According to the report by the WHO in 2015, 3.3 million deaths per annum worldwide were associated with alcohol abuse. Globally, over 200 diseases and injuries were att-ributable to alcohol abuse, which represented 5.1% of the global burden of disease. Furthermore, about 5.9% of all global deaths and almost 25% of all deaths between the ages of 20-39 years were attributable to excessive alcohol consumption [1].

The effects of harmful alcohol use, including liver cirr-hosis, pancreatitis, susceptibility to infections, various mali-gnancies and interpersonal violence, have been reported in the literature world-wide [2-4]. It has also been shown that alcohol is a psychoactive substance with dependence-pro-ducing properties and that it is associated with violence, marital breakup and spouse abuse [5]. It also leads to poor life quality of individuals in general as it leads to poor productivity [5].

It has been reported that the fifth leading cause of death in South Africa is harmful alcohol use and that the country has a high rate of foetal alcohol disorders, affecting at least 500 000 South Africans country-wide [6]. Furthermore, drunk driving has been found to be responsible for up to half of all road accidents in South Africa [7], making this practice one of the biggest threats to road safety in South Africa.

In 1984, Ewing devised a tool which he abbreviated “CAGE” to assess chronic harmful alcohol use. Using this tool, respondents are asked four close-ended questions: (1) if s/he has the feeling to cut (C) down on alcohol consumption, (2) has been annoyed (A) by critics for his/her alcohol consumption, (3) ever felt guilty (G) about his/her alcohol consumption and (4) needs a drink to steady the nerves on waking up in the morning (eye-opening), hence E. A “Yes” in any of the questions asked is allocated 1 mark. A score of ≤ 1 indicated “non-harmful alcohol use” while a score ≥ 2 indicates “harmful alcohol use [8]. In addition to the definition of harmful alcohol use according to the CAGE assessment, binge drinking has been defined as taking above four drinks (alcohol standards) in one occasion regardless of the sex [9].

According to the report by the WHO in 2015, health educators and researchers employ different definitions of a standard drink (a notional drink that contains a specific amount of pure alcohol) because of differences in the typical serving sizes in various countries [5] To this effect, one standard drink in Canada = 13.6 g of pure alcohol, in the UK = 8 g, in the USA = 14 g, in Australia and New Zealand = 10g and in Japan = 19.75 g. However, according to the guidelines provided by Fabor on alcohol use at primary care, the amount of alcohol contained in a standard drink is the conversion factor of ethanol and allows for conversion of any volume of alcohol into grams. For each millilitre of ethanol, there are 0.79 grams of pure ethanol. For example, one can of beer (330ml) at 5% (strength) x 0.79 (conversion factor) = 13 grams of ethanol [10]. Using this formula, a glass of wine (140 ml at 12% ethanol) and a shot of spirit (40 ml at 40% ethanol) represent a standard drink of about 13 g of ethanol.

Most studies conducted on knowledge regarding alcohol quantities and use focussed on the general public [11], health workers and health worker trainees [12] and learners [13, 14]. However, the study by Sprague and Vinson in the USA on primary health care patients’ knowledge on risky alcohol drinking revealed that 21% screened positive for risky drinking and only 10% correctly estimated daily low risks limits and 9% weekly limits. Patients with a positive screen were twice as likely to say that they knew what a standard drink was, but only 33.3% gave accurate estimates [15].

This study sought to assess patients’ knowledge of safe alcohol use and practices regarding alcohol consumption among patients attending the Family Practice Clinic at DGMAH in Pretoria. The finding that patients at primary health care lacked knowledge on safe alcohol consumption and had unsafe alcohol consumption practices could be used by policy makers as evidence to raise awareness on the various local brands of alcohol at patients’ disposal. The various alcohol types, and the frequency of alcohol use in relation to patients’ demographic characteristics could be used as context on which policies are based. It is hoped that the study findings will assist in curbing unsafe alcohol use among patients.

