Welcome to where parents talk. My name is Lianne Castelino. Our guest today is the director of the Canadian Institute for substance use research at the University of Victoria. Dr. Tim Naimi is also a professor at UVic School of Public Health and Social Policy, and an alcohol epidemiologist. He is currently supported by the National Institutes of Health, and the Centers for Disease Control in the United States for his research on binge drinking, and youth drinking, among other areas. Dr. Naomi is also a father of two teen girls, and he joins us today from Victoria BC. Thank you so much for taking the time.

thanks so much for having me.

So Dr. Naimi let me start by asking you about the science. What can you tell us about the latest science as it relates to alcohol consumption?

Well, I think you know, a lot of your a lot of people would be aware that, you know, alcohol consumed it, obviously at high levels has lots of health and social problems. But what’s happened over the last 20 years as we’ve got better at pulling apart the studies is we’re understanding that the risks start to increase at very low levels. And that kind of has culminated in the recent release of the Canadian guidelines or guidance on alcohol and health. I was fortunate and honored to be one of 22 or 23, scientists from 16 Different institutions across Canada that that participated in that work. But the bottom line is we can get into the numbers. But the bottom line is, is that, you know, for people who drink alcohol, when it comes to health, anyways, less is better. And the risk of an alcohol cause death or other problems actually start to go up above just two drinks per week, which is surprising to people.
It is certainly starting when you are startling when you compare them to the last guidelines, the last national guidelines, which were released in 2011. And which showed that limiting alcohol use of 10 drinks for women and 15 for men. Worse, we’re fine. And so now you’re talking about two drinks per week.

Can you take us through some of the key findings of this new guidance?

Well, the first thing I want to do is just take what you said and just kind of put a little bit of context on that. So what we’re doing this time is a little different from what they did last time where they kind of just gave a number for men and a number for women. What we’re doing this time is giving different risks zones. Our overall goal Leanne was we didn’t want to pull our punches scientifically, like we don’t we want to let people know when the risk starts to increase. But we also understand that a lot of people aren’t willing or interested to get down to the very lowest levels. So we did give, so the what is considered the zero risk zone is actually not drinking at all, which is, you know, very, you know, which is healthy, and you know, so should be socially acceptable. And then the sort of what we call low risk was no added risk, which was up to two drinks a week. So once you get over two drinks a week, your risk of a death just to be more, you know, a bit more explicit, since we have some time is about one in 1000. Right? So and then once you’re up to over, over six drinks a week, your risk of having an alcohol cause death is over one and 100. So we have these different risks zones. And of course, you know, we as health people, we’d love people to want to minimize minimize the risk is excuse me, as much as possible. But I think part of the reason why, to get back to your question, why the guidelines kind of changed, or at least the way they report in the public is for two reasons. One is the science has changed. And number two is that a lot of people that the our low risk zone is is actually a lower risk than was related to the previous guidelines. In other words, we felt why should there be a public health document, which tells a low risk amount that actually increases the risk of harms? Right. So I think this time, it’s again, it’s the science showing that the harm start at lower levels than previously appreciated, as well as the idea that we’re going to tell people exactly where those harms start to increase. And that wasn’t quite the same philosophy on the last guidelines.

What would you say struck you most as you waited through and pored over this research?

Well, I think, you know, there’s, I think the the number at which, you know, that risk starting to go up above two drinks a week was interesting, but in in another way, like I’ve been following this kind of literature for for many, many years. And I think you know, broadly, you know, first of all our study is made up have 1000s of previous studies. So in a way, I wasn’t quite surprised by the results. I think, even though make people are making a big deal about these Canadian guidelines, in part because we call out the lower levels of risk, and in part because people perceive it as a big change. But in fact, the the overall concluding message of the guidance, and which is very consistent in the research has been very consistent. Is that drinking less is, you know, better for health. That’s, that’s even the previous research would be showing that. So I think that’s the main message from a health health standpoint, again, is that less is less is more when it comes to health.

