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Low-risk Drinking Guidelines Around the World: An Overview of the Current Situation

Paula, Tassiane C.S. MS*; Chagas, Camila MS*; Martins, Leonardo B. PhD; Ferri, Cleusa P. PhD*,‡

Author Information
Addictive Disorders & Their Treatment: December 2020 - Volume 19 - Issue 4 - p 218-227
doi: 10.1097/ADT.0000000000000225

Abstract

BACKGROUND

Guidelines for low-risk drinking have been used as a strategy in many countries to reduce health problems and provide parameters to alcohol consumption within the limits considered less harmful to health. The different standards adopted in these guidelines such as “standard drink,” “unit,” or just “drink” are often for the public to fully understand and incorporate into their daily life.1 In general, a standard drink contains a specified amount of pure alcohol (ethanol).2 The concept of the standard drink was introduced as a means of providing information to drinkers to help them measure their alcohol consumption and is often used in alcohol awareness or education campaigns as a way of communicating official guidelines regarding low-risk drinking and being used to describe drinking patterns.2 Finding a simple way to quantify alcohol consumption and disseminating information on low-risk drinking limits are central to any activity aimed at reducing alcohol-related harm.2

A 2016 study indicated that countries that adopt guidelines for low-risk drinking present information mainly to the young adult population and have different alcohol consumption standards for men and women.3 However, specific guidelines aimed at older adults (over 65) are usually not produced, although alcohol consumption by older people is potentially more harmful than that of adults in general. A recent meta-analysis gathered data on 599,912 current drinkers and indicated that the limit for low-risk alcohol consumption for adults (regardless of sex) was 100 g of alcohol per week, but this level of consumption was not associated with less risk to older people.4

The characteristics of alcohol consumption also differ according to the income level of countries. In 2016, mortality rates caused by alcohol and the alcohol-attributable disease burden were higher in low-income countries (LICs) and lower-middle-income countries (LMICs) than in upper-middle-income countries (UMICs) and high-income countries (HICs). However, alcohol dependence was more prevalent in HICs.5 These different impacts can be explained, in part, by income, but also by the context of alcohol consumption, access to health care, and quality of life.5

A study published in 20163 gathered data from 37 countries on government definitions of low-risk drinking and a standard drink. They included 51 countries from the World Health Organization (WHO) list of countries supplemented with 24 others countries (using the author’s judgement). Our study adds substantially to this publication by including all of the countries in the world and updating the information provided in the 2016 study. We explored the guidelines for low-risk drinking (in grams of alcohol per day, week, and occasion) for adults, older adults, and other vulnerable groups. In addition, we analyzed differences in the guidelines for specific groups in the population (usually stratified by age and/or sex) according to income level and assessed whether or not the countries had a national action plan for alcohol.

METHOD

This study aims to identify how a standard drink is defined in different countries and the existence of guidelines defining low-risk drinking in each country according to different population groups: adults, older adults, and vulnerable groups (adolescents, children, pregnant and breastfeeding women, vehicle or machine operators, individuals with pre-existing health conditions, and those using of prescribed medication). The list of countries of the WHO6 was used that identifies 194 countries. We prioritized web sites of Ministries of Health for information on policies for the use of alcohol and other drugs, and of the Nutrition Guidelines in each country.

Search Strategy

A search for the terms “alcohol” and “drinking” and “guidelines” was conducted on government sites in each country (Ministry of health policies on alcohol and other drugs and nutritional guidelines). For each country, we first tried to identify the existence of a definition of a standard drink and low-risk consumption. Second, we searched for the terms “older adults” and “elderly”. In addition, a search was conducted for the same definitions for a standard drink and the vulnerable groups described above. The information about the action plan was taken from the Global Alcohol Report (2018).5 When finding >1 source with different recommendations, we opted by the most recent document. The search was conducted from February to May 2020.

Extraction and Data Management

Two researchers extracted the data independently, using a predefined table. The following information was included for each country if available: (1) definition of standard drink (in grams of alcohol); (2) definition of low-risk drinking for male and female individuals and for older people (when available); (3) country’s income level; (4) existence of a national alcohol action plan; (5) specific guidance on alcohol consumption for vulnerable groups (adolescents, children, pregnant and breastfeeding women, vehicle or machine operators, individuals with pre-existing health conditions, and those using prescribed medication);. Information that was not available in Portuguese, English, or Spanish was assessed using Google translator.

