Abstract
Aim
This paper contrasts health-oriented low-risk drinking guidelines (LRDG) with social drinking marketing and popular advice on the amount of alcohol to be provided for social occasions. The questions addressed include: What is the underlying evidence base and rationale for health-oriented vs. socially-oriented drinking guidelines? What are the recommended amounts of alcohol per person from the LRDGs and from popular advice?
Method
This paper draws on existing research, archival data, web sites, print media, and key informant interviews. The focus is on recent information on LRDGs and social drinking indicators in Canada, the U.S., Australia, and the U.K.
Results
There is extensive epidemiological research indicating the associations between drinking pattern and risk for chronic disease and trauma as well as certain potential health benefits from drinking small amounts regularly. This body of evidence is one resource for government or medically-sanctioned LRDGs in many jurisdictions. In contrast, for those planning social events where liquor is served, information is available from the hospitality industry, retailers, and liquor control boards. While some overlap exists between these two sources of information, in some contexts normative recommendations support drinking at potentially dangerous levels.
Discussion
The inconsistency among the different guidelines highlights one of the challenges of conveying health information on a drug that is integrated into social life and used extensively. It also reflects a siloed approach to alcohol policy – where retailing and harm reduction practices are managed by different sectors of government that seldom reflect a coordinated response.
Keywords: Alcohol, low-risk drinking guidelines, popular advice, responsible drinking messages, and social drinking
Store clerk: It comes to $166.41
Michael [Scott]: Alright, you're the expert…tell me, is this enough to get 20 people plastered?
Store clerk: 15 bottles of vodka? Yeah, that should do it.
Quote from The Office [1]
Introduction & Context
In October 2007 the World Cancer Research Fund and the American Institute for Cancer Research released their second report on Food, Nutrition, Physical Activity, and the Prevention of Cancer. They suggest – on a population level – the portion of the population that drink above the recommended amounts be reduced by one third every 10 years; and on an individual level, that the consumption of alcoholic drinks be limited to no more than two drinks a day for men and one drink a day for women. The author noted that they would have been inclined to recommend lower levels were it not for the association between a modest level of consumption and reduced risk of cardiovascular disease among older adult consumers [2].
In contrast, an article in the Toronto-based Globe and Mail (2009) outlined what a host should stock for a New Year's Eve party of 12 guests: six bottles of champagne, six bottles of wine, 24 bottles of beer, and one bottle each of vodka, gin, rye whiskey, scotch, and rum [3]. Our estimate is that this provides approximately 14 standard drinks [13.6 grams of ethanol = 1 standard drink] per person for the event.2 The article was likely to have been intended as a joke, but was not signaled as such. Only one letter to the editor, in the print version of the newspaper, drew attention to the health and safety risks of heavy consumption and labeled the article irresponsible.
Alcohol is consumed by 50–90% of the adult population in many western cultures and is thoroughly integrated into social life. In contrast, there is extensive growing evidence that social problems, trauma, and chronic disease are associated with its use [4–7].
Low-risk drinking guidelines (LRDGs) have the potential to balance some of this ambivalence about alcohol use. LRDGs have been around for some time, with examples from Greek philosophers dating back to 375 BC [8]. Evidence-based guidelines around the world have been created to assert a certain level of acceptability around drinking. At the same time, they can be justified as a basis for raising the profile of alcohol on precautionary grounds. These guidelines however, also create a number of challenges, including balancing the risk of chronic disease and trauma – where drinking thresholds associated with risks will vary by the individual [9]; determining which caveats to include in documents designed to be user-friendly; and how to handle competing interests – e.g., public health and the alcohol industry. A persistent challenge is that the guidelines' upper threshold may be out-of-line with the reality of the drinking culture, where some subsections of the population typically surpass the daily recommended maximums on a typical drinking day. This may be cause to dismiss the guidelines for being too strict. When this occurs, it is tempting to allow popular advice and social norms to trump epidemiological evidence.