For those of us who don’t study this, and don’t have that scientific background, as you do, it just comes across jumps off the page, when you look at those statistics. And it makes you wonder like, are we not understanding what is in our house alcohol, as is what is in alcohol changed in the last 12 odd years? How would you go about defining first of all, what is in alcohol? And what is causing the statistics that you just outlined?

Well, the active ingredient in in alcohol is ethanol. That’s the technical, that’s the chemical. So ethanol has a lot of properties. It’s very small, it goes lots of places in the body. That’s why alcohol can affect so many organ systems, the heart, you know, the tissues to cause cancer, the stomach, the liver, the brain, it’s a small molecule, that’s the that that is the substance that contributes most of the calories from alcohol. So like, for example, a lot of your audience might not be aware that there’s more calories in a gram of ethanol there is than there is an a gram of sugar, for example, that that information, by the way, is not on any bottle, right? You have to you have to kind of dig around to find that. It’s the ethanol that is also the carcinogen, the cancer causing agent, as well as the breakdown of ethanol. And again, I don’t know in your audience, but our alcohol or ethanol more, more accurately has been classified as a it’s called type one carcinogen or cancer causing agent for more than 40 years by the World Health Organization. It is a can be a causal contributor to more than seven types of cancer, including breast cancer. And so it’s a really important thing, the the company that, you know, some other class one carcinogen, that’s the most carcinogenic type of chemical. So cigarette smoke is in that that category, benzene, you know, which is we’re getting hearing a lot about in cosmetic products, asbestos. So, you know, ethanol is a very carcinogenic substance. Just to give you an idea in terms of breast cancer, that’s one of the cancers that alcohol can contribute to. For each drink, that a woman consumes more per day, on average, her risk of breast cancer will increase by approximately 9%, relative to her baseline level of risk. Why I’m mentioning the cancer part is that this is one of the areas where the evidence has become much, much stronger over the past 20 years. And it’s also an area where most Canadians or Americans for that matter, are very little understanding of the you know, the fact that alcohol can cause cancer. Another way to think about alcohol and cancer is in cigarette equivalents. So each drink that you take of alcohol has about the same cancer causing potential is either one or to cigarettes, depending on if you’re a man or a woman. So, again, anyways, I’m not trying to scare people, it’s not a huge overwhelming risk. But I think the purpose of our guidelines is to just, you know, again, inform people that you can lower your risk of, of alcohol cause problems by drinking less, and at a more broad level is to engage Canadians to better sort of familiarize themselves with with the health effects that are related to alcohol.
One of your areas of expertise and research has to do with youth drinking, and binge drinking. And I’m curious as to what would be your message to parents, of teenagers and young adults today about what they should know, as it relates to alcohol consumption, and this age group of young people.

Well, that’s nice. I’m glad you’re asking me. You’re, as you mentioned, is the father of two teens. This is something that’s on my mind, but as you mentioned, I’ve done a lot. I’m actually also a board certified pediatrician.

So I’m really Interested in this age group to take a step back. You know, alcohol is the most common substance that’s used by youth.