RESULTS

There are 194 countries in the world, of these 56 (29%) are HICs, 55 (28.3%) UMICs, 49 (25.2%) LMICs, and 32 (16.5%) LICs, and 2 countries (1%) do not have a definition of the level income (Cook Island and Niue).

Of these 194 countries, 29.9% adopted a guideline/definition of a standard drink and 35.1% presented guidelines for low-risk drinking. Most of the countries that had a definition of a standard drink were HICs, followed by UMICs, LMICs, and LICs (54.3%, 36.8%, 7.4%, and 1.5%, respectively).

The majority (62%) of the information obtained about guidelines for low-risk drinking was extracted from Governmental Policy Reports on the use of alcohol and other drugs, and the other 38% was obtained from Governmental Health Agencies. Most countries that provided low-risk drinking guidelines (60.3%) are HICs, followed by (32.8%) UMICs and (6.9%) LMICs. No guidelines were found in LICs.

Regarding national action plans on alcohol, only 31% had a current action plan; of these, 34% were HICs, 32% UMICs, 27% LMICs, and 7% LICs. Among all countries, 23.2% have an alcohol action plan and 8 (4.1%) had a total ban policy.

In addition, it is important to highlight that not finding standard drink definitions or low-risk drinking guidelines does not necessarily mean that they do not exist, but just that they were not found (Table 1).

TABLE 1 - Number of Countries According to the Level of Income With Information Standard Drink Definition, Guidelines for Low-risk Drinking, and Action Plan National
n (%) Guidelines Low-risk, n (%)
Total of Countries (N=194) Standard Drink (N=67) Adults (N=58) Older Adults (N=10) Action Plan (N=44)
HIC 57 (29.4) 37 (54.4) 35 (60.3) 9 (90.0) 15 (33.3)
UMIC 55 (28.4) 27 (36.8) 19 (32.7) 1 (10.0) 14 (31.1)
LMIC 49 (25.3) 5 (7.4) 4 (6.9) 0 (0.0) 12 (26.7)
LIC 31 (16.0) 1 (1.5) 0 (0.0) 0 (0.0) 3 (6.7)
Unknown 2 (1.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (2.2)
HIC indicates high-income countries; LIC, low-income countries; unknown: countries were not identified by Word Bank; LMIC, low-middle income countries; UMIC, upper-middle-income countries.

Standard Drink

The standard drink ranged from 8 to 20 g in different countries. Sixty-five percent of these countries, regardless of the level income, do not present information about standard drinks adopted nationally. However, most countries (28.4%) used 1 standard drink ranging from 10 to 12 g.

Guidelines for Low-risk Alcohol Consumption

Considering all the 194 countries, 30% present low-risk drinking guidelines for adults and only 5.7% have guidelines for older adults.

For Adults

Among the countries that present a guideline, the majority of these (84.5%) have different guidelines for adult men and women. Among those that indicate the difference between the sexes, 73.5% recommend that alcohol consumption for women should be half of the amount recommended for men; and the remaining 26.5% recommend that alcohol consumption for women should be less than half of the amount for men (between 25% and 34%) (Appendix Table S1, Supplemental Digital Content 1, http://links.lww.com/ADTT/A11). Albania, Chile, France, Grenada, Guiana, Kazakhstan, Netherlands, Japan, and the United Kingdom do not make a distinction by sex.

Some countries adopted a guideline for low-risk drink per day, others per week, and either per 1 occasion. Of the 58 countries that presented a guideline for low-risk drinking, 86.2% presented recommendations per day (from <8 to 60 g), 46.5% recommendations per week (from <15 to 294), and 20.6% recommendations per occasion (from <30 to 98 g) (Table 2).

