Aotearoa New Zealand’s outdated low-risk drinking advice: the need for review

Alcohol is a leading contributor to preventable morbidity and mortality globally. Its health impacts are significant and continue to rise in many countries. According to the World Health Organization’s 2024 report, alcohol use was considered responsible for 2.6 million deaths, around 5% of all global deaths. Men account for three-quarters of those fatalities.¹ Alcohol contributes to a range of health problems, including cancer, cardiovascular disease, injuries from road crashes, mental health disorders and infectious diseases.¹ Alcohol-related harm also imposes substantial economic costs, underscoring the broader societal impact of alcohol use.

Governments have developed low-risk drinking advice to communicate epidemiological evidence about alcohol-related risk by defining thresholds of consumption associated with lower levels of harm.^2,3 This advice is intended to inform public understanding, clinical practice and policy discussions. However, its effectiveness in improving population health outcomes is shaped by the wider regulatory and social environments in which alcohol is produced, marketed and consumed. A range of social, economic, commercial and environmental factors influence alcohol consumption, including the availability and marketing of alcohol, social norms and the broader conditions of inequity.^4,5 In Aotearoa New Zealand, low-risk drinking advice is currently under review, although concerns have been raised about alcohol industry influence in this process, and the challenges of revising alcohol policy.⁶ Any review of low-risk drinking advice must be assessed not only against current scientific evidence, but also against Te Tiriti o Waitangi obligations to protect Māori health, reduce inequities and enable Māori participation and decision making in alcohol policy.

The burden of alcohol-related harm in Aotearoa New Zealand

Within this global context, alcohol continues to impose a heavy toll on Aotearoa New Zealand’s health, society and economy. Despite its normalised place in social life, the harm caused by alcohol use is profound and persistent. Alcohol has a significant impact on New Zealanders’ health. It remains one of the leading causes of preventable illness and early death, responsible for about 5% of all deaths and 5% of all healthy years of life lost.^7,8 Alcohol contributes to a large proportion of injuries and physical and mental health conditions, with nearly 4% of alcohol-related deaths caused by breast, colorectal and liver cancers.^9–11 While alcohol-related death rates from some chronic conditions are lower than Organisation for Economic Co-operation and Development (OECD) averages (7.4 vs 8.5 per 100,000 for cancer and 1.9 vs 7.2 per 100,000 for liver disease),¹² alcohol causes a substantial proportion of acute harms, including road trauma, suicide and drowning, accounting for approximately one-third of fatal crashes and suicides.^13–15 Alcohol-related road traffic deaths are significantly higher in Aotearoa New Zealand than in other OECD countries, at 5.1 per 100,000, nearly double the OECD average of 2.8.¹² In 2018, alcohol was linked to 901 deaths, 1,250 cancers, 29,282 hospitalisations and almost 50,000 Disability-Adjusted Life Years (DALYs) lost.¹⁶

Alcohol-related harm extends beyond the individual drinker, with significant harms experienced by others in Aotearoa New Zealand. Casswell et al. estimated that more than 78,000 healthy life years were lost in 2018 as a direct result of other people’s drinking, including harms from road injuries, child maltreatment and interpersonal violence.¹⁷ A substantial proportion of this burden is driven by foetal alcohol spectrum disorder (FASD), which results from prenatal alcohol exposure and causes lifelong disability. The total cost of FASD in Aotearoa New Zealand has been estimated at NZ$4.8 billion, reflecting both healthcare expenses and long-term social and economic losses.¹⁸ Around one-third of people who are pregnant in Aotearoa New Zealand report consuming alcohol, with about 12% engaging in binge drinking and 13% continuing beyond the first trimester.^19–21 Alcohol use during pregnancy is shaped by a range of contextual factors, including intimate partner violence, poverty, stress, trauma, abuse, discrimination and partner drinking patterns.^22,23 These conditions constrain individual agency and highlight the limitations of approaches that rely solely on information or advice to reduce harm. Alcohol-related violence, sexual assault and road crashes add billions more in annual costs, destabilising families and communities.^18,24 These harms disproportionately affect whānau and communities already experiencing disadvantage, deepening existing inequities and perpetuating cycles of harm across generations. This pattern highlights that alcohol-related risk extends beyond the drinker and has implications for how low-risk drinking advice is conceptualised, developed and communicated. Collectively, these findings show that alcohol-related harm in Aotearoa New Zealand is a major public health issue produced through structural and relational conditions.

