Alcohol risk, guidelines and messaging with Tom Chivers & Colin Angus

In this episode I talk to two guests about the risks of alcohol use and attempts to communicate these via the UK's recommended guidelines of 14 units a week.

Firstly I talk to Tom Chivers,  science editor at UnHerd and author. We talk about how the risks of alcohol use can or should be evaluated and communicated. Tom recently co-authored a book How to read numbers which includes a Statistical Style Guide  for journalists.

Next I speak to Colin Angus,  a Senior Research Fellow in the Sheffield Alcohol Research Group within ScHARR. We talk about the science and development of the UK’s 14 units a week recommended guidelines. 

Transcript

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James Morris: 0:00

So Hi, Tom, thanks so much for joining us. Can you tell us a bit about yourself and issues perhaps you think are really interesting from a kind of outside perspective from the alcohol field?

Tom Chivers: 0:10

Okay, sure. Yeah, my name is Tom Chivers, I am a science journalist. My job title is science editor Tom Hurd. And I'm the author of a couple of books most recent one was called How to Read numbers. And it's about how numbers in the news go wrong and how people can learn to trust or learn when to trust statistics and things that they read in or see in the media. And I suppose the stuff that I'm most interested in is risk communication, how these how the numbers and how the sort of information about alcohol behaviour, alcohol risk, and any any sort of health related behaviour or anything at all, how that makes how the information makes it from the scientific community from scientific studies, the population surveys, epidemiology and so on into public understanding. And that's obviously mediated via science journalists like me and the media as a whole. And I think that is probably the stuff I'm most interested in.

James Morris: 1:00

And I guess, you know, the classic example, the kind of ongoing issue around this is the recommended guidelines, you know, currently 14 units a week, which were revised again in 2016. And, you know, within the public health community, there's ongoing debates and tensions about is it useful word and how its interpreted. And obviously, amongst the public at large, there tends to be this well, often low awareness of it, but particularly, we see people who drink above the guidelines tend to discount it, because it's kind of not congruent with their behaviour. So that kind of motivated reasoning approach. But yeah, I think the media has a large role to play in that in terms of, as you say, just reporting individual studies in ways that kind of attention grabbing or headline, maybe they receive or clickbait. So, yeah, that's the kind of classic example, isn't it?

Tom Chivers: 1:48

Yeah, the guidelines, I think, are a really interesting thing, because they have this this sort of this hard cutoff, right? You know, you said the 1414 units is your recommended level, you know, or whatever. And there's a sort of sense that there is a low that is finally above that is bad, you know, and that's just how it runs. And I think there's what we what needs to be communicated a lot more is that actually, there's, you know, that that's not how it works, there's this really, this is a sliding scale of impact. And actually, you know, if you drank 13, instead of units a week instead of 15, or something like that, it's fundamentally it's not, there's some sharp cut off, it is a fairly arbitrary level. But you know, what I also think is really problematic with it is that they're just saying 14 level units is the safe level right there. That is the recommended level, it doesn't actually give people the information, they need to make decisions about their own health behaviour, their whole behaviour, like, I think I'm sure you're aware of David Spiegelhalter, the statistician, he wants people to talk about the risk impact on individuals. And so you know, if I, if what we want, what you really want to know is, if I drink an extra glass of wine, how likely is that to cause health problems for me to further down the line? So what is really important when you're talking about risk presentation is like, how many people does it actually affect if I do change my behaviour in this way, and it's and it's something that if it was something like 50, people out of every 100,000 would would have an alcohol related disease they don't know, wouldn't normally have, if they drink, I think it's something like two drinks a day, you know, also, and I think so. So what is really important there is to, is to provide these numbers so that someone who I mean, my cousin, David, who I wrote the book with how to read numbers, he is a big big wine fan, he'll spend, you know, loads more money on a bottle of really nice wine than I ever would, because he has, he's able to taste these differences and understand it, and it matters to him, right. And he and if we were to take wine out of his life, then he would have a much less fun life. Because it's a really big, you know, it's a really enjoyable, you know, in this, you know, later hobby for him. And so he might look at that, you might say, well, if I drink two drinks a day, and that gives me this 50 and 100,000, or whatever chance of a disease that I otherwise wouldn't have. But on the other hand, I get loads of benefit out of it. So that slight risk was like a real risk should be taken into account, but also those, it should be weighed against the very real reality that I will have less fun in life. And I might trade off for some, you know, small risk of having a shorter life against a very definite chance that I will enjoy life more if I do these things. So I think that you know that I think that is really the fundamental issue with guidelines and with risk presentation in general is that this sort of oversimplification this select here is a safe level above it is bad below it is good doesn't actually give you information you need to navigate the world to make decisions, informed decisions about what is the right decision for my health, nice sort of quality of life, I think, I don't know how you go about changing the guideline system to something like that. But I certainly think we in the media can do more to present these numbers in a way that's meaningful for readers rather than just sort of start cut offs, which really flatten and compress information beyond use.

James Morris: 4:41

And I think there's quite a few kind of inherent tensions within it because exactly as you say, a having a single one size fits all arbitrary cutoff is no just just problematic on so many levels, not least because people look at that and they will just know that there are individual variations, not just in terms of physiological reactions to alcohol, but in terms of exactly as you say that the value that individually we might place on alcohol, you know, some people are massively fast about drinking, don't drink at all for that, and other reasons. And other people value it highly, because they're really into wine or you know, it's a big part of their social lives, or their work culture, or whatever. And those are all very complex factors that that kind of come into play. So just trying to Yeah, presenting it as a kind of one size fits all is gonna just not resonate with people. But the really difficult thing is that, you know, in terms of risk communication, if you're trying to appeal to people who have perhaps low level of motivation to kind of process or think about a particular issue, they will be biassed towards, you know, very simplified interpretations of things, possibly that then allow them to kind of come to their the conclusion that they want. So, for instance, heavy drinkers, you know, my research kind of looks at how people, you know, differences between thinking categorical binary ways Evie, or problem drink, or you're not versus more of a kind of spectrum approach. And heavy drinkers often are kind of biassed towards that categorical way. Because they might be able to say, Well, you know, I'm not an alcoholic, therefore, I don't have a problem. And similarly, they might just say, well, the guidelines rubbish, because it's a one size fits all, so I'm not going to pay any attention to it. But then we also, you know, just as humans innately have a tendency towards simplifying things that, you know, if we saw the world in or looked at everything that we came across, in all its complexity we'd never get anywhere. So we have to categorise and produce things down. So there's that tension between, you know, presenting a guideline, that simple and that people can understand versus all of those complications, just that we started to kind of scratch the surface on.