TABLE 2 - Countries with Governmental Standard Drink Definitions and Low-risk Consumption Guidelines in Grams of Pure Ethanol5,7,8
Low-risk Consumption Guidelines*
Adults (♂/♀) Adult Woman Adult Men Older Adults (♂/♀) Woman ≥65 y Men ≥65 y
Countries Action Plan Standard Drink* Day Week Occasion Day Week Occasion Day Week Occasion Day Week Occasion Day Week Occasion Day Week Occasion
High income (HI)
 Argentina No 10 20 40
 Australia Yes 10 20 140 40 20
 Austria No 20 16 24
 Belgium No 10 20 140 40 40 210 60
 Canada No 13.54 27 136 41 41 204 54 27 136 42 204
 Chile No 10 10 40 50
 Croatia No 10 10 20 10
 Czechia Republic Yes 16 40 16 24
 Denmark No 12 60 84 168
 Estonia Yes 10 20 80 40 160
 Finland Yes 12 10 20
 France No 10 20 100 20 30
 Germany No 12 12 24
 Hungary No 10 10 20
 Iceland No 12 168 294
 Ireland No 10 110 170
 Israel Yes 10 10 20
 Italy Yes 12 10 20 12
 Japan Yes 10 20 10
 Latvia Yes 12 16 96 24 156
 Luxemburg No 10 10 20
 Malta No 8 16† 112† 32‡ 16† 168‡ 32‡
 Netherland No 10 10
 New Zealand No 10 20 100 30 156 20 100 30 150
 Norway No 10 10 20
 Poland Yes 10 20 140 40 280
 Portugal Yes 12 12 24
 Republic of Korea No 8 20 40
 Singapore No 10 10 20
 Slovenia No 10 10 70 30 20 140 50 10 70 30
 Spain Yes 10 20 170 40 40 280 60
 Sweden No 12 108 48 168 60
 Switzerland No 12 10 40 20 50
 United Kington No 8 16 112 32
 United States of America Yes 14 14 56 28 70 14 98 28 42
 Uruguay No 10 30 70 50 40 140 50
Upper-middle income (UMI)
 Albania Yes 10 20
 Armenia No 10 10 20
 Bosnia and Herzegovina No 10 10 20
 Bulgaria No 8 8 16
 China No 10 15 25
 Fiji No 10 20 100 40 30 150 50
 Grenada No 14 14 98
 Guyana No 8 8
 Kazakhstan Yes 12 80
 Macedonia No 14.2 10 20
 Mauritius No 8 8 16
 Mexico Yes 13 39 117 52 156
 Namibia No 10 10 20
 Paraguay No 10 10 20
 Peru No 10 10 20
 Romania No 10 10 70 20 140 10
 Serbia No 13 13 91 26 182
 South Africa Yes 10 20 40
Low-middle income (LMI)
 Georgia Yes 10 10 20
 India No 10 10 20
 Philippians Yes 12 12 24
 Vietnam Yes 10 40 60
Action plan5: information found in the Global Alcohol Report, 2018.
*References of the government publications see Appendix Table S1 (Supplemental Digital Content 1, http://links.lww.com/ADTT/A11).
†Age group: 18 to 21 years.
‡Age group: above 21 years.
HI indicates high income; LMI, lower-middle income; UMI, upper-middle income.

For Older Adults

Only 10 countries (19%) had guidelines for the older population (above 60 or 65 y), 9 are HICs (Australia, Canada, Croatia, United States, Slovenia, France, Italy, Japan, and New Zealand) and 1 is UMIC (Romania) (Appendix Table S1, Supplemental Digital Content 1, http://links.lww.com/ADTT/A11). From this group, only Canada, the United States, and New Zealand present different guidelines according to sex among older adults. In general, the guidelines of these 11 countries are not similar, ranging from <10 to 42 g/day, <70 to 204 g/wk, and <28 to 42 g per occasion (Table 2).

Although Australia, Germany, Denmark, Estonia, Finland, and Mauritius do not present specific low-risk drinking guidelines for older adults, they highlight that people over 65 years of age should exercise caution in relation to drinking alcohol and/or should drink less than the low-risk guidelines, whereas Paraguay recommends total abstinence for the older adults.

Low-risk Alcohol Consumption Among Vulnerable Groups

Only 58 countries had guidelines for low-risk drinking, of these 72.4% also highlight guidelines for vulnerable groups. Among the groups considered more vulnerable to alcohol consumption are pregnant and breastfeeding women (69%), adolescents (30%), older adults (29.3%), people with pre-existing health conditions (27.5%), users of prescribed medication (26%), vehicles or machine operators (24%), and children (22.4%). In some cases, the guidelines recommend total abstinence and, in other cases, caution and/or reduced alcohol consumption (Fig. 1). Of the countries with these guidelines, 71.5% were HICs and 28.5% UMICs.

