A single sip of a strong alcoholic beverage causes exposure to carcinogenic concentrations of acetaldehyde in the oral cavity

The aim of this study was to explore oral exposure to carcinogenic (group 1) acetaldehyde after single sips of strong alcoholic beverages containing no or high concentrations of acetaldehyde.Eight volunteers tasted 5 ml of ethanol diluted to 40 vol.% with no acetaldehyde and 40 vol.% calvados containing 2400 μM acetaldehyde. Salivary acetaldehyde and ethanol concentrations were measured by gas chromatography. The protocol was repeated after ingestion of ethanol (0.5 g/kg body weight).Salivary acetaldehyde concentration was significantly higher after sipping calvados than after sipping ethanol at 30 s both with (215 vs. 128 μmol/l, p < 0.05) and without (258 vs. 89 μmol/l, p < 0.05) alcohol ingestion. From 2 min onwards there were no significant differences in the decreasing salivary acetaldehyde concentration, which remained above the level of carcinogenicity still at 10 min. The systemic alcohol distribution from blood to saliva had no additional effect on salivary acetaldehyde after sipping of the alcoholic beverages.Carcinogenic concentrations of acetaldehyde are produced from ethanol in the oral cavity instantly after a small sip of strong alcoholic beverage, and the exposure continues for at least 10 min. Acetaldehyde present in the beverage has a short-term effect on total acetaldehyde exposure.     

A Parallelogram Approach for Safety Evaluation of Ingested Acetaldehyde

Route-specific carcinogenicity data are often lacking for compounds of regulatory importance. Acetaldehyde (AA), for example, a natural constituent in foods, is a rodent carcinogen via the inhalation route, but oral carcinogenicity data are not available. In the absence of such data, a parallelogram approach can be used to estimate the oral carcinogenic potency of this chemical. The relative potency of AA to the structurally related compound formaldehyde (FA) in the nose and the relative potency of FA in the nose and stomach serve as the basis for estimating the potency of AA in the stomach. On a dosimetric basis, inhaled AA is 14- to 35-fold less potent than FA in producing nasal DNA–protein crosslinks (DPX), subchronic tissue injury, and tumors. Ingested AA is also considerably (∼5-fold) less potent than FA in producing gastric injury and DPX. Compared to the nose, the stomach is 10- to 60-fold less sensitive to both AA- and FA-induced DPX and subchronic tissue injury. The parallelogram approach will not supplant long-term oral carcinogenicity studies with AA; however, the consistent pattern of decreased sensitivity of acetaldehyde compared to formaldehyde, lower sensitivity of the stomach to the nose, and the lack of gastric tumorigenicity of orally ingested formaldehyde strongly suggests that ingested acetaldehyde is not likely to be carcinogenic. Successful estimation of the carcinogenic potency of ingested glutaraldehyde, for which chronic oral and inhalation data are available, provides further support that the parallelogram approach can provide a reasonable estimate of the carcinogenic potency of closely related aldehydes, such as AA.     

Hypochlorhydria induced by a proton pump inhibitor leads to intragastric microbial production of acetaldehyde from ethanol

BACKGROUND: Acetaldehyde, produced locally in the digestive tract, has recently been shown to be carcinogenic in humans. AIM: To examine the effect of iatrogenic hypochlorhydria on intragastric acetaldehyde production from ethanol after a moderate dose of alcohol, and to relate the findings to the changes in gastric flora. METHODS: Eight male volunteers ingested ethanol 0.6 g/kg b.w. The pH, acetaldehyde level and microbial counts of the gastric juice were then determined. The experiment was repeated after 7 days of lansoprazole 30 mg b.d. RESULTS: The mean (+/- S.E.M.) pH of the gastric juice was 1.3 +/- 0.06 and 6.1 +/- 0.5 (P < 0.001) before and after lansoprazole, respectively. This was associated with a marked overgrowth of gastric aerobic and anaerobic bacteria (P < 0. 001), by a 2.5-fold (P=0.003) increase in gastric juice acetaldehyde level after ethanol ingestion, and with a positive correlation (r=0. 90, P < 0.001) between gastric juice acetaldehyde concentration and the count of aerobic bacteria. CONCLUSIONS: Treatment with proton pump inhibitors leads to hypochlorhydria, which associates with intragastric overgrowth of aerobic bacteria and microbially-mediated acetaldehyde production from ethanol. Since acetaldehyde is a local carcinogen in the concentrations found in this study, long-term use of gastric acid secretory inhibitors is a potential risk-factor for gastric and cardiac cancers.     