Tom Chivers: 6:45

Yeah, I mean, you're absolutely right. It's not as straightforward as loving people have limited time in their day and don't want to say don't want to start working out their risks and benefits and so on. But I think it is also the case that this sort of, like if you do flatten it down to a simple for 14 units is the correct amount, then you'll have people making the wrong decisions for their own enjoyment. Yeah, there are a lot of people I know who just don't drink alcohol, and that is fine. But we should also not avert our eyes too much from the fact that people do drink alcohol enjoy it have have a positive relationship with it, which may come at some cost to their health, but which is, you know, valuable in its own right. And I think there's a real thing in public health in general, I mean, of almost just discounting the idea that things can be fun, right things other people have enjoyment I could people do risky behaviours and the knowledge that they will come at some cost to they're likely helpful, they're likely they might might get hurt, doing skydiving, I don't know. And that is that needs to be taken into account, you know. So it's the economists idea of the personal preference, and we know that they are rationally choosing enjoyment in the short term over long life in the long term, I think that needs to be sort of addressed. And people I'm aware of people who say gigantically misinterpret the actual risk of drinking above 14 units, and therefore don't drink at all drink tiny amounts, because I think it is really high risk. And also, I know people who sit here look at this video, well, don't drink far too much, because I think, well, this is silly. And it's and I think, not merely that I'm saying they their decisions are wrong, but I think they're making decisions on badly on their own terms, they are not drinking alcohol, because they think it is riskier than it is or they are drinking too much because they are sort of ignoring the risks that they are and I think the important thing is giving people information to make these decisions in a rational way. So they can say yeah, the value of me enjoying it is x, the value of my continued health past the age of 70 is why and I consider x to be bigger than y you know, that that is that is I think we need to let people make these decisions as sort of fully and rationally as you can

James Morris: 8:37

Of course the kind of critical psychologist in me will say, you know, how how capable are we of making rational decisions because of motivated reasoning, you know, we're, we're very strongly drawn towards often kind of thought processes that justify our existing behaviours, rather than starting off with a thought process and then deciding what our behaviour is going to be but it's a bit of an aside because you know, I totally do agree that that the public health community and I think I've been guilty of this in the past can be a bit too siloed about well, you know, there are lots of people who drink heavily and you know, we've got you know, over a million people with some kind of alcohol related hospital admission each year and many of those you know, don't fit the stereotype of being a problem drinker and you know, maybe the alcohol is just contributed partly to their high blood pressure or any huge number of conditions that alcohol is associated with it's quite easy to get kind of drawn into that and and forget about the you know, that there's still a majority of people that drink within the guidelines or at least close to them most of the time and won't experience any serious health effects at least throughout their lifetime. And yes, it is really important you know, I drink you know, I drink moderately having had you know, kind of past problems and a long period of not drinking but I do think I obviously drink because I believe that alcohol enhances aspects of my social life or you know, Having a drink or two does relax me. And there's interesting questions about that in terms of what my motives are or whether that how much of that is expectancies because, you know, just have an idea that alcohol is going to cause this effect. So a lot of might be psychological more than it is the actual physiological effects. So, yeah, I totally, totally agree that to have a balanced and balanced debate and nurture kind of more informed decision making, we absolutely can't ignore the the kind of value that people place on Alcoa and much of it very legitimately. So no,

Tom Chivers: 10:32

I agree with you. You're sort of your aside his own, it's quite an important aside right there, people aren't rational, and people do make decisions that are bad for them in various ways, you know, and I think that is worth is worth keeping really quite close to the forefront of your mind, I think what you need to do is start by assuming that people broadly know best for themselves, right, you know, they're not in that, and then you can sort of go from there. Well, actually, I think I think the one case, for instance, that I think was instructive here is smoking. I think actually, almost all smokers of tobacco cigarettes will tell you I would, I haven't got any studies to hear by hand. But I'm reasonably sure I've read this. And I hope people can write to me and tell me if I'm completely wrong. If If I am, I think a large majority would say I would like to quit smoking, I know it's bad for me the the costs of my health outweigh the benefits I get, but I find it hard to quit. And I think that most of us would agree that is by their own on their own terms and irrational behaviour, but they are forced into it by addiction, which is limiting their freedom. Right? That is that is a difficult thing. And I think what would be an interesting comparison, there is something like vaping, which has so much lower health impacts that I would if someone said to me, I actually enjoy vaping I'm doing it for the foot. And I know I'm aware of the health risks, I will be much less willing to say you are behaving irrationally, and you're, you don't know your own preferences, or you are being driven by addiction. You know, there's I think there is, I guess a body be a sliding scale a spectrum of you know, to what extent you are in control of your own actions. And then you get into this complicated discussion about freewill and you know, addiction and how that interacts. But I generally think with alcohol, the majority of people, I will be willing to say, your your behaviour is, I will start from the assumption that your your behaviour is rational and you're you have your own you have your freewill and you have your your ability to judge these things. And then as you know, as people slide up the scale towards more problem drinking and addiction and faith and inability to control it, then you start saying no, you're making decisions by your own lights, by your own reason, you know, you're on your own terms would be would be bad decisions, and you wish you would make them and then you start the thing that certainly there's a role for public health community of offering help out of it. And but I think the the fundamental thing is to make these decisions about your own health behaviours, you need the information presented in a way that is understandable and presented in a way that lets you make sense of it. So you can navigate these risks and navigate the benefits and say, Yes, I am. I enjoy this. And I don't enjoy being ill. And I can trade these things off in the in the correct levels, you know, yeah.

James Morris: 12:59

I mean, there's so many interesting issues in there. And, you know, I kind of think that, I mean, firstly, when you're saying about smokers, I'm drawing on anecdotes here. But I think it totally depends on the way in which context and the way in which you framed the question. Yeah, I was just thinking about someone I met the other day, and someone introduced me, and this chap was a very, you know, heavy smoker. And the person introducing me said, Oh, he's an addiction psychologist, or whatever. And the bloke defensively said, Well, I'm not addicted. I like it, you know, you know, he smokes. So 40 cigarettes a day. And, you know, I was quite aware that there was probably nothing I could say at that point that was going to kind of change his position. But yeah, I'm sure if I mean, you know, what kind of happens in addiction treatment is, you know, certainly from the kind of psychological perspective motivational based interventions which explore that cognitive dissonance of the person usually has so so I suppose what I'm getting at is there's all these kinds of very complex thought processes that that often mean that Yeah, the more embedded in programmatic the behaviour is the more that kind of motivation to justify it might come out and you know, it's very good reasons for that, not just because of that's kind of human nature, but also because of stigma and you know, social norming that people who smoke or drink heavily socialise with people who do the same. So it just that seems like the norm rather than than drinking or smoking less.