In addition to these broader effects, alcohol has a significant impact on Aotearoa New Zealand’s economy. The New Zealand Institute of Economic Research (2024) estimated that alcohol costs the country around NZ$9.1 billion annually, equivalent to nearly one-third of the national health budget.¹⁸ This total includes healthcare and treatment for alcohol use disorders as well as broader economic impacts from lost productivity, premature death and incarceration. The Government also spent an additional NZ$810 million directly through hospitalisations, emergency services and Accident Compensation Corporation compensation, highlighting the substantial direct fiscal burden on the government and the importance of alcohol policy in shaping health system costs. Together, these figures demonstrate that alcohol-related harm is not confined to individuals but reflects wider social and economic systems that generate substantial collective costs.

Alcohol-related harm in Aotearoa New Zealand is not experienced equally. Māori, Pacific people and people living in socio-economically deprived areas face much higher rates of alcohol-related disease, injury and early death than other groups.^7,16 These inequities are produced through structural and commercial factors, such as the higher density of alcohol outlets in disadvantaged areas, targeted marketing and limited access to culturally safe health and addiction services.^16,25 These environments are actively shaped by the alcohol industry through marketing practices, pricing strategies and influence over regulatory settings. For example, off-licence alcohol outlet density is almost three times higher in high-deprivation communities (94.6 per 100,000 people) than in low-deprivation areas (31.0 per 100,000).^16,25 Communities with a higher proportion of Māori also face greater exposure, with 74.5 outlets per 100,000 people compared with 56.4 per 100,000 in areas with fewer Māori.^16,25 These patterns reflect a well-established alcohol harm paradox, whereby groups experiencing greater socio-economic disadvantage experience disproportionately high levels of harm despite similar or lower levels of consumption.¹ In Aotearoa New Zealand, these inequities are further intensified by colonial and contemporary policy arrangements that have concentrated harmful alcohol environments in already disadvantaged communities and limited Māori access to self-determined, culturally safe forms of prevention and care.^16,26 Under Te Tiriti o Waitangi, the Crown has a responsibility to protect Māori health and address inequities in alcohol-related harm disparities, and enable Māori self-determination in alcohol policy. Addressing these inequities requires structural policy responses, including stronger regulation of alcohol availability and marketing, greater investment in prevention and treatment, and Māori and Pacific leadership and decision-making authority to ensure policies promote health equity.²⁷

Low-risk drinking advice: purpose, impact and importance

Government low-risk drinking advice provides thresholds derived from epidemiological evidence to indicate levels of consumption associated with lower risk of harm.¹ Such advice translates complex epidemiological evidence into accessible public health information and is intended to support informed decision making, clinical practice and policy development.^28–31 By defining recommended daily, weekly and single-occasion (binge) limits, low-risk drinking advice specifies levels of consumption associated with lower probabilities of acute alcohol-related harms (e.g., accidents, injuries and violence) and chronic conditions (e.g., cancers, liver disease and cardiovascular illnesses). This is especially important given that while some alcohol use is labelled “low risk” or “safe” for consumption, current evidence shows that no level of alcohol use is completely risk free.³²

Beyond informing individual behaviour, low-risk drinking advice also informs national health policies. It contributes to the evidentiary and normative basis for population-level measures, such as taxation, licensing rules and labelling requirements. These regulatory interventions themselves, rather than advice, are the primary drivers of reductions in alcohol-related harm.³³ Low-risk drinking advice also helps health professionals to identify at-risk drinkers through screening, provide opportunistic advice in the form of a brief intervention and link individuals to support before serious harm occurs. Collectively, these functions position low-risk drinking advice as one component within a broader system of alcohol control, rather than a standalone intervention. However, to remain effective, low-risk drinking advice must be kept up to date as scientific understanding evolves.^34,35 Earlier advice was developed when evidence on long-term health outcomes, particularly at low levels of consumption, was more limited. Current evidence demonstrates that even small amounts of alcohol can increase the risk of disease, meaning outdated thresholds may underestimate harm and contribute to the normalisation of higher-risk consumption patterns.³²

