Public Health Policy Decisions Research Articles

Alcohol Use during Pregnancy: What Is the Risk?

Alcohol use during pregnancy now is believed generally to be a serious risk to the health of the fetus. As a result, women of childbearing age are urged to avoid, if not to eliminate, alcoholic beverages from their diet. This increasingly common view states that, because there is no known safe threshold for alcohol use, abstinence is the safest road to travel. Clearly, this important recommendation, symbolized by the labeling of alcoholic beverages as dangerous during pregnancy, should be based upon the best available scientific data. The report that women metabolize alcohol differently than men and that a smaller amount (compared with men) produces a higher blood level only emphasizes the need to quantify the risk of drinking during pregnancy.1 Scientific information is needed to make the best possible clinical, public health, and public policy decisions. This paper reviews what is known about the risk of alcohol for the well nourished woman who drinks two or less alcoholic beverages (drinks) per day while pregnant. Our conclusion is that there is no measurable or documented risk from this level of drinking during pregnancy. Therefore, by urging well nourished pregnant women to abstain from alcoholic beverages, we may be turning our attention away from negative health behaviors of far greater danger than consuming a glass of wine or its alcoholic equivalent.

Alcohol Use during Pregnancy: What Is the Risk?

Alcohol use during pregnancy now is believed generally to be a serious risk to the health of the fetus. As a result, women of childbearing age are urged to avoid, if not to eliminate, alcoholic beverages from their diet. This increasingly common view states that, because there is no known safe threshold for alcohol use, abstinence is the safest road to travel. Clearly, this important recommendation, symbolized by the labeling of alcoholic beverages as dangerous during pregnancy, should be based upon the best available scientific data. The report that women metabolize alcohol differently than men and that a smaller amount (compared with men) produces a higher blood level only emphasizes the need to quantify the risk of drinking during pregnancy.1 Scientific information is needed to make the best possible clinical, public health, and public policy decisions. This paper reviews what is known about the risk of alcohol for the well nourished woman who drinks two or less alcoholic beverages (drinks) per day while pregnant. Our conclusion is that there is no measurable or documented risk from this level of drinking during pregnancy. Therefore, by urging well nourished pregnant women to abstain from alcoholic beverages, we may be turning our attention away from negative health behaviors of far greater danger than consuming a glass of wine or its alcoholic equivalent.

Scientific trends in risk assessment research.

The use of risk assessment approaches to evaluate the effects of toxic chemicals had its primary origin in 1976 when the U.S. Environmental Protection Agency (EPA) adopted the first federal guidelines to commit a major regulatory agency to risk assessment approaches for the evaluation of suspect carcinogens. The accompanying policy statement also adopted a risk management policy, which acknowledged that the agency would accept risk in making public health policy decisions; in essence, this represented a primary departure from the zero-risk goal that had dominated the first half of the environmental movement of the 70s. The approach adopted in 1976 was based on the experience of risk assessment approaches used for assessing low-dose-radiation effects on human health. To be certain that no public health risk be underestimated, particularly in light of the prior zero-risk goal, the practice of risk assessment for the first decade relied heavily on extremely protective assumptions in all aspects of the assessment process. For example, these assumptions included ranking the weight-of-evidence according to results in all related studies without regard for distinctions of tumor end point relevance to humans and the possibility that low-dose effects at environmental exposures might not be the same as high-dose effects. For low-dose-response characterization, the practice has been to characterize a plausible upper bound on risk by the use of a low-dose linear non-threshold dose-response curve. Exposure assessment likewise relied on maximum plausible assumptions to characterize exposure. More recently, more attention is being paid to developing accurate scientific databases that advance almost every aspect of the risk assessment process in the direction of more accurate risk characterization. This paper will discuss the recent trends in weight-of-evidence characterization, dose-response modeling, and exposure assessment and will compare the outcomes of these refined assessments to those evaluations that have relied on the earlier, conservative approaches. In essence, if the practices of the first decade for establishing plausible upper bounds on the risk were accurate, improved scientific data by and large should be expected to lower the overall theoretical risk. Indeed, this is the case when recent risk assessment research is applied but there are examples to the contrary. This paper represents a survey of recent trends and applications.

AIDS CONFERENCE: New findings, but no breakthroughs

The 4th International Conference on AIDS, held last week in Stockholm, illustrated the central role acquired immune deficiency syndrome has taken on in basic biomedical research and public health policy decision making. More than 7000 people attended the week-long conference, at which more than 3000 papers on a wide variety of AIDSrelated topics were presented. Despite impressive advances in understanding the molecular biology of the human immunodeficiency viruses (HIV-1 and HIV-2) and how they interact with the human immune system to destroy it, the worldwide picture of the AIDS epidemic remains grim. I am afraid that the picture in its entirety that will develop . . . will be frightening, in some respects even more frightening than we expected, said Lars Olaf Kallings, chairman of the conference, in his keynote address. Jonathan Mann, director of the World Health Organization's AIDS program, reported that as of June 1, 1988, 96,433 cases of AIDS have been reported ...

Quantitative Approaches in Use to Assess Cancer Risk

Scientists have long used conventional toxicological methods to establish “safe levels of exposure” for chemicals presumed to have threshold health effects or doses below which significant effects are unlikely to occur. These same methods cannot be used to establish safe levels of exposure for non‐threshold pollutants, such as carcinogens. Therefore, Federal regulatory agencies in the United States are using risk assessment methods to provide information for public health policy decisions concerning increases in risk associated with increases in exposure to carcinogenic and other non‐threshold pollutants. Acceptable exposure/risk levels are decided by policymakers who consider descriptions and estimates of risks together with social and economic benefits from the uses of the chemical. This paper focuses on the development of quantitative risk assessment approaches by Federal regulatory agencies in the United States, and identifies the mathematical models currently being used for risk extrapolation, including their inherent uncertainties. The uncertainties and limitations of these methods have led some scientists to question the utility of quantitative risk extrapolation. The experience of the U.S. Environmental Protection Agency (EPA), as summarized in this paper, can provide a realistic basis for evaluating the pros and cons. Finally, shortcomings in current risk assessment methods and their use in policy decisions are explored, and areas for possible improvement, given current scientific knowledge, are identified.