It’s very commonly consumed. And as you mentioned, most youth when they consume alcohol or not having like a glass of wine, they tend to be binge drinking, what has been drinking binge drinking, when I was talking about the risks before that we outlined in the guidelines, we’re talking about drinks per week, or that sort of thing. But binge drinking is referring to drinking that’s clustered in time. So for men or boys, it’s often defined as consuming five or more drinks, on an occasion or in a row. For women, it’s similar, a little lower, so four or more drinks, even if you consume exactly at those levels, you will reach a blood alcohol concentration that is point O eight or higher. So you will be in the impairment range. Of course, many people who are binge drinking or drinking much more than five or four even. So it’s a really important pattern of consumption, right. And in addition to causing all the, you know, problems to tissues, you have the problem of acute impairment or intoxication. So that’s why binge drinking is so critical to things like domestic violence, to car crashes, to drownings to, you know, things of this nature, this is the predominant form of drinking that, that underage youth engage in. So it’s really important, also to remember that most kids, you know, teenagers and so forth, they tend to be leaner. You know, when I’m, I would like to tell you that I was skinny at one point in my life, it’s not quite true, but, but if I told you that you might believe me, because, you know, naturally, as we age, we get, you know, a little bit, you know, larger, we have more body mass. So, you know, five drinks, or four drinks, for a typical teenagers tends to result in higher blood alcohol concentrations than it would for, for me, certainly. So for all those reasons, and plus, you know, when kids are younger, as they’re still developing socially, they have less, you know, impulse control these sorts of things. Anyways. So what would I tell parents? Well, a lot of parents have a lot of questions about alcohol consumption. But I would say that the main thing that parents can do is the research is quite clear that it’s not what you say, it’s what you do. And actually, the bigger area in my research as it relates to youth drinking, is this whole concept that in US states and Canadian provinces and territories, we can really predict the amount of youth drinking by looking at the adult drinking in that same state or province, right. Why is that? Well, it’s for a number of reasons. First of all, you know, adults are kind of modeling behavior, whether that’s in the home, right, as in the case of parents and kids, or in the broader community, you know, kids are exposed to largely an adult environment as they grow up. Second of all, adults are the people who are creating the alcohol policies that in which kids grow up in. So things like how high are the alcohol taxes, how late to the bar stay open at night? These types of things are there warning labels and alcohol containers. And, and then, finally, adults, or people who are of age are the primary source of alcohol that’s consumed by youth. So if you look, you know, most alcohol consumed by youth is actually not stolen from their parents, or it’s not purchased with a fake ID. It’s provided by of age adults, typically, sometimes it’s parents, but often it’s associates, friends, acquaintances that are, you know, just over the drinking age. So the what I’m saying is, is that it’s the folks who are of age or who are adults that are the main determinants of youth drinking. So if you’re, if you have kids at your home, and you want to model that, you know, that means not drinking much, or when you drink, drinking very little, and not not having alcohol be the sort of the central focus of you know, the parents social life. These types of things are really, really important and are actually more important than, you know, if parents are drinking excessively, and then they turn around and say, you know, it’s bad to drink too much and you’re underage, you know, that’s not necessarily going to make it’s it’s questionable, how much of an impact that has.

You mentioned cancer as one of the chief potential diseases associated with excessive alcohol consumption. Could you take us through some of the other disease diseases and conditions and also those that may appear in the short term because there are going to be people that listen to and watch this interview and say to themselves, you know what? If it happens to me, it’ll happen in several years, I’m good. Until then I’m not really concerned, this is exaggeration, etc, etc. So how would you counter that argument?

Well, it’s actually interesting youth are catching on faster than adults about that the their, their knowledge about health and alcohols actually, sort of in many ways, surpassing that of adults. What we’ve seen in the US in the past 10 years is very interesting, because, you know, I just told you that the relationship between adult drinking and youth drinking is very tight. And I should have said that that’s generally the case. But in the last 10 years, what we’ve seen in the States, and I believe in Canada, as well, is that we’ve actually seen total consumption going up among adults, while among youth, it stayed stable and actually declined to some extent, which is a wonderful development. But you’re right, of course, you know, if I’m, if I were 14 years old, and I heard, oh, you know, drinking, drinking alcohol. And by the way, it’s not even, of course, the risk of cancer is higher at high levels, but the risk of cancer starts to increase with any alcohol. But if I heard about that, and I’m 14, you know, I’m not going to be thinking about, you know, well, maybe I’ll die at age 55, or 60, from some cancer, because it’s just, it’s hard to even for adults, we don’t tend to appreciate risks that occur, you know, there might occur many years in advance. But with respect to alcohol, again, a lot of the most important health effects and certainly social consequences occur from acute intoxication, or, and the bad things happen, like soon I mentioned a couple of them. Violence, we can explore that apart, you know, violence in terms of domestic violence in terms of sexual assaults, many sexual assaults, either the perpetrator or the victim, or are impaired by alcohol. Things like, you know, bar fights, or fights in the street, or homicides are associated with alcohol. Suicide is very strongly associated with alcohol, not just through its relationship with alcoholism or alcohol dependence. But when people are impaired by alcohol, and they they’re depressed, right, they’re that part of their brain might tell them don’t kill yourself is kind of overwhelmed, it gets to kind of shut off. So there’s a role for alcohol in people who attempt or commit suicides, it does not help the situation, then there’s things that are more social in nature, we could say things like unprotected sex, or, you know, sexual encounters that might not otherwise have happened if the person either male or female, were not impaired by alcohol. Things like car crashes, again, drownings, even things like arguments with friends or loved ones, right, that that are, you know, so there are a lot of these kinds of social social effects. Those could extend to things like finances, you know, alcohol is not inexpensive in Canada. So, you know, a lot of people unfortunately spend spend some of their discretionary money are quite a bit of it on alcohol. So these are some of the menu of things that can happen in the relatively in the short term, stomach irritation hangovers, all these other things, but are milder ones, too.

