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Abstract
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The National Board of Health and Welfare (NBHW) in Sweden (Socialstyrelsen, 2023) recently updated its threshold for risky drinking, to be considered by healthcare staff in patient work. This is part of their national guidelines for the treatment and prevention of unhealthy lifestyles. The scientific basis for NBHW's threshold consists of recent guidelines published in other countries and two additional systematic reviews identified through literature searches. According to the new threshold, women and men who drink 10 or more standard units (referred to as "standard glasses") of alcohol during a week are drinking risky ("riskbruk"). Drinking four or more standard units on one occasion at least once a month is also considered risky. As a reference, a standard unit of alcohol in Sweden is defined as 12 g of pure ethanol, corresponding to, for example, 330 ml of strong beer, or 120-150 ml of wine. Below, we raise some concerns with the threshold.
Guidelines for low-risk drinking play an important role in alcohol policy and are considered legitimate as they essentially do not violate people's freedom (Lovatt et al., 2015). The guidelines are said to provide more or less objective information that individuals can utilise to decide about their drinking. There are different approaches to the development of guidelines, but typically a baseline risk is set that is considered acceptable, and then the highest level of drinking compatible with this baseline is identified. Drinking levels that equal this baseline risk are considered low risk. In some cases, the baseline risk is drawn from that of abstainers and in other cases it is an estimate of a risk that is assumed to be acceptable by the public (e.g., Holmes et al., 2019). Regarding the latter, when the outcome is alcohol-attributable mortality, the acceptable risk is typically set at either one death per 1000 individuals or one death per 100 individuals. The basic assumption is that people can accept drinking at a level where the lifetime risk of death attributable to alcohol consumption is 1‰ or 1%, respectively (Holmes et al., 2019). The same logic applies when using a measure such as years of life lost (YLL) due to alcohol consumption. For instance, in the recent Canadian low-risk drinking guidelines, a YLL of 17.5 was used based on the average number of years lost per death in Canada (Paradis et al., 2023). Thus, in this case, a 1 ‰ lifetime risk of death would correspond to 17.5 YLLs per 1000 people and a 1% lifetime risk would correspond to 17.5 YLLs per 100 people (Paradis et al., 2023).
The only risk curves shown by the NBHW are the Canadian YLL estimates. For the average reader (including healthcare staff), these estimates are probably difficult to comprehend. To take the most extreme example included in the figure (Socialstyrelsen, 2023, p. 6), which pertains to men, drinking 35 standard Canadian units per week corresponds to approximately 2500 YLLs per 1000 individuals. Converting these estimates back to a more intuitively understandable metric, 143 out of 1000 men (i.e., 14.3%) drinking 35 units a week would die from alcohol during their lifetime (2500/17.5) whereas 85.7% would not die from this alcohol consumption. We believe that this information should be much easier to understand and relate to for most people. It also appears less dramatic compared to YLL figures.
An important difference between the threshold provided by the Swedish NBHW and recent guidelines published in other countries, such as Canada, Denmark and Australia, mentioned by the board itself, is that the former should be used for making recommendations to healthcare. For people exceeding the low-risk threshold, Swedish healthcare is recommended to provide counselling or other support. This difference...
Language: en |