Discussion

Summary of findings

The overall findings of this project are that the announcement of the revised UK lower-risk drinking guidelines (1) was not subject to large-scale promotion by any organisation following the initial media launch, (2) was not associated with substantial and sustained changes in most influences on behaviour change and (3) was not associated with clearly detectable changes in drinking behaviour. In this chapter, we expand on and discuss these three findings in turn.

The drinking guidelines were not subject to large-scale promotion by any organisation following the initial announcement

Paid, earned, shared and owned media promoting the drinking guidelines

Marketers differentiate between paid, earned, shared and owned (PESO) media to classify different types of marketing activity or means of communicating a marketing message.165 There are overlaps between these four categories but they can be broadly understood as follows. Paid media are purchased advertising spaces such as sponsored social media postings, TV and radio advertisements and paid-for endorsements. Earned media are publicity generated by, for example, press releases or other activities resulting in news reports. Shared media include social media posts that may then be distributed further by others. Finally, owned media are information under the complete control of the marketer, including apps, e-mail lists and websites. We summarise evidence for each PESO medium below.

Paid media

We detected no reports or evidence of any large-scale paid media to promote the revised UK drinking guidelines.

Earned media

The guidelines were initially promoted prominently via earned media, which was generated by a press launch, broadcast and print interviews, and published materials. This activity is clearly visible in our survey-based measures of exposure to the guidelines, with sharp increases in exposure via ‘TV or radio’ and ‘newspapers or magazines’ in January 2016. As demonstrated by our news review, the earned media exposure generated by the initial announcement extended for many weeks, although the tone of news reports was often negative as commentators queried and criticised the guidelines. Underneath this commentary was an additional, more incidental, form of earned media whereby the guidelines were routinely mentioned in articles on other topics, usually still related to alcohol or health.

Shared media

We did not directly examine shared media; however, our survey of the promotional activities of key organisations suggests that this existed in only a limited and passive form. For example, organisations reported occasionally posting a small amount of material related to the drinking guidelines on social media, but this did not amount to a large-scale co-ordinated campaign.

Owned media

We also did not directly examine owned media but we observed that the guidelines were rapidly incorporated into the published materials, websites, apps and other media of major organisations, such as PHE, Drinkaware and the leading alcohol and public health charities. Drinkers were still required to access this information in order to view it, and our survey data, and findings from previous studies, suggest that such passive promotion of alcohol-related health information has limited reach or impact.46,47,60 One additional form of owned media is product labels. Approximately 80% of alcoholic product labels carried the previous guidelines in 2014;44 however, the revision to the guidelines did not, in most cases, lead to these labels being updated, for reasons discussed below.

Overall, it appears the UK Government and other organisations responsible for interested in promoting the drinking guidelines relied on a short earned media campaign that announced the revisions in January 2016, followed by small-scale, and largely passive, earned, shared and owned media activities over the remainder of our study period.

Promotional activities outside the study period

The data collection period for this study ended in November 2017 and two large-scale promotional activities took place after this date.

First, Drinkaware launched a campaign in September 2018 to promote the recommendation to have at least 2 drink-free days per week. This activity included a press launch, social media postings and interactive website materials. The campaign attracted substantial criticism following the decision by PHE to endorse it and allow Drinkaware to use its branding on their campaign materials.166 As Drinkaware is almost exclusively funded by alcohol producers and retailers, it is argued by many public health actors to be an inappropriate partner for PHE.167 PHE commissioned the market research company Kantar (Kantar Group, London, UK) to provide an independent evaluation of the campaign. This concluded that that the drink-free days message had reached its intended targets, and was credible and well understood, but that there was little evidence of attitudinal or behavioural change.168

Second, the Scottish Government, through NHS Health Scotland, launched a paid mass media campaign that ran in Scotland for 3 weeks in March 2019, entitled ‘Count 14’. The campaign aimed to improve drinkers’ understanding of units and the main guideline recommending that drinkers do not consume > 14 units per week. The forthcoming evaluation of the campaign is not yet published at the time of writing. Although this may provide additional information on the potential effectiveness of promoting the revised drinking guidelines in England, the campaign ran only in Scotland and is, therefore, unlikely to lead to substantial changes in any of our outcome measures.