The study demonstrated that there was a larger proportion of respondents who consumed alcohol among the older age-groups and the single. Poor knowledge regarding the quantities of alcohol consumption which do not cause harm to health was also shown. A large proportion of men consumed beer than women who consumed wine and cider more. When comparing harmful and non-harmful alcohol use according to age and academic level progression, there was an inverse relationship in both cases.

Most of the respondents enrolled in the study belonged to the age groups of above 57 years old (33.3%) compared to the other age-groups. There was an increase in alcohol consumption as the participants’ age groups increased toward 57 years and above, in contradistinction with the study by Knott et al. [21], where alcohol consumption and related problems were found to decrease as drinkers grew older because of ill-health that set in with age. However, the study by Grant et al. [22]. tallied with our study in also finding an increase in harmful alcohol use with age. In South Africa, the study by Peltzer et al. found that there was an increase in high risk drinking and alcohol abuse among older adults putting them at risk for increased morbidity and mortality [23]. The researchers in the current study are of the view that differences observed in the other studies are ascribable to the differences in sample sizes and the fact that the quoted studies were cohort studies over a period of time, unlike the cross-sectional method used in this study. Nevertheless, the current study suggests that health care professionals need to specifically enquire about alcohol abuse among elderly patients as well and not assume that they are unlikely engage in the harmful use of the substance.

In this study, the highest age group among the alcohol users were single (49.7%), in keeping with the study by Halme et al., who found an association between “not being married” and alcohol drinking problem [24] and Dan, who also found binge drinking in men to be associated with those who were divorced, separated or widowed (i.e. living single) [25]. This suggest that being single for whatever reason renders the individual vulnerable to harmful alcohol use.

The current study demonstrated that only about one-in-ten (10.7%) respondents were aware of the maximum number of drinks per day that a male individual can take without causing harm to health, while nine-in-ten (89.3%) were not. These findings are almost similar to a study conducted by Rosenberg et al., in the UK were the level of awareness on recommended alcohol limits stood at 8% [26]. The same trend was displayed in the current study on the level of awareness on the maximum number of drinks per day recommended for a female individual without causing harm to their health – only 7% were aware. Furthermore, on the maximum number of days per week that an individual can take alcohol for, without causing harm to their health, awareness was only found in 13.3%. According to the United States Department of Health and Human services and the United States Department of Agriculture, recom-mendations for moderate drinking has been defined as one alcoholic drink for females and two drinks for males per day [27]. Low risk for developing Alcohol Use Disorder (AUD) was described for males as drinking a maximum of 4 drinks on any day of the week to a maximum of 14 drinks per week, and a maximum of 3 drinks on any day of the week to a maximum of 7 drinks per week for females [19]. Lack of awareness by individuals about these recommended alcohol quantities and frequencies of ingestion could be a reflection on the lack of patient education in this regard by health care professionals.

The study demonstrated that beer was considered fav-ourable amongst respondents accounting for almost half of all respondents’ consumption (48.4%) and was followed by ciders with almost a third of the respondents (31.3%) using it. The finding regarding beer consumption was also reported by the WHO [28], in its Global Status Report on alcohol and individual country profiles for South Africa in 2014 where beer was found to constitute 48% of all alcohol consumption. However, unlike in the current study, the beer frequency was followed by wine at 18%. Globally, the most consumed beverage type is spirits (50.1%), followed by beer (34.8%). Wine constituted only 8.0% of the total recorded alcohol consumption (ibid). Given that what matters most is the number of alcohol standards consumed by an individual, health care professionals have the responsibility to educate patients that it is the quantity consumed that matters [8], and not the alcohol types.

