Recent discussions about alcohol and risk often repeat the mantra that “the science has changed.” This is especially apparent in the difference between the 2011 Canadian low risk drinking guidelines and the 2023 “Low Risk Drinking Guidance” from the Canadian Centre on Substance Use and Addiction (CCSA).
This is not an unreasonable thing to state, given that nearly a decade of research had been published between 2011 and when the research for the CCSA study was initiated in 2020. (Let’s just not get into how much of that research was done by the contributors to the 2023 report).
But even a cursory comparison of the two documents shows that it is not only the “science” that changed: it is the tone, moral positioning, cultural understanding of the place of alcohol in lives, and the underlying theme of the two reports.
Consider this: the 2011 report opens with a broad and (to a historian) valuable quote from Greek philosopher Eubulus (375BC):
Three cups do I mix for the temperate; one to health, which they empty first, the second to love and pleasure, the third to sleep. When this bowl is drunk up, wise guests go home. The fourth bowl is ours no longer, but belongs to violence; the fifth to uproar, the sixth to drunken revel, the seventh to black eyes, the eighth is the policeman’s, the ninth belongs to biliousness, and the tenth to insanity and the hurling of furniture.
(Quoted in Butt et al 2011 p12)
It’s a statement about the value of moderation versus the hazards of over consumption, and would have no place in the 2023 report.
The authors then proceed to acknowledge that different people drink different substances at different times, indicating for example that there is a regional variation in both quantity and substance consumed (Butt et al, 2011, pp18-19) and a consideration of the behaviour within physical locations where people consume, such as “bars, discos or taverns.. [versus] in a restaurant or at home” (p18).
They define different types of health outcomes (short term/acute; long term/chronic) and engage with the difference between mortality (something that kills you) and morbidity (something that harms you).
The 2011 study also recognizes difference:
Different people drink different amounts in different frequencies, with varying consequences for their health and safety. The amount drunk (or ‘dose’ consumed) on one drinking occasion will determine their subjective experience, physical reactions and how they behave, in accordance with blood alcohol concentration (BAC) achieved and individual tolerance to alcohol effects
(Butt et al 2011 p 16)
It’s as if they recognize that people consume alcohol differently, have different subjective experiences, and that any guidance needs to recognize this difference and address it.
The study even frames its results in a degree of uncertainty, which to me indicates respect for the reader. It includes a clear statement about the difference between relative risk and absolute risk (p 14) and it recognizes that “the quality of science… is as yet far from perfect” (p13) (which arguably every scientist should say about pretty most topics) but the CCSA (2023) document most certainly does not.
What is most striking though about the two studies is not the results of the research. Of course if the research “has changed” over a decade, you might expect different results.
What is instead most notable to me is the acknowledgement in the 2011 document that there are a range of variables to consider, and that drinking patterns are different for different people, in different locations, and at different times of their lives.
For example younger people are more likely to binge and therefore the risks of accidents is higher for them (pp 21-22), and the cardio-protective effects of alcohol don’t really seem to matter until people are older. That’s right, they do recognize and address cardio-protective effects (pp 26-27). In fact they make the remarkable admission that
an estimated 1,828 deaths from cancer (as well as several thousand other causes of death) could be attributed to alcohol use in 2002, while alcohol prevented an estimated 2,589 cardiovascular deaths.
Butt et al 2011 p 27 emph added
Let me repeat: the very fact that there may be some protective effects of moderate drinking (which let’s be clear the CCSA 2023 document also shows) is addressed and not dismissed in 2011.
The CCSA 2023 document does give lip service to the idea of “risks and benefits” but then pretty much dismisses the benefits by generalizing all types of drinking, all types of people, and dismissing variety in patterns, ages, risk factors, substances consumed, and locations.
Even the huge bugbear of drinking during pregnancy is addressed with some equivocation. While concluding that it is better that pregnant women not drink at all, the 2011 study does recognize that some of the meta analyses they used indicate “significant “protective effects” for infant health associated with light drinking by the mother” (Butt et al 2011 p20).
In contrast, the 2023 CCSA study opted not to look at the literature about drinking while pregnant at all (arguing that since they are looking only at the effect of drinking on the drinker themselves, that a discussion of the effect of a mother’s drinking on her child is outside the scope of the study) (pp 20-21).
Nevertheless, their recommendations do include the statement that for pregnant women or women “trying to get pregnant… there is no known safe amount of alcohol use” (Paradis et al, 2023 p.9 ). They also repeat this advice for breastfeeding, even though the evidence about breastfeeding and infant health is, to put it mildly, mixed. (NASEM , 2024, 13-14).
Finally, and something that the CCSA writers may wish to consider is this statement: Alcohol is most safely and enjoyably consumed when mental, physical and social demands on the drinker are at a minimum. (p 22). What, alcohol can be consumed safely and enjoyably? Tell me more!
Oh, and you may be saying “yes, but what about the dismissal of the J-curve and evidence that there is no health benefit to moderate drinking.” Well, that research came out mostly after the 2023 report, and that report did not engage in it at all. The 2023 report shows a J curve in its all-cause mortality graph, just as previous research had done (Paradis et al 2023 p 29). They just don’t talk about it.
I could go on, but I think you get the point.
What we see in the difference between the 2011 and 2023 guidelines is not just a change in the science, but a change in the tone, attitude, and ideology.
In 2011 alcohol was a potentially problematic substance with risks that could be moderated by most people; in 2023 it had become a health hazard that should be problematized and, ideally, eliminated from everyday life.
To summarize:
- 2011 is a moderation document
- 2023 is a reduction document
- 2011 treats alcohol as a risky but ordinary practice
- 2023 treats alcohol as a harmful exposure whose social normalization must be challenged
- 2011 speaks to the drinker as a practical decision-maker or what in liberal parlance is called a “rational actor”
- 2023 speaks past the drinker toward a public-health environment that should make drinking less likely, less acceptable, and more fraught with danger. The drinker is no longer a rational actor, so their choice should not be complicated by nuance
Anyone who is trying to figure out why the Canadian government decided not to accept the results of the 2023 CCSA report should think about these things first. What happened between 2011 and 2022 was not just “changed” “science” but an ideological repositioning of the role of alcohol research.
This is why I call it neo temperance.
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