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A good measure: Units and drinking guidelines

What is a unit of alcohol?

In the UK, consumption of alcoholic drinks is measured in units. Units are a simple way of expressing the quantity of pure alcohol in a drink, offering a standardised comparison of the volume of pure alcohol between alcoholic beverages.[1] They are calculated as follows:

In the UK, 1 unit is equal to 8 grammes of pure alcohol, which is also equivalent to 10 millilitres of pure ethanol (alcohol). This takes approximately an hour for the average adult to process in the body (although there are many varying factors which mean all drinkers process alcohol differently).[2] The number of grammes that make up a unit varies between countries.*

The UK’s low risk drinking guidelines: How did we get here?

In 2016, the Chief Medical Officers for the UK regions published a new set of alcohol consumption guidelines, split into three main categories: 1) regular drinking; 2) single drinking episodes; and 3) drinking in pregnancy.


 

The new guidelines replace a set of recommendations that were originally based on evidence submitted in a report by the Royal College of Physicians (RCP) to the UK government in 1987. This report acknowledged that there was “insufficient evidence to make completely confident statements about how much alcohol is safe”.[3] However, in making the judgement that the public needed to be informed about the risks associated with drinking, it suggested the following guidelines for 'sensible limits of drinking':

  • Men – no more than 21 units per week
  • Women – no more than 14 units per week
  • Both men and women should have 2 or 3 alcohol-free days
  • The total number of weekly units should not be drunk in 1 or 2 bouts

These guidelines were based on the underlying assumption that they did not apply to children and adolescents, to adults who had particular health problems or a family history of alcohol problems or to women during pregnancy.

In 1995, the recommendations were reviewed by an inter-departmental government working group, following the publication of scientific evidence stating that small amounts of alcohol may have a protective effect against coronary heart disease. Despite this finding, leading health experts – including the British Medical Association (BMA)[4] and the RCP – came to the conclusion that the 1987 guidelines were still the most appropriate means of communicating to the public the risks associated with drinking.[5]

Furthermore, it was agreed that clauses should be added to take account of short term episodes of heavy drinking which was argued to often correlate strongly with both medical and social harm. The Sensible Drinking report called for the establishment of daily benchmarks to help individuals ‘decide how much to drink on single occasions and to avoid excessive drinking with its attendant health and social risks’.[6]

These new guidelines recommended that 'men should not regularly drink more than 3–4 units of alcohol a day and women should not regularly drink more than 2–3 units a day', and advised against the consumption of alcohol for at least 48 hours after an episode of heavy drinking, in order to allow affected parts of the body to recover fully.

The transition from weekly to daily guidelines effectively increased the weekly limit for men by 33% and women 50%, exceeding the previous threshold for low risk drinking as presented by the medical profession. These changes were met with concern by members of the health community, as they contradicted the evidence base and seemingly recommended 'safe' levels of drinking that were in fact over and above what was deemed a 'low risk' threshold.

The categorisation of weekly alcohol units consumed into low / moderate and high risk levels became part of the recommended guidelines.

 


 

The 1995 report also extended the reach of the original recommendations to include guidance for pregnant women. They were warned against drinking alcohol – especially in the first three months of the pregnancy to lower the risk of miscarriage – but that if they did still drink, to consume not more than 1–2 units of alcohol once or twice a week and not to become intoxicated.

In 2009 the then Chief Medical Officer (CMO) for England introduced a new guideline, that no children under the age of 15 years should consume alcohol, after evidence indicated that drinking before this age increased the risk of alcohol dependency in later life and also affected cognitive development. The CMO guidance recommended:

An alcohol-free childhood is the healthiest and best option, but;[7]

  • If children do drink alcohol, they should not do so until at least 15 years old;
  • If 15 to 17-year-olds drink alcohol, it should be rarely, and never more than once a week. They should always be supervised by a parent or carer; and
  • If 15 to 17-year-olds drink alcohol, they should never exceed the recommended adult daily limits (3–4 units of alcohol for men and 2–3 units for women)

In December 2011, the House of Commons Science and Technology Committee launched an inquiry into the current UK drinking guidelines, calling for a review of the evidence that had emerged since 1995 on the health risks associated with drinking, and also on levels of public understanding of the guidelines. The Committee received evidence from a number of organisations, including public health interest groups and the alcohol industry.