Almost one-in-two respondents reported that they consumed alcohol mostly on special occasions, followed by “on weekends” (33.3%). These two occasions accounted for almost one-in-five (84.0%) of all the occasions during which alcohol was consumed, in keeping with the study by Lau-Barraco et al. [29]. Weekend drinking was found to be associated with more risks of violence compared to during the week drinking [30]. There was no difference in the proportion of patients based on the duration of time they have been ingesting alcohol. However, there is evidence that excessive alcohol drinking for longer duration is associated with a number of diseases, notably liver cirrhosis, some types of cancer and immune system disorders [5]. Health care professionals need to factor in the possibility of binge drinking on weekends and the duration of excessive alcohol intake in their enquiry on the history of alcohol intake by their patients.

Binge drinking which represents acute alcohol use in the current study was demonstrated in almost 60% of the respondents whereby five or more drinks per sitting were consumed. The deleterious effects of binge drinking on cognition – particularly among adolescents [31], health and safety [32] its contribution towards Alcohol Use Disorders (AUD) [33] have already been reported. Beer in both 330ml and 750 ml bottles was consumed the most per day by about half of the respondents. Regarding the types of alcohol consumed, the 2016 report by STATS SA has shown that beer is currently the most popular alcohol type in South Africa and accounts for 2.1% of total household spending [34]. The large proportion of men consuming beer compared to women has also been reported by Colen and Swinnen, whose study on the determinants of global beer consumption among beer drinking nations found that men were more likely to drink beer than women and that beer was more popular in the younger ages (18-44 years) [35]. However, this has no clinical significance as all types of alcohol are amenable to abuse, depending on the amount consumed [8].

The current study findings indicated that there was a significant difference between the patients who were non-harmful chronic alcohol users (CAGE score ≤ 1) versus those who were (CAGE score ≥ 2) among those in the age groups ≥ 38 years. There were less respondents in the age group ≥ 38 years who engaged in chronic harmful alcohol consumption (CAGE score ≥ 2) compared to their younger counterparts. This finding suggests an inverse relationship between age and harmful alcohol use. In this study, comparing males and females, the CAGE screening showed no significant difference between them regarding non-harmful and harmful alcohol uses (CAGE score ≤ 1 and ≥ 2). However, a study conducted by Bradley et al., using the Alcohol Use Disorders Identification Test (AUDIT-C) tool illustrated a higher prevalence of alcohol-related problems and disorders in primary care among men compared with women [36]. This could be explained by the differences in the parameters used in these two tools, with the AUDIT-C questionnaire looking more at the quantity and frequency of alcohol ingestion, compared to the CAGE questionnaire which looks at the individual’s social behaviour and his/her functionality as a result of alcohol use [8].

Regarding the use of the CAGE scoring system in relation to the highest level of education, the current study demonstrated that the higher the level of education, the greater the difference between the proportions of those who had harmful alcohol use (CAGE score ≥ 2) versus those who did not (CAGE score ≤ 1). However, the percentages of users increased with education in each category – more among the non-harmful alcohol users compared to their counterparts. This suggests that the higher the education level, the fewer the harmful users of alcohol. This could suggest that education brings about awareness on the dangers associated with harmful alcohol use. However, other studies have shown an increasing harmful alcohol consumption with an increase in academic levels, as a result of the socio-economic status conferring affordability to the individual [37-39]. This studies are multicentre large sample surveys which could explain the different finding in the current study. Furthermore, there was paucity of comparative studies conducted specifically among patients.

The finding that there was lack of knowledge on safe alcohol use among the majority of the respondents in this population suggests introduction of alcohol use awareness campaigns targeting especially the middle aged and the elderly. Furthermore, the finding that women consumed more wine and cider, compared to men who consumed more beer offers an opportunity to health care professionals to raise awareness to patients that safe use is determined by the amount rather than necessarily the type of alcohol used. This awareness should include the deleterious effects of binge drinking observed among the younger age groups, with caution for all patients against harmful alcohol use on special occasions and weekends. The finding through the use of the CAGE scoring system that with an increase in the highest level of education there were significantly more patients who did not engage in chronic harmful alcohol use should be leveraged on by health care professionals in educating patients against indulgence in harmful alcohol use.