Why was there not more promotional activity?

Given that the review of drinking guidelines was a major component of the UK Government’s alcohol strategy,5 it is reasonable to ask why promotional activity was so limited. This question is outside the scope of the present project, but some elements of our findings and wider aspects of alcohol policy debate point towards potential answers.

First, the guidelines were received poorly by alcohol producers, retailers and some sections of the news media. As demonstrated by our review of news media coverage, the reasons for this include the decision to lower the male guideline to 14 units per week, the prominent linking of the guideline announcement to alcohol-related cancer risks and the associated use of the ‘no safe level’ of alcohol consumption message. A further contributory factor may have been the quality of the press launch itself, which was discussed in Chapter 3 and was criticised by the GDG in the minutes of its final meeting.169 The UK Government has often developed and implemented alcohol policy in partnership with the alcohol industry over recent decades, and this allowed the government to avoid politically challenging and potentially costly regulation of the industry in favour of voluntary or self-regulatory agreements. Examples of such agreements include the Portman Group’s codes of practice on alcohol marketing and product labelling, the financial support provided by industry to Drinkaware and the pledges made under the Public Health Responsibility Deal (PHRD) by the alcohol industry.167,170–172 The lack of support for the drinking guidelines among industry actors threatens this partnership-based approach and may have directly or indirectly influenced government decision-making regarding promotion of the guidelines.

Second, the broadly negative view of the guidelines within the alcohol industry also influenced their promotion via product labels. The Portman Group updated its best practice guidance on product labelling in 2017 and removed a previous requirement that producers include the drinking guidelines on labels.173 The new guidance required only active signposting to Drinkaware’s website.172 This is part of a broader pattern of behaviour whereby alcohol producers seek to limit the health-related information available on product labels. For example, the Department of Health and Social Care notes that alcohol producers agreed in 2007 to include health and unit information on the majority of UK product labels by 2008.174 By 2009, only 15% of products included such information, and producers stated only that they had plans to increase this to 19% by the end of 2010. In 2011, some producers suggested that they could achieve 50% by the end of 2012 but ultimately committed to the PHRD pledge to include the guidelines on 80% of labels, a pledge they now appear to have tacitly withdrawn from. The decision by the Portman Group not to include drinking guidelines in its best practice guidance explains, in part, why only 7.5% of 320 products reviewed by the Alcohol Health Alliance in 2018 included the updated guidelines on their label.175 In 2019, the Portman Group announced that its members would update product labels, but to an unspecified timetable.

A third potential reason why the guidelines were not promoted more extensively is the 18% decline in alcohol consumption per capita adult between 2004 and 2016.176 In contrast to the 1990s and early 2000s, when alcohol-related problems were often front-page news and therefore a major government priority,177 there is now less immediate pressure on the government to demonstrate that it is tackling the problem. In this context, there is no immediate political or policy need for a mass media campaign promoting guidelines that enjoy only lukewarm support among several key government stakeholders.

Fourth, the shifts in the broader political context since the guideline review was announced in 2012 may have contributed to the lack of promotional activity. The UK Government changed from a Conservative–Liberal Democrat coalition to a majority Conservative government in 2015. In the build-up to the election that delivered the Conservative majority, it was widely reported that the Conservatives had deliberately sought to ‘scrape the barnacles off the boat’, meaning they dropped or deprioritised all potentially unpopular policies, including those relating to alcohol, and this approach continued into the subsequent parliament.66 In 2016, the UK voted to leave the European Union and the resulting political crisis led to a change of Prime Minister and to increased government and parliamentary attention, both political and legislative, focusing on European matters in the subsequent years.178 As developing, financially supporting or launching a large-scale campaign to promote drinking guidelines is an uncommon occurrence under any circumstances in the UK, it seems unlikely to be a government priority during this period.