Tom Chivers: 14:23

Yeah, no, I completely random but funnily enough, we had a piece in and heard by David Hockney, the the artist saying, basically, I smoke and I really like it and you can all go No, I don't want to I don't want to say he is behaving irrationally. But then also I do like to say that the human brain is not a single thing is it right you know, there's, there's loads of different bits of my brain saying, telling me that I want this at this moment and this at this moment, and they can they can disagree with myself a lot of the time and pretending that we are one unitary rational thing that has it has one particular desire that is thwarted in some way by other parts. You know, that doesn't make sense. We are complicated beings with lots of desires, and I suspect that And I think I'm right in saying that in the case of smoking there, there is a much greater tendency to say I smoke, but I wish I didn't, then there is with alcohol or with other things. Yeah, I suspect. Yeah, I think that that ends up in a sliding scale spectrum issue. I don't want it to So even with smoking, I wouldn't want to say to people that you were making the wrong decision, if they consciously and calmly say, No, I've thought about this, I know that I know, the risks. I am aware of them. I have, you know, I've looked into it and I enjoy it enough to want to carry on No. And sometimes it is motivated reasoning. But at some point, you have to say, Okay, well, you've done your reasoning and motivated or not, it's not my place to come in and say, You are wrong. You know, I think that to some degree, without sounding too much like a, an internet, libertarian, you know, there's that you got it, you've got it, you've got to let people make their own decisions and do their own harm themselves. And you can give them information. Now, I think I think the right thing to do is giving them information, which is why you know, like calorie counts at restaurants, I cannot see why people have a problem with that. I think that is you're giving people correct information to make decisions with and that is a good thing. And I think that is that is the case here like like anything about changing the information universe information, the meme Plex around us. Like, I don't have problem with limits on advertising, for instance, because I feel like that is there are a lot of ways in which limits on advertising can skew the information that gets to people, I don't have a problem with providing things like calorie counts, information on, you know, health warnings on cigarette packets, even health warnings on alcohol, as long as Yeah, as long as they are provided providing accurate information. That's the thing. I think that is all fine. As long as it's done with the intent of providing information to people rather than necessarily scaring them. I think there's a line to be drawn there between providing information to allow people to make their own decisions and providing information deliberately to scare to push towards a certain course of action, which, you know, it's a line and it's complicated, which is which but I think that's interesting.

James Morris: 16:47

I mean, I'd agree with that just largely on the basis that kind of scare tactics probably don't work that, you know, I think, you know, I've done some work around kind of defensive processing, you know, how people kind of subconsciously look away or kind of just just avoid information. So kind of health warnings on cigarette packets, famously, you know, don't tend to work for existing smokers, because their subconscious is so good at identifying it as a threat and just blocking it out. And a lot of complicated theories about how that works, and kind of things that moderate that effect. But they may actually have some effect in terms of preventing new smokers who, you know, might look at the pack and go, Oh, yeah, I don't want that I might not, I might be less inclined to take it up. So yeah, generally, I'd agree with the kind of scare tactics in I don't think the evidence is good that they actually work. Whereas, you know, providing good information in the right context might hold more value. The big issue here, I think, really, though, is that, you know, there's no mandatory labelling for alcohol, despite a being of, you know, potentially addictive, very potentially dangerous drug, even if many people use it without such consequences that, you know, it's a no brainer, that it should have basic health risk information and some calorie information on it, that's not the case, because there's a long history of, you know, self regulatory pledges that kind of have or haven't been met. But essentially, the kind of providing basic information, you know, on containers or whatever is a no brainer, and that should be kind of mandatory. Really, that's, that's my view on that. I think the more interesting or, in fact, more important debates are around those kind of environmental influences of behaviour, which we know really huge, where it does, where there is a more of a legitimate argument about how much of a government role is there to play but the the argument that, you know, sort of the so called anti nanny status, say Is that too much interference, but then surely, the flip side of that is then all drugs should be legally available, and you know, kind of regulated to some degree that everything is a balance of regulation, you can have too, too much regulation, which is prohibition, and you can have too little which is widely available and widely accessible, including to children who are exposed to too much marketing and the products far too, or is very cheap, and can be easily accessed in dangerous quantities for not a lot of money. And that's kind of where we are least have been with alcohol. So I do think the issue about choice and kind of the idea of individuals responsibility is dangerous if because people are heavily influenced by by the environment and social norms and all those kinds of things. And that from a public health point of view, again, not not discounting or rejecting the positives of alcohol, but I think there's a balance to be struck and I think a case for pricing and advertising curbs that are more effective than what we currently have. Yeah,

Unknown: 19:33

I think on the subject of drugs in general, I mean, it is always Oh my my instinct is always to treat alcohol like one more drug, you know, and I think I think my my ideal position would be a weird like hybrid of libertarianism as in every you know, all drugs should be legally available, but you know, but I think it was transformed drugs policy, the think tank or pressure group, whatever you want to call them who suggested like a five tiered level way And it can get hurt, you can get heroin and coke, cocaine or heroin and crack cocaine on prescription and then all and then further down, you can buy other ones in pharmacies over the counter and you know, all the all these drugs regulated down to caffeine which you can buy. And in any shop, you know, that all I feel like that sort of system and alcohol being one more thing on that system where people can be are allowed to buy it, you know, and in personal situations, but there should be respect, I think the important thing would be if you if you have that system, you need to have restrictions on on advertising. So there isn't a sort of information free for all of you know, that buy our beer and all these, you will be attractive and successful pipe, you know, the ideas that people had, and I think I think that is to maximise sort of the individual freedom to choose the thing that you want, you need, the ability to choose all different things, the different drugs that they might want to do and might therefore enjoy. And that is, that should be fine. But also, then there is a need to they need to be made aware of the different risks and benefits of our risks, especially because they can do they can discover their own benefits, I guess, the red meat, you know, made of made aware of the risks of the health risks, and also kept free from as far as possible advertising that can skew the information and give a wrong give a bad sense of the risks and benefits. And I think that so I think that I've got this sort of weird, half quite libertarian half quite restrictive idea that you could be really libertarian with the actual substances, but extremely restrictive and conservative on the advertising information that is that they is allowed to be sort of commercially put out around them would be my ideal situation. Yeah, I

