Part 1: The misrepresentation of individual risk
In November 1986, public health officials met in Ottawa and developed the Ottawa Charter for Health Promotion. This shifted the priorities of public health to include the idea that public health should be informing citizens of risks in order to help them make informed decisions about their behaviour. It’s a great idea, and the foundation for a lot of very good work in public health.
The problem is: how do you communicate risk? Everyone’s context is different. As I have noted in my post about Social Determinants of Health, context matters. So as a white, middle class, well educated, well paid, cisgendered man, my risk of harms from various dumb things I do is different than someone who does not live in that position of privilege.
The alcohol researchers seem to think using population level data is appropriate. But is it? Population level data aggregates experiences across populations. It attempts to adjust for things like gender, socio-economic status, etc, but cannot catch everything.
So in the end it distorts risk.
Even if I share the same risk from drinking 7 drinks a week with someone from a much more precarious and insecure economic status, saying that 7 drinks a week increases my risk of colorectal cancer by 9.2% does not consider things like whether I eat red meat or lots of fruit and veggies, how active I am, and so on. (If I were a woman I’d make a statement about how breast cancer’s causes are even more diverse).
Major proclamations about the risk of drinking such as those released in 2022-23 by the Canadian Centre on Substance Use and Addiction (CCSA) — which mislabeled their advice as “Canada’s guidance” (“Canada” has not made this guidance) and has disseminated its findings around the world — use something called Years of Life Lost data (YLL). This is problematic.
I showed the YLL data tables from the 2023 “Guidance” to an epidemiologist colleague who did a double take. “That’s not how we use YLL data,” he said.
YLL data is a measure of global disease burden. It helps governments and public health agencies prioritize interventions that thus help address premature death. It is not a measure of individual risk.
What the CCSA did was come up with some definition of how many lost YLLs would be considered reasonable and used that as their baseline for acceptable risk. I am not going to get into the specifics partly for fear of being accused of misrepresenting it and partly becasse it does not matter.
The point is that YLL is meaningless for individual health decisions. Meaningless.
So how do we gauge risk? And how can the vast research that says alcohol is bad for you be translated into meaningful health information? There are ways, but let’s first consider the core dilemma: health is about balance, making decisions in life requires assessing risk and benefits. And understanding risk requires a sense of proportion that is often missing from alcohol research.
Saying alcohol increases your risk of cancer or other diseases is also meaningless, at least without some important context. Walking outside increases my risk of skin cancer. But the increased risk is marginal. Moreover, walking is a good form of cardiovascular activity, so it balances the risk of skin cancer against the benefits of walking.
Alcohol research these days, even when it uses language like the “risks and benefits of drinking” usually jettisons any sense of proportional benefit. Instead of talking about things like the benefit of socialization, the relaxing effect of having a drink with friends (or heaven forbid alone), the sheer pleasure of a wine tasting event or a food and beer pairing session, or the creativity that can emerge from a few drinks while mulling over a problem, they reduce all drinking to a biological process that ignores such context.
And what is worse, they call those sorts of events “normalization” of alcohol, spitting out the term as if there is some conspiracy to make alcohol a normal part of our lives (it is a normal part of most people’s lives, and I would argue that pushing people to stop drinking is what is abnormal… But I digress).
As a result we have no really useful ways to assess any risks associated with drinking, and we have a distorted impression of what drinking does to and for us.
Now, as I said earlier, there are other ways of making risks meaningful for individuals. The CCSA’s preliminary report gave a bit of this information (it put annual death rates beside each disease or injury in its risk tables) but it removed it for the final report. Yet even such data can distort, because it also misses the complexity of our context.
I will talk about some of these other ways of assessing risk in a future post.
For now just keep in mind that all this hyped up alcohol risk data is at least disconnected from actual life. At worst, it is complete misdirection designed to strike terror in the hearts of moderate drinkers.
By the way, fear and anxiety are also risky.
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