How do we talk about alcohol?

We often talk about 'problem drinking', ‘addiction’, ‘dependent drinking’ and so on, but it isn’t always clear what these terms mean or who gets to decide on how they are used. In an ideal world, we would all be speaking the same language; in reality we are not.

There are also different ways of measuring levels of risk associated with drinking. Screening tools, such as the AUDIT test, assess not only how much you drink, but consumption patterns and feelings about drinking. Alternatively, risk can be assessed simply on number of units consumed each week. These different methods can use similar language, even though they are not measuring exactly the same thing.

It is now commonplace to describe different patterns of drinking in terms of increasing risk. This reflects the fact that there is a spectrum of risks that tend to increase with consumption. However, the language is often confusing.

The National Institute for Health and Care Excellence (NICE) defines ‘hazardous drinking’ as ‘a pattern of consumption that increases someone’s risk of harm’. In some cases, this is defined as someone with an AUDIT score of between 8 and 15. In other cases (such as the models used by the Sheffield Alcohol Research Group) it is defined as a woman drinking between 15 and 34 units a week, or a man drinking between 15 and 49 units a week. Generally speaking, it means above low risk but not at a level where harm is likely.

‘Harmful drinking’ means drinking in a way which is likely to cause harm – either physical or mental. Again, this is sometimes defined using AUDIT scores (usually 16 and above) or unit consumption (regularly drinking above the ‘hazardous’ level of 35 units a week for women or 50 for men). Anyone drinking at this level should consider cutting down, and may benefit from support in doing so.

These terms are often used instead of moderate, hazardous and harmful. ‘Increasing risk’ is defined by NICE as 15-34 units a week (for a woman) and 15-49 units a week (for a man). Higher risk is regularly drinking at above these levels, while lower risk is regularly consuming below them.

The revised guidelines from the Chief Medical Officers have since defined ‘low-risk drinking’ as up to 14 units per week. At 14 units a week, the risk of dying from an alcohol-related condition is around 1 in 100. Drinking above this amount is increasingly used when reporting levels of ‘increasing risk’ or ‘hazardous’ drinking.

The establishment of new guidelines does not mean that all risk above 14 units a week is equal – or that any consumption above this level is dangerous. It means 14 units is where the risk is lowest.

Alcohol dependence is a complex idea, and has been replaced by terms such as ‘severe alcohol use disorder’ in some contexts. This is because the term ‘dependence’ can imply it is a fundamentally different pattern to other forms of harmful drinking, whereas the boundary is often blurred in reality.

Nevertheless, the term is still widely used (often interchangeably with ‘addiction’) to mean persistent drinking despite harmful consequences, a strong and often overwhelming desire to drink, and the prioritisation of drinking over other activities or obligations. Dependence can also be defined using AUDIT scores: a score of 20 or above signifies ‘probable dependence’ while a score of around 17-19 signifies possible dependence.

Just as there is no clear line between harmful and dependent drinking, so dependence can vary in severity. The Severity of Alcohol Dependence Questionnaire, for example, distinguishes between mild, moderate and severe levels of alcohol dependence.

Alcohol use disorders' is an umbrella term used by the WHO International Classification of Diseases (ICD-10) to describe a range of mental health problems associated with alcohol. These include 'acute intoxication', 'harmful use', ‘dependence syndrome’, and 'pyschotic disorders'. The term is also used in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) where, using an 11-point scale, alcohol use disorders can be defined as mild, moderate or severe.

The word 'addiction' is widely used, but not without its problems. The same is true for 'alcoholism'. Both imply that alcohol addiction is a disease which, like another disease, you are either suffering from or not. This idea remains widely accepted: it forms the basis of the work of Alcoholics Anonymous, for example; and, in America especially, the idea that addiction is a 'chronic relapsing disorder' has become very widely accepted – though it remains controversial.

While we recognise that for many people, self-defining as an alcoholic is an important stage in their recovery we are also conscious that terms like 'alcoholic' can act as a barrier to change for other people. Trying to work out if you are 'alcoholic' or not can sometimes reinforce the idea that alcohol problems are a black-and-white issue. We take the view that they are more subtle than that, and that we need to be mindful of the varying degrees of severity. That is why we tend not to use the word ‘alcoholic’ in our work. We recognise that for many people, identifying as 'alcoholic' is important; however, we seek to avoid language that reinforces the notion that there are just two types of drinker: those with a disease and those without.

We are also conscious that language can be stigmatising, and that a term such as 'problem drinker' can imply that individuals are fully defined by their alcohol consumption, and should be judged accordingly. We, therefore, prefer to use the term 'drinking problems': because anyone can experience problems with their drinking, they can range in severity and they can change over time. Helping people to recognise the existence of problems is important, but categorising people by the problems they face is not something we wish to do.

We recognise that risks linked to drinking do not fall neatly into categories. For example, someone who reduces their consumption from 50 units a week to 20 would have achieved a significant reduction in potential harm, even though still formally categorised as 'increasing risk'. No system of this kind is perfect. Because of this, we favour the use of a graded approach to risk, which better reflects the complexities involved.

Further resources

National Institute for Health and Care Excellence: Alcohol use disorders – prevention (glossary)

World Health Organisation: Management of substance abuse – terminology and classification.

Department of Health and Social care: Alcohol consumption – advice on low-risk drinking