Concurrent with the proliferation of LRDGs, there has been extensive alcohol marketing and promotion, including the use of many forms of electronic media, sponsorship, Internet and product placement [10, 11]. Alcohol is often presented as an essential ingredient for any social gathering and for those planning events, advice is available from numerous sources on the amount of alcohol to have on hand.
This paper contrasts health-oriented LRDGs with advice from retailers and the hospitality industry on the amount of alcohol to be provided for social occasions. The following questions are addressed: What is the underlying evidence base and rationale for health-oriented vs. social occasion drinking guidelines? Given that LRDGs from different jurisdictions are not identical in recommended upper thresholds, what are the range of standard drinks and upper limits per person from the LRDGs and the contrasting popular advice?
Methods
Several methods were used in this pilot study, including web site searches, research literature, consulting colleagues, and brief email interviews. They are summarized by foci: 1) low risk drinking guidelines and 2) social drinking indicators.
First, for the LRDGs, we collected information on current guidelines for Australia, Canada, the United Kingdom and the United States. It was beyond the scope of the paper to undertake a comprehensive review of international drinking guidelines; the guidelines reviewed here have the most relevance to the Canadian experience.
Second, the information on social drinking indicators, including responsible drinking messages3, was collected by conducting a systematic search of web and print documents and consulting with hospitality organizations and licensed vendors using a brief email interview.
Information on social drinking indicators was collected through a systematic search of websites and print materials and focused on information from Canadian and U.S. sources. Key words and phrases for the search were identified by the research team based on a preliminary scan of the literature; see Table 2A for a list of key words and phrases. An online search was completed using Google. The scope of the search was expanded by conducting a manual search of all provincial liquor board web sites and current issues of several popular North American entertainment magazines. To be selected for review, articles had to provide quantitative advice on the amount of alcohol to stock or serve at a social function. Articles and postings from discussion-based forums were excluded unless advice was offered by an expert who was affiliated with the site.
Table 2A.
Summary of Survey on Social Drinking Indicators
| Key words and phrases | serving alcohol at a party, planning a party, how to host a party, how much alcohol should I buy for a party, how much alcohol do I need for a party, and hosting a party/cocktail party/bachelorette/bachelor party/BBQ/dinner party/social event | ||
|---|---|---|---|
| Source6 | Type of source: | Number of sources | Number of articles |
| Information webpage: | 6 | 14 | |
| Entertaining website: | 8 | 19 | |
| Canadian Provincial Liquor Boards: | 7 | 18 | |
| Entertaining Magazine: | 4 | 6 | |
| Newspaper Article: | 2 | 2 | |
|
|
|||
| Total: 5 | 27 | 59 | |
|
| |||
| Country of origin | Canada: 27 USA: 17 Unknown: 15 |
||
| Event specific information and recommendations | Number of events reviewed (N) | Public responsibility messages (%) | Standard drinks per person7 per event | Standard drinks per person7 per hour | ||||
|---|---|---|---|---|---|---|---|---|
| Range | Mode | Mean | Range | Mode | Mean | |||
| Party (generic): | 24 | 71 | 1.25–9.00 | 3.00 | 4.5 | 1.00–2.50 | 1.25 | 1.50 |
| Cocktail party: | 11 | 55 | 1.50–9.75 | 2.50 | 3.75 | 0.75–5.00 | 1.25 | 2.00 |
| Dinner party: | 9 | 56 | 2.00–3.00 | 3.00 | 2.75 | 0.75–1.50 | 1.00 | 1.00 |
| Luncheon: | 6 | 100 | 1.50–3.00 | 1.75 | 1.75 | 0.75–1.50 | 0.75 | 1.00 |
| Wedding: | 4 | 25 | 1.25–5.00 | na | 3.00 | 0.50–1.75 | 1.00 | 1.00 |
| Special event (milestone birthday, stag(ette): | 5 | 40 | 2.50–14.00 | na | 7.5 | 1.00–2.75 | na | 1.75 |
| Total (all events) | 59 | 63 | 1.25–14.00 | 3.00 | 4.00 | 0.50–5.00 | 1.25 | 1.50 |
* Factors mentioned by licensed vendors that affect the quantity of alcohol served include: length of event, time of day of the event, gender; with women drinking 25% less than men, cash or host bar, ethnicity, type of event, age group, and the food being served
Many of the sources contained multiple articles. Data was collected from 59 articles, from a total of 27 sources.