Fifth, organisations outside the government that could have promoted the guidelines at scale were not able to do so. PHE relies on the UK Treasury to fund any campaign and is therefore subject to the problems discussed above. Drinkaware is among the most visible alcohol health information charities in the UK but is financially reliant on the alcohol producers and retailers, who had significant concerns about the guidelines. Alcohol Concern, previously a major health promotion charity, lost its block grant from the Department of Health and Social Care in 2011,179 and its resulting financial difficulties eventually forced a drawn-out merger with another organisation, Alcohol Research UK, that limited the activities of both in the ensuing period.180 A succession of other alcohol and public health charities suffered similar financial difficulties over recent years. These arose in part from problems in securing funding during the UK Government’s austerity policies, but also from new rules that restricted how charities could use public grants for campaigning purposes.181

Overall, it appears likely that the guidelines were not promoted owing to a combination of competing interests, indifference and distraction on the part of the UK Government, opposition on the part of the alcohol industry and infeasibility on the part of other organisations.

Announcing revised guidelines did not lead to substantial and sustained changes in most influences on behaviour change

Analyses of trends in key influences on behaviour change, specifically drinkers’ awareness, knowledge and exposure to drinking guidelines and their capability, opportunity and motivation to change their behaviour, suggest that none of these outcomes changed substantially or in a sustained way following the announcement of revised guidelines. This is perhaps unsurprising given that large-scale promotional activity was limited to a short period of earned news media coverage rather than a well-designed campaign aiming to change drinkers’ behaviour or affect their preparation to change their behaviour. Nonetheless, the lack of substantial changes in drinkers’ awareness and, especially, knowledge of the guidelines merits discussion.

Over 85% of drinkers were aware of guidelines before the announcement and, although this did not increase after the announcement, this figure is a high baseline. However, fewer than 25% of drinkers were able to correctly identify the guideline, and fewer than half gave a figure below 14 units per week or 2 units per day. These findings are broadly in line with a separate nationally representative UK survey conducted 1 month after the revised guidelines were announced, which found that just 8% of drinkers knew the revised guidelines.182 In the present study, the proportion of men who knew the guideline did increase significantly after the revision was announced but remained below 25% at the end of the study period. The equivalent figure for women was only 29%, despite the guideline for women changing to a lesser degree, suggesting a general lack of knowledge of drinking guidelines among both sexes. It is unlikely that the government’s aim for drinkers to use the guidelines to make responsible and healthy choices about alcohol consumption will be achieved with such low rates of knowledge about what the guideline is.

Responses to other questions assessing influences on behaviour change varied. Among the COM-B measures of drinkers’ capability, opportunity and motivations to change behaviour, most drinkers felt that it was easy to drink at moderate levels (i.e. ≤ 3 units per day), felt that their lifestyle made it easy to do so, wanted to do so, intended to do so and said that they knew where to get help if they wanted to cut down. However, drinkers gave less positive responses on two capability measures. First, only around one-quarter of drinkers kept track of their units. Although unit counting may be unnecessary for those already drinking moderately, the proportion doing so was even lower among drinkers exceeding the guidelines. Second, only around one-third of drinkers said that 1–2 units is the most they can consume on 1 day before it does significant harm. This aligns with the findings above on drinkers’ low knowledge of the guideline, but it also suggests that drinkers may require convincing that the guideline is set at an appropriate level. Drinkers also had mixed motivations for behaviour change. Most drinkers wanted to and intended to stay within safe limits but only half of drinkers were trying not to drink more than is good for them and, as with tracking units, this was more common among those already drinking within the guidelines than among those exceeding them. Only one-quarter of drinkers were concerned by drinking more alcohol than is good for them, and < 40% were trying to avoid drinking excessively. The contradiction between these responses and drinkers’ wanting to and intending to stay within safe limits suggests that, although, in a general sense, drinkers are motivated to stay within the guidelines, they are not strongly motivated by concerns about alcohol-related health risks or necessarily willing to forgo heavier drinking. This appears to reflect a concern expressed repeatedly in prior literature regarding a conflict between the consumption threshold set by guidelines and the desire of drinkers to become intoxicated.23,42,142 This, in turn, reflects a broader concern that drinking guidelines, like other forms of health promotion, engage insufficiently with positive motivations for unhealthy behaviour, such as pleasure, transgression and the enhancement of traits such as self-confidence, and we return to this point below.183,184