James Morris: 21:27

think I think that's a quite sensible approach, really. And I certainly think that, you know, kind of staged approach to regulation is, as I was kind of saying, everything's on a scale of kind of regulation, or kind of should be, it's about getting that difficult balance. Right. But yeah, I kind of sort of think that, you know, the idea that you can have neutral or totally accurate advertising is maybe a bit of a contradiction in terms, isn't the whole idea of advertising to kind of frame something in a way that makes it maybe more appealing than it really is. Yes, exactly. Yeah, completely agree, sometimes of kind of the science journalism, and what kind of the can the media do, you know, I'm certainly very interested in terms of how kind of the media reports on people with alcohol problems. And, as you probably know, you know, I'm not keen on the idea of alcoholism, which has, you know, long been retired from medical kind of scientific practice, partly for reasons that again, it's a kind of false binary, that people aren't either alcohol dependent, and there's a cut off or which you either are on the it's a kind of spectrum and dependence is only one part, you know, alcohol use and problems. So that's one area that I'm, you know, quite keen, that's, you know, I even wrote wrote a piece for The Guardian quite a few years ago, saying, you know, kind of making these arguments, but the editor still put a headline in that, you know, kind of use the term alcoholism, even though the articles explicitly calling for it not to be used. Of course, there's exceptions of people self identify that term, etc. but but do you have any kind of thoughts? I mean, you know, you kind of write pieces that, you know, look at the evidence and try and disentangle and come to a kind of reasonable position, but but, you know, how might we kind of appeal to, to kind of media outlets who, by their nature are kind of more clickbait or kind of just attention grabbing kind of news is their last cause? No, no,

Unknown: 23:11

no. Okay. So. So I want to first I want to say that the I have quite a high opinion, despite my work being quite often, I hate the word debunking. But you know, like, critically assessing other journalists work and sort of saying, well, this, this piece of journalism that's come out is in some way missing the wider story I do, as on the whole have quite a high opinion of journalists. And obviously, selection bias being what it is or survivorship bias, the ones that get through the ones that I am writing about will tend to be the bad ones. And that will give an impression that I'm only looking at badger and I genuinely think journalists are decent people brought in broadly pretty intelligent and who want to do to do good in the world. I think that is true. A lot of the time, but I do think also, you know, and most most journalists see journalism as a public service, right? They're not just out for making money or being getting being famous. They want to help the public understand the world they live in. And that is my it's not like I've done some survey on this or anything, but that is, you know, my my possibly biassed opinion of journalists from the journalists. I know, that said, journalism is a public service, but it's also a business and the business of journalism relies on eyeballs on paper or eyeballs on news or listening to radio, whatever, you know, people paying attention, right. And that it's an it's an intention economy. And it is just it's just the case that they they have a piece which gets more attention is of more value to a journalistic outlet, a media outlet, the one that doesn't and this is why, you know, there's a slight aside and a rant here, but you know, this is why people complain all the time while you're you aren't covering this story of Yemen, Yemen or whatever, you know that the mainstream media is not covering this whatever actually 99 times out of 100 they are covering it you're not reading it like that's that's what's going on is and you know, people read the the exciting stuff, you know, cultural war stories that get everyone riled up and they ignore these this is the serious thing about that 10s of 1000s of people Have malaria every day. This is not this is not just on a media This is on the readers as well. Right. But the problem I have in what that translates to in size journalists in particular is that there is we are looking constantly for exciting things. And we're looking things constantly for new things. And that means that the in science journalism typically what the new thing that comes out with is we report the news and the news in science is often new studies, right? So you get a, you get headlines of new studies. And since we're talking about alcohol we will focus on alcohol. We've quoted in the book a few you know, that even one glass of wine a day raises the risk of cancer alarming study revealed boozers linked totally seven forms of the disease headline from the mail in 2016. Or, you know, then one glass of antioxidant rich red wine a day slashes men's risk and prostate cancer by more than 10 templates out of 10 times or 10%, it's over 10%. But Chardonnay has the opposite effect study finds Daily Mail 2018 in it. And the trouble there is that actually there is a great big body of evidence on the impact of wine, alcohol, whatever on health, and each new study is not coming out, you know, straight fresh out of a clear blue sky, it is a new data point to be added to this massive mountain of data points, which at most can shift the opinion of you know, if it's an if it's a new study on observational study of a few 1000 people, it's one little blob of information, which can most shift our opinion a very little bit from the from the centimetre from the the massive opinion we already have. And if we if we say if we just ignore all the previous studies and say, Well, now this new study says that alcohol is good for you this week. And then next week, we ignore that and say, alcohol is bad for you this week. And it gives us an impression of the science jumping around, whereas actually, the science is agglomerating, lots of new data points, which will slowly form a, I guess, a bell curve around, you know, around the real limb around the real value, which is alcohol may or may not have some tiny protective effect at small amounts that Jacob whether it's real or not, is a ongoing debate. And I think you're possibly isn't now I don't know, I get so confused about it. But then, you know, broadly, the real story is there is a steadily increasing risk and more the more you drink, and it's fairly low at low levels, it gets hard to hard to detect, but real large levels, if you're drinking five drinks a day or whatever, then there is a detectable impact of on health. And that's just been the case for years now. We know that new studies come out and they they throw them on the pile. And they just sort of add to that picture. And I think there is a the journalism is very bad at saying new study adds small amount of information to already existing pile of information and very keen to say new study totally overthrows everything we already knew. And that is really unhelpful. And that is because we want novelty, we want excitement, we want a headline that grabs and I think that is, you know, it is it is really hard to avoid because the incentive strike, you know, we need a functioning media system. The media system is important medium media industry is vital for democracy and for, you know, continued sort of public life. But it is also a business. And it relies on this information economy, this sort of attention economy. And I don't have a good way of saying incentivizing journalists not to look for excitement and novelty. But I do think the role of the responsible journalist is to put these new studies into context and say, so this is this is a new study, it slightly changes what we think but only very slightly, or it is very much in line with what we think and you know, wait for the new big meta analysis or a Cochrane report or something like that, before the end, see if that has changed with the given the weight of opinion. And I think that is, that is something that science journalism as a whole needs to be better at, I have tried to do over my career, and this is a real failing, when you see those, wanting, you know, drinking a glass of wine is good for you this week type headlines.

James Morris: 28:49

And I think it's also not fair just to, you know, point the finger at the media, you know, publication bias is real, you know, science journals are guilty of just the same thing often, you know, finding that, you know, positive finding or will be more likely to be published and studies that don't don't have positive results can be really important, but much harder to get published, because they're not exciting.

Tom Chivers: 29:13

Yes, no, this is actually true. This is we talk about this a lot in the book. And it's really, really important that a lot of it isn't journalists fault, a lot of it is well upstream of journalists. And you can't really expect a guy you know, the guy on the science on the science desk at the express or something to be running funnel plots to work out whether this new steer this new meta analysis is a victim of them have publication bias. And yes, you're right. There's a lot that science has to do to get its house in order and all this sort of stuff. And I think there are great things about pre registering studies and registered reports and things which can sort of tie scientists to the master or more importantly, science journals to the master of like, we will publish publish this study whether it finds a result or not. But I concentrate on journalists in the book, we concentrate on journalists in the book, but we do point out that actually there's a lot that's going on in science, which is just not journalism's fault and science needs to do a lot of work to get it out in order as well.

