselves. So, we need to create some distance, look at the relationship more objectively, and think about ways that we can impact this. Eating before and while drinking helps to reduce the amount people consume, as well as choosing drinks with a lower percentage of alcohol. The hospitality industry has been good, as well as some of the other aspects of the industry, in producing 0% alcohol beer and 0% alcohol wine. Their chemists have been hard at work because this niche is expanding.Although, cynically, you can look at how some of these distilleries and breweries are putting 0% alcohol beer into grocery stores as a form of product placement, it also has nutrition labeling on it. All the pearl-clutching and handwringing and so on that the industry does about warning labels and how difficult it is to put warning labels on is false. Very quickly, when they recognized that they could get their product in grocery stores with 0% alcohol, they slapped on nutritional labeling. No problem whatsoever. They were financially motivated. So, there's a greater variety of lower-percentage alcohol beverages out there. Encouraging people to drink slowly in small sips, rather than the police procedurals — where everyone on television or in movies is pounding back their shots — is important. Drinking water helps to reduce hangovers. There's an additional benefit to spacing out those alcoholic beverages. Alternating between alcohol and nonalcoholic beverages and, as I mentioned, exploring alcohol-free products, are other ideas. There's a whole list of things that we can provide to people to help them make some of these changes.Again, the clinician can impart this in a way that's encouraging, supportive, and health-focused, rather than being an agent of constriction and prohibition, as we tend to be characterized by the industry. There's a range of things here that we can provide clinicians with. In addition to the information about that association between specific conditions and alcohol, we can help them work more effectively with people to help them to reduce consumption. Greb: Thank you both very much. This has been an excellent discussion that has provided a good overview of the current thinking on alcohol consumption, the challenges that clinicians and patients face, and how we can work together to overcome them. I'd like to thank Dr Butt and Dr Rehm for taking part in this discussion. And thank you for watching.Butt: Thank you very much. Rehm: Thanks a lot.