In addition to examining time trends in behavioural influences, we also examined the social patterning of these influences and identified important inequalities. In particular, drinkers in social grade DE were the least likely to be aware of guidelines or to know what the guideline is. They also found it more difficult to drink moderately, were less motivated to do so and were less sure where to get advice on cutting down. Taken together, these findings suggest that drinkers of lower socioeconomic status are less able and less likely than their counterparts of higher socioeconomic status to use the revised drinking guidelines to make responsible and healthy choices about alcohol consumption. As drinkers of lower socioeconomic status also suffer greater harm from alcohol despite drinking less, on average,161,185 it is likely that these differences will contribute to the perpetuation and, possibly, exacerbation of alcohol-related health inequalities.

Furthermore, drinkers exceeding the guidelines also differed significantly from those not doing so on the measures of behavioural influences. Heavier drinkers were more likely to be aware of and exposed to the guidelines, potentially reflecting an accumulation effect from seeing guidelines on product labels and more general engagement with or sensitivity to alcohol-related materials. However, these heavier drinkers were no more likely than moderate drinkers to know what the guideline was. It is difficult to explain this anomaly. It may be a form of psychological reactance, in which individuals reject or disengage from information that threatens their freedom to act.58 Support for this interpretation is provided by the finding that heavier drinkers were also substantially less likely to say that 2 units per day is the most they can drink without harming their health. As with the low level of agreement on this measure across the population, it suggests that heavier drinkers in particular require convincing that the drinking guidelines are set at an appropriate level. Heavier drinkers were also less likely to respond positively to other questions about their capability to change behaviour. They were less likely than those drinking within the guidelines to find it easy to drink at moderate levels and were less likely to track the units they consume. They also responded less positively on most measures of their motivations.

In general, these findings suggest that those at elevated risk from their drinking are among the least well prepared to use the drinking guidelines to make informed or healthier choices about their alcohol consumption.

Announcing revised guidelines did not lead to clearly detectable changes in drinking behaviour

The main evaluation analyses present a somewhat mixed picture of the impact of announcing the revised guidelines on alcohol consumption behaviours, with different findings for different outcome measures and analytical models. Analyses of our primary outcome measure suggest that the revised guidelines were associated with an increasing trend towards more problematic alcohol consumption, but this trend appears to have begun 6 months prior to the revised guidelines being announced and it may also have been only a short-term trend. The findings were also specific to our primary outcome measure of AUDIT-C scores and were not seen in our secondary measures of drinking behaviours derived from graduated frequency questions and alcohol taxation data. There was evidence of a step change to a lower level of hospital admissions for alcohol poisoning and assaults following the guideline announcement, but these changes were too large to be attributed plausibly to the guidelines given the lack of evidence of change in any other outcome measures. We judge that these changes in hospitalisations are more likely to result from other uncontrolled confounding factors or from artefacts of the research methods.

These findings are in line with previous studies examining the effects of alcohol-related health information on alcohol consumption, including previous announcements of new or revised drinking guidelines, evaluation or testing of health warning labels and evaluation of mass media campaigns.28,41,49,63 They are also in line with our logic model, shown in Appendix 1, which suggests that changes in alcohol consumption behaviours are contingent on promotional activity, which was limited, and changes in influences on behaviour change, which did not take place.