James Morris: 30:00

Yeah, it's a bit like kind of turning your oil tanker around as well, I think it's this progress and nothing You are now more likely to get a lot of studies will only be published if they have pre registered. And and, yeah, I think just on the kind of j curve issue that that is an interesting one. I think, again, that's kind of a nice example of what you say that we, you know, over the last few years, there have been more studies using different methods, you know, kind of genetic sequencing or Mendelian randomization, that kind of the evidence is mounting that actually these are likely to be far more likely to be, you know, kind of confound confounder affects that there actually aren't benefits to heart health, through the mechanism of alcohol itself, rather than more likely, people who drink low amounts of alcohol have healthier lifestyles overall, but it's still still not conclusive. We still don't quite know yet. But again, I think that's an interesting example, because it's something that in the past, the media has picked up on. And people really do often lap that up. You know, I think, I don't know if there's been studies about how many people would say, Yes, a glass of red wine or whatever is good for you. But I think it'd be pretty high. And again, that I know that there's studies that show that those kind of biases are higher in people that do drink, whose behaviours that will make them feel better about and how do you think you know what you've looked at? Or thought about alcohol? And does it sort of feed into how you approach alcohol? Well, there was a famous case where the former chief medical officer said something like, every time I reach for a glass of wine, I think, do I really want to increase my risk of cancer and it causes, you know, absolute outrage kind of crucified for kind of scaring people. But you know, one level, it's a kind of valid thought process, particularly if that's one she wants to have. that's a that's a rational thing to do, isn't it? Yeah, exactly. But on another level, you know, perhaps it's fair to say that not everyone should have to think about their level of cancer risk when trying to enjoy a glass of wine.

Tom Chivers: 31:59

Well, I guess the window surprise, no one at all, to know that I drank more in my 20s. And I do now that I'm 40. And when I was in my 20s, I do remember think I remember thinking, you know, that the evidence hadn't changed that much now. And then between now and then I remember thinking this is probably more than they'll drink, and being aware of the health aspects of it without, without me knowing also being aware that I was in my 20s, and was pretty healthy and was fine, and also smoked a bit and was aware that wasn't something I wanted to do forever. And I did think I want to stop this. I think I've got actually properly drunk twice in the last couple of years or something, you know, I have, sometimes I'll have three drinks on a Friday night, you know, and normally, it's like, I'll have a pint on a gin and tonic with my wife. And what has changed is not that I've made any particular health decisions, it is that I've had kids and I've had gone, my jobs got more responsible. And I've, you know, I go out less because I'm older. And it's, you know, and it's just, I've naturally become less in situations when I want to drink eight pints, you know, I would, you know, it's really hard to tease out what is the cause of that. And I do think you know, that I'm sure that there is some bit of the of the brain that that takes into account the fact that I'm aware of alcohol risk and alcohol risks, and in my decision not to drink a bottle of frog every night, but because yeah, but there was basically at some point in my 30s, I found that alcohol around the house doesn't disappear from them immediately. And you can even have a bottle of wine that sits in the in the cupboard for a few days until you actually want to have it. And I just think that's a lot of just getting older and life changing. And you know, being settled down and being more boring. So though, Yeah, I do. I do think that alcohol health risks. I've always been aware of them. But yeah, but I don't I don't see them as particular driver of my changing behaviour that said, you know, when you go to the GP and they ask you or you fill out some online form, I'm aware of the finding that everyone underestimates how much they drink? And I do, I'd be really intrigued to know whether if I actually did it out, but you know, if I say well, I don't think that I get past the 14 units, I'm probably under the underneath it. And Wait, are you really if I actually sat down and took a dark kept a diary of it? Would I find that I am drinking much more than I think I don't think I do. I think I'm reasonably on it. But I you know, like we've discussed throughout so throughout this thing, there's, there's a lot of sort of complicated psychological stuff goes on about hiding your own level of drink from yourself and all that sort of stuff. So anyway, this is a big, long, one wofully ramble, but I don't think that my behaviour has been gigantically driven by alcohol risk. And I think it is mainly just driven by the fact that I haven't got time to drink these most of these days. I'm not in situations where I would. And I hate hangovers.

James Morris: 34:31

I think those are all kind of perfectly normal and quite typical responses or behaviours that you know, there's a lot of stuff about over the life course transitions, just most people mature out of alcohol problems, you know, problematic drinking, many people do it in their early years and 20s, but just simply mature out of it because of quarrel of responsibilities and so on. But similarly, I just don't think many people do factor in the health risks partly because of delay discounting and it feels so far away, but Kind of in the moment decisions are kind of more more powerful. And you know, how does it affect us the next day might be a more powerful driver than you know whether you might increase your risk of X 20 years down the line or whatever. So, yeah, thanks so much, Tom, that that's been a really, really interesting chat. And yeah, best of luck with with a new book, what's the name of the book? And where can you get it?

Tom Chivers: 35:24

How to Read numbers, a guide to statistics in the news and knowing when to trust them all good bookshops obviously. But if you go to how to read numbers.com, you'll find links to various places you can buy it and also a link to our statistical style guide when the book is for readers, you know, sort of how to navigate numbers in the news. But there's also a bit on the end, which is sort of for journalists to try and do better. Sort of a few simple tips for journalists to sort of how to present numbers more effectively and more informatively. We asked readers to come and sign a petition to encourage people to sign up to that or a similar statistical style guide to to improve statistical literacy in the media, I think that'd be a really useful thing for exactly the sort of stuff we've been talking about for presenting information about everything, including alcohol in ways that readers can then use to make informed decisions about their own risks and benefits and their own lives.

James Morris: 36:12

Next, I spoke to Colin Angus about the science and development of the UK, his weekly drinking guidelines. Thanks so much for joining me, Colin. Can you just tell me briefly a bit about what you do? And then yeah, we'll we'll try and kind of unpick this question around 14 units, how much risk does it really raise?