Recent international revisions of low-risk drinking advice

Over the past decade, research has shown that alcohol increases the risk of multiple cancers, heart disease and injury, and that any potential health benefits once linked to moderate drinking are minimal or non-existent.^1,32 This evidence has led to a shift in how alcohol-related risk is conceptualised and communicated, moving away from categorical notions of “safe” drinking towards a continuum of risk. As a result, several high-income countries have revisited their national low-risk drinking advice.^29–31

In 2016, the United Kingdom (UK) completed its review and replaced low-risk drinking advice previously established in 1995.²⁹ The 2-year review process drew on expert national and international evidence, including mathematical models of population drinking and mortality data, which estimated 14 units per week as the upper limit of low risk, equivalent to about a 1% lifetime risk of death from alcohol-related causes. The low-risk drinking advice determined by the UK expert working group was that adults who choose to drink should consume no more than 14 units of alcohol per week (with one standard drink defined as 8g of pure alcohol), spread evenly over several days with alcohol-free days each week. In 2020, Australia also published a comprehensive review to update its 2009 national alcohol advice.³⁰ Using a similar methodology to the UK, the review defined thresholds below which the lifetime risk of alcohol-attributable death remains less than one in 100. The revised advice recommends that adults consume no more than 10 standard drinks per week (one standard drink equalling 10g of pure alcohol), with the same limits applying to men and women. Following these updates, the Canadian Centre on Substance Use and Addiction was commissioned by the Canadian Government to review the national alcohol guidance, following which it released updated recommendations for the Canadian public in 2023.³¹ Although these have not yet replaced the official government advice, the review used similar approaches, including modelling consumption and mortality. The findings indicated that consuming more than two standard drinks per week (with one standard drink defined as 13.45g of pure alcohol) exceeded a one-in-1,000 lifetime risk threshold for alcohol-related death, while more than six standard drinks per week exceeded the one-in-100 threshold. The expert group therefore recommended classifying up to two standard drinks per week as low risk, three to six drinks as moderate risk and more than six drinks as increasingly high risk.

Across these reviews, several conclusions are evident: no level of alcohol use is completely risk free; risk increases in a dose–response relationship with consumption (i.e., the more you drink, the worse the harm); and advice has shifted towards lower risk thresholds and gender-neutral recommendations. Abstinence is identified as the lowest-risk option, essential for those who are pregnant. Together, these revisions reflect a broader shift towards more precautionary and transparent approaches to communicating alcohol-related risk.

Why revision of Aotearoa New Zealand’s drinking advice is overdue

Aotearoa New Zealand’s current low-risk drinking advice, last updated in 2011, was developed in a different scientific context³⁶ when evidence linking alcohol use to chronic disease, particularly at low levels of consumption, was less developed. Since then, considerable evidence has led to a growing consensus that no amount of alcohol can be considered completely safe.³² Research has strengthened the understanding of alcohol’s contribution to a wide range of harms, including several types of cancers and cardiovascular disease.^37,38 Aotearoa New Zealand’s current guidance is therefore misaligned with current scientific evidence and with advice in other comparable countries. This misalignment has implications for how alcohol-related risk is communicated and understood at the population level.

The amount of alcohol that people drink contributes to risk levels. In an international context, Aotearoa New Zealand has relatively high levels of alcohol consumption, reflecting the normalisation of alcohol use within social life. According to World Health Organization data, New Zealanders consumed about 9.3 litres of pure alcohol per person per year, compared with an OECD average of 8.3 litres.¹² Around 80% of Aotearoa New Zealand adults reported drinking alcohol, compared with about 70% across the OECD. Approximately 41% of adults in Aotearoa New Zealand reported heavy episodic drinking (defined as consuming six or more standard alcoholic drinks on one occasion, with one standard drink containing 10g of pure alcohol) in the past month, compared with 33% across the OECD, placing Aotearoa New Zealand among the top five OECD countries. Among drinkers, this figure rises to 47.6%, which is also higher than the OECD average (40.6%).¹² Similar patterns appear among young people aged 15–19 years, with 64% of younger New Zealanders reporting current drinking and more than one-third reporting binge drinking in the past month, figures that are both higher than OECD averages.¹² These patterns indicate that alcohol use is normalised through social, commercial and policy environments in Aotearoa New Zealand. Current low-risk drinking advice in Aotearoa New Zealand recommends weekly limits of 15 standard drinks for men (no more than three per day) and 10 for women (no more than two per day), with at least two alcohol-free days each week.³⁶ In this context, the effectiveness of guideline-based approaches is constrained by commercial environments in which alcohol is actively promoted and normalised. In recent years, this has been further intensified by the growth of social media and algorithmically targeted digital marketing, which increases exposure and engagement with alcohol promotion, particularly among young people and other population groups.^39–41 Guideline-based approaches, therefore, need to be accompanied by broader policy measures that address availability, marketing and social norms.

