The marketing of public health messages can bear some disturbing similarities to the way the tobacco, alcohol and food industries go about promoting their products.
Recent suggestions by the Cancer Council of Australia (CCA) that there is no safe level of alcohol consumption appears to be a marketing strategy rather than a valid assessment of the evidence.
First, let’s consider the evidence.
Drinking in moderation
A recent meta-analysis combining various alcohol studies (over one million people) found that people who drank about one drink a day had an 18% reduced risk of death, compared with those who didn’t consume alcohol.
The benefits of low levels of consumption are primarily evident for cardiovascular disease.
But that doesn’t mean we should increase our alcohol consumption. Heavy drinking substantially increases the risk of death.
The UK Million Women Study which involved following up 1.3 million women who had presented for breast cancer screening, confirmed that women who consumed three or more alcoholic drinks a week had a slightly higher risk of breast cancer. But women who drank no alcohol also had a slightly higher rate of all cancers (but no different rate of breast cancer).
So people who don’t consume alcohol have a higher death rate than those who consume a small quantity of alcohol, but death rates rise with increasing consumption of alcohol. This trend of mortality is described as a J-shaped curve.
The CCA acknowledges the existence of this J-shaped curve, but they deny the benefits of low levels of alcohol consumption.
Instead, they argue that abstainers have higher deaths rates because people with a serious illness stop drinking alcohol or that abstainers are different in their social and demographic characteristics.
These differences, the CCA says, explain their poorer outcomes.
It’s not just the sick who abstain from drinking
It may be the case that a proportion of the elevated health risk for abstainers can be attributed to social selection. But there is compelling evidence that demonstrates abstainers do have an increased risk of death.
Firstly, some studies of alcohol consumption and mortality involve very long-term follow up. The longer the period of follow up, the less likely that one can attribute the higher mortality of the abstainer to a pre-existing, serious illness.
In addition, some studies exclude people who have a pre-existing illness or those who have reduced their level of alcohol consumption in the years before the study commenced.
For these studies, the data tend to be consistent – at worst there are minimal differences in mortality between those who don’t drink alcohol and those who drink small quantities every week.
Where differences do exist, they favour the health of those who consume small quantities of alcohol.
Secondly, while studies consistently confirm that the risk of some cancers (such as breast cancer) increases with greater alcohol consumption, the magnitude of the increased risk is modest.
There is, of course, a substantial increase in risk of death attributable to some other causes (some injuries, liver cirrhosis) associated with higher levels of alcohol consumption.
Thirdly, the cardiovascular benefits of alcohol consumption appear real and substantial with about a 30% to 40% reduction of mortality from cardiovascular disease.
With cardiovascular disease accounting for a substantial proportion of all deaths, this advantage outweighs the deaths contributed by other causes.
Interestingly, the US Cancer Prevention Study (a prospective cohort study of 490,000 adults) found that moderate alcohol consumption (one drink a day or less on average) was associated with lower rates of death.
This study excluded those who may have quit drinking because they’d had an existing illness within the last 10 years. So it only compared long term abstainers with drinkers and found that the life expectancy of abstainers was shorter.
The balance of evidence is clear – the consumption of a small quantity of alcohol (perhaps up to a drink a day) is not detrimental to health, though the benefits may be modest.
Binging or consuming high levels of alcohol is a net risk – and women may be more exposed to this risk than men.
There’ll be continuing debate about the health consequences of moderate levels of alcohol consumption and judgments about risk will need to be based on the gender, age and lifestyle characteristics of those who drink alcohol.
So does the hyperbole used by the CCA serve the interest of public health?
Abstinence doesn’t work
The CCA has attempted to shift the message from drinking at safe levels to one of abstinence. But by mis-stating the evidence, the CCA has lowered its credibility and the confidence one might have in whatever advice it offers.
By arguing that there is no safe level of alcohol consumption, it labels the drinking patterns of about three in five Australians as unhealthy.
If we accept the cumulative weight of a number of large-scale and well-controlled studies, then those who consume small quantities of alcohol have a mortality advantage.
Therefore, to advocate that abstinence is a healthier option potentially exposes a large number of Australians to an increased risk of death.
There’s no doubt that present levels of alcohol consumption are too high and too many young people are binge drinking. And it is likely that there has been a recent increase in binge drinking by young women.
These issues need to be addressed but an abstinence message is neither accurate, appropriate nor realistic. The alcohol debate in Australia is in desperate need of a new direction and some real leadership.