FIGURE 1
FIGURE 1:
Guidelines for vulnerable groups adopted by different countries.

Other Specifications

Some countries give other details in their guidelines. The Japanese guidelines for moderate alcohol consumption, for example, specify that the daily average of no >20 g is only for drinkers that have a normal capacity to metabolize alcohol. Malta provides separate guidelines for men and women, and also for age groups: 18 to 21 years (16 g/d) and above 21 years (women: 112 g/wk and ≥32 g/occasion; men: 168 g/wk and ≥32 g/occasion). Canada also provides specific guidelines for different age groups: 26 g/d for 15 to 24 years old and 39 g/d for adults in general. Luxembourg specifies that adolescents between 16 and 18 years of age should not consume >10 g/wk, whereas, for people aged between 18 and 20 years, alcohol consumption should be lower than the guidelines for adults because brain development is only completed after the age of 20.

The guidelines in Germany, New Zealand, Slovenia, and the United States are specifically for healthy adults of all ages, in other words, without health problems and using prescribed medication.

Details the guidelines for low-risk drinking of different countries. This table presents guidelines for the day, week, and occasion for adults in general and older adults (separated by sex), and income level, and whether there is a national action plan (Table 2).

DISCUSSION

The present study found low-risk drinking guidelines for 58 countries against the 37 found in a previous study.3 We were able to include 21 new countries that have adopted a guideline for low-risk drinking and updated information for 15 countries, 10 of which have found discrepant information and 5 that introduced them after 2016. Regarding the definition of a standard drink, we updated information for 8 countries—6 had reduced the number of grams of alcohol in their definition (varying between 2 and 5 g reduction). We believe that differences found in relation to this previous publication3 can be explained by the methodology adopted, the different data sources, the updating of data, and the inclusion of all countries in the world.

In this study, significant variability was found for low-risk drinking guidelines, ranging from 8 to 40 g/d and 15 to 170 g/wk for women; 8 to 60 g/d and 15 to 294 g/wk for men. These data are higher than those found in the article by Kalinowski and Humphreys probably because the number of countries in this study is higher when compared with the last publication. Recent studies indicate that mortality rates increase if alcohol consumption exceeds >8 to 10 g/d for women and 15 to 20 g/d for men9 and the brain structure can be affected if alcohol consumption exceeds 112 to 168 g/wk.10 Therefore, the limits adopted by countries identified in this study exceed the above limits and also those identified in a review to define safe thresholds of low-risk drinking in respect of all causes of mortality and cardiovascular disease (no >100 g/wk).4

In general, different measures for a standard drink (in grams of alcohol) and low-risk drinking guidelines were found, which makes it difficult to compare countries. Although the difference among countries could be explained by inherent cultural characteristics, they may also be because of the different methodologies adopted to formulate these guidelines.

Standard drink and guidelines for low-risk drinking were adopted predominantly in HICs (54.5%, 60.3%) and UMICs (36.8%, 31%) and in lower proportion in the low-middle-income (7.4%, 8.6%) and LICs (1.5%, 0%). This indicates that although alcohol consumption in LMICs and LICs may negatively impact population health, guidelines for low-risk drinking are still scarce.

Regarding national alcohol action plans, similar data were identified. Although the number of countries with a strategy for action plain being small (23.2%), the smallest proportion was found in LICs (6.7%) and similar proportions were found in HICs, UMICs, and LMICs (33%, 31%, and 27%). This shows a lack of systematic global action to reduce harms related to alcohol.

It is important to mention that if on one hand, the proportions of alcohol consumption per capita in the LICs are lower than in HICs, then on the other side, the prevalence of excessive use and dependence is high, as are mortality rates attributed to alcohol.5 Thus, the clear evidence of the impact of alcohol on health is enough to justify the need for guidelines that encourage less harmful consumption, even if we were to ignore the wider social damage and the fact that, as stated in the last global report on alcohol, it frequently strengthens inequalities between and within countries and that the harm for a given amount of alcohol may be higher for poorer drinkers than for richer ones.