Recommendations

Low-risk drinking advice in Aotearoa New Zealand needs urgent review. The current advice, last updated in 2011, is outdated, developed before research demonstrated that even small amounts of alcohol can increase the risk of cancer, heart disease and other chronic health conditions. Updating national advice using evidence-informed review processes like those used in comparable countries is necessary to ensure that risk is communicated accurately.

We recommend that the first step should be a comprehensive review of the 2011 low-risk drinking advice. This review needs to draw on the latest national and international evidence about alcohol’s health, social and economic impacts, as well as how harm is distributed across the population. The review should be situated within an understanding of the wider structural conditions that shape alcohol use, including alcohol availability (such as outlet density), marketing exposure, socio-economic inequities and access to culturally safe support.

We also recommend, following examples set by other jurisdictions, that Aotearoa New Zealand should develop population-specific modelling to estimate how drinking affects health outcomes. Such modelling would quantify both short-term risks (such as injury) and long-term risks (such as cancer and heart disease) and help identify thresholds that better reflect local drinking patterns and health priorities.

We recommend that the advice review process prioritise those most affected by harm and be carried out in genuine partnership with Māori and Pacific communities, consistent with Te Tiriti o Waitangi. This includes ensuring substantive Māori and Pacific leadership in decision making, drawing on mātauranga Māori and Pacific knowledges and supporting community-led approaches to prevention, education and treatment. Reducing inequities in alcohol-related harm must be central to this review process, and advice may produce or exacerbate inequities if it is based primarily on population averages rather than the distribution of harm, which currently most severely impacts Māori, Pacific people and people living in low socio-economic areas.

We further recommend the establishment of a multidisciplinary national expert panel to guide the review, one that includes Māori and Pacific health experts, addiction specialists, public health clinicians and researchers and communication professionals, and explicitly excludes representatives of the alcohol industry. This stated expertise and the exclusion of industry influence will maintain the independence and credibility of the panel, thus aligning it with panels utilised in reviews in other jurisdictions. The panel’s role would be to assess the evidence, develop recommendations and ensure that guidance is transparent and contextually appropriate.

We strongly recommend that the review process include public consultation. A staged approach, similar to that used in Canada, would involve presenting evidence and rationale for revision, followed by consultation on draft recommendations. Such processes can strengthen transparency, public accountability and legitimacy.

Finally, we recommend that careful attention be given to the implementation of revised advice. Implementation science can be used to assess how messages are understood across different communities and to monitor their effects over time. Continuous review will ensure the advice remains useful and up to date as new evidence emerges.

Conclusion

Updating Aotearoa New Zealand’s low-risk drinking advice is more than a technical exercise; it is an opportunity to improve how alcohol-related risk is defined and communicated. Aligning national advice with current scientific evidence and international practice would strengthen its credibility and relevance. To maintain integrity, the review process must be independent of the alcohol industry’s influence. Importantly, alcohol-related harm is produced through structural and commercial conditions that shape patterns of consumption and distribute risk unevenly across the population. Therefore, to be effective, low-risk drinking advice updates must be undertaken as part of a broader public health strategy that addresses the commercial and structural production of alcohol-related harm, centres equity and upholds Te Tiriti o Waitangi. Without such an approach, revised advice may improve the accuracy of official risk communication while leaving the underlying distribution of harm largely unchanged.