Sildes presentation for the debate on alcoholic beverages labelling Presentazione per il dibattito sulle informazioni da porre in etichetta delle bevande alcoliche A contribution for the European Researchers' Night 2017 #mscanight

1. Is there a European standard drink ?
Emanuele Scafato
Istituto Superiore di Sanità , Rome, ITALY
Osservatorio Nazionale Alcol – WHO CC Research on Alcohol
President SIA, Società Italiana Alcologia
Vice President EUFAS , European Federation Societies on Addictions

2. Standard drink is a notional drink that contains
a specific, fixed amount of pure alcohol usually
expressed as a certain measure of beer, wine,
spirits or any alcoholic beverage.
One SD ( or unit of alcohol) always contains the
same amount of pure alcohol regardless of
container size.
SD may not reflect customary serving sizes.
What is a Standard Drink?

3. Health and
Consumers
BE 10 g
CZ 10 g
DK 12 g
DE 10 g
EE 10 g
ES 10 g
FR 10 g
IE 10 g
IT 12 g
LU 12,8 g
HU 17 g
NL 10 g
AT 20 g
PL 10 g
PT 14 g
SI 10 g
SK 10 g
FI 12 g
SE 12 g
UK 8 g (“unit”)
Definitions in
grams pure alcohol
Based on various sources,
including ICAP, PHEPA &
Wikipedia.
No info available: BG, EL, CY,
LT, LV,MT,RO
Standard Drinks in 2012

4. What are WHO definitions of a "standard
drink"?
 10 grams of ethanol equivalent to approximately 12.5 ml of
pure alcohol (International guide to monitoring alcohol-
related harm, WHO, 2000; AUDIT: The Alcohol Use
Disorders Identification Test. Guidelines for Use in Primary
Care. Second edition, WHO, 2001; STEPS survey, 2012-
2014…). H
 12 grams of ethanol ("A standard drink is a measure of the
amount of pure alcohol consumed, usually between 8 g and
12 g. If the amount of alcohol contained in a standard drink
in that country is outside these limits, the number of
standard drinks may need to be adjusted"). (mhGAP
Intervention Guide. WHO, 2010).
V. Poznyak, RARHA European expert meeting
"Low risk drinking guidelines and standard drink definitions"
Rome, 4th November 2014

5. Standard Drinks Vary Across Countries...
Grams of Pure Alcohol Contained in a Standard Drink
6
8
10
12
14
16
18
gramsofpurealcoholinastandarddrink
Note: Belgium, Mexico, Norway, Slovak Rep, Turkey, USA do not have national standard drinks
Source: OECD, Drinking Lives Away, forthcoming

6. Standard drink differs across Countries
Low risk drinking guidelines in Europe: results of the JA RARHA survey

7. Low risk drinking guidelines in Europe: results of the JA RARHA survey
The “standard drink” - or “unit of alcohol” is an important
concept for
• conveying information about alcohol intake for drinkers,
• measuring alcohol intake in research studies and
• estimating and communicating risks or benefits of drinking
based on these measures.
The main use of standard drink concept :
a) as a means of communicating levels of consumption in low
risk drinking guidelines and
b) as a means of asking respondents to some drinking surveys
to estimate the amount of alcohol they drink.
Understanding standard drinks

8. JA RARHA: 3 executive core Work Packages
http://www.rarha.eu
WP4: Monitoring
WP6:Tool kits
WP5: Guidelines

9. Good practice principles for the use of low risk drinking guidelines
a public health tool summarizing good practices on how addressing alcohol as risk factor
•to inform «at risk» drinkers about how much
alcohol is harmful and to draw all alcohol
consumers’ attention to the risks that may be
involved in their drinking habits
•to be used as part of brief interventions
targeted to at risk drinkers or disseminated to
the general public as advice to alcohol
consumers to help reducing it
•to provide guidance for policy makers on the
scientific basis and policy implications of LRDG
for future actions and policy developments;
•for professionals to share common ground in
communication on alcohol related harm ... for all
settings

10. 10
Low risk drinking guidelines in Europe: results from RARHA survey
Averagealcoholintakeinadaynottobeexceeded
(gramsofpurealcohol)
Low risk drinking guidelines in Europe: results from RARHA survey
0
5
10
15
20
25
30
35
40
45
50
AUSTRIA(24)
BELGIUM
BULGARIA
CROATIA(40)
CYPRUS
CZECHREPUBLIC(40)
DENMARK(24)
ESTONIA(40)
FINLAND(20)
FRANCE(30)
GERMANY(24)
GREECE(30-48)
HUNGARY(24-48)
ICELAND
IRELAND
ITALY(24)
LATVIA
LITHUANIA(30-40)
LUXEMBOURG(24)
MALTA(36)
NETHERLANDS(THE)(20)
NORWAY
POLAND(40)
PORTUGAL(20)
ROMANIA
SLOVAKIA
SLOVENIA(20)
SPAIN(40)
SWEDEN
SWITZERLAND(20-36)
UNITEDKINGDOM(24-32)
Men
0
5
10
15
20
25
30
35
40
45
50
AUSTRIA(16)
BELGIUM
BULGARIA
CROATIA(20)
CYPRUS
CZECHREPUBLIC(20)
DENMARK(12)
ESTONIA(20)
FINLAND(10)
FRANCE(20)
GERMANY(12)
GREECE(20-32)
HUNGARY(18-21)
ICELAND
IRELAND
ITALY(12)
LATVIA
LITHUANIA(20-30)
LUXEMBOURG(12)
MALTA(27)
NETHERLANDS(THE)(10)
NORWAY
POLAND(20)
PORTUGAL(10)
ROMANIA
SLOVAKIA
SLOVENIA(10)
SPAIN(20-25)
SWEDEN
SWITZERLAND(10-24)
UNITEDKINGDOM(16-24)
Women
E. SCAFATO 2014
Public Health use of Standard Drink