Number of drinks has been rounded to the nearest quarter drink
Furthermore, a brief email interview inquiring about individual service and responsible drinking messages was distributed to hospitality organizations and licensed retailers. Licensed vendors were identified by entering the keywords: hospitality and restaurants, along with the respective province name: Ontario, British Columbia, Nova Scotia, and Alberta into Google. The first 100 licensed vendors yielded by the Ontario search results were selected to receive the brief email interview. A similar process was used in order to identify vendors in each of the other provinces as well as hospitality organizations. Twenty vendors in each of the other provinces as well as 22 hospitality organizations were selected to receive the brief email interview.
An a priori template was developed for classifying information gathered for LRDGs and social drinking indicators. Extensive working tables were developed and the results were reviewed by the co-authors. Summary data were then assembled into the tables presented below.
Results
Tables 1A and 1B provide an overview of LRDGs and the caveats for males and females across four countries: Canada, the United States, Australia, and the United Kingdom. The recommended limits of alcohol consumption vary, ranging from a daily maximum of 14g to 42g of pure alcohol for women and 20g to 56g for men. Weekly limits range from 98g to 168g for women and 190.4g to 272g for men. As well, each of the four countries identifies a different definition for a standard drink (UK: 8g; Australia: 10g; Canada: 13.6g4; U.S.:14g).
Table 1A.
A comparison of low risk drinking guidelines in North America
| Variable | Canada - CAMH (updated 2007) [15] | Canada - CARBC (2007) [12] | Canada - Educ'Alcool (2007) [16] | Canada- National Low Risk Drinking Guidelines (2010) [8] | US - NIAAA (2010) [17] | US - Dept of Agriculture and Dept of Health & Human Services (2010) [18] | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| M | F | M | F | M | F | M | F | M | F | M | F | |
| 1. Amount of alcohol per standard drink | 13.6 g | 13.6g | 13.6g | 13.6g | 14g | 14g | ||||||
| 2. Standard drinks per day (g of alcohol) | No more than 2/day (27.2g) | No more than 2/day (27.2g) | No more than 4/day (54.4g) | No more than 3/day (40.8g) | No more than 3/day (40.8g) | No more than 2/day (27.2g) | 0–3 /day (40.8g) | 0–2 /day (27.2g) | No more than 4/day (56.0g) | No more than 3/day (42.0g) | No more than 2/day (28.0g) | No more than 1/day (14.0g) |
| 3. Total per week (g of alcohol) | No more than 14/week (190.4g) | No more than 9/week (122.4g) | No more than 20/week (272g) | No more than 10/week (136g) | No more than 14/week (190.4g) | No more than 9/week (122.4g) | No more than 15/week (204g) | No more than 10/week (136g) | No more than 14/wk (196g) | No more than 7/week (98g) | No more than 14/wk (196g) | No more than 7/week (98g) |
| 4. Comments and caveats | LRDG don't apply if:
|
Avoid intoxication; Choose abstinence in situations where "no alcohol" is the most sensible option; Put limits on drinking frequency and amounts. | Have at least 1 day/week where no alcohol is consumed. If you are a woman of child-bearing age, do not drink alcohol from the time you decide to become pregnant, or if you think you might be pregnant. To avoid intoxication, males: max = 5 on a single occasion; females: max = 4 on a single occasion. | Have some non-drinking days/ week. Do not drink when pregnant or planning to be pregnant, operating a vehicle/ machinery, engaging in physical activity, working or making decisions, caring for others, taking medications/ drugs, suffering from an illness or if below the legal drinking age. On a single occasion, do not exceed: 3 drinks for women and 4 drinks for men. Only drink at these upper guidelines occasionally, not on an empty stomach, never more than 2 drinks in a 3 hour period, alternate with caffeine free, nonalcoholic beverages, and avoid risky situations. | Safest to avoid alcohol if you are: -taking medications that interact with alcohol; -managing a medical condition that can be made worse by drinking -pregnant or trying to become pregnant | Alcoholic beverages should not be consumed by those who cannot restrict their alcohol intake, women of childbearing age who may become pregnant, pregnant and lactating women, children and adolescents, individuals taking medications that can interact with alcohol, those with specific medical conditions and those planning to drive, operate heavy machinery or participate in activities requiring attention, skill or coordination. | ||||||
Table 1B.