Colin Angus: 36:28

Yeah, so I'm a senior research fellow at the University of Sheffield and my work is primarily modelling the effect of alcohol policies on drinking behaviour and unhealth. So I've done a lot of work on sort of mathematical modelling relating drinking to health outcomes. And when the UK Chief Medical Officer announced that they were going to review the drinking guidelines A few years ago, myself, and some of my colleagues did some modelling work as part of that review, to look at how the risks the health risks associated with drinking changed at different levels. So that was to inform the development of the guidelines. So the there are obviously lots of different ways in which you can set drinking guidelines. And in the past, they've generally been set by getting a load of clever people who know stuff in a room and kind of locking the door until they all come up with what they think is a, you know, a good answer. And I was an acceptable guideline based on all that they know about the evidence in terms of the health harms associated with drinking, but more recently, with kind of, you know, improvements in the evidence and a tendency of like a desire to try and be a little bit more rigorous about it, right, rather than just some people criticise the previous drinking guidelines is basically just sort of sticking a finger in the air. And we recognise this. So there's two different approaches that have been used in other countries to try and sort of empirically guide the process of setting drinking guidelines. And they're known as the Canadian and the Australian approaches, because they were first used in Canada and Australia. So the Canadian approach says that you set your guideline, at the point at which, if you drink any more than that your risk of death is higher than someone who doesn't drink at all. Okay, so it's it's saying that you set the guideline at the point at which your risk is elevated at all, right? So any point of which drinking increases your risk of death. And the Australian approach says that, well, actually, you know, all sorts of things that we do in the world are risky, and, you know, have risks associated with them, right, you know, driving a car is risky, but we still drive cars all the time. And so it's based on this idea that there is an acceptable level of risk that we're willing to take on when we do stuff. And so they came with the idea that an acceptable level of risk was a 1% lifetime chance of dying as a result of, of your drinking. The idea there is that you set the drinking guideline to the point to which if you drink at that level, across your whole life, there's a 1% chance of that drinking being the thing that will kill you. And so with my colleagues we took in so we reviewed the latest evidence on associations between drinking levels and risks of death for a whole range of different health conditions. And then use that to try and estimate the risk associated with drinking at different levels to use these two different approaches to say, Well, if you use the Canadian approach, then your drinking guideline is going to be x and if you use the Australian approach, it's going to be why.

James Morris: 39:36

So does our our kind of current 14 unit a week guideline? Was it an attempt to lie somewhere between the two or

Colin Angus: 39:43

Well, it's complicated because you know, the relationship between drinking and health is a very multifaceted and complicated thing because there are a whole range of different health conditions that are affected by alcohol, and these include conditions They're associated with long term chronic drinking. So that things like liver disease, but also cancer and heart disease. And then there are also health conditions associated with intoxication. So things like alcohol poisoning and injuries. And so you have to try and sort of account for both of these things, right. So the chronic health conditions, they're only related to how much you drink on average, whereas these acute conditions related to intoxication, they're also related to the patterns in which you drink. So if you have a, you know, two people who are drinking at the same average rate to people who are drinking out the guidelines, let's say, 14 units a week, and one of them has two units every day, and the other one has 14 units on one day, they're not facing the same risk, right? They probably have similar chronic risks, but their risks of alcohol poisoning or their risks of injury are very different, because one of them is, you know, is getting drunk, probably, and the other one isn't. And so it's important to try and take that into account. So we modelled, we model the risk associated with different patterns of drinking, right? So it's not that we can say, Oh, the Australian approach says the guidelines should be 14, because we said with the Australian approach, if you assume that everyone drinks all of their alcohol, on one day of the week is this. And that gives you a much lower guideline, because that's a much riskier pattern of drinking, compared to saying, If everyone spreads out nicely across the seven days of the week, so sort of 14 is kind of somewhere in the middle of all of these different numbers that we produced, essentially. So we had separate results for men and for women, separate results for the Canadian and the Australian guys. And then there's separate results for these different patterns of drinking. So there's, you know, big tables with whole slews of numbers in them. And the 14 was is kind of somewhere in the middle ish.

James Morris: 41:53

So yeah, it's really, really well explained. And I think the point about, you know, saving up versus spreading it out is really important, because I think that question does come up a lot people want to know, you know, what's worse to to, you know, to binge drink or to drink? Less, but but more often, and, you know, again, it just depends on so many things. But I keep assuming there was at least an equal amount, then then they're just different types of risk. And, yeah, it really is so individually dependent. But yeah, any reflections on how we then try and communicate this that, as I discussed with Tom, that there's this 14 unit a week guideline, albeit the guideline itself has kind of small print, if you like, you should take was it three days off for me to set it suggested is to drink three days? I think that's right. Yeah, I was kind of go for three, because I think it suits me better. But yeah, and you know, it doesn't specify don't binge drink, or how much or binges but it says, you know, don't, don't drink it all in one go. So they did build in some kind of caveats to it, didn't they, but it's still essentially a kind of one size fits all. And that does present the challenge that people know that they're not an average person or that, you know, as I discussed with Tom, that people face different levels of value on on their drinking for different reasons, and in different contexts. So, you know, what, how best to try and navigate this kind of risk of this kind of all or nothing interpretation of this threshold of 14 units?

Unknown: 43:22

Yeah, I think it's, it's, it's incredibly challenging. I think part of the part of the difficulty is that as you say, this is an average, right? This is this is sort of the guideline for an average person. And obviously, not many people are actually average. But it's also it's also tricky, because the risks that any individual faces are, you know, there's a whole host of things influencing that. So there are biological factors. There are behavioural factors. And then there's kind of situational factors, right? So, so behavioural factors are stuff like the drinking patterns, the ways in which you're drinking, and obviously, you have some control over that. And you can choose to drink your 14 units, or however much you're drinking in, you know, a smaller number of heavier drinking occasions, or you can spread it out more, but you're much you're not really in control of the biological differences, right? So men and women face different biological risks associated with drinking, for example. And then there's the sort of the situational risk, which is kind of other factors, things like being in poor health, which you don't necessarily have direct control over, which can also feed into to your risk. So although you can modify your own risks to a certain extent, right, you can, so you could drink more heavily, but in a way that sort of moderated your own risk by spreading your drinking out, for example, but how you try and communicate all of that to individuals is really, really tricky. So something the big change when the the new drinking guidelines were announced is the fact that the male guideline came down from 21 to 14 units to join the female guideline, and there's quite a lot of sort of kickback. against that people didn't really like it. And I think the the, the rationale for bringing it down is actually really interesting. So if all else being equal, if a man and a woman drink the same amount of alcohol, the woman will generally face a slightly higher risk because of biological factors, right. And so that's sort of always historically been the reasoning behind men having higher guidelines, which has been the case in lots of countries around the world. But actually, what we found is that, although that's true, basically, men do more stupid stuff. So men are much less good than women at moderating the behavioural risks, okay, we're much more likely to get drunk and get in a fight or whatever. And so actually, those two things kind of cancel each other out. So at low levels of relatively lower levels of drinking, men are at a higher risk, because these behavioural factors are dominating. And then at higher levels of drinking above the guideline, women face a higher risk, because of the biological factors are dominant in which, you know, which is really interesting, I think, can kind of, you know, speaks to the complexity of trying to, to explain this, right, because the, you know, you can you can control those behavioural factors to some extent, but you can't control the biological factors.

