When does alcohol use become harmful for the individual, and who bears responsibility when use turns into risk? The same scientific evidence ought to lead to the same results. Yet a review of national guidelines and recommendations shows that the Nordic countries approach these issues in strikingly different ways.
Sweden
In Sweden, the National Board of Health and Welfare uses the term risky alcohol use to identify individuals who should be offered support. Risky use is defined as consuming ten or more standard drinks per week, or four or more standard drinks on a single occasion at least once a month. These thresholds are the same for women and men. One standard drink corresponds, for example, to 33 centilitres of regular beer or 12 centilitres of wine.
The recommendations thus indicate when healthcare and dental services should offer support. They emphasize that it is not possible to define a threshold at which alcohol consumption is risk-free, but that the less alcohol consumed, the lower the risk of injury, disease, and premature death. When these recommendations were published in 2023, however, many interpreted them as advice to individuals rather than guidance for healthcare providers, which led to heated debates.
Sven Andréasson, an addiction medicine physician and professor emeritus of social medicine at Karolinska Institutet, comments:
– I think it is a mistake for the National Board of Health and Welfare to assume that guidelines aimed at professionals won’t reach the general public. Of course they will. The issue isn’t that the message is unclear, but it reflects difficulty in interpreting the mandate. Still, the strong reactions were excellent, because I do not think similar guidelines have previously drawn this much public attention.
Finland
In Finland, Käypä hoito is the national, standardized care guideline used in primary care, occupational health, and specialized health services. According to the guideline, assessing the health risks of alcohol can be difficult. The purpose of the recommendations is to improve the identification, treatment, and prevention of harmful use.
Käypä hoito uses a so-called alarm threshold, meaning a high-risk level, set at 12–16 alcohol units per week for women and 23–24 alcohol units per week for men. At these levels, health risks increase markedly and healthcare interventions are recommended. Moderate risk is defined as seven units per week for women and 14 for men. Consumption unlikely to constitute a risk for a healthy person is 0–1 units per day for women and 0–2 units per day for men.
Iceland
Iceland’s Directorate of Health provides guidance on policy and scientific research on alcohol and other drugs. According to the Icelandic recommendations, there is no known level of alcohol consumption that is entirely risk-free. High risk is defined as consuming five drinks on a single occasion. Older adults are advised to avoid alcohol altogether, and women who are trying to become pregnant are advised to abstain entirely.
Iceland’s guidelines thus differ from those in Sweden and Finland in that they are not framed as clinical thresholds for healthcare providers, but as public health recommendations aimed at the population at large.
Norway
In Norway, the dietary guidelines issued by the Directorate of Health apply, and these are also directed at the general public. From a health perspective, they recommend keeping alcohol consumption as low as possible. The guidelines stress that there is no health-based safe lower limit for alcohol consumption, and that alcohol use is associated with cancer and other diseases. The Directorate of Health is currently investigating whether there is sufficient scientific evidence to introduce more specific guidance on alcohol consumption, possibly including recommended upper limits. The review is expected to be completed later this spring.
Denmark
In Denmark, the Danish Health Authority recommends that adults drink no more than ten standard drinks per week, a guidance that applies equally to women and men. The authority notes that drinking three times per week is the most common pattern in Denmark and frames the issue from a public health perspective aimed at the general population:
“If one drinks ten standard drinks per week spread over three days, the average person faces a lifetime risk of 1–2 percent of dying from an alcohol-related disease or injury. With higher consumption, the risk increases. It is important to remember that some people are particularly vulnerable to alcohol, and therefore ten standard drinks per week is not a safe threshold for everyone.”
Faroe Islands, Greenland and the Åland Islands
The Faroe Islands have their own official recommendations for alcohol consumption, developed by Fólkaheilsuráðið, the Faroese Public Health Council. Overall, the council recommends drinking as little alcohol as possible, as no level of alcohol consumption is free of health risk. For those who choose to drink, both men and women are advised not to exceed ten alcohol units per week and no more than four units on any single day.
Greenland does not currently have a national strategy for alcohol prevention, but has recently published recommendations for such a policy, including bans on marketing and expanded support for families.
The Åland Islands have not adopted any specific guidelines regarding risky alcohol use.
A challenging work
Pia Mäkelä is a research professor at the Finnish Institute for Health and Welfare, and has been working on alcohol research since the 1990s, regularly contributing expertise to alcohol-related policy decisions. She notes that the Finnish guidelines are currently being updated. The existing guidelines are based partly on nutritional recommendations and partly on clinical care guidelines, both of which are now more than ten years old.
– The fact that the current alcohol guidelines are based on outdated recommendations highlights the need to update them. The science has advanced. For example, awareness of alcohol’s cancer risks has increased, says Pia Mäkelä.
Mäkelä also works on the JA-SAFE project (Joint Action on Health Promotion and Disease Prevention including Smoke and Aerosol Free Environments). Co-funded by the European Commission and member States, the project brings together more than 60 institutions from 23 European countries to safeguard public health across Europe. Mäkelä and her colleague Jaana Markkula lead the alcohol-related work in collaboration with 13 European countries. Their work includes reviewing the existing scientific evidence and providing recommendations to EU countries, helping each country to make decisions based on solid scientific grounds.
Currently, European alcohol guidelines are built on very different foundations.
“Some countries base the guidelines on the work of special expert groups, some on dietary or clinical care guidelines, while others have been created without any formal process”,
Mäkelä explains.
She notes that among the Nordic countries, Danes have the highest alcohol consumption while Finnish people have considerably reduced theirs in recent decades, partly thanks to higher alcohol taxes. The Nordic countries base their guidelines on the same scientific evidence.
– But science cannot pinpoint exactly when the risk becomes too high. That must be an individual decision, Mäkelä says.
– Some people want to avoid all risk, while others value the social benefits of drinking or simply enjoy the taste. People’s preferences vary greatly, and in modern European countries, individuals have the right to decide what risks they are willing to take.
At the same time, authorities have a responsibility to communicate the risks of alcohol consumption. This makes developing guidelines challenging.
– That’s where the differences between countries come in, Mäkelä explains. How do we communicate risk to the public, and how do different working groups interpret what level of risk is too high? Most guideline working groups try to avoid giving prescriptive instructions to the population.
Sven Andréasson believes that clear guidelines for the general public are important.
– It is somewhat peculiar not to have them, when there is evidently a scientifically grounded view of what is healthy that is already communicated to professionals, he says.
MORE ABOUT THE GUIDELINES
Sweden: Socialstyrelsen
Finland: Käypä hoito
Denmark: Sundhedsstyrelsen
Iceland: Island.is
Norway: Helsedirektoratet
Faroe Islands: Fólkaheilsuráðið
This article is produced in collaboration between Alkohol & Narkotika and PopNAD.
If you prefer to read the article in Swedish, click here: Norden och alkohol: Samma risk, men olika råd.
