Alcohol Use Disorders (131) How can we define and measure alcohol use disorders? (6)

8 March, 2024

[Re: ]

Thank you very much Richard for your contribution. The approach is very interesting.

I have some comments:

You said:

1. “Is it feasible to reach a point where everything is clear? From my perspective, this seems unlikely.” There are many reasons for this, but it is mainly because different organizations DO focus on different issues;”

If the problem is that different organizations focus on different issues, shouldn't we promote a global discussion on alcohol regulation that takes into account these various issues: health, social, economic and legal, to try to reach a consensus?

2. “Some of these definitions are throwbacks to a much older conceptualization, where there was a simple binary distinction between being ‘an alcoholic’ and not being one”

I completely agree, and this is in line with a topic that we discussed a few weeks ago: avoiding or reducing the stigma related to AUDs, if we want to help people who suffer from it.

3. “alcohol-related problems exist on a continuum, from Mild through Moderate through to Severe, or from Hazardous (or Risky) drinking through to Harmful drinking through to Dependent drinking”

I also agree with this statement, which is why the way the American Psychiatric Association handles the issue seems quite “logical” to me.

4. “…the idea of issue of “focus(sing) on the number of units of alcohol consumed per week” runs not the problems you have raised and discussed previously – there is no consensus over what a 'Unit' of alcohol (or a 'standard drink') consists of, nor over what is an amount which might be considered 'problematic'

It is true that only the “number of units of alcohol consumed per week” is not enough to address this complex issue, but it is a good marker, based on evidence.

I agree that different countries have different definitions regarding the unit of alcohol and the amount of alcohol in different drinks. That is part of the problem.

Isn't it time for a global discussion on this matter (and others)?

Something similar to the WHO- FCTC. [Framework Convention on Tobacco Control]

Probably very difficult, but it could be tried.

5. “So, it is NOT about some fixed amount of alcohol consumed, it is about the consequences of the consumption”

The problem with this statement is that the available evidence indicates that at the population level there IS a relationship between the amounts of alcohol consumed by the population and the problems linked to it. And when you want to have an impact on the health of the population, you have to apply population strategies.

6. “My own definition of an alcohol problem is very simple: if someone's drinking causes problems for him or her, or for someone else, in any area of their lives, then that drinking is problematic…”

I understand the reasoning and it seems rational, and it could apply to some individual consumers, my concern is that it places the “responsibility” of the problem exclusively on “the consumer”, as if he were oblivious to the influences of marketing and the influence of a social environment that openly promotes alcohol, and presents it as an essential tool for social life.

There is a clear responsibility of those who benefit from the alcohol business, (which is not assumed) and, therefore, it is the State that should protect people, starting with children and adolescents, from the strategies of the alcohol industry to promote a higher consumption for increasing their revenues.

Another concern I have with this definition is the issue of “causing problems”:

What would be the definition of a problem? What is the limit to define a situation as a problem? Who sets the limit?

We said that it is difficult to put a limit on the fixed amount consumed; I think that finding this “limit” can be even more difficult.

Furthermore, this approach assumes that the person who has an AUD is aware of the problem and acts accordingly. But this clashes with reality. A significant percentage of people with AUD often deny that they have a problem with alcohol until the advanced stages of the problem.

Let us also not forget the case of domestic violence related to alcohol, in which there is a situation where the wives of people with AUD “tolerate” or “are afraid” to recognize/report these “problems” (including violence) for fear of retaliation.

7. “It means that whether or not someone has a drinking problem is not determined by fixed quantities of alcohol, or fixed timings, but instead is a matter of negotiation.”

Negotiation is a very valid social tool for interpersonal relationships, and I believe that we should all be trained in “negotiation” and apply what we learn in our daily lives.

I do not deny that negotiation cannot occur in many cases of alcohol consumption, but it seems to me that it would be more feasible in non-severe cases. I have serious doubts that negotiation can be applied in these cases.

But yes, it can be a strategy for “individual addressing” alcohol-related problems. As long as both parties are in equal conditions to “negotiate”.

8. “…now, someone’s ability to drive after drinking has been re-negotiated by society such that it is determined by their blood-alcohol level…”

This is completely true, this measure is being applied, but it was not due to a “social negotiation” between alcohol consumers and no-consumers, but rather an imposition from “the majority of society”. Society has imposed this limitation to protect third parties and the alcohol consumers themselves from the dangerous consequences of driving after consuming alcohol.

This was achieved despite the “resistance” of many alcohol consumers and the alcohol industry (which fiercely opposed the measure).

I can argue this with knowledge of the facts, given that in my country, Uruguay, the permitted level of alcohol is “ZERO”.

I also want to highlight that the solution here is simple: there is no level of alcohol that does not impair the ability to drive, there is an objective measure of the problem (level of alcohol detected) and this measure is applied by an “independent” third party. (the police or traffic inspectors).

I appreciate this type of contribution, because it can allow us to exchange opinions on a complex topic, and on which there is much to do.

Kind regards,


Dr. Eduardo Bianco

Director, Addiction Training Program (ATP)



HIFA profile: Eduardo Bianco is a medical doctor and Cardiologist, Certified Tobacco Cessation Expert with a Masters in Prevention and Treatment of Addictive Disorders. Currently, he is Chair of the World Heart Federation Tobacco Expert Group. Dr. Biancos research examines tobacco control and cessation, and he is a prominent member of several organizations that address tobacco control in Latin America. Dr. Bianco has worked for 25 years in Uruguay and Latin America to promote and train in smoking cessation treatment and tobacco control policies. He is also the former Regional Coordinator for the Americas of the Framework Convention Alliance and former Technical Director of the MOH Center for International Cooperation for Tobacco. ebianco AT