Strengths and limitations

Strengths

This is the most comprehensive evaluation to date of the impact of promoting new or revised low-risk drinking guidelines. The study includes a focused analysis of how the drinking guidelines are promoted. Despite drinking guidelines being discussed extensively within the research literature, including studies of people’s knowledge and adherence to the guidelines,33,34,36–38,40,46,182 their attitudes towards them23,142,186,187 and more general discourse around their utility and effectiveness,15,16,18,43,188 no previous study has examined their promotion in detail. Similarly, although there are studies of news media coverage of policy debates relating to the pricing, advertising, licensing and general regulation of alcohol,74,77,80,81,99 only one briefly reported study has examined how alcohol-related health information and, specifically, drinking guidelines are reported by news media.102 To the best of our knowledge, the present study is also the first to use high-frequency survey data over an extended time period (i.e. 24, 44 or 48 monthly data points depending on the analysis) to examine the effects of drinking guidelines on individual drinkers. Previous studies have tended to use annual or less frequent data series36–38 or a small number of repeated surveys over a shorter time period.41 Although informative, such studies lack sufficient data points to allow the well-controlled time series analyses undertaken here.189 Finally, we included a set of measures of drinkers’ capability, opportunity and motivation to change behaviour that were informed by an established model of behaviour change and were based on measures found to predict smoking behaviour.68,145

The main evaluation analyses in this study are also strengthened by the use of multiple outcome measures. Alcohol consumption behaviours are widely acknowledged to be difficult to measure via survey data because of a range of biases embedded in sampling frames, research instruments and participants’ self-reports.153,164 However, in the absence of viable individual-level objective measures of alcohol consumption, measurement via surveys is essential to capture differences in alcohol consumption behaviours across population subgroups. We therefore used two well-established alcohol consumption measures: the AUDIT-C tool and graduated frequency questions.149,152,190–193 We then supplemented these with an objective population-level measure derived from government alcohol taxation data and also used measures of hospitalisations for alcohol poisoning and assaults as proxy measures for heavy episodic drinking and alcohol-related violence, respectively. We also controlled for two potential confounders of alcohol consumption trends: alcohol prices and weather. Finally, we conducted sensitivity analyses to test the robustness of the results to alternative model specifications, several of which suggested important caveats to the findings of the primary analysis (e.g. that an identified change in trend actually occurred 6 months before the guidelines were announced).

Limitations

Limitations of the individual components of the project are discussed in the relevant chapters and here we discuss overarching limitations.

The lack of promotional activity beyond the initial announcement of the revised guidelines means that our conclusions regarding the effectiveness of promoting drinking guidelines as a behaviour change intervention have only limited generalisability to scenarios where more extensive promotion takes place. Our results are likely to remain useful evidence as limited promotional activity is common in other countries, such as Australia.102 However, our results will be less useful in informing the likely effectiveness of future promotional campaigns.

The short pre-intervention period of data collection for some outcome measures, which arose because of a delay in securing research funding, means that our conclusions regarding changes in influences on behaviour change should be treated with some caution. It is possible that these measures were subject to large random variations during the pre-intervention period, which included November and December 2015 only, and this may mean that our findings are misleading. However, the lack of large random variations or time trends in these measures across the post-intervention period suggests that the risk of misleading findings is modest.

Our understanding of how drinkers responded to the revised guidelines is informed only by survey-based data. We may also gain indirect insights into drinkers’ responses to the extent that news media reporting reflects public opinion, but separating public opinion from other aspects of reporting, editorial influence and journalistic personal perspective is challenging.76,79,80 Understanding public responses is important, as previous qualitative research on drinking guidelines, units and product labelling has identified that some drinkers not only struggle to understand and use key concepts such as units and guidelines, but also actively reject the content of these concepts. For example, several studies demonstrate that drinkers motivated to drink to intoxication find typical guidelines unhelpful as they do not accommodate such practices and think that the idea of counting units on heavier and social drinking occasions is unrealistic.23,42,142,187 Beyond alcohol, studies of dietary advice in Denmark reveal that, even when campaigns promoting such guidance are effective in raising public awareness and knowledge, the public do not follow the guidance in a literal sense, but interpret and enact it through their pre-existing understandings and attitudes towards what constitutes healthy eating.127,130 Therefore, it is important to not make assumptions regarding why drinkers did not change their behaviour. Insufficient promotional activity affecting influences on behaviour change is likely to be part of the story, but there may be additional factors that this study has not examined.