Carcinogenic compounds in alcoholic beverages: an update

The consumption of alcoholic beverages has been classified as carcinogenic to humans by the International Agency for Research on Cancer (IARC) since 1988. More recently, in 2010, ethanol as the major constituent of alcoholic beverages and its metabolite acetaldehyde were also classified as carcinogenic to humans. Alcoholic beverages as multi-component mixtures may additionally contain further known or suspected human carcinogens as constituent or contaminant. This review will discuss the occurrence and toxicology of eighteen carcinogenic compounds (acetaldehyde, acrylamide, aflatoxins, arsenic, benzene, cadmium, ethanol, ethyl carbamate, formaldehyde, furan, glyphosate, lead, 3-MCPD, 4-methylimidazole, N-nitrosodimethylamine, pulegone, ochratoxin A, safrole) occurring in alcoholic beverages as identified based on monograph reviews by the IARC. For most of the compounds of alcoholic beverages, quantitative risk assessment provided evidence for only a very low risk (such as margins of exposure above 10,000). The highest risk was found for ethanol, which may reach exposures in ranges known to increase the cancer risk even at moderate drinking (margin of exposure around 1). Other constituents that could pose a risk to the drinker were inorganic lead, arsenic, acetaldehyde, cadmium and ethyl carbamate, for most of which mitigation by good manufacturing practices is possible. Nevertheless, due to the major effect of ethanol, the cancer burden due to alcohol consumption can only be reduced by reducing alcohol consumption in general or by lowering the alcoholic strength of beverages.     

Degrees of alcohol intoxication in 117 hospitalized cases

The correlation among degrees of alcohol intoxication, facial flushing, blood alcohol concentration (BAC) and blood acetaldehyde level was studied in 117 male alcoholic patients who underwent various tests to assess alcohol influence. Blood samples were collected and alcohol and acetaldehyde levels were determined. BACs ranged from 29 to 577 mg/dl in all patients and from 200 to 299 mg/dl in 48 of them. Fifty-one patients could stand erect (mean BAC [+/- SD] = 189 +/- 80 mg/dl), while 48 showed apparently normal reaction to a walking and turning test (mean BAC = 192 +/- 78 mg/dl). Some of the cases having BACs over 300 mg/dl could still stand and walk while others with BACs under 100 mg/dl already showed psychomotor impairment. Facial flushing was recognized in 75% of the subjects. Acetaldehyde concentrations in 27 patients ranged from 24 to 147 micrograms/dl. Appearance of facial flushing was correlated with relatively high concentrations of blood acetaldehyde. Seven out of 10 healthy volunteers given 1.6 to 2.0 g/kg of alcohol as a control could do nothing but sleep after reaching peak BAC (mean = 232 +/- 21 mg/dl). These findings are taken to indicate a great difference in response to alcohol between alcoholics and healthy men. This study is the first to report the occurrence of facial flushing and raised blood acetaldehyde concentration among Japanese alcoholics.     

Advertising and alcohol sales: a legal impact study.

According to the single distribution theory increases in the availability of alcoholic beverages in the general population are associated with increases in average consumption and increases in alcohol-related damage. If it can be demonstrated that advertising contributes to availability, perhaps in the form of what has been called social or subjective availability, then advertising could be considered an appropriate target of prevention. A 58-year ban on advertising of alcoholic beverages was lifted in Saskatchewan in 1983. Data on monthly sales of beer, wine and distilled spirits were examined for the years 1981 to 1987. Box-Jenkins time series techniques were used to estimate the statistical relationship between the policy change and volume of sales of alcoholic beverages. The results revealed that sales of beer increased and sales of spirits decreased following the change in legislation that permitted alcohol advertising in Saskatchewan. The main finding is that there was no impact on wine and total alcohol sales from the introduction of alcohol advertising. Alcohol advertising may have produced a substitution effect with respect to beer and spirits, but this was not predicted. This evaluation suggests that alcohol advertising is not a contributory force that influences the overall level of alcohol consumption. The place of advertising in the single distribution theory remains not proven, and the place of advertising as an instrument of public policy with respect to the prevention of alcohol-related damage remains in question.     