James Morris: 46:12

Yes. So very interesting. And I suppose I do, though, think, you know, and this is just kind of based on an assumption that the people are more interested in the guidelines from a health risk or long term health risk point of view, because people know that, you know, when I think when I drink problematically, you know, I knew that I was probably more likely to do something stupid, and that, you know, I was getting hangovers, and they probably weren't a good sign, I was never really thinking about the long term health consequences. So I think, you know, people were probably more aware of the kind of short term acute risks and already factoring those in a bit more, but but the question mark really is probably more Well, what is my risk of those longer term health consequences? And obviously, things like cancer, you know, highly political, because of the resonance that has and, you know, the uncertainty and, you know, arguably the very low level of risk of cancer from low levels of alcohol use. But yeah, it's also so complex, because as when you said, you know, well, if you minimise your risk by spreading it out a bit more than I agreed on a technical level, but then at the same time, there's other knock on risks from drinking, maybe less, but more often, which might include what we might call habit, or psychological dependence, or tolerance, or whatever. And that thing creeping up over time and possibly leading up to more drinking, so it's just endlessly complicated, and so many ifs and Oreos, he could attach to every individual, I guess.

Unknown: 47:38

Yeah, absolutely. So I think that habit ideas quite is really interesting, because so something that we looked at, but which wasn't really given very much provenance in sort of the final the guidelines themselves is we looked at how risk varies with age. And basically, at younger ages, alcohol is responsible for a higher proportion of deaths, particularly among young men. But at older ages, obviously, it's responsible for there are a lot more deaths, right people, you know, a lot more people dying, thankfully, at older ages than younger ages. And so in absolute terms, alcohol is responsible for a lot more deaths in, in older ages. And so if you were setting a guideline in terms of absolute risk, you would say that younger people can have a higher guideline, because their absolute risk of death from drinking at higher levels is much less than people are older ages. Okay, so you could make an argument there that you should have higher drinking guidelines for young people and older people. But there's two problems with that. And one of them is this sort of habit, idea that you're talking about, right? In a sense, the, if you just say, Oh, well, it's fine for younger people to drink more, then maybe that means that makes it more likely that they're going to become older people who drink more, because it sort of is become a habit. But there's also the fact that the association between when you drink and when you face the risk, can actually like that, like there could be a long time, it can take a long time for the full health impact of your drinking to develop over time. And so even though the young people might not be facing those risks of their drinking, now, they will have to face the risks in the future of their drinking now, as you see what I mean. So, you know, 20 years down the line, they might face an increased risk of developing cancer because of the drinking they were doing now. And so that makes everything a bit more a little bit trickier,

James Morris: 49:33

or just impossible to you know, it just comes back you know, how on earth do we communicate this versus You know, this this single threshold guideline? I mean, I think I quite like kind of traffic light systems. You know, in the past we've had how called risk based messages with a green and Amber and red, no kind of arrow that tries to reflect a spectrum nature of it, ie the you know, the more you into red or above that level, the higher the Risk will be still obviously goes nowhere close to capturing some of the nuances that that we're touching on, but at least it does convey it's not a binary or or nothing. It's not 14 units, once you hit that, you know, is death. And if you stick to below that there's no risk at all. Any other ideas?

Unknown: 50:19

I mean, you know, I totally agree with you on that point. And I, you know, I think it's important that we're careful in terms of the way we talk about drinking guidelines, right. I don't like them being called Safe Drinking guidelines, for example,

James Morris: 50:33

limits, because it implies that limit for me is like a speed limit, you have to stick to it. So

Unknown: 50:38

yeah, absolutely. You know, I think so I think it's, you know, they're presented as lower risk guidelines. And, and I think the wording in the guidelines themselves is sort of is okay, it's talking about, you know, generally, if you stick within these guidelines most of the time, then your risk should be relatively low. You know, it's that kind of slightly woolly language, which I think is appropriate. Right? It is, you know, it is useful for people to have an understanding that it is a spectrum, but also that, you know, that the overall risk curve gets steeper the further up the curve you are. So you know, that the additional risk of drinking one more unit is more for someone who's drinking 50 units a week than for someone who's drinking 20 units a week.

James Morris: 51:23

So essentially, the more you drink, the more having one less a day or one less a week, or whatever is going to be beneficial for you in health care.

Unknown: 51:31

Yeah, yeah, absolutely. Sort of the bigger the marginal gain from each from each unit or drink you cut out, the higher the heavier, you are a drink?

James Morris: 51:40

Yeah, we see that from the kind of classic curves, including, like the J curve, you know, steeper, the higher up the level. Yeah, I mean, that's why, I guess we see, you know, liver disease and health harms concentrated in the heaviest sections of drinkers, etc,

Unknown: 51:56

I think there's something else that's really interesting about the risks associated with drinking, which differentiates it from, say, smoking, right. So, if you smoke heavily throughout your life, there's a pretty good chance that that smoking is going to kill you is a pretty good chance you'll develop lung cancer or you know, something else as a result of your smoking. And it will kill you,

James Morris: 52:18

I've heard kind of try and persuade people to quit by saying, Well, you know, if you quit before you're 30, then it probably won't. But if you don't, by that point, and, you know, I guess it's probably a similar kind of thing to the 14 units, and might be an aggregated estimate based on some some data. But of course, it's still hugely dependent on the individual and their multifactorial circumstances,

Unknown: 52:40

for sure. But but the diff, the important difference between smoking and drinking is that it's really great, it's really likely that your smoking is good, you know, if you're a heavy smoker is really likely that smoking is going to be the thing that kills you, and you'll die a few years earlier than you might otherwise have done. Right, you, you maybe die in your late 70s, on average, rather than in your 80s. Whereas if you're a heavy drinker, right, you might face a similar reduction in life expectancy. Okay, in terms of the average years of life, you might expect to lose to alcohol. But actually, it's much more of a gamble, you're much more likely to die very young, right? There are a lot of heavy drinkers who die in their sort of 40s and 50s. But then there are other heavy drinkers who don't, and who go on to lead other relatively long lives. And so it's much more of a gamble than it is with smoking. If you you know, if you drink heavily, you might face the same expected loss of life. But actually, there's a chance that you'll die really young.

James Morris: 53:36

But that's more because of, you know, the behavioural consequences, the accidents and injuries that are likely to be fatal, more so than the health risk, right?