Finally, the drinking guidelines examined here were developed for the UK as a whole. This study focused on England only as this is the sampling frame for the ATS. It is possible that the guidelines had a larger effect in Scotland, Wales or Northern Ireland where the wider alcohol policy context is different, particularly in Scotland, which has followed a more public health-oriented approach to alcohol policy in recent years.194 It is also possible that promotional activity was more extensive in these contexts, although we are not aware of any large-scale campaigns beyond the Count 14 campaign mentioned in Promotional activities outside the study period, which fell outside the study period. The evaluation of the Count 14 campaign may provide insights into whether or not Scotland differs from England on key outcome measures.

Patient and public involvement

We conducted two PPI sessions throughout the course of the project to support the interpretation of the early and final results of the evaluation analyses. The sessions took place in 2016 and 2018. In the absence of a pre-existing and appropriate PPI panel in England, we worked with an established PPI panel comprising approximately 30 adults within the general population of Scotland who regularly consume alcohol. The lead researcher gave a presentation on drinking guidelines, the present project and the preliminary findings at that point in time. He then led a discussion of panel members’ views on drinking guidelines, their exposure to the revised guidelines and their perspective on the results.

The main outcome of these sessions was to confirm our interpretation that the guidelines had had little impact on drinkers in the general population. The comments of panel members generally matched our own interpretations of the extent of promotional activity, the likelihood of the guidelines affecting behaviour and the reasons underlying this. For example, some panel members said that they had noticed the news reports announcing the new guidelines but had seen little other information and had largely forgotten the content of those news reports. Panel members were apathetic towards the guidelines for a variety of reasons, including their impenetrability, scepticism about the ‘nanny state’ and their lack of usefulness for those motivated to drink to intoxication. These views aligned well with the findings of our survey data and the themes we discuss above when interpreting our results. Panel members also suggested that the messaging they had seen, particularly in news media, was generally negative and focused on the risks of drinking. They were keen to see more positive messages that engaged with drinkers’ motivations to drink or the benefits of not drinking. They also wanted to see messaging that set out the positive actions that drinkers could take to gain these benefits.

The PPI sessions were useful to the extent that they confirmed our interpretations of the data, but they did not substantially influence the methods or write-up of the study as no new practicable suggestions or ideas for research activities or interpreting the data and results emerged. Panel members were engaged and insightful in their comments and the format of the sessions worked well.

One panel member also attended Project Advisory Group meetings and made useful suggestions regarding sources of news media data.

Implications for policy

The findings of this project suggest that the public is not in a position to use the revised drinking guidelines to make the responsible and healthy choices about their drinking envisaged by the 2012 Alcohol Strategy.5 This finding echoes those from previous studies relating to the 1995 UK guidelines40,186 and to guidelines internationally.33,36 Although governments aspire to use drinking guidelines and unit or standard drink information to help drinkers to consume alcohol in moderation, they have not been successful in equipping drinkers with the knowledge and skills to achieve this or in persuading drinkers that the guideline is appropriate or useful. Below, we discuss three key areas of concern: problems with units, problems with the guidelines in general and problems with the specific revised UK guideline.