Differences in trouble per litre of different alcoholic beverages - A global comparison with the GENACIS dataset

Different alcoholic beverages are seen as causing more or less trouble, with spirits historically often seen as the most troublesome. Differences in the "trouble per litre" could reflect differences in the beverages themselves (e.g., faster effect of stronger beverages, additives/contaminants in informal beverages), or could reflect characteristics of those drinking each beverage. Using two alternative definitions of beverage choice and measures of personal and of social consequences of drinking, the paper examines trouble per litre among beer, wine and spirits drinkers in 19 different societies represented in the GENACIS dataset. There is no general pattern which holds across cultures of more or less trouble being associated with a particular beverage type. Wine seems to be less associated with trouble than beer or spirits in a number of societies, but there are counter-instances in other societies. There is no overall trend across cultures in comparing trouble associated with beer and with spirits. In a number of societies, drinkers with no predominant beverage report more problems than those mainly drinking beer or wine. Controlling for gender and age reduces the tilt towards less trouble from wine drinking, particularly for social consequences of drinking.     

Potential mechanism for Calvados-related oesophageal cancer

The old Normandian habit of consumption of hot Calvados is associated with an increased risk of oesophageal cancer compared to other alcoholic beverages. The role of alcohol consumption in the risk of oesophageal cancer is well established. The first metabolite of alcohol, acetaldehyde is a potential local carcinogen in humans. Accordingly, different acetaldehyde concentrations in different beverages could account for some of the variations in cancer risk with regard to the type of alcoholic beverage. Eighteen samples of farm-made Calvados were collected in Normandy. Samples of commercially available beverages were purchased, including factory-made Calvados, other spirits, wines, beer and cider. The samples were analysed gas-chromatically for acetaldehyde and ethanol concentrations. All results are expressed as mean ± SD. The mean acetaldehyde concentration of all Calvados samples (1781 ± 861 μM, n = 25) differed highly significantly (p < 0.001) from that of all wine samples (275 ± 236 μM), from all other spirits samples (1251 ± 1155 μM, p < 0.05), and from all beer and cider samples (233 ± 281 μM, p < 0.001). Farm-made Calvados and farm-made cognac had the highest mean acetaldehyde concentration of the measured beverages. The high concentration of acetaldehyde combined with possible effects of the high temperature at which Calvados is consumed could account for the increased risk of Calvados-related oesophageal cancer.     

Quantitation of an acetaldehyde adduct in human leukocyte DNA and the effect of smoking cessation

Acetaldehyde is one of the most prevalent carcinogens in cigarette smoke. It is also a major metabolite of ethanol and is found widely in the human diet and environment. Acetaldehyde DNA adducts are critical for its carcinogenic properties. The role of acetaldehyde DNA adducts in human cancer related to tobacco and alcohol exposure could be investigated with a suitable biomarker. Therefore, in this study, we have developed a method for analysis of the major DNA adduct of acetaldehyde, N2-ethylidene-dGuo (1), in human leukocyte DNA. Leukocyte DNA was subjected to enzyme hydrolysis in the presence of NaBH3CN, which converts adduct 1 to N2-ethyl-dGuo (2). [15N5]N2-ethyl-dGuo was used as the internal standard. After solid-phase extraction, N2-ethyl-dGuo was quantified by LC-ESI-MS/MS-SRM. The method was sensitive, accurate, and precise, and applicable to low microgram amounts of DNA. It was applied to investigate the effect of smoking cessation on levels of adduct 1, measured as adduct 2. Twenty-five smokers who were only light drinkers were eligible for the study. Levels of adduct 2 were quantified at two baseline time points separated by one week and again after four weeks of abstinence from smoking and alcohol consumption. The mean (+/-S.D.) levels of adduct 2 measured in the leukocytes of the smokers were 1310 +/- 1720 (range 124-7700) and 1120 +/- 1140 (range 138-5760) fmol/micromol dGuo at the two baseline points and 705 +/- 438 (range 111-1530) fmol/micromol dGuo after 4 weeks of cessation. The median level of adduct 2 decreased significantly by 28% upon quitting smoking (P = 0.02). These results demonstrate that the major acetaldehyde DNA adduct can be reliably quantified by MS/MS methods in human leukocyte DNA and that cigarette smoking has a modest but significant effect on its levels.     

Wine and migraine: compatibility or incompatibility?