So with this science now, out there, the guidelines now published, what do you think it’s going to take to get the public’s attention, regardless of age? Whether we’re talking about adults or young people with respect to how they view alcohol consumption in light of these findings?

Well, that’s a great question, you know, as a scientist, but I but I’ve also worked in public health for many years, where, hopefully, you’re going to do a great job and the media, yourself included, has been very helpful in in getting the word out. And I think the goal here is not that we want people not to drink at all, but that there should be kind of a cultural shift, because of course, you know, alcohol is quite iconic culturally in Canada, in the US, and so we kind of want to increase people’s awareness that’s going to happen, hopefully, over time, you know, just releasing a guideline, you know, can’t accomplish that. There’s going to be a lot of efforts to make sure that the guidelines are widely disseminated. But the other thing that we know, Lianne, is that and we’re excited about our guidance this way. Most national drinking guidelines are directed to people right. But most behavior change doesn’t occur through the individual like we are all very much products of our environment is where I’m going with this and So, you know, it’s one thing for a bunch of scientists to put out all this information. But that’s not by itself, likely to that can change the climate around alcohol in terms of the way people think of it, they’re not going to be thinking of it as a sort of a health product, or oh, it’s going to be great for my heart anymore, because that science has all been pretty much debunked. But what makes a difference in change is, is our policies or you know, government policies. So, you know, when the alcohol costs a little bit more is not available, you know, at all hours of the day at night, by clicking a button on your phone, when the advertising is throttled back a little bit, these are the things that are shown through science and through public health, to make the big difference. Let’s think about cigarette smoking, right, which is declined so dramatically. In Canada, in the US, it’s not because people wag their finger and say, we might get lung cancer, if you smoke cigarettes, it’s because that information was translated into action that resulted in massive increases in cigarette taxes, clean indoor air laws that, you know, makes it not possible for people to smoke in buildings. All these kinds of policy changes that actually make smoking either more inexpensive, or more inconvenient, or less socially desirable, right? You know, drinking in Canada is still very socially desirable, as is drinking to get drunk. It’s kind of like, thought of as a joke, right? You know, we might come in on Monday and say, Oh, my God, I was so hammered on Saturday, and everyone will kind of laugh. So that is changed. When it comes to things like drinking and driving, that’s no more like people, even if they do that, they’re not going to come into the office and joke about it, but like drinking to get drunk is still sort of, you know, anyways, what back to the idea is you got to make, you got to make changes at the policy level, you can’t just have a bunch of scientists telling. And that’s what we’re looking for. That’s what we also call on in this report is for the government to complement this with the kind of effective policy interventions that are unfortunately lacking in Canada. And one of them that’s really important is we call on the government to require labeling for alcohol products. Because Lianne if I’m telling you, okay, your risk of you know, dying from an alcohol cause death, it’s seven drinks a week is x. And you’re sitting there with a bottle of whiskey in your hand, you have no idea how many Canadian standard drinks are even in that bottle? You have no idea how many ounces is in a standard drink, right? But why is that information, simple information about the number of drinks in a container, not on the label. When if I go to the store, and I buy a can of peas, it’s going to say, oh, there’s five servings and this is you know, how many you know what the volume of serving, it’s going to tell me how many calories there are right. And meanwhile, we have alcohol, which is an intoxicating, addictive cancer causing highly calorie dense substance with lots of health problems. And all we know is it’s there’s a little thing it says you know, 40% out ABV or alcohol by volume. We don’t know how many drinks are in there. We don’t know how many calories in there in there. There’s no information for consumers that this can cause cancer, those sorts of things. So we’re calling for labeling. In Canada. If you look at the in Canada, our tobacco products have warning labels on them. Our cannabis products have, you know, health warnings on them, even though warning labels on them, even though cannabis is you know, far less dangerous substance and alcohol. And as I said before, even a can of peas has basic nutritional information, particularly for alcohol, the calories matter. But so anyways, we need we need to have drink information and warning health information on the warning and it has to be mandatory. And that’s another thing we’re calling on the government to implement. Backed by Sorry for the long answer, by the way,
no, not at all. Backed by such compelling science as you now have evidenced in these guidelines. How far away do you believe that start labeling like we saw with cigarette packaging? Is how far away are we from that with alcohol?