A comparison of low risk drinking guidelines in Australia and the UK
| Variable | Australia - NHMRC (2009) [13] | UK - Department of Health (updated 2009) [19] | UK - Scottish Government (updated 2009) [20] | |||
|---|---|---|---|---|---|---|
| M | F | M | F | M | F | |
| 1. Amount of alcohol per standard drink | 10g | 8g | 8g | |||
| 2. Standard drinks per day (g of alcohol) | No more than 2 on any day, reduces lifetime risk of harm from alcohol-related disease or injury (20g). Max= 4 on a single occasion, reduces risk of alcohol-related injury arising from that occasion (40g). | No more than 3–4/ day, regularly (24–32g) | No more than 2–3/ day, regularly (16–24g) | No more than 3–4/day (24–32g) | No more than 2–3/day (16–24g) | |
| 3. Total per week (g of alcohol) | No more than 14/wk (140g) | No more than 28/wk (224g) | No more than 21/wk (168g) | No more than 21/wk (168g) | No more than 14/wk (112g) | |
| 4. Comments and caveats | At higher levels of drinking, lifetime risk of alcohol-related disease increases more quickly for women and the lifetime risk of alcohol-related injury increases more quickly for men. For women who are pregnant, planning a pregnancy, or breastfeeding, not drinking is the safest option. For those under 18, not drinking is the safest option. | Regularly = drinking every day or every other day of the week. Take a break for 48 hours after a heavy drinking session. Don't mix alcohol with any kind of medication; Don't mix alcohol with recreational drugs. Be careful if you have mental health problems such as depression, as alcohol can make these worse. | None | |||
Each of the eight organizations across the four countries profiled in these tables reports its low-risk guidelines, based on the most recent evidence, to minimize the harm from alcohol consumption as it relates to health and social outcomes. The rationale provided for these guidelines also include beliefs about educating citizens [12] and informing future policies and prevention initiatives [13]. The drinking recommendations vary as the evidence base sourced for each of the guidelines differs. The caveats (Tables 1A and 1B, section 4) indicate conditions when the guidelines do not apply.
Table 2A provides summary information from our survey of social drinking indicators. A total of 27 websites and print ads were surveyed for advice on social drinking indicators resulting in 59 articles providing social drinking advice. The websites were colourful, the recommended alcohol stock was easy to locate on the page and alcohol was always considered in the social occasion planning process. As shown in Table 2A, advice was categorised by event type; most of the social drinking advice on websites and in print media pertained to generic parties (N=24). There was a wide range in the recommended number of standard drinks to serve, both between and within the different event types. Overall, the popular advice recommends serving the fewest number of standard drinks per person (N=1.75) at luncheons and the highest number of standard drinks per person (N=7.5) at special events such as stag(ette) parties or parties celebrating a milestone birthday. However, the number of standard drinks recommended per person per hour ranged, on average, from one standard drink at weddings, luncheons and dinner parties to two standard drinks at cocktail parties.