According to popular belief, alcoholic beverages are to be avoided in the case of headache, a term which includes migraine, the most common type of headache. An imbalance between pain transmission and inhibition has been suggested and partly proved to be the mechanism of migraine. This means that peripherally acting substances following wine intake are unlikely to trigger migraine attacks. We hypothesized that factors other than the mere consumption of alcohol can trigger migraine attacks. In an attempt to corroborate this assumption, we carried out a 14-month study in 307 volunteers. All the volunteers had no health problems apart from suffering from migraine without aura. During the entire study period, patients had to complete a diary/questionnaire every time they consumed alcohol. The questionnaires included items regarding the quantity (measured in dl) and the type of alcohol they consumed as well as information about their lifestyle. The volunteers also had to complete a pain diary. It was observed that spirits and sparkling wines were significantly (p > 0.0001) more frequently related to migraine attacks than other alcoholic beverages. Nonetheless, there was no statistical relationship between the consumption of alcohol and migraine attacks. On the other hand, a positive relationship was established between stressful events and the onset of migraine attacks. As an overall result, it was observed that low amounts of alcohol (i.e., 1 dl of 4-14% alcohol/vol. and 0.4 dl of 35-42% alcohol/vol.) did not induce a significant increase in the frequency of migraine attacks. Moreover, it emerged that alcoholic beverage intake during stress periods was related to a significantly higher frequency of migraine attacks (p > 0.0001 for spirits and sparkling wines, p > 0.009 for red wine and p > 0.006 and p > 0.004 for white wine and beer, respectively). Routine blood tests revealed that the subjects who prefer red wine showed a lower level (p > 0.05) of total cholesterol, independently of sex or age. Due to the small sample size (197 vs. 96 tested subjects), this last observation can not be regarded as conclusive.     

Strains Toward Convergence in the Consumption of Alcoholic Beverages: The Canadian Case and Implications for Public Health

Sulkunen's observations that international trends in the consumption of alcoholic beverages involve quantitative as well as qualitative homogen ization of drinking practices are tested against the experience of Canada and its provinces from the mid 1960s to late 1970s. Per capita con sumption of spirits, beer, and wine, and the contribution of each of these types of alcoholic beverages to total consumption are examined for each province for the fiscal years 1966, 1972, and 1978. On the whole, the findings are consistent with worldwide trends. Per capita consumption is increasing generally and there is a trend toward greater similarity in per capita consumption across the provinces (quantitative homogenization). Consumption of different types of beverages is be coming more similar (qualitative homogenization) and increases in the beverage with the lowest share of the market (i.e., wine) appear to be additive to overall consumption. The observation that increases in con sumption of the traditional types of beverages have the most impact on overall consumption is not observed for beer, but is observed in the case of spirits. Implications for public health and social policy are discussed.     

Formulation and in-vivo evaluation of L-cysteine chewing gums for binding carcinogenic acetaldehyde in the saliva during smoking

Cigarette smoke contains toxic amounts of acetaldehyde that dissolves in saliva, posing a significant risk of developing oral, laryngeal and pharyngeal carcinomas. L-cysteine, a non-essential amino acid, can react covalently with carcinogenic acetaldehyde to form a stable, non-toxic 2-methylthiazolidine-4-carboxylic acid. The main aim of this study was to find out whether it is possible to develop a chewing gum formulation that would contain cysteine in amounts sufficient to bind all the acetaldehyde dissolved in saliva during the smoking of one cigarette. The main variables in the development process were: (1) chemical form of cysteine (L-cysteine or L-cysteine hydrochloride), (2) the amount of the active ingredient in a gum and (3) manufacturing procedure (traditional or novel compression method). Saliva samples were taken over 2.5 minutes before smoking and since smoking was started for 2.5 minutes periods for 10 minutes. During a five minutes smoking period with a placebo chewing gum, acetaldehyde levels increased from 0 to 150-185 microM. Once smoking was stopped, the acetaldehyde levels quickly fell to levels clearly below the in-vitro mutagenic level of 50 microM. All chewing gums containing cysteine could bind almost the whole of the acetaldehyde in the saliva during smoking. However, elimination of saliva acetaldehyde during smoking does not make smoking completely harmless. Cysteine as a free base would be somewhat better than cysteine hydrochloride due to its slower dissolution rate. Both traditional and direct compression methods to prepare chewing gums can be utilized and the dose of L-cysteine required is very low (5 mg).     

