Calling the shots: how much alcohol is too much?

It is never easy to find out how much someone is drinking, but it has become a formal part of a doctor’s job to ask. The Government’s Quality and Outcomes Framework allocates points to GPs for discussing such topics with patients; the points attract money earmarked for health promotion. If you can’t face asking directly, there are various tactful quizzes for establishing if someone is developing a problem with alcohol. The Cage questionnaire, for example (have you ever felt you should Cut down on your drinking? Ever felt Annoyed that someone criticised you about drinking? Ever felt Guilty about your drinking? Have you ever needed an Eye-opener? – the usual response to these questions is “yes, yes, yes … NO!”).

There are less formulaic ways of guessing when someone might be drinking too much. Excess alcohol is a risk factor for heart disease, stroke and many cancers; it causes internal bleeding and cirrhosis. But patients who are heavy drinkers also come in with more niggling complaints: heartburn, stomach ache, skin problems, headaches. Too much alcohol can cause difficulties at work and trouble at home; patients need sick notes; they become depressed. Anyone who quotes you the line about an alcoholic being “a man who drinks more than his own doctor” is also worrying – something forced about the gaiety? – although it does capture a truth.

Ethics questions featuring inebriated colleagues are a staple of professional medical exams – you’re on your way to an emergency when you spot a bottle of gin in the consultant’s locker, or assisting at an operation when you notice the surgeon’s hands are shaking and there’s an odour of sherry. What should you do next?

How do we work out how much alcohol is too much? The unit of alcohol measurement is just that, a “unit”. Units were introduced in the UK in the mid-1980s, with the intention of making it easier for people to work out how much they are drinking. (The standard measure, alcohol by volume, ABV, only tells you what percentage of a drink is pure alcohol; it doesn’t tell you how much you’re consuming.) Units provide a way of comparing unlike with unlike: an espresso martini with a can of Special Brew (in case you ever need it – just over two units in a two-shot martini, and four units in a 440ml can of Carlsberg Special Brew). To calculate a unit, you need to multiply the volume of your drink (measured in millilitres) by the ABV, then divide the result by 1,000. If you’re clear-headed enough to be doing the calculation, you’re probably not the target audience. Yet although most people are now familiar with the concept of units, fewer seem to know what they denote in terms of actual drinks drunk. The recent government advice reiterating the recommended weekly limits (14 units for women, 21 for men) remains hazy for many.

There is a code for labelling alcoholic drinks, but it’s voluntary; the unit count is usually in tiny print on the back of the label, about where your thumb rests if you pick up a bottle to pour from it. And it doesn’t help at home, where you pour your own servings (into your own enormous glasses). Alcohol, like food, is a difficult topic for health promotion – a source of benefit and pleasure as well as potential hazard, it’s difficult to quantify, and unreliably reported. Smoking is so much easier: perhaps the one benefit of an unambivalent evil. You needn’t fiddle about asking people to calculate the tar and nicotine load per cigarette – you can just print an ailing lung on the front of the packet, and leave it at that.

Sophie Harrison is a hospital doctor in South Yorkshire

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