Lifestyle
Alcohol
❍ At a glance
- Approximately 1 in 5 NZ adults drink at hazardous levels. Most are not physically dependent, do not know their consumption is a health risk, and have never been asked. This is where brief intervention has its effect.
- Screen with AUDIT-C (3 questions, under 1 minute). Positive screen: complete the full 10-item AUDIT to characterise use and assess for dependence. CAGE is no longer the recommended tool.
- NZ's updated 2024 guidance (aligned with Canada and Australia): no amount of alcohol is completely risk-free. Cancer risk (breast, bowel, liver, oropharyngeal) begins at low levels of use. The old "two standard drinks a day is safe" framing should not be used.
- Brief intervention (5 minutes, FRAMES framework) reliably reduces consumption at 6-month follow-up in non-dependent drinkers. It is one of the most cost-effective interventions in primary care.
- Alcohol withdrawal with CIWA ≥10 is a medical emergency. Thiamine 300 mg IM or IV before any glucose in any nutritionally depleted patient - Wernicke's encephalopathy is preventable.
New Zealand has one of the highest rates of hazardous alcohol use in the OECD.1 Approximately one in five NZ adults drink at hazardous levels. Hazardous use is not the same as dependence - most people drinking at harmful levels are not physically dependent and have never been asked about their consumption in a healthcare setting. Brief, targeted inquiry and intervention in primary care is where the population-level impact happens.
❍ Screening: AUDIT-C and when to go further
The AUDIT-C is a validated three-question screen with good sensitivity and specificity for hazardous and harmful use in primary care.2 It takes under a minute and can be incorporated into a health review or annual check. Questions cover frequency of drinking, number of standard drinks on a typical day, and frequency of heavy episodic drinking. Scoring thresholds: 5 or above in women, 6 or above in men indicates hazardous use.
A positive AUDIT-C should prompt completion of the full 10-item AUDIT to characterise the level of use and assess for dependence. The full AUDIT differentiates hazardous use, harmful use (current health consequences), and probable dependence - this distinction guides management. CAGE is less sensitive than AUDIT and is no longer the recommended screening tool.
❍ Current NZ guidance: revised risk thresholds
The New Zealand guidelines on low-risk alcohol use, updated in 2024, align with the significant shift in evidence-based guidance in Canada, Australia, and the UK toward substantially lower thresholds than earlier advice.3 Key messages:
- No amount of alcohol is completely risk-free
- Cancer risk - particularly breast, bowel, liver, and oropharyngeal cancers - begins at low levels of use, with no demonstrable threshold below which risk is zero
- The previous framing of "two standard drinks per day as safe" should not be used; the evidence base on alcohol and cancer that has consolidated over the past decade does not support it
These are not fringe positions. The updated guidance reflects a genuine change in the evidence base, particularly around alcohol and cancer risk. When counselling patients, acknowledge that these thresholds have shifted and explain briefly why - most patients respond better to "the evidence has changed" than to apparent inconsistency in health advice.
❍ Brief intervention for hazardous use
Brief intervention (BI) for hazardous alcohol use is one of the most cost-effective interventions in primary care. A 5-minute structured conversation using the FRAMES framework reliably reduces alcohol consumption at 6-month follow-up in non-dependent drinkers:4
- Feedback: share the screening result and what it means for health
- Responsibility: change is the patient's decision
- Advice: give a clear recommendation to reduce use
- Menu of options: offer different strategies and support
- Empathy: non-judgmental,