Alternative approaches to the measurement of consumption and price of alcoholic beverages, Canada, 1957-1983

Alternative accepted methods of aggregating prices and quantities of beer, spirits and wine could yield different conclusions for intertemporal comparisons. In this study Fisher's index is used to measure changes in per capita consumption and price of alcoholic beverages in Canada, 1957-83. The results are typically very close to those obtained from measures based on pure alcohol content.     

Effects of red wine, alcohol, and quercetin on coronary resistance and conductance arteries

Moderate consumption of alcoholic beverages is associated with a reduced risk of coronary heart disease (CHD). Some evidence suggests that red wine is particularly beneficial in this regard and may account in part for the French paradox, although the mechanism of this effect is unknown. We assessed the effects of red wine, ethanol, and quercetin, a major flavonoid constituent of red wine, in coronary resistance vessels (80-150 microm, i.d.) and conductance vessels (300-525 microm, i.d.) of the rabbit. Vessel wall tension was measured in isolated segments maintained in a wire-type myograph (37 degrees C) and preconstricted with 30 mM K+. At an alcohol concentration (14 mM) equivalent to moderate consumption, red wine evoked a small, transient constrictor effect in resistance and conductance vessels (9+/-4%, n = 5; 8+/-1%, n = 7, respectively; p < 0.05). Ethanol alone at this concentration was without effect. Quercetin (5.6, 8, and 30 microM) significantly relaxed resistance (-32+/-4%, n = 10; -47+/-2%, n = 7; -82+/-6%, n = 8, respectively) and conductance (-20+/-3%, n = 8; -32+/-4%, n = 8; -72+/-7%, n = 8, respectively) coronary arteries. Vasorelaxation by quercetin was endothelium-independent and was significantly greater in resistance than in conductance vessels. These data suggest that red wine and ethanol do not evoke relaxation in small coronary arteries at concentrations associated with moderate consumption. Quercetin elicits marked coronary vasorelaxation that is endothelium-independent. However, the concentrations of quercetin necessary to achieve this action are not attained with moderate red wine consumption.     

New evidence on controlling alcohol use through price

A problem in earlier studies of the demand for beer, wine and distilled spirits was determining the effect on one category of alcoholic beverage of price changes in other categories. The present study estimates the demand for all alcoholic beverages, finding a stable relationship over a 40-year period. Policy implications are also discussed.     

The health benefits of moderate alcohol consumption: a review of the literature

A review of the literature on the positive benefits of light and moderate alcohol consumption suggests the following: Alcoholic beverages are food, containing approx. 7 calories per gram of ethanol. Beer contains small percentages of the recommended daily allowance of vitamins and significant proportions of the recommended daily allowance of trace metals and minerals. Wine, while possessing significantly smaller amounts of vitamins and minerals than beer, has considerably more iron. Both beer and wine have a favorable potassium to sodium ratio. Coronary heart disease (CHD) seems to have a negative association with regular alcoholic beverage use. While some report a linear relationship, most studies agree that the relationship is U-shaped. Many studies have suggested that this inverse relationship is due to alcohol's effect of increasing levels of high density lipoprotein cholesterol (HDL), which acts in the removal of cholesterol from tissue. Other explanations for moderate alcohol's cardioprotective effect include: associated diet changes in moderate drinkers, the silicon content in wine and beer, decreased platelet aggregation and coagulation, and the ability to lessen stress and/or alter personality patterns associated with CHD risks. Dry non-sweet wines and diluted distilled spirits have been recommended in the treatment of diabetes. It has been suggested that alcohol may improve glucose tolerance and blood glucose response to ingested carbohydrates. Due to reported decreased HDL values in diabetics, alcohol has been suggested as useful for its HDL-increasing function.     

A change from public to private sale of wine: results from natural experiments in Iowa and West Virginia

Several proposals to change the existing structure of state alcoholic beverage control authorities have been advanced over the past 10 years in the United States. Most call for eliminating or substantially reducing the state's role in retail sales of alcohol, particularly distilled spirits and wines. In recent years the states of Iowa and West Virginia eliminated state monopolies for retail sales of wine, and now allow such sales by privately-owned licensed establishments. Using time-series methods, we assessed the effects of these policy changes on the alcoholic beverage market in each state. Privatization was associated with statistically significant increases in wine sales in Iowa and West Virginia, after controlling for an initial stocking effect and broader nationwide trends in alcohol sales in the 1980s. In addition, there was a net increase in absolute alcohol consumed in both states across all beverages (beer, wine and distilled spirits) associated with privatization.     

