Sensible drinkingBMJ 1996; 312 doi: https://doi.org/10.1136/bmj.312.7022.1 (Published 06 January 1996) Cite this as: BMJ 1996;312:1
Doctors should stick with the independent medical advice
In April 1995 the BMA's board of science and education reaffirmed previous medical advice that women should drink no more than 14 units and men no more than 21 units of alcohol a week.1 The board accepted evidence that low levels of alcohol may protect older people against coronary heart disease, but it concluded that abstainers should not be encouraged to drink “for their health.” In June a joint working party of the royal colleges of physicians, psychiatrists, and general practitioners examined the research evidence in detail2 and confirmed the validity of the existing limits. Older men and postmenopausal women who drank low to moderate amounts of alcohol were found to have lower rates of coronary heart disease than abstainers, but the colleges concluded, “a decision to begin drinking should not be made for medical reasons.”
Advising patients about drinking is an inescapable medical responsibility. The general practitioner contract in Britain makes inquiring into alcohol consumption a formal requirement. The goverment's Health of the Nation sets targets based on the medically accepted sensible limits,3 and the Health Education Authority has used the same criteria as the basis for health education. The need for continued and strengthened involvement of health professionals in the issue of alcohol consumption is evident: survey data show that 11% of women and 27% of men in Britain continue to drink over sensible limits,*RF 4, 4a* and research shows that simple advice from a doctor is often effective in ameliorating excessive drinking.5
Doctors need to feel confident that the advice they are asked to give is based on good evidence, untainted by puritanism, political expedience, or commercial interest. Until mid-December they were justified in such confidence, but the consensus has now been thrown into disarray. The Department of Health, which has not recently shown finesse in handling its advice to the public,6 chose a pre-Christmas date to launch the report of an interdepartmental working group on “sensible drinking.”7 This document conflicts with the position of both the BMA and the royal colleges in several respects. Firstly, its statement that “regular consumption of between two and three units a day by women of all ages will not accrue any significant health risk” represents a 50% rise on the previous ceiling. Secondly, men are offered a 33% increase with a new ceiling of three to four units a day. Thirdly, the report suggests that older people who abstain or drink alcohol infrequently “may wish to consider the possibility that light drinking might benefit their health.” Finally, the word “limit” is replaced by the ambiguous term “benchmark.”
Although the data on alcohol and health do not allow micrometer exactness,8 9 the formula of two drinks a day for women and three drinks a day for men represents a prudent but not overcautious interpretation of complex evidence. What the BMA and royal colleges have said about the practical importance of the link between alcohol and heart disease is also sensible in clinical and public health terms. Only if there were good reasons would one wish to see the previous consensus overthrown and the message to the public muddled. No such good reason can be found in the interdepartmental working group's report. The group decided to reach a different conclusion unsupported by either persuasive new analysis or new evidence. To understand its decision, we must look at the group's credentials rather than at the science. Unusually for a health review, the group was made up exclusively of civil servants with no scientific experts from outside the civil service, and the chairman (G J F Podger) was a civil servant rather than a scientist or public figure with established independence. Two of the 13 full members were civil servants from the Ministry of Agriculture, Fisheries, and Food, which works closely with the drink industry, which has long campaigned for an increase in the advised limits. Concern has inevitably arisen that the independence of a group with a health advisory remit could be compromised.
What then should a doctor say to the next patient who wants to talk about drinking? There is a persuasive case that it should be business as usual. Advice derived from independent medical authorities should be preferred to that of an interdepartmental government body. Civil servants, especially those from the food ministry, are not appropriate arbiters on what doctors say to their patients. That such a group was allowed to advise the public on a matter where there is such strong pressure from commercial interests is deplorable.