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Alcohol consumption is a well-known risk factor for a series of conditions.
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 is 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°C.
Standard drink (or 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 (pdf)) 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 (pdf)).
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 used (usually expressed as alcohol by volume; ABV, abv or % abv).
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 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 (pdf)). 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).
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. In Europe, the most prevalent alcoholic beverages are beer, wine and spirits in different proportions.
Table 1: Examples of alcoholic beverages and their alcohol content
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 together with sector-specific annexes was submitted by the European alcoholic beverages sectors, followed by Memoranda of Understanding signed by representatives of the spirits', beer, and cider and fruit wine industries (ECa).
Regulation (EU) 2021/2117, amending previous regulations, states that wines should provide a full nutrition declaration and a list of ingredients. Producers have the option to only provide the energy value on the label, making the rest of the information (full nutrition declaration and list of ingredients) available by electronic means. These electronic means must avoid any collection or tracking of user data and may not provide information aimed at marketing purposes.
The European Commission adopted Europe's Beating Cancer Plan (EBCP; EC 2021) on 3 February 2021. The Plan foresees that the Commission will propose the introduction of mandatory indications of the list of ingredients and the nutrition declaration on labels of all alcoholic beverages, as is already the case for other pre-packed foods. Following up on EBCP, the Commission launched a public consultation between December 2021 and March 2022 on the revision of rules on information to consumers for alcoholic beverages. The initiative included rules on labelling alcoholic beverages, stipulating a mandatory list of ingredients and a nutrition declaration.
Member States may adopt additional national measures on labelling, 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 , Seimas 2018). In 2018, Ireland passed its Public Health (Alcohol) Act 2018 and related Regulations (2023), setting out details of the health warnings, health symbol and health information that will have to be visiblyincluded in containers of alcoholic beverages. This information refers to the direct link between alcohol and cancer, to the danger of consuming alcohol, and to the danger of consuming while pregnant. The regulations will come into operation in May 2026.
No alcoholic beverage containing more than 1.2 % abv is allowed to bear health claims of any kind in the EU. Regarding nutrition claims, 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).
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 usually refers 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. Authorities in the UK and the Netherlands provide single low-risk guidelines for both women and men, based on men's higher risk of injury and mortality (see RARHA 2016 (pdf)).
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, cancers, and dependence ( WHO 2018a ).
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 monthly (WHO GHO). 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.
Table 2: Health outcomes related to alcohol consumption
In general, because of the potential of alcohol to cause a variety of health and social problems, authorities do not recommend the intake of alcohol, but rather recommend limiting its intake, as detailed in Table 3a. For children and pregnant women, the common guidance is not to drink alcohol at all. Some groups of people are often advised to limit alcohol consumption because they are more likely to be adversely affected by alcohol, such as those at risk of falls or those taking certain medications that may interact with alcohol.
Low risk drinking guidelines have been introduced by national health bodies in most EU Member States. These advise adult alcohol consumers on those drinking levels and consumption patterns that entail lower risks for health, and frequently include specific advice for older adults, people taking medication, and pregnant and breastfeeding women (RARHA 2016 (pdf)). In addition to (or instead of) low-risk drinking guidelines, some EU Member States have introduced maximum amounts of alcohol consumption within their dietary guidelines.
Table 3a summarises examples of guiding levels for alcohol consumption formulated by authoritative sources. Table 3b features examples of national low-risk drinking recommendations for adult men and women, as well as of standard units and drinks, as defined nationally.
Table 3a: Guidance for alcohol consumption as described by relevant health-related organisations
Table 3b: National low-risk drinking recommendations and standard units
The level of adult per capita alcohol consumption is a European Core Health Indicator ( ECHI 2023 ) and a Sustainable Development Goal Indicator (SDG Indicator 3.5.2), as it reflects the magnitude and trends in alcohol–related harm. It allows for a certain degree of comparability between countries, however, rates of abstinence and patterns of drinking are difficult to account for with this indicator. Annual per capita alcohol consumption is based on tax revenue and most Member States correct the estimate with balance sheets (production/imports/exports) ( WHO 2000 ).
