American Journal of Epidemiology Advance Access originally published online on August 18, 2008
American Journal of Epidemiology 2008 168(10):1130-1131; doi:10.1093/aje/kwn219
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Taylor et al. Respond to "Alcohol and Trauma and Chronic Disease Mortality"
Correspondence to Dr. Benjamin Taylor, Centre for Addiction and Mental Health, 33 Russell Street, Room T411, Toronto, Ontario, Canada M5S 2S1 (e-mail: bennyjtaylor{at}gmail.com).
Received for publication May 29, 2008. Accepted for publication June 17, 2008.
We thank Dr. Giesbrecht for his commentary (1) on our method of calculating lifetime risk of alcohol-attributable injury mortality (2) and its wider applications, specifically as part of an evidence-based tool in the construction of guidelines on low-risk drinking. Guidelines have often taken on a normative, indeed moral, cast, alongside the framing in terms of science and risk—particularly when industry influence is strong. Setting a guideline inherently involves drawing arbitrary lines on multiple risk curves between alcohol and various disease and injury outcomes, and there have previously been no explicit standards for how that line should be drawn (with the exception of a guideline oriented only toward chronic disease (3)). The work we did was stimulated by a wish to put guidelines on the risk of alcohol drinking into the framework of lifetime risks, which is more generally used in the estimation of health risks (such as those related to water contamination or radon), and to make explicit and transparent the basis on which any line was to be drawn in adopting guidelines. This can be seen as a positive first step in establishing an evidence base on which governments or consumers can make necessary judgments regarding risk from alcohol or, for that matter, any other potentially harmful exposures.
We have proposed the first systematic analysis based on drinking pattern and volume per occasion to be applied to a lifetime risk approach and the first ever to be applied to low-risk drinking guidelines, despite the existence of such guidelines in over 30 countries (4). It is of course subject to continued scrutiny and improvement, but it is the first step towards rigorous risk estimation of this nature for alcohol specifically. In addition, this first step points to a much higher risk than was previously estimated for Canadians and Australians (5), indicating that personal judgment, even by experts in the alcohol field, may be more sympathetic to an extra pint than rigorous evaluation may indicate.
We share some of Dr. Giesbrecht's skepticism about the previous development and impact of low-risk drinking guidelines in the past (see also Rehm and Single (6)). Although there are certainly older antecedents (7), national guidelines on alcohol drinking are primarily a product of the last 30 years. These guidelines have often come from sources which are authoritative but not specifically concerned with alcohol policy, such as medical associations; persons with a specific interest in the relation between alcohol and public health have often treated them with some skepticism (8). All of the guidelines are about risk, usually risk to the drinker him- or herself; no guideline has yet been based specifically on the risk to persons other than the drinker, though this is presumably the strongest rationale for government action. Instead, risks to others have been covered by legislation enacted one risk factor at a time—for example, blood-alcohol limits for driving a car or operating a boat. Some of the guidelines also include a semi-explicit normative element; something called "sensible drinking" obviously involves more than just a calculus of risk.
In our view, if there continues to be a demand for alcohol consumption guidelines, there should be explicit separation of the scientific judgments from the normative judgments. Science can specify the degree of risk—to the drinker and to others around the drinker—with increasing accuracy. Such calculations of risk should be periodically repeated and the risk estimates updated. The schedule of every 5 years specified by the Australian National Health and Medical Research Council seems sensible. What is to be done with these calculations in terms of normative advice about drinking is then a matter which involves more than research technicalities. How much risk it is appropriate to take, on any drinking occasion and in cumulative terms over time, is part of a discussion about how social life should be conducted and what place alcohol drinking should have in society. Making the cumulative risks explicit is a basis for this discussion, but it does not settle the question.
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ACKNOWLEDGMENTS |
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Author affiliations: Centre for Addiction and Mental Health, Toronto, Ontario, Canada (Benjamin Taylor, Jürgen Rehm, Jaydeep Patra); Department of Public Health Sciences, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada (Benjamin Taylor, Jürgen Rehm, Susan Bondy); Institute of Clinical Psychology and Psychotherapy, Dresden University of Technology, Dresden, Germany (Jürgen Rehm); School of Population Health, University of Melbourne, Melbourne, Victoria, Australia (Robin Room); and AER Centre for Alcohol Policy Research, Turning Point Alcohol and Drug Centre, Fitzroy, Victoria, Australia (Robin Room).
Conflict of interest: none declared
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- Giesbrecht N. Invited commentary: is alcohol a risk factor for trauma and chronic disease mortality? Narrowing the gap between evidence and action. Am J Epidemiol. (2008) 168(10):1126–1129.
[Abstract/Free Full Text] - Taylor B, Rehm J, Room R, et al. Determination of lifetime injury mortality risk in Canada in 2002 by drinking amount per occasion and number of occasions. Am J Epidemiol. (2008) 168(10):1119–1125.
[Abstract/Free Full Text] - Burger M, Brönstrup A, Pietrzik K. Derivation of tolerable upper alcohol intake levels in Germany: a systematic review of risks and benefits of moderate alcohol consumption. Prev Med. (2004) 39(1):111–127.[CrossRef][Web of Science][Medline]
- International Center for Alcohol Policies. International Drinking Guidelines (2003) Washington, DC: International Center for Alcohol Policies. (ICAP reports 14).
- Rehm J, Room R, Taylor B. Methods for moderation: measuring lifetime risk of alcohol-attributable mortality as a basis for drinking guidelines. Int J Methods Psychiatr Res. In press.
- Rehm J, Single E. Reasons for and effects of low-risk drinking guidelines [in German]. In: Strategien und Projekte zur Reduktion alkoholbedingter Störungen—Bühringer G, ed. (2002) Lengerich, Germany: Pabst Science Publishers. 78–90. (ISBN: 3-936142-73-4).
- Baldwin AD. Anstie's alcohol limit. Am J Public Health (1977) 67(7):680–681.
- Hawks D. A review of current guidelines on moderate drinking for individual consumers. Contemp Drug Probl. (1994) 21(2):223–237.
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Related articles in Am. J. Epidemiol.:
- Determination of Lifetime Injury Mortality Risk in Canada in 2002 by Drinking Amount per Occasion and Number of Occasions
- Benjamin Taylor, Jürgen Rehm, Robin Room, Jayadeep Patra, and Susan Bondy
Am. J. Epidemiol. 2008 168: 1119-1125.[Abstract] [FREE Full Text]
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