Alteration of biochemical parameters related with exposure to lead in heavy alcohol drinkers.

Blood lead levels (PbB), delta-ALA dehydratase activity (ALAD) and erythrocytic protoporphyrin (EPP) values were studied in heavy wine and spirit drinkers. Results were compared in both groups and with a control group (teetotalers). Results in all cases are expressed as arithmetic means +/- SD. PbB values found in the three groups were statistically different inter se: wine group, 195 +/- 82 microg l(-1); spirits group, 159 +/- 69 microg l(-1); teetotalers, 72 +/- 43 microg l(-1). ALAD was significantly lower in the drinker groups (wine 26.9 plus minus 11.4 U l(-1)and spirits 28.3 plus minus 11.6 U l(-1))vs the control group (48.3 plus minus 13.5 U l(-1)). Differences in EPP levels in the three groups were only significant between the teetotaler and the wine drinker groups. Our findings indicate that, in heavy drinkers (more than 2 liters of wine per day), not only are lead levels increased in the blood but there are also biochemical alterations that affect the heme biosynthetic pathway, which should be taken into account in treatment for alcoholics.     

Defining maximum levels of higher alcohols in alcoholic beverages and surrogate alcohol products

Higher alcohols occur naturally in alcoholic beverages as by-products of alcoholic fermentation. Recently, concerns have been raised about the levels of higher alcohols in surrogate alcohol (i.e., illicit or home-produced alcoholic beverages) that might lead to an increased incidence of liver diseases in regions where there is a high consumption of such beverages. In contrast, higher alcohols are generally regarded as important flavour compounds, so that European legislation even demands minimum contents in certain spirits. In the current study we review the scientific literature on the toxicity of higher alcohols and estimate tolerable concentrations in alcoholic beverages. On the assumption that an adult consumes 4 x 25 ml of a drink containing 40% vol alcohol, the maximum tolerable concentrations of 1-propanol, 1-butanol, 2-butanol, isobutanol, isoamyl alcohol and 1-hexanol in such a drink would range between 228 and 3325 g/hl of pure alcohol. A reasonable preliminary guideline level would be 1000 g/hl of pure alcohol for the sum of all higher alcohols. This level is higher than the concentrations usually found in both legal alcoholic beverages and surrogate alcohols, so that we conclude that scientific data are lacking so far to consider higher alcohols as a likely cause for the adverse effects of surrogate alcohol. The limitations of our study include the inadequate toxicological data base leading to uncertainties during the extrapolation of toxicological data between the different alcohols, as well as unknown interactions between the different higher alcohols and ethanol.     

Using taxes to curb drinking: a report card on the Australian government's alcopops tax

Introduction and Aims. In 2008, the Australian government introduced an ‘alcopops tax’ on spirit‐based ready‐to‐drink (RTD) beverages to reduce alcohol consumption and particularly binge drinking by young people. Design and Methods. Data regarding sales of alcoholic beverages in Australia from 2004 to 2009 were used to examine the possible effects of the alcopops tax. In addition, population data were used to calculate and examine per capita consumption. Results. Various measures of consumption of wine‐based RTDs, spirits, cider, wine and beer remained fairly stable or increased annually from 2004 to 2009. Consumption of spirit‐based RTDs increased annually from 2004 to 2007, but then decreased in 2008 and 2009. Per capita alcohol consumption in terms of pure alcohol increased annually from 11.52 litres in 2004 to a peak of 11.79 litres in 2007, but then dropped to 11.55 litres and 11.41 litres in 2008 and 2009, respectively. Discussion and Conclusions. Consumption of spirit‐based RTDs dropped and consumption of other alcoholic beverages increased following the introduction of the tax. The increased consumption of other alcoholic beverages could be interpreted as indicating that RTD drinkers switched to purchasing spirits or wine‐based RTDs or cider. However, those increases could also be interpreted as a continuation of long‐term trends rather than a ‘substitution effect’. It is impossible to know how much of the changes were due to the tax, to the ‘global financial crisis’, to adaptive marketing by the alcohol industry, to the Government's national binge drinking strategy, to mass media coverage of these issues or to other factors.[Doran CM, Digiusto E. Using taxes to curb drinking: A report card on the Australian government's alcopops tax. Drug Alcohol Rev 2011;30:677–680]