Unknown: 53:45

Well, no, no, not not necessarily, because a big part of it is liver disease, for example, right? There's some statistics around alcoholic liver disease being one of the biggest causes of years of working life lost by it, it's a disease that kills people in their sort of in their 40s and 50s, typically, much more so than smoking related diseases, kill people that sort of working. So, you know, that's interesting, and I don't know how you, you know, whether you should communicate that to people or how you communicate that to people, right? It's much more of a gamble, I guess, you know, and some people might fancy their chances. Or maybe maybe that's not so good to communicate to people. But, you know, maybe people have the

James Morris: 54:24

right to know that. And also definitely seen figures on the risk of, you know, the synergistic effects of being overweight and a heavy drinker. And again, it just really goes through the roof in terms of liver disease risk. So it's not just the power of the alcohol as well. It's about all the other stuff. Now, absolutely. You

Unknown: 54:41

know, for the same reason, if you were a smoker and a heavy drinker, you face a much greater risk of throat cancer, for example. And these, these things aren't factored into the calculations that we did the modelling we did that informed the guidelines, so we're not accounting for those No additional risks. It's also worth saying that all of the work that we did is only focused on death as as the outcome, right, we haven't really accounted for ill health. And we also haven't all that we looked at is the harm to the health of the drinker themselves. We didn't look at any of the harms to other people that might arise from someone's drinking. So in those senses, right, if you also consider those, they're only going to lower the guideline, because that you know, that there are extra risks and harms that we haven't considered, you know, what economists would call externalities.

James Morris: 55:34

Yeah, definitely no simple take home messages. And I just keep thinking back to say, a listener who might be thinking, Well, you know, where does this leave me. And now the CMOS comment about years ago that I mentioned, with Tom about reaching for a glass of wine and thinking, the risk of cancer, you know, I do drink and you know, moderately, having had past problems. But when I say moderately, I mean, basically, within the guidelines, but I'm still always mindful about actually, this isn't good for my health, but I enjoy it. Because it's, you know, social thing to do. And I do feel a bit relaxed and have a drink, and so on. But I guess ultimately, we want the understanding of the risk to be one more people to have to be able to factor in that risk. Albeit, it's so complicated, but to have just a general sense of, well, I'm going to drink or I'm going to drink for these reasons. But I'm also going to factor in these reasons, even though, you know, hopefully won't keep me up at night worrying if it's a fairly low level.

Unknown: 56:30

Yeah, it's super complicated. I mean, you know, I almost feel like it's it because of all the complexity, it's, you know, it's just best communicated to saying, you know, if you generally stick within the guidelines, then you're unlikely to be doing yourself significant amount of harm. And if you drink above the guidelines, then Congress comes up, yeah, exactly. Your risk increases, you're probably you're not doing yourself much good. And the further above the guidelines you are, the more you're doing, but it does become very difficult when you want to try and I understand that it's, it's good to try and give people an understanding of what that means, right? So to say, you know, if you're drinking 21 units a week, how's that different from 35 units a week or 50 units a week. But it's, it's tricky to communicate all of that.

James Morris: 57:21

Hopefully, this conversation has gone some way to helping maybe interested people, again, a little bit. And you know, all that work, you've done all that modelling was kind of put into summary guidelines and documents, I think you can make sense of if you're motivated enough to go and read them.

Unknown: 57:39

Yeah. So something that I think is potentially quite useful and informative is that in the report that we wrote, We put together a couple of tables that said, you know, on one side, we've got average drinking level, and then across the top, we've got drinking patterns, right? How many days a week do you spread that over, and then in the boxes is sort of the basically the proportion of deaths in people drinking at that level that you would expect to be caused by alcohol, right? So people who are drinking at 14 units a week, you know, if they're, if they're having to drink three days, right, so they're drinking 14 units spread over five days, it's just over 1%, right? That's that for me, just over 1% for men is under just under 1% for women, so and then you can see how there is changes. So if you're drinking at 49 units a week, because you're drinking really very heavily, and you spread that over five days, then that goes up to 15% for men and 23%. For women, okay, so there's a, you know, a pretty significant chance that if you're drinking at that level of alcohol, that's gonna kill you. So I think those tables may be a quite might be, you know, a helpful way for people who are interested to be able to assess, or to make more informed choices, but that, you know, that that relies on people being interested enough to work out and go and try and look it up.

James Morris: 59:00

I think, yeah, some kind of simplified version of those might be useful as a kind of health risk campaign, potentially. But you know, as I said to Tom, is lots of other very difficult challenges, including people who tend to drink above the guidelines are more motivated to discount them because maybe they're not at a stage where they're ready to, you know, think about their alcohol use. And of course, many people drink above the guidelines for reasons that are far from lack of understanding of the awareness of the risk is, you know, because our lives are difficult and challenging and stressful law, we may have developed codependency before a whole multitude of reasons. So yes, you know, what can we do to basically communicate these risk levels in ways that might reach some people but acknowledging, you know, the whole complex set of factors that exists beyond the guidelines as well,

Unknown: 59:49

I think it's, you know, it's also worth saying that we've got all this uncertainty because risks are going to vary lots between individuals, but there's also a you know, a significant amount of scientific uncertainty about the risks, right? We've, you know, we've had a huge number of studies and people continue to do studies looking at the risks of the health risks associated with drinking, but because, you know, running randomised control trials, which would be the gold standard in which you either force people to drink a fixed amounts, or no forced them not to drink at all, and then follow them up for 20 years and see how their health, you know, see if there's any health differences between the two groups. There's all sorts of, you know, moral and logistical complications about trying to try to do that. So we don't really have that sort of evidence. And we've got to try and make do with look slightly lower quality evidence, and that's why there's, you know, there's still huge uncertainty about whether or not drinking at low levels is protective or not. Right. And, you know, if you want to start a fight in a room full of alcohol, epidemiologists just express a strong opinion about whether protective effects are real or not. And, you know, chaos will ensue, because I

James Morris: 1:01:00

thought they'd kind of consensus was forming around, you know, particularly in light of the recent more recent studies based on, you know, the kind of genetic variants tending to point in the direction that there aren't likely health benefits is more confounding factors, like sequitur effects and so on.

Unknown: 1:01:17

I mean, I guess I'm still kind of a bit agnostic about it. You know, that's that certainly is evidence that points in the direction that says they're not real. But you know, there's also limitations in that approach as well. It's not, you know, that's still not a randomised control trial, it's still, you know, it's still just a different imperfect way, albeit maybe slightly less imperfect, then the other ways that we have looking at it.

James Morris: 1:01:42

The other thing might be worth saying always is that if you're looking for health benefits, there's far easier ways to accrue them then taking up drinking low levels if you don't drink already.

Unknown: 1:01:52

Absolutely. And, you know, I don't think there's any anything in the evidence to suggest that if you're a non drinker, you should take up drinking because it'll improve your health. I think that's, you know, that's certainly not borne out by the evidence.

James Morris: 1:02:06

epidemiologists would agree on that, presumably, yes. Well, thanks so much, Colleen. That's that's been really, really useful. And we'll we'll kind of watch this space, I suppose, as the evidence continues to emerge about different levels of risks amongst different drinkers at different stages and so on. Alright, thanks, James.