In: Detels, R., McEwen, J., Beaglehole, R. & Tanaka, H., eds. Oxford Textbook of Public Health, 4th ed., vol. 3, pp. 1521-1531. Oxford, etc.: Oxford University Press, 2002.

 

ALCOHOL

 

DRINKING AND ITS EFFECTS

            Alcohol beverages have been consumed in most, but not all, human societies since the beginning of recorded history.  Beverages containing ethanol (C2H5OH) can be fermented from most organic materials containing carbohydrates, and in one part or another of the world are prepared from fruits, berries, various grains, plants, honey and milk.  Under most circumstances, such fermented beverages can range up to about 13% ethanol in content.  The most widely commercialized fermented beverages are beer prepared from barley or other grains (usually 3-7% ethanol), apple and other fruit ciders (usually 3-7%), and grape wine (usually 8-13%).  Other fermented beverages are also prevalent in particular cultures, often both from home production and in commercial form: e.g., sorghum or millet beers in eastern and southern Africa, palm wine toddy in west Africa and the Indian subcontinent, pulque (prepared from the maguey cactus) in Mexico, and rice wine (sake) in eastern Asia.

            Distilled beverages, where ethanol is concentrated by evaporation and condensation from a fermented liquid, were a Chinese invention which came to Europe via Arabia in the middle ages.  In Europe, their use was primarily medicinal at first, but by the 1600s popular use as a social beverage spread rapidly.  Distilled beverages can be almost pure ethanol, but as sold for drinking most distilled beverages contain between 25% and 50% ethanol.  Distilled alcohol is also added to wine, producing “fortified wines” with about 20% ethanol.  Since distilled beverages and fortified wines do not readily spoil, they could be shipped long distances even before refrigeration and airtight packaging were available, and played a particularly important part in commerce and exploitation in the age of the European empires.  Cultures vary in the strength at which they consume different alcoholic beverages, with water or a “mixer” often being added to distilled beverages, and in some cultures also to wine and other fermented beverages.

 

USE-VALUES FOR ALCOHOL

            Ethanol has many uses in human life.  These include non-beverage uses as a fuel and as a solvent.  Important use-values as a beverage include use as a medicine, as a religious sacrament, as a foodstuff, and as a thirst-quencher (Mäkelä, 1983).  But alcoholic beverages receive special attention as a public health hazard because of their psychoactive properties.  These carry with them another set of use-values: in terms of psychopharmacology, ethanol is a depressant, and alcoholic beverages have long been used to affect mood and feeling.  With enough consumption, alcohol becomes an anodyne and indeed an anesthetic; distilled spirits were used as an anesthetic in surgical practice before the mid-19th century.  Many drinkers seek and appreciate levels of intoxication which lie between mild mood-alteration, at one end of the spectrum, and being comatose, at the other.

            Decisions to drink and how much to drink are, however, often not made by the individual in isolation.  Drinking is usually a social act, and the pace and level of drinking is often subject to collective influence.  Drinking together is often an expression of solidarity and community.  While drunkenness may be sought to relieve misery or loneliness, more commonly drunkenness is associated with sociable celebration.

 

 

ADVERSE EFFECTS

            Alcohol consumption can have a variety of adverse effects.  Some are acute effects associated with the particular drinking occasion. Drinking progressively impairs physