We have known since case reports from the early 1970s that heavy drinking in pregnant mothers leads to problems with growth and development in the foetus. The “foetal alcohol syndrome” has been well-characterised since then. What is not so clear is whether “light drinking” is as harmful during foetal development and later childhood. Print and web media have been obsessing all day about whether pregnant mothers are alright to have the odd gin-and-tonic or glass of wine. It is a comment on the prominent place of alcohol in UK culture that all the commentaries are calling for relaxation of current recommendations which advise abstinence during pregnancy, rather than calling for a cautious re-examination of data.

The furore is due to findings based on the UK Millenium Cohort Study, which looked at over 11 000 infants
born across the UK, selected “such that disadvantaged residential areas are over-represented”. These infants were seen at 9 months, 3 years and 5 years and detailed data about the health and behaviours of mother and child were recorded. So immediately, we see that the authors can only comment about childhood upto 5 years of age and not beyond. This study has previously claimed that at 3 years of age, children of mothers who drink 1-2 drinks of alcohol per week are not at increased risk of behavioural or learning difficulties.

In the current study, the authors compared behavioural and learning difficulties in children of mothers in light, moderate and high drinking categories with children of mothers who were always tee-total. They adjusted their findings for possible confounding factors:e.g. child's age, birth weight, mother's age at time of birth, number of children in the household, mother smoked during pregnancy and other socioeconomic factors. The p-values for odds ratios are not reported in the paper, but the implication is that children of mothers who stopped drinking during pregnancy were worse off than children of mothers who were light drinkers. They did find a much higher prevalence of learning and behavioural difficulties in children of mothers who drank heavily though, and so they refer to a “U-shaped relationship” between alcohol consumption and risk of disease, which has previously been documented in adults. That is to say that a bit of alcohol is good for you, in fact it is better than none at all, but a lot of it is bad for you.

Importantly, the authors found that “light drinkers were more socioeconomically advantaged compared with mothers in all other categories. The socioeconomic profile of mothers in the ‘not-in-pregnancy’ group was more advantaged than the ‘never-drinker’ group but less advantaged than the ‘light’ drinking group”. The authors themselves admit that the effects may be explainable by socioeconomic status, i.e. mothers who are light drinkers have other beneficial environmental factors which may explain any differences in development of the children more plausibly than alcohol. Unsurprisingly, this was not reported by any of the blogs or newspapers I read today. Thankfully the Department of Health is being a bit slower to open the floodgates to heavy boozing during pregnancy. Surely, longer follow-up and more studies are required before we recommend all mothers to drink during pregnancy.

After smoking, alcohol is the next public health behavioural challenge of our generation. There have been moves at national and international level to recognise and tackle the problem of alcohol misuse. Its consumption is increasing, particularly among younger adults.

Alcohol consumption increases risk of liver disease. However, levels and patterns of alcohol consumption do not fully explain the rises in liver disease mortality that have occurred in some countries.

A recent Scottish study showed that body mass index(BMI) is related to liver disease, suggesting that the current rise in overweight and obesity may lead to a continuing epidemic of liver disease. Looking in the same cohort of men in Scotland, the same authors found that raised BMI and alcohol consumption are both related to liver disease, with evidence of a supra-additive interaction between the two. This led the study authors to suggest that BMI-specific "safe" limits of alcohol consumption may need to be defined. In the same issue of the BMJ, a study of 1.2 million middle-aged women in the UK showed that 1800 of the women developed or died from liver cirrhosis during follow-up. Increasing BMI was associated with increased liver cirrhosis, with a 28% increase in risk for every 5 unit increase in BMI. In addition to the effect of BMI, the absolute risk of liver cirrhosis increased as alcohol intake increased. The authors estimated that 17% of liver cirrhosis is due to excess body weight, compared to 42% due to alcohol.

An accompanying editorial makes the point that “compared with the risk of cardiovascular events in middle aged people, an absolute risk of one case per 1000 people over five years for liver cirrhosis seems low. However, this absolute risk still represents a substantial burden of illness for the patients concerned and for the health service”. The upshot is that alcohol and obesity in combination cause liver cirrhosis, another negative consequence of unhealthy lifestyle. Reductions in alcohol consumption and obesity are currently the only way we can prevent non-viral liver disease.

It’s been a bad week for booze lovers. An Oxford study estimated that in 2005, alcohol caused over 30 000 UK deaths, costing the NHS over £3 billion. 6% of deaths and 10% of all “ill-health” (as measured by "disability-adjusted life years”) are caused by alcohol. To put it in context, the same researchers showed last month that smoking caused 19% of all deaths and 12% of ill health, costing over the NHS £5 billion per year.

The President of the Royal College of Physicians, Dr Ian Gilmore, has made no secret of his desire to raise the profile of alcohol-related disease as a problem that can no longer be ignored. Writing in this week’s British Medical Journal, he speaks of “many factors that are deeply embedded in society and individual behaviours that influence how, why, and how much people drink. Previous public health campaigns, such as weekly alcohol limits, have been unsuccessful in reducing binge-drinking. On the other hand, the alcohol industry spends £800 million annually on marketing (about a quarter of what their product costs the NHS per year). A report commissioned by the British Medical Association shows that existing controls on alcohol advertising are inadequate, especially in young people, and as Gilmore says, “We should have learnt from tobacco that voluntary partnerships with the relevant industry do not work”. Calls are being made to curb merchandising, sponsorship of sporting events, competitions and loyalty schemes.

A systematic review of 13 studies of almost 40 000 young people found good evidence to support the impact of media exposure and alcohol advertising on subsequent alcohol use, including initiation of drinking and heavier drinking among existing drinkers. The UK is the only country in Europe with no restrictions on alcohol advertising and this method has been shown to work in other countries. Therefore, a Europe-wide ban on alcohol advertising has been recommended as a cost-effective health policy.

However, research and policy will have to be more innovative than simple bans if we are to change the current drinking behaviour of young people. For example, measures to change behaviours of college or university students were found to be more effective if they were web-based, compared with mail-based feedback.