The Science and Technology Committee report, published in January 2012, concluded:

 

There are sufficient concerns about the current drinking guidelines to suggest that a thorough review of the evidence concerning alcohol and health risks is due. The Department of Health and devolved health departments should establish a working group to review the evidence and advise whether the guidelines should be changed. In the meantime, the evidence suggests that (i) in the context of the current daily guidelines, the public should be advised to take at least two alcohol-free days a week; and (ii) the sensible drinking limits should not be increased.[8]

 

The Coalition Government's Alcohol Strategy, published in March 2012, accepted a need to improve the UK public's poor understanding of and adherence to the current drinking guidelines, with around a third of adult men and a fifth of adult women drinking above the recommended limits. In order to tackle this problem, the government tasked the UK’s Chief Medical Officers with overseeing a review of the drinking guidelines, with the mission of:

 

… tak[ing] account of available science on how we can best communicate the risks from alcohol, improving the public's understanding of both personal risks and societal harms. This will include whether separate advice is desirable for the maximum amount of alcohol to be drunk in one occasion and for people over 65. This could complement the existing guidelines for young people and women who are pregnant or trying to conceive.[9]

 

After two-and-a-half years of discussion led by the UK CMOs, involving three independent groups of experts considering the evidence on the health effects of alcohol, the new guidelines were published in January 2016.[10]

It was recommended that the guidelines should revert to a weekly, rather than a daily, recommended limit. A weekly format was seen to be an easier benchmark for people (most of the population) who do not drink alcohol daily.

The most notable change from the 1995 guidelines was the reduction in men’s weekly recommended alcohol units to that of women, 14 units per week. Part of the reasoning for this decision was that:

 

… when drinking within the low risk guidelines, overall levels of risk are broadly similar for men and women; although the risks of immediate harms such as deaths from accidents are greater for men; longer term harms from illness are greater for women.[11]

 

The new evidence also indicated the following:[12]

  • The benefits for heart health of drinking alcohol are less and apply to a smaller group of the population than previously thought. The only group with potential to have an overall significant reduction in risk of death in the UK is women over the age of 55 (especially if drinking around 5 units a week or less);
  • There are adverse effects from drinking alcohol on a range of cancers – this was not fully understood in 1995 – and these risks start from any level of regular drinking and then rise with the amounts of alcohol being drunk.

The expert groups stated that their advice on regular drinking “is based on the evidence that if people did drink at or above the low risk level advised, overall any protective effect from alcohol on deaths is overridden, and the risk of dying from an alcohol-related condition would be expected to be around, or a little under, 1% over a lifetime”, comparable to risks from other everyday activities, such as driving.[13]

* A roundup of drinking guidelines by nation is available on Wikipedia

 

Next: UK alcohol consumption


[1] BBC News Health (November 2011), ‘Health Explained: What is a unit of alcohol?’ <http://www.bbc.co.uk/news/health-15501779>

[2] NHS Choices, ‘Alcohol Units’ <http://www.nhs.uk/Livewell/alcohol/Pages/alcohol-units.aspx>

[3] Royal College of Physicians (1987), ‘The medical consequences of alcohol abuse, a great and growing evil’, Tavistock Publications Ltd

[4] British Medical Association (BMA) (1995), ‘Alcohol: guidelines on sensible drinking’, BMA, London

[5] Royal College of Physicians, Royal College of Psychiatrists, Royal College of General Practitioners (1995), ‘Alcohol and the Heart in Perspective, sensible limits reaffirmed’, Oxprint, Oxford

[6] Department of Health (December 1995), ‘Sensible Drinking – The report of an Inter-Departmental Working Group’, DH, London, p. 24 <http://bit.ly/2fsH8qA>

[7] Donaldson, Liam, (Sir) (December 2009), ‘Guidance on the consumption of alcohol by children and young people. A report by the Chief Medical Officer’, Department of Health, pp. 13–29 <http://bit.ly/2eFV4ir>

[8] House of Commons Science and Technology Committee (December 2011), ‘Alcohol guidelines: eleventh report of session 2010-12’, p. 3 <http://www.publications.parliament.uk/pa/cm201012/cmselect/cmsctech/1536/1536.pdf>

[9] Secretary of State for the Home Department (March 2012), ‘The Government's Alcohol Strategy’, p. 24 <https://www.gov.uk/government/publications/alcohol-strategy>

[10] Gov.uk (August 2016), ‘Alcohol consumption: advice on low risk drinking’, p. 2 <https://www.gov.uk/government/publications/alcohol-consumption-advice-on-low-risk-drinking>

[11] Gov.uk (January 2016), ‘Alcohol consumption: advice on low risk drinking’, p. 5

[12] Gov.uk (January 2016), ‘UK Chief Medical Officers’ Alcohol Guidelines Review: Summary of the proposed new guidelines’ <https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/489795/summary.pdf>

[13] Gov.uk (January 2016), ‘Alcohol consumption: advice on low risk drinking’, p. 5