Well, we strongly believe that the consumers have a right to know information again, the philosophy behind what what we traded for in the guidance is we’re trying to tell people not telling them what to do. We’re not saying you have to get to a number. We’re trying to inform them but the compliment to If we’re not going to take that sort of heavy handed approach is that people have to have clear simple information that’s accessible to them. And that is not available to them. And consumers have a right to know. And one of the ways they should, the most important way they should have a right to know, is right on the label of the product, just like any other dangerous product. Now, when will that happen? And why is alcohol, you know, treated as a special situation compared to other substances sold in Canada? Well, I think the answer to the two of those questions relates to the same thing, it relates to the political will and the political clout of the alcohol industry, and the willingness and the fortitude of the government to sort of stand up to that. So I know are we know, we that, for example, Health Canada has been involved in overseeing funded our process, they have been very strongly supportive of our science. But we are, you know, we we are interested to see when and if, for example, the government or the provincial governments will endorse the new guidelines. And we are interested to see what they will say about our call for labeling in particular. And, you know, well, of course, I understand it’s politically it’s very difficult. But that’s, I have no more insight on that than you do. I don’t believe I wish I did, though.

Let me ask you this as a researcher, as a scientist, as a physician who’s been on top of this space for some time, you know, what kind of sense of urgency Do you feel around what you just described? Like, is there? Is there a tipping point that we’re entering that you think needs to be addressed? On the heels of this science?

Well, I think the guidelines, I think there’s a lot of energy around labeling. I mean, here’s another point. Lianne, you know, I’m from the US, you know, US has pretty much of a freewheeling free market economy, we don’t like even the US has had alcohol warning labels for more than 40 years. So I’ll just say it’s time for candidate to up its game. And yeah, so I think I’m hopeful I don’t, you know, I’m hopeful that there’s a tipping point, I think the guide, the new guidance is part of it. But there’s also been a lot of momentum. You know, in some other countries, as well, that have recently put on on warning labels, including in Australia and Ireland. There’s lots of interest at the grassroots level and labeling for alcohol. I think, again, it’s a matter of sort of consumer awareness, consumer fairness. But again, I’m I’m sort of, I don’t know how these processes work. And I know there’s, you know, policymakers have lots of things to weigh when they make changes like this.

The timing of this new guidance is very interesting for multiple reasons. The last time as we mentioned, it’s been about a dozen years since we’ve had national guidelines in this area. But substance abuse across the board has been impacted in different ways by COVID-19. So I wonder, Dr. Namie, what concerns you most as we’re looking at the last sort of two or three years in particular, with respect to alcohol consumption?