First, the available evidence suggests that drinkers in the UK have only a partial understanding of units and few use units to monitor their consumption.23,34,40,47,146 Drinkers typically overestimate the size of 1 unit, suggest that it is difficult to remember the unit content of drinks when this information is not provided (e.g. in on-trade settings) and argue that it is difficult to use the information in real-life contexts.8,34,42,195 This is problematic as units are the metric by which guidelines communicate the recommended maximum level of consumption to the public. However, the problem is slightly more complicated than it appears at first glance. The UK Opinions Survey found that 90% of adults had heard of units in 2009 and that, although only one-quarter of respondents knew that 1 unit of wine was less than a 125-ml glass, two-thirds knew that 1 unit of beer was half a pint and 1 unit of a spirit was a single measure, and half said that 1 unit of wine was a ‘small glass’.40 This suggests that the basic knowledge of units is less of a problem than the skills necessary to apply that knowledge in practice, for example to estimate the number of units in a particular drink, to adapt estimates to beers, wine or spirits of different alcoholic strengths or to calculate the total number of units consumed across a number of differently sized drinks drank during a night out. Equipping people with these skills is likely to be important if drinkers are to effectively use units as part of an effort to moderate their alcohol consumption.

Second, the evidence from the present project and previous research is also clear that drinkers have only a limited understanding of drinking guidelines, which, coupled with an incomplete understanding of units, is likely to hinder their ability to respond to guidelines as envisaged by the government’s alcohol strategy. The present project additionally demonstrates that drinkers’ capabilities, opportunities and motivations to use the guidelines to change behaviour are inconsistent. Key areas for attention include drinkers’ knowledge of the guidelines, their beliefs regarding the riskiness of exceeding the recommended maximum consumption level, and aspects of their motivations relating to deliberate efforts to drink at moderate levels and avoid excessive drinking. The need for greater knowledge and preparedness to use the information to change behaviour is also not evenly distributed across the population. In particular, those drinkers at greatest risk from their alcohol consumption, namely heavier drinkers and those in lower socioeconomic groups, differ in important ways from those at lower risk. Our findings suggest that enabling heavier drinkers to change their alcohol consumption behaviours will require increases in their motivations to do so and also changes in their beliefs about the riskiness of higher levels of alcohol consumption. Those in lower socioeconomic groups require greater awareness and knowledge of guidelines if they are to use them effectively and, if they are to change their drinking behaviour, efforts may also be required to influence their motivations to do so.

Third, evidence that drinkers believe that they can drink > 2 units per day without being at risk of serious harm suggests that the UK guideline of 14 units per week does not align well with drinkers’ perceptions of risky levels of alcohol consumption. This may reflect that the guideline is set to recommend a low-risk level of consumption rather than to identify a high-risk level. However, it may also reflect drinkers’ perceptions of the risks associated with lower levels of alcohol consumption. For example, several studies have demonstrated low awareness of the relationship between alcohol consumption and cancer risk,196–198 which is an important driver of risks at low consumption levels. There is also widespread awareness among drinkers of evidence that low levels of alcohol consumption may provide some protection against cardiovascular disease,199,200 despite the most recent evidence suggesting that such protective effects may be smaller and less certain than previously thought.201–203 Furthermore, qualitative evidence suggests that drinkers’ judgements regarding the risks of exceeding the guidelines are informed less by their understanding of epidemiological data and more by a wider set of considerations that jointly amount to a lay epidemiology of alcohol.23,131,204 These considerations do include formal scientific evidence, as reported via news media, but also include drinkers’ understandings of alcohol-related risks as developed through their own experience of alcohol consumption and alcohol-related problems and the consequences of alcohol consumption they observe and discuss within their families, social networks and communities. Drinkers’ judgements also draw on embodied understandings of risk, regarding whether they feel they are intoxicated or unwell or have reached their personal consumption limit.23,42,142,187,205 In combination, this mixture of inconsistent awareness of epidemiological evidence and risk perceptions informed by a wide set of personalised factors presents two options for increasing drinkers’ use of guidelines. First, health authorities may seek to increase public understanding of alcohol-related health risk and increase their motivations to avoid these risks. One approach to this may be to promote the basis for the guidelines, that drinking 14 units per week entails an approximately 1% risk of dying due to alcohol (although note that we have argued elsewhere that this basis for the guidelines is problematic188). The 1% figure could be set in context by comparing it to the risk associated with other everyday activities. However, the effectiveness of this approach may be limited to the extent that drinkers find that information does not accord with their own experience and lay epidemiological perspectives and their positive motivations for drinking.184 The second option, therefore, is to develop further evidence on how drinking guidelines can be designed and prompted. This evidence should address how drinkers use, or might use, guidelines in practice.188