In this study, in addition to the gender difference, the age-related difference is also presented. Among the countries that have a guideline low-risk drinking, 84.5% of these (n=49) have separate guidelines for adult men and women. These data can be justified because women become intoxicated with lower doses of alcohol for a number of reasons including higher amounts of body fat. Therefore, they experience physiological problems earlier, and mortality rates are higher, mainly because of underdiagnosed hepatic and cardiovascular diseases,11 which highlights the importance of having different guidelines for men and women. However, the United Kingdom justify not making this distinction between sexes in adults, claiming that although the long-term risks are greater for women, men face more risks of immediate damage (eg, from accidents and injuries).12

In addition, health conditions more prevalent in women (such as breast cancer), medication use, and changes related to age (eg, menopause) may also contribute to a further reduction in the capacity of older women to tolerate alcohol, making even low-risk levels dangerous for them.11,13 However, this is not reflected in the guidelines for people aged over 65 years, as out of the 10 countries that make specific guidelines for older adults, only 3 have different guidelines for men and women (Canada, United States, and New Zealand). Most countries (n=9) that have guidelines for older adults do not make this gender distinction, and some countries such as Australia, Croatia, France, Slovenia, and Romania use exactly the same orientation for women and for older adults (men and women). Thus, the amount of alcohol provided for in the guidelines for men is reduced with age, whereas for women, there is no reduction. Guidelines should be applied more cautiously, especially when it comes to older people who are likely to be more sensitive to alcohol-related harm through the effects of ageing, having more complex physical and mental health problems, greater risk of interactions with prescription drugs, and a higher probability of cognitive impairment than younger people.14

Among the documents of guidelines for low-risk drinking (n=58) also was found specific recommendations for vulnerable groups. Of these, 72% highlight some type of guidelines for the most vulnerable groups, however, few have specific guidelines, only mention caution (reduce the amount of alcohol) or abstinence. The most cited groups were pregnant and breastfeeding women (69%), followed by adolescents (30%) and to a lesser extent other groups that also deserve attention, such as older adults (29%). Is important to highlight that these groups also should be the target of the guidelines, considering that they are in vulnerability, even just then, because of biological and neurological factors (use medication and health condition) or that require total attention and focus (vehicles or machine operators).

Recent research has discussed the challenges involved in defining low-risk consumption. In general, such discussions highlight factors that should be considered when producing any health behavior guidelines, such as epidemiological evidence (mortality, QALYs, damage to others, and inequalities); specialized judgment; pragmatic considerations (interpreting the guideline in the context of pre-existing practices).1 The guidelines are little used precisely because of the difficulty in understanding the proposed units (standard drink) and mainly incorporating them into the daily life of the population.1

In this sense, future research could verify how the guidelines for low-risk drinking are transmitted for the population and health professional and what the impact of such measures on less risk alcohol consumption.

CONCLUSION

There are few similarities in standard drink definitions and low-risk drinking guidelines among different countries. This suggests that many definitions and guidelines do not seem to consider biological and social aspects and scientific studies. According to sex and age groups, and in respect of other vulnerable groups is essential to the dissemination of appropriate and accurate information on alcohol that has a preventive effect and helps to reduce harm to the population.

Although alcohol use is considered a leading risk factor for disease burden worldwide, the lack of proper definitions and guidelines in relation to alcohol consumption is a challenge that needs to be addressed to improve the health of current and future generations. Finally, it is important to highlight the lack of guidelines in LICs and LMICs in particular, as they would benefit greatly from these measures.

It is important to highlight the lack of guidelines in LICs, but by the other side, it needs to consider that these countries are low resourced, and therefore, it is hard to imagine how they would be able to adopt these guidelines and action plans without the aid from other partners countries.

ACKNOWLEDGMENT

FAPESP (São Paulo Research Foundation) Thematic Project: grant ref. number 2015/19472-5. T.C.S.P. was supported by CNPQ (National Council for Scientific and Technological Development) - PhD scholarship: no. 142486/2018-3.

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      Keywords:

      alcohol; low-risk drinking; guidelines; standard drink; older adults; income levels

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