Inspired by the 19th-century English physician Francis E Anstie, Dr Erik Skovenborg explores attitudes to risk and safety when it comes to drinking alcohol.
There is no safe limit of skiing—hour for hour, skiing is 300–400% more likely to kill you than flying on a scheduled airline, Larry Laudan (PhD and expert in the logic of scientific inference) warned readers of his Book of Risks.1 Virtually everything is risky to some degree or other; risks lurk everywhere. “Once we understand that risk can never be totally eliminated from any situation and that, therefore, nothing is completely safe, we will then see that the issue is not one of avoiding risks altogether but rather one of managing risks in a sensible way.”
Anstie’s limit
Life is full of hazards that—like alcoholic beverages—are both fun and potentially fatal. In the 1860s, alcoholism was widespread in London, and a fervid temperance movement called for total abstention from alcohol. Francis E Anstie (1833–74)—a skillful English physician who was active in the advancement of therapeutics and questions of public health—was regarded as a defender of alcohol in moderation, realizing that, like common salt, it was impossible to draw an absolute line between poison and medicine. Anstie’s limit refers to “an amount of absolute alcohol which our own experimental researches have shown to be about the limit of what can habitually be taken by persons leading a not very active life without provoking symptoms of chronic malaise.”2
The limit (1.5oz [42.5g] alcohol, which corresponds to 5 units) was for men, while women should settle for 0.75oz (21.25g)—“two ordinary glasses of the highly fortified sherry or port which ladies prefer.” Anstie noted the existing lack of a clear and uniform counsel regarding the alcohol problem: “We wish to compel the upper and middle classes and their medical advisors to look at the facts of alcohol consumption honestly in the face, though we fear that a good many persons will characterize these points of advice as utopian in its standard of temperance.”
Related
To low-risk drinking guidelines
Any set of guidelines is, at best, a kind of advice indexed to the average person and encoding expectations about which risks it is reasonable to take with one’s health, the role that alcohol consumption should play within a life, and so on. The English road toward sensible drinking is delineated by David Ball and colleagues, and their comprehensive information about each step of the journey is quoted extensively in this review.3
In 1979, the Royal College of Psychiatrists, steering clear of a “utopian standard of temperance,” recommended that 4 imperial pints (each 20 oz), four double whiskies, or one bottle of wine a day “constitute reasonable guidelines of upper limit of drinking.” The report’s conclusion was that a weekly consumption of about 56 drinks was the “absolute upper limit.”4
The Department of Health and Social Security (DHSS) published Drinking Sensibly in 1981, pointing out drawbacks to establishing alcohol consumption guidelines, such as the varied effect of alcohol on different people and the fact that people might drink up to suggested limits in the belief that such behavior was “safe.” Responsible behavior and self-risk management characterized the “sensible drinker,” and encouraging “sensible” behavior was a way to balance risk but also permit individual choice. In 1984 ,the Health Education Council (HEC) published a booklet titled That’s the Limit, which suggested “safe limits” for drinking that would be unlikely to cause damage: 18 standard drinks a week for men and nine standard drinks for women. “Too much” was defined as 56 standard drinks for men and 35 for women.
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The 1987 edition of That’s the Limit introduced the concept of “alcohol units” (about half a pint of beer = 8g of alcohol). The sensible limit—the amount to which people should limit their drinking if they wanted to avoid damaging their health—was now set at 21 units a week for men and up to 14 units a week for women. Too much was said to be 36 units for men or 22 units for women—provided the total amount were not drunk in one or two bouts and that there were occasional drink-free days. Drinking became hazardous when men drank 21–49 units a week and women drank 14–35 units a week.
Plucked out of the air
Reports published in 1986–87 by the Royal Colleges of Psychiatrists, Physicians and General Practitioners endorsed the 1987 HEC suggestions of sensible drinking limits. The difficulty, however, was to determine what constituted moderation and the basis on which this should be determined. The DHSS was aware that the setting of limits was “arbitrary” and that, “in any case, the evidence on which they were based is not yet as good as we could wish.”5
Several critics pointed out that the evidence tying risk to specific amounts of alcohol was unclear, and 20 years later The Times revealed that the recommended weekly drinking limits (21 units of alcohol for men and 14 for women) introduced in 1987 had no firm scientific basis whatsoever. The disclosure came from Richard Smith, a member of the Royal College of Physicians working party that produced its first health report on alcohol abuse: A Great and Growing Evil: The Medical Consequences of Alcohol Abuse. He told The Times what happened when the discussion came around to whether the group should recommend safe limits for men and women. David Barker was the epidemiologist on the committee, and his line was, “We don’t really have any decent data whatsoever. It’s impossible to say what’s safe and what isn’t.” The feeling was that we ought to come up with something. So, those limits were really plucked out of the air. They weren’t really based on any firm evidence at all. It was a sort of an intelligent guess by a committee.6
The issue was not the importance of warning against “the great and growing evil” of alcohol abuse but rather the challenging need to balance imperfectly understood risks of a widespread level of alcohol consumption with the benefits many associated with “sensible” alcohol consumption. The government was reluctant to “adopt unacceptably paternalistic policies” and constrain the legitimate pleasure of many.