Implications for future research

We identify three priority areas for future research, namely identification of effective alcohol-related health promotion messages, how to tailor those messages to be effective for particularly at-risk groups and how to set drinking guidelines to be effective as a behaviour change intervention. We discuss each of these in turn.

There is an extensive literature describing effective approaches to changing behaviour, but there is a lack of evidence to inform the specifics of what alcohol-related health promotion messages should say if they are to be effective. For example, a review by Hassan and Shiu64 found that the literature on the effectiveness of warning labels for alcoholic products was ‘weak and fragmented’,64 with little consistency in research approach and few clear recommendations available on key questions such as the use of imagery, recommendations and specific versus general messages.64 The small literature evaluating the effectiveness of promoting drinking guidelines similarly provides little guidance on which messages are more or less effective, often because evaluation studies do not focus on particular campaigns or do not describe those campaigns in detail. Addressing these problems through a more structured programme of research that promotes comparability across studies and focuses on key unanswered questions is an important priority going forwards.

A corollary to this is the need to identify messages that are effective for particular population groups. This project identifies heavier drinkers and those of lower socioeconomic status as groups of particular concern as both groups are at elevated risk from their alcohol consumption and less prepared to change their behaviour. The existing literature offers little guidance on how to tailor alcohol-related health promotion messages to these groups. Studies evaluating the mandatory US alcohol warning labels do describe diffusion processes by which heavier drinkers, who are exposed to the labels through increased contact with alcoholic products, are more aware of and able to recall the warning labels.52 This literature also demonstrates that there are limits to diffusion of awareness and knowledge via the simple accumulation of exposure, as trends in these outcomes plateaued 3–4 years after the labels were implemented.52 Study authors often discuss the possibility that this reflects psychological reactance or the effects of repeated exposure that no longer attracts attention,58,64,136 but there is little direct evidence to support these arguments. We are unaware of any evidence discussing the effectiveness of alcohol-related health promotion messages targeting those of lower socioeconomic status. As above, developing an evidence base in this area is an important priority.

Finally, greater attention is needed to the design of drinking guidelines themselves. As we have discussed elsewhere, guidelines are often designed with reference, or at least explicit reference, only to formal epidemiological evidence.188 This is particularly true of the guideline consumption threshold. Little consideration or evidence is brought to bear on questions regarding whether or not guidelines and the consumption threshold are appropriate to achieve the desired effect. This omission is particularly concerning where guidelines are conceived as a behaviour change intervention, as in the UK,5 but remains important where the purpose of guidelines is to communicate scientific evidence to the public, as reducing an extensive and nuanced evidence base to a single number is inevitably a simplification of that evidence and different approaches may communicate the full implications of the evidence in better or worse ways. The EU-funded Reducing Alcohol Related Harm project made best practice recommendations for the development of drinking guidelines in 2017,8 but these appear to be based primarily on epidemiological considerations and do not engage with considerations drawn from the wider scientific literature, such as how drinkers actually use guidelines in practice, how guidelines intersect with positive motivations for drinking (e.g. pleasure) and how the effectiveness of drinking guidelines is shaped by their acceptability and credibility within public debate.

Conclusions

The announcement of revised UK low-risk drinking guidelines was not subject to large-scale promotion by any organisation following the initial media launch, was not associated with substantial and sustained changes in most influences on behaviour change and was not associated with clearly detectable changes in drinking behaviour. Therefore, we conclude that the limited promotional activity does not appear to have led to the guidelines being used to inform responsible and healthier choices among drinkers, as intended by the UK Government.