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

Abstract

Objective: 

Identify the standard drink and the differences in low-risk drinking guidelines for adults and older adults around the world according to sex and country-income level.

Method: 

A search for standard drink definitions and low-risk drinking guidelines for adults and older people in current governmental documents was undertaken; items sought: (1) low-risk drinking guidelines for different age groups and sex; (2) definitions of a standard drink in grams of alcohol; (3) country-income level; (4) whether there was a national action plan for alcohol; (5) identification of particular vulnerable groups.

Results: 

Of the 194 countries in the world, the authors were able to identify 58 that have low-risk drinking guidelines, 60.3% being high-income, 32.8% upper-middle-income, and 6.9% low-middle-income countries (no guidelines were found in low-income countries). Definitions of a standard drink ranged from 8 to 20 g. Low-risk drinking guidelines (grams/week) ranged substantiality: from 15 to 170 g for women and from 15 to 294 for men. For older adults, ranged from 70 to 204 for women and for men over 65 years of age.

Discussion/Conclusion: 

Important differences among definitions of a standard drink and in low-risk drinking guidelines adopted by the countries were found. These differences can partially be explained by inherent aspects of each country; however, many guidelines do not seem to consider biological and social aspects or scientific evidence. In addition, it is important to highlight the lack of guidelines in low and low-middle income countries that would benefit from these measures.

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 Ethanol^5,7,8

			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: 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.