The Health of the Nation
The sensible drinking message was integrated into the 1992 white paper “The Health of the Nation,” stating that “drinking less than 21 units per week by men and 14 units per week by women is unlikely to damage health.” A report published in 1993 under the auspices of the Department of Health and the Royal College of General Practitioners defined sensible drinking as about two units a day, because at this level there is a “possible beneficial effect on the heart.” A critique published in the British Medical Journal (BMJ) on January 22, 1994, pointed out that the suggested drinking limits had become progressively more conservative with no supporting scientific evidence. An analysis of two major British studies found the minimum all-cause mortality occurring at a consumption of about 26 units a week. “It seems that evidence of harm rapidly becomes received wisdom, but evidence of benefit is challenged or disregarded.”
Weekly or daily drinking limits?
Britain’s Royal Colleges of Physicians, Psychiatrists, and General Practitioners reviewed the totality of evidence in 1995, in order to readdress recommendations for “sensible limits” for the general public. The authors of this authoritative, comprehensive review recommended that there be no change from the prior recommendations of 21 units (168g of ethanol) a week for men and 14 units (112g ethanol) a week for women. The recommendations suggested weekly limits for alcohol consumption because most studies tend to consider only average daily intake and disregard the specifics about how or when the beverage was consumed.
An editorial in the BMJ noted that southern Europeans tend to drink wine with meals, whereas northern Europeans may tend to drink distilled spirits at times other than mealtimes. Furthermore, the risks and benefits of alcohol consumption may be different for someone who consumes seven beers on a weekend night compared with one who consumes a glass of wine with dinner every day, despite an almost identical average weekly alcohol consumption. Setting a weekly limit permits those who binge drink at weekends to regard their drinking habits as sensible. “For this reason, it may be more prudent to emphasize daily limits of three units a day for men and two units a day for women.”7
Sensible drinking
On December 12, 1995, Sensible Drinking was published by the Department of Health, stating that “regular consumption of between 3 and 4 units a day by men will not accrue significant health risk, while consistently drinking 4 or more units is not advised. In addition, the regular consumption of between 2 and 3 units a day by women will not accrue any significant health risk, while consistently drinking 3 or more units is not advised.” While accepting the benefits of daily benchmarks, the daily drinking limits were generally interpreted as representing a 50% rise on the previous upper limit for women and a 33% increase for men. The result was swift denunciation from the medical fraternity and a confused public-health message. “In summary, the sensible drinking message is confused and poorly understood,” was the conclusion of David Ball and colleagues.
In the next WFW chapter of the never-ending guideline story, we will review the UK Chief Medical Officers’ Low Risk Drinking Guidelines from 2016 and compare these guidelines with 58 low-risk guidelines from around the world.
NOTES
1. L Laudan, The Book of Risks (John Wiley & Sons, New York; 1994).
2. DB Baldwin, “Anstie’s alcohol limit,” American Journal of Public Health 67 (1977), pp.679–81.
3. D Ball, R Williamson, J Witton, “In Celebration of Sensible Drinking,” Drugs: Education, Prevention and Policy 14:2 (2007), pp.97–102.
4. Alcohol and Alcoholism: Report of a Special Committee of the Royal College of Psychiatrists (Tavistock Publications, London; 1979).
5. A Mold, “Alcohol, Health Education and Changing Notions of Risk in Britain, 1980–1990,” Drugs (Abingdon, England) 28:1 (2021), pp.48–58.
6. “Drink Limits ‘Useless,’” The Times, October 20, 2007.
7. JM Gaziano, C Hennekens, “Royal Colleges’ Advice on Alcohol Consumption,” British Medical Journal 311: 6996 (1995), pp.3–4. ▉
