1. Defining alcoholic beverages
Alcoholic beverages are drinkable liquids containing ethanol (ethyl alcohol; C2H5OH) (MeSH database 1), a substance rapidly absorbed from the gastrointestinal tract and distributed throughout the body (MeSH database 2) with psychoactive effects. As ethanol is the main type of alcohol found in alcoholic beverages, the term alcohol will be used in this chapter as a synonym for ethanol and, by extension, for alcoholic beverages.
Alcoholic beverages vary in their alcohol content, which is usually indicated in alcohol percentage by volume, defined as the millilitres of pure ethanol contained in 100 millilitres of the beverage (% v/v) measured at 20°Ca.
A standard drink or a standard unit is a term referring to a specific amount of pure alcohol, usually expressed in the form of a specific measure of a certain product. Standard units are generally proposed within low-risk drinking guidelines as a means to monitor and limit own alcohol consumption. There is no international consensus (Furtwaengler 2013) on how much pure alcohol is contained in a standard unit; among EU Member States, the most frequent value is 10 g of pure ethanol, followed by 12 g (though they range from 8 to 20 g)(RARHA 2016).
Because of this variation, rather than expressing alcohol intake as number of drinks or number of units, throughout the brief grams of pure alcohol or volume of pure alcohol are usedb.
Most frequently, alcoholic beverages result from the fermentation of sugars by yeast, usually Saccharomyces cerevisiae. Yeast typically tolerates ethanol concentrations of 10-15 % alcohol by volume (abv), so yields above 15 % abv are not usually obtained by yeast fermentation only; further distillation distillation of the products of fermentation must take place.
Alcohol provides energy upon intake, too; the energy conversion factor for alcohol (ethanol) is 29 kJ/g or 7 kcal/g (EFSA 2013). This is lower than the general energy conversion factor for fats (37 kJ/g or 9 kcal/g), but higher than those of sugars and proteins (which is 17 kJ/g or 4 kcal/g in both cases).
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The predominant source of alcohol in the diet is that of alcoholic beverages, which are mostly consumed directly or, to a lesser extent, as an ingredient in culinary preparations. Due to fermentation processes, alcohol can also be present in small amounts in fruit juices and dairy (kefir, yogurt), but these are out of the scope of this brief. In Europe, the most prevalent alcoholic beverages are beer, wine and spirits in different proportions. For example, according to 2010 data from the Global Information System on Alcohol and Health, (GISAH 2015) in Austria, Czech Republic, Germany, Iceland, Poland, and Romania, at least 50 % of the recorded per capita consumption of alcohol originated from beer, and in Belgium, Finland, Ireland, Latvia, Lithuania, Netherlands, and Spain, between 45 % and 50 % of pure alcohol consumed also originated from beer. In Denmark, France, Greece, Italy, Portugal, Slovenia, Sweden and Switzerland, more than 45 % came from wine instead. In Bulgaria and Slovakia spirits contributed most to this figure.
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In the EU, Regulation (EU) 1169/2011 (EU 2011) on the provision of food information to consumers requires that the 'actual alcoholic strength by volume' of an alcoholic beverage containing more than 1.2 % by volume of alcohol is given. The figure given should have no more than one decimal place, and be followed by the symbol % vol. It may be preceded by the word alcohol or the abbreviation alc. The same regulation exempts alcoholic beverages containing more than 1.2 % abv from having a nutrition declaration and a mandatory list of ingredients. The presence of specific compounds, such as frequent allergens (mostly sulphur dioxide/sulphites, egg and milk products in the case of wine), and glycyrrhizinic acid or its ammonium salt shall be added in the list of ingredients or, in the absence of such, accompany the name of the beverage. The Regulation also states that it is not mandatory to indicate a date of minimum durability in the case of beverages containing more than 10% abv.
A European Commission report on mandatory labelling of the list of ingredients and nutrition declaration of alcoholic beverages (EC 2017) acknowledged the progress made by the industry sector in providing consumer information on a voluntary basis, and invited the industry to present ‘a self-regulatory proposal that would cover the entire sector of alcoholic beverages'. A joint self-regulatory proposal (EC 2018a) together with sector-specific annexes (ECa) was recently submitted by the European alcoholic beverages sectors and is currently under assessment by the Commission. If it is considered unsatisfactory, an impact assessment will be launched by the Commission to review other options, including regulatory and non-regulatory options.
No alcoholic beverage containing more than 1.2 % abv is allowed to bear health claims of any kind in the EU. As far as nutrition claims are concerned, only claims referring to low alcohol levels, the reduction of the alcohol content, or the reduction of the energy content for these beverages are permitted (EC 2006a).
In addition to the EU labelling requirements, Member States may adopt national measures on the matter, subject to a specific notification procedure and positive assessment of the European Commission. For example, in France and Lithuania, labels of alcoholic beverages are required to warn consumers about the potential health consequences of alcohol exposed pregnancies, either with a pictogram or with text (Legifrance 2006).
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Alcohol consumption is a well-known risk factor for a series of conditions detailed in Table 2. Alcohol consumption patterns are often divided into low-risk (with some potential beneficial and some detrimental effects), and high-risk drinking (with clear detrimental effects). At low doses alcohol consumption may exert beneficial effects to some population groups in relation to cardiovascular disease and diabetes mellitus. However, there is a positive dose-response relationship between any alcohol consumption and cancer at certain sites, with no apparent lower threshold. Moreover, in addition to its acute intoxicating effects, long-term heavy use of alcohol may result in dependence and disease.
Although there is no international definition of what constitutes low-risk drinking, this term is frequently used to refer to up to 10-20 g pure alcohol per day for women, and up to 20-30 g pure alcohol per day for men, without heavy drinking occasions, with several alcohol-free days and preferably consuming alcohol with food (see Table 3b). These low-risk drinking guidelines are generally set at lower levels for women than for men because women generally reach a given blood alcohol concentration (BAC) with smaller amounts of alcohol than men. Recently, authorities in the UK and the Netherlands have provided single low-risk guidelines for both women and men, based on men's higher risk of injury and mortality (see RARHA 2016 for discussion).
In high-income countries, such low-risk drinking patterns can be associated with better health and lower all-cause mortality than are lifetime abstinence or heavy drinking. In turn, drinking substantially above the limits suggested in low-risk drinking guidelines increases the risk of alcohol-related harm. Overall, the net health effect of alcohol use is detrimental, even after the beneficial impact of low-risk patters of consumption on some diseases is taken into account, and even moderate alcohol consumption increases the long term risk of certain conditions such as liver diseases, and cancers, and dependence (WHO 2014a).
Heavy episodic drinking, colloquially known as 'binge drinking', is defined by the World Health Organization as the consumption of ≥60 grams of pure alcohol on at least one single occasion at least monthly16. Other institutions define different drinking patterns. For example the NIAAA (NIAAA 1) defines binge drinking as a 'pattern of drinking that brings blood alcohol concentration (BAC) levels to 0.08 g/dL'. Heavy episodic drinking is associated with acute consequences of drinking such as alcohol poisoning, injuries and violence. This pattern is associated with negative health consequences regardless of the average level of consumption of the person (WHO 2014a).
Apart from the health consequences of alcohol consumption to the person drinking, a wide range of negative health consequences to third parties may occur. These are often referred to as harms from other people's drinking, and include: foetal alcohol syndrome/ foetal alcohol spectrum disorders (FASD) caused by prenatal exposure to alcohol, injuries and deaths in accidents caused by other people's drinking, and other intentional or unintentional injuries and deaths (including homicides and suicides) (WHO 2014a). Table 2 summarises examples of health outcomes associated with alcohol consumption.