Hmm. Well, that’s a great question. You know, of course, it’s like, we know that consumption has gone up. In Canada, if you look at probably five or 7%. Overall, if you look at just the total volume sold, the health harms from alcohol have gone up, disproportionately higher even than that. So probably, it’s a combination of drinking more and having kind of less access to, you know, medical resources and a lot of other issues that came with the pandemic. You know, it’s funny, because people like to talk about how the pandemic influenced alcohol consumption. But I think not enough people talk about how alcohol consumption influenced the pandemic. And by that, I mean, there’s lots of studies that have come out that showed how much people who drank particularly heavily or excessively not even meaning that they’re all alcohol dependent, but had greater risks of getting COVID of transmitting COVID A lot of the super spreader events at the beginning of the outbreak in particular, were driven by alcohol and very alcohol centric events. You know, when people were drinking, they can’t, you know, you’re not masking and there’s some really cool studies showing that like for each additional drinks, somebody’s consumed, like if I was talking to you, you know, we would get closer and closer and closer with each drink. So people are like, there’s less distancing. So at Uh, actually, in the countries that really curtailed, alcohol consumption had big positive impacts on on their COVID epidemics. Now, if we look at Canada and the US, what was the initial response to COVID was to declare alcohol and essential product. I mean, right there that was like, so like alcohol. And then meanwhile there all these really like important businesses and other other forms of economic activity that were not, you know, so this was, once again, you know, alcohol was sort of raised up above everything else, and declared an essential product. And then what transpired over the next two years, is that a lot of the common sense, you know, policy guardrails we have for alcohol, got rolled back. In many cases, they were temporary, but almost all of them have become permanent. So these are things like you probably are aware, but like changes in relaxing sort of policies around home delivery. So you know, in Canada never have, we’ve been able to get so much alcohol from so many different places, you know, from so many in so many different ways, it’s so many hours of the day and night, these kinds of things make a difference. And I’m a strong believer that alcohol should be illegal and available product. But you know, if you think about it, for people who are vulnerable to the effects of alcohol are vulnerable to drink too much, or for whatever reason, we have guidelines in place related to keeping the price a little bit higher than it could be, or letting you know, keeping alcohol a bit more inconvenient to access to keep the marketing and stuff under control. So we have this whole system of sort of common sense guardrails that are kind of helping people to take this dangerous legal product, and hopefully that so that more people can, you know, use it and enjoy it safely compared to who have a problem or cause problems for others. So I think the biggest impact, frankly, of the COVID epidemic on alcohol, has been in the rollback of a lot of alcohol policies, basically, a 20 year wish list from industry got granted within a year, year and a half. And unfortunately, that is going to have negative impacts on alcohol related problems in the population for many years to come.

Dr. Naimi, I’d like to ask you, what do you want parents in particular, to take from the guidance that was released in January of this year, particularly as it relates to their children?

Well, we do have, you know, we do have a section on that, you know, we of course, the most important message for kids, because I think there is, the more the more use delay they’re beginning to drink, the better it is in terms of their health outcomes. And that’s not just talking about what happens in the moment. But there’s really good research showing that the later people start to drink, that their drinking trajectory for their whole life is fundamentally altered. So again, for kids or for parents, delaying the onset of drinking, and obviously, binge drinking, is really critical and will pay back dividends, not only in the near future, but will pay back dividends over the life course, for parents, again, it’s to model you know, sort of that if they drink to drink, you know, very small amounts and to not make it like a central aspect of of thing, but I would again come back to the larger environment is that we think about our, our communities and our policies there as that sort of the sort of parental control or modulating factor and the rest of us are here. So I think it’s more that we want to create environments where people will take their knowledge and, you know, hopefully make decisions that are, you know, more healthy than not, and, you know, in the day to day,

Certainly incredibly important food for thought. Dr. Tim Naimi, director of the Canadian Institute for substance use research at the University of Victoria, thank you so much for taking the time to share your insight with us today.

Okay, thanks for having me. Lianne