11. Rarha European average : 11 grams
Low risk drinking guidelines in Europe: results of the JA RARHA survey
8
10
12
14
16
18
20
AUSTRIA(20)
CROATIA(10;14)
CZECHREPUBLIC(16)
DENMARK(12)
ESTONIA(10)
FINLAND(12)
FRANCE(10)
GERMANY(10;12)
GREECE(10;16)
HUNGARY(12;14)
ICELAND(8;12)
IRELAND(10)
ITALY(12)
LATVIA(12)
LITHUANIA(10)
LUXEMBOURG(12)
MALTA(8;10)
NETHERLANDS(THE)(10)
NORWAY(12;15)
POLAND(10)
PORTUGAL(10)
ROMANIA(12)
SLOVENIA(10)
SPAIN(10)
SWEDEN(12)
SWITZERLAND(10;12)
UNITEDKINGDOM(8)
Mean=
Median=
11

12. What doesWHO recommend in
terms of drinking guidelines?
“Less is better”

13. Levels of drinking and associated risks
of acute problems
Criteria for risk of consumption on a single drinking day – for
comparative research purposes only (International Guide for
Monitoring Alcohol Consumption and Related Harm, WHO, 2000)
Males Females
 Low Risk 1 to 40g 1 to 20g
 Elevated Risk 41 to 60g 21 to 40g
 High Risk 61 to 100g 41 to 60g
 Very High Risk 101+g 61+g
V. Poznyak, RARHA European expert meeting
"Low risk drinking guidelines and standard drink definitions"
Rome, 4th November 2014

14. Levels of drinking and associated long-term risks
of chronic illnesses (WHO, 2000)
GENDER LEVEL OF RISK
LOW ELEVATED HIGH
Male 1-40g 41-60g 61+g
Female 1-20g 21-40g 41+g
V. Poznyak, RARHA European expert meeting
"Low risk drinking guidelines and standard drink definitions"
Rome, 4th November 2014

15. www.rarha.eu
Why explore the concept of a standard drink
The standard drink is appropriately a notional concept
because drink pours and beverage choices vary
considerably across countries.
“Grams of ethanol” is the most basic and comparable
measure and is relevant to consumers in comparison to
other ingredients on nutritional labels in relation to
calories.
However, grams or other weight-based measures are
unlikely to be useful in helping drinkers to understand
alcohol content.
Kerr and Stockwell Drug Alcohol Rev . 2012 March ; 31(2): 200–205.

16. Drinking guidelines used in the context of early identification and brief interventions: results from EU RARHA survey
WHY EU RARHA SURVEYS
ON STANDARD DRINK/ UNIT?
There is the need to enable consumers to
make informed choices about their alcohol
consumption supporting a main Public
Health need to ensure their rights to
comprehensive information and increase
people awareness :
• on how to deal with alcoholic beverages
consumption
• on health risks associated with drinking
alcoholic beverages.

17. Consumers needs
Drinking guidelines used in the context of early identification and brief interventions: results from EU RARHA survey
Consumers need to track their ethanol
consumption to
• limit their risk of negative consequences
• follow drinking guidelines
Kerr and Stockwell Drug Alcohol Rev . 2012 March ; 31(2): 200–205.

18. ITALY. STANDARD UNIT
Drinking guidelines used in the context of early identification and brief interventions: results from EU RARHA survey

19. 19
Low risk drinking guidelines in Europe: results from RARHA survey
Standard Drink concept currently used
RARHA
RARHA survey
SD in grams of pure alcohol:
19
2 9
1
19
2 10
1
30
21
2 1 7
0
31
Yes
No
missingdata
Countrynot
investigated
Yes
No
missingdata
Countrynot
investigated
Yes
No
missingdata
Countrynot
investigated
Yes
No
missingdata
Countrynot
investigated
Review WHO 2012 WHO 2013 OECD2014
no.ofCountries
Low risk drinking guidelines in Europe: results from RARHA survey
8
10
12
14
16
18
20
AUSTRIA(20)
CROATIA(10;14)
CZECHREPUBLIC(16)
DENMARK(12)
ESTONIA(10)
FINLAND(12)
FRANCE(10)
GERMANY(10;12)
GREECE(10;16)
HUNGARY(12;14)
ICELAND(8;12)
IRELAND(10)
ITALY(12)
LATVIA(12)
LITHUANIA(10)
LUXEMBOURG(12)
MALTA(8;10)
NETHERLANDS(THE)(10)
NORWAY(12;15)
POLAND(10)
PORTUGAL(10)
ROMANIA(12)
SLOVENIA(10)
SPAIN(10)
SWEDEN(12)
SWITZERLAND(10;12)
UNITEDKINGDOM(8)
Mean=
Median=
11