The first two maps below present the average daily intake in grams of pure ethanol among drinkers aged 15 and older (i.e. excluding abstainers, based on data from the WHO annual per capita consumption (WHO GHO)). The exclusion of abstainers in this case allows for a rough comparison to be made between the estimated consumption of a drinker and the low risk drinking guidance. While there are limitations to such analyses (e.g. the use of different sets of data and surveys to disaggregate consumption by sex), the data indicate that the average consumption among drinkers aged 15 and older generally exceeded maximum low-risk limits set by health authorities. These average consumptions do not, however, reflect the skewed distribution of consumption and hence of individuals actually drinking above or below the low-risk drinking guidelines. The chart compares these average daily intakes between men and women,
The third map presents the total alcohol per capita consumption, which comprises both the recorded and the unrecorded consumption. It is the amount of alcohol consumed per person (15 years of age or older) over a calendar year, in litres of pure alcohol, adjusted for tourist consumption.
According to the 2021 Global Burden of Disease study ( GBD 2021 study ), almost 210 000 deaths and almost 6.8 million Disability-Adjusted Life Years (DALYs) ( GBD 2021 study ) are estimated to be attributable to high alcohol consumption in the EU Member States in 2021. 'High alcohol use' is defined by the GBD study as 'Alcohol consumption in excess of the region-, age-, sex-, and year-specific theoretical minimum risk exposure level (TMREL), ( IHME 2024 ) and in the EU countries ranges between 0 and 1.7 g of pure alcohol per day for women and between 0 and 1.9 g per day for men, depending on their age group and country.
Approximately 190 000 deaths and over 5.8 million DALYs are related to noncommunicable diseases (NCDs) and approximately 17 000 deaths and over 900 000 DALYs to injuries. Within NCD burden, over 57 000 cancer deaths are attributable to high alcohol use alongside another 50 000 deaths from cirrhosis and chronic liver diseases. Over 9 000 estimated deaths by self-harm (suicide), approx. 460 estimated deaths from interpersonal violence, and almost 2 100 estimated deaths arising from transport injuries were attributed to high alcohol consumption in 2021. Overall, approximately 75% of this burden affects men, up to almost 90% for self-harm and transport-related injuries.
Beyond health effects, drinking behaviour may have negative economic and social consequences both on the person drinking and on third parties, including loss of earnings, unemployment, family problems, violence, crime, stigma and barriers accessing healthcare ( OECD 2015 ,OECD 2021, PHE 2016 ).
The OECD Strategic Public Health Planning for non-communicable diseases (SPHeP-NCDs) model (OECD 2021) estimates that drinking more than one drink per day for women and 1.5 drinks per day for men:
View map: Deaths attributable to alcohol consumption in men in EU Member States in 2019
View map: Deaths attributable to alcohol consumption in women in EU Member States in 2019
Several recommendations for policies to reduce alcohol-related harm have been issued. For example, Europe's Beating Cancer Plan (EC 2021), the EU Strategy to support Member States in reducing alcohol related harm (EC 2006), the WHO Global Action Plan for the prevention and control of non-communicable diseases 2013-2020 ( WHO 2013a (pdf) ) and it updated annex 3 (WHO 2017), as well as the Global Alcohol Action Plan 2022-2030 (WHO 2023) put forward policy options to reduce the harmful use of alcohol. The SAFER Inititiative (WHO 2018) supports member states in the implementation of these recommendations. Examples of policy recommendations to restrict access to and availability of alcoholic beverages (Table 4a) and to reduce harm from others’ drinking (Table 4b) are shown below.
Table 4a: Policy recommendations to restrict access to and availability of alcoholic beverages.
Governments and local administrations have adopted different measures to regulate the production, sale and consumption of alcoholic beverages, as well as to respond to alcohol-related problems. Integrated approaches in the form of national alcohol policies, action plans or strategies have been rolled out in several European countries, e.g. Alcohol Laws in Finland ( Alcohol Act Finland ) Sweden ( Alcohol Act Sweden (pdf) ) Iceland ( Law on alcohol Iceland ), and recently in Lithuania ( Law on alcohol control Lithuania ). Examples of implemented alcohol policies are summarised in Table 5.
Table 5: Implemented policies addressing harm from alcohol consumption.
| Originally Published | Last Updated | 21 Oct 2020 | 27 Jun 2024 |
| Knowledge service | Metadata | Health Promotion Knowledge Gateway | Risk factors of non-communicable diseases | Alcoholic beverages |
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