Several of the sources had social responsibility messages, tips or guidelines, however this varied greatly by event type with these messages being most associated with luncheons (100%) and least associated with weddings (25%) and special events (40%). None of the websites or print materials made reference to the LRDGs nor did they quantify in their materials what it means to “drink/enjoy/consume responsibly”. Furthermore, some web pages offered conflicting advice. For example, in one area of a webpage, a maximum of 1–2 drinks per person per event was recommended. However, this quantity was surpassed by the amount of alcohol suggested by the same website's online party calculator5. Furthermore, many of the sites made serving recommendations based on etiquette and social norms, rather than evidence-based safe drinking levels as contained in the LRDGs. For example, at events such as a back yard BBQ or bachelor/ette party there was an expressed expectation that alcohol be served, often in abundance. The provision of alcohol was often associated with being a “good host/ess”. The websites and print media were both reinforcing and creating expectations of social norms around alcohol service and use. Images of smiling, happy guests and the use of bright colours all create associations between the service of alcohol and a successful party and host.
Table 2B summarises the advice obtained from a small scale email survey of hospitality organizations and licensed vendors; overall 182 retailers were contacted and 19 responded. Responses were organised according to the type of event, publicly accessible vs. private function, typically hosted by the responding organization. The advice provided by bars and restaurants, which host publicly accessible events, suggests a more conservative range of standard drinks per person compared to that provided by hosts of private events. It was recommended that between two and five standard drinks be served per person at publicly accessible events, with the average recommendation being 3.25 standard drinks per person. For private functions the recommended number of drinks per person ranged from 1.25 to 10 with an average recommendation of 5.25 standard drinks per person. However, the average recommended number of drinks per person per hour is similar for both private (1.5 drinks) and publicly accessible events (2.0 drinks). Again, several respondents indicated they had a social responsibility message as part of the information provided to their clients, however this differed depending on whether it was a publicly accessible venue or a private event.
Table 2B.
Licensed Canadian Vendors- Summary of Survey on Individual Service and Responsible Drinking Messages
| Vendor specific information and recommendations | Number of licensees reviewed (N) | Public responsibility messages (%) | Standard drinks per person9 per event | Standard drinks per person9 per hour | ||||
|---|---|---|---|---|---|---|---|---|
| Range | Mode | Mean | Range | Mode | Mean | |||
| Restaurant, Bar or Pub (publicly accessible events): | 13 | 31 | 2.00–5.00 | 3.00 | 3.25 | 1.00–3.00 | 2.00 | 2.00 |
| Banquet hall, conference centre, private club or caterer (private functions): | 6 | 838 | 1.25–10.00 | na | 5.25 | 0.75–3.00 | 1.50 | 1.50 |
| Total (all vendors) | 19 | 47 | 1.25–10.00 | 3.00 | 4.00 | 0.75–.00 | 2.00 | 1.75 |
If the required messaging in Ontario on the risks associated with drinking during pregnancy are removed the rate of private functions promoting responsible drinking messages decreases to 50%
Number of drinks has been rounded to the nearest quarter drink
Discussion
This paper explores and contrasts recommendations for alcohol use from two main sources of information: LRDGs, which are informed by research on the health and social damage from alcohol; and social drinking indicators and marketing which are informed by hospitality and business motives. Nevertheless, as shown in the accompanying tables, there is overlap between these two sources of information. While the social drinking indicators data shows a wide range of alcohol amounts, the modal amount per event – assuming one event per day – is not dissimilar from the upper daily limits from some of the more liberal LRDGs. Furthermore, when taking event length into consideration, popular advice typically does not promote drinking more than 1–2 drinks per hour and events where food is served are typically associated with lower alcohol consumption. Normative recommendations most commonly promote drinking above the LRDGs at private functions and special events. It should be noted that the normative recommendations discussed in this pilot study are likely a conservative estimate of the amounts of alcohol actually served at social functions. This is due to the fact that hospitality organizations and alcohol retailers may be susceptible to response bias. These respondents may not accurately or willingly divulge the actual quantities of alcohol they typically serve at social functions, especially if those amounts are excessive. This may also be the reason for the low response rate for the brief email interview.