20. 20
Low risk drinking guidelines in Europe: results from RARHA survey
Standard Drink concept currently used in
a) clinical advice b) education messages c) alc. beverages
Low risk drinking guidelines in Europe: results from RARHA survey

21. Drinking guidelines used in the context of early identification and brief interventions: results from EU RARHA survey
• Drinkers have difficulty defining and pouring standard drinks with over-
pouring being the norm that intake volume is typically underestimated.
• Drinkers have difficulty using percentage alcohol by volume and pour
size information in calculating intake but can effectively utilise standard
drink labeling to track intake.
Consumers perceptions

22. Which is people’s understanding
of standard drinks ?
A review of the evidence indicates that while there
seems to be awareness of the term ‘standard drink’,
understanding of what it actually means is limited.
Drinkers are not able to define standard drinks
accurately.
They tend to overstate the appropriate
volumes, leading them to overpour
drinks and underreport levels of
consumption.

23. Survey- Responses
This confusion over standard drinks can have serious
consequences.
In terms of low risk drinking guidelines drinkers may
interpret them in terms of numbers of drinks that
correspond to levels of intake that are smaller or larger
than those intended by the standard drink definitions
included in the guidelines.
Regarding the challenging issue of drinkers’ inability to
accurately gauge their consumption in standard
drinks, one potential way to deal with this issue is to
place serving size information on alcoholic beverage
containers.

24. LOOKING HOW TO REDUCE ALCOHOL RELATED HARM
SHARING THE RESULTS
RARHA - FINAL CONFERENCE
Support measures at European and national level
Legislating for health relevant information on alcoholic beverage labels.
 Ingredients and nutrition values
 The amount of calories in the bottle or can
 The amount of pure alcohol in the bottle or can, in grams of ethanol
 Message/s on the health and safety risks related to alcohol consumption
Requiring information on health and safety risks on alcoholic beverage
packages and alcohol advertisements.
 Alcohol consumption during pregnancy;Vulnerability of minors
 Drink driving; Mixing alcohol with medications
 Effects on the brain; Addictive nature of alcohol
 Loss of self-control;Violence; Decreased perception of risk
For effectiveness, health and safety messages should be:
 Rotating – designed to fill in gaps in information
 Clear and powerful
 Highly visible, of sufficient size, placed on the front of containers
Accurate, clear, neutral

25. www.rarha.eu
Delphi results: Standard drink
0
5
10
15
20
25
30
35
Totally in favour Somewhat in favour Undecided Somewhat against Totally against
Would you be for or against agreeing on a common definition of standard drink
Round 1 (N=38) Round 2 (N=39)
• A common definition would
widen the reach of consumer
information campaigns while
decreasing the possibility of
misunderstanding

26. www.rarha.eu
Delphi results: Standard drink

27. Would an agreed EU SD definition be helpful
to the population in your country to measure
their personal alcohol consumption?
 To support health and social care practitioners
to assess patient / client alcohol consumption
 To be better informed of the alcoholic content
of drinks
 To measure personal alcohol consumption

28. WHY an agreed SD definition
would NOT be helpful:
 There are existing national definitions and comprehensive
information packages in place
 Due to variations it would be difficult to agree a standardised
measure and would cause confusion
 Variation in classic beverage sizes across countries and even
regions would require comprehensive consumer information
and cultural acceptance may take a long time

29. www.rarha.eu
Delphi results: health related information provided are inadequate

30. STANDARD DRINK
Drinking guidelines used in the context of early identification and brief interventions: results from EU RARHA survey
Standard drink labeling is an effective but little used
strategy for enabling drinkers to track alcohol intake
and potentially conform to safe or low risk drinking
guidelines.
Kerr and Stockwell Drug Alcohol Rev . 2012 March ; 31(2): 200–205.

31. www.rarha.eu
RARHA Recommandations : call for actions

32. THE DOSE MAKE THE POISON …
but a common language to quantify alcohol consumption and an accurate and neutral
information is what EU consumers needs to better understand how to risk less and
prevent an avoidable harm.
Drinking guidelines used in the context of early identification and brief interventions: results from EU RARHA survey

33. E-mail: emanuele.scafato@iss.it Website: www.iss.it
Is there a European standard drink ?
THANK YOU FOR YOUR ATTENTION
Emanuele Scafato
Istituto Superiore di Sanità , Rome, ITALY