It is possible that normative recommendations are simply allowing for a greater selection in beverage choice, however many of the sources examined accounted for differences in beverage preference and recommendations were often qualified by statements suggesting hosts keep their guests' glasses full from the moment they arrive. Also, responsible drinking messages are not commonly promoted alongside these special events and are typically vague from a harm reduction standpoint. The messages promoted among the sources examined did not directly indicate that the use of alcohol can be damaging to one's health. Instead, these messages focused on having the individual manage the risks associated with alcohol use by encouraging “responsible use” and the avoidance of drinking and driving. This is one illustration of how, by design or default, health information or advice is separated from alcohol promotion even within a government agency. The quality of these messages may reflect the fact that few Canadian provinces have regulations that mandate the use of these messages; this is an opportunity for government to initiate provincially-regulated standardized messaging.
The inconsistency among the different guidelines highlights one of the challenges of conveying health information on a drug that is so extensively integrated into social life; it also reflects a difference in interests. While some LRDGs are influenced by alcohol industry stakeholders, the guidelines primarily aim to reduce alcohol-related harm; whereas the socially oriented recommendations promote hospitality and aim to generate revenue from the sale of alcohol. This dichotomy can be exceptionally challenging for government monopolies where liquor boards are responsible for the retailing of alcohol which involves providing hospitality advice to consumers while still upholding their social responsibility mandates through a harm reduction approach. It is important for policy makers to facilitate a coordinated response that considers both retail and harm-reduction practices in order to deliver a more consistent message when it comes to alcohol consumption.
In addition to the other challenges, these guidelines typically do not provide concrete advice or specific guidance on how a person drinking above the guidelines should go about curtailing their drinking; therefore, they may have greater utility in clinical and counselling settings where this advice can be offered, rather than as a prevention tool for dissemination to general populations.
As indicated by Babor et al. (2010), there is no evidence to date to suggest these guidelines had an impact on drinking levels or patterns in the population where they were promoted [6]. For example, in Ontario, alcohol consumption and high-risk drinking has increased since the extensive promotion of the LRDGs in 1996 [14]. However, it is feasible that the increase in consumption and high-risk drinking might have been even greater without wide dissemination of the guidelines. Since to date there is no evidence that the guidelines alone will have substantial impact on alcohol consumption, other resources should be considered in order to reduce the harm from alcohol. Guidelines may be a complementary tool when implemented in combination with other interventions with greater potential for impact, such as minimum prices and controls on outlet density [6].
Social drinking indicators may have an impact on consumption, although to our knowledge their specific impact at the population level has not been evaluated. Further work is needed to determine the quantity of alcohol provided and consumed in various settings. Key informant studies might explore the rationale and expectations on the part of hosts and attendees about alcohol availability, where they obtain social hosting information, whether they use different `authorities' for different contexts, how they judge these sources, and which source/content combinations are likely to have the greatest impact on the behaviour of which consumers.
Acknowledgements
We thank Kate Vallance for the tabulations of official alcohol sales in Canada, and Claire Wilkinson for information on the Australian guidelines. Thomas Greenfield's participation was undertaken as part of Center Grant P30 AA005595 (PI T. Greenfield) form the U.S. National Institute on Alcohol Abuse and Alcoholism (NIAAA) to the Alcohol Research Group of the Public Health Institute.
With regard to Norman Giesbrecht's contribution, it is noted that support to the Centre for Addiction and Mental Health for the salary of scientists and infrastructure has been provided by the Ontario Ministry of Health and Long Term Care.
The views and opinions expressed in this paper are those of the authors and do not necessarily reflect the policies or positions of the persons or institutions acknowledged.
Footnotes
We are assuming 341 ml bottles of 5% strength beer, 750 ml bottles of champagne, table wine [each 12% ethanol] and 750 ml bottles distilled spirits [40% strength].
Responsible drinking messages refer to messages that promote “drinking of alcoholic beverages in moderation; drinking that does not lead to loss of health or other harm to the drinker or to others” [5]
In Canada a standard drink is 13.6 grams of ethanol, or one 341 ml of 5% strength beer, one 142 ml glass of 12% strength table wine, or one 43 ml portion of 40% strength spirits.
A Party Calculator is a tool that estimates the amount of alcohol required for an event upon entering the event details such as number of guests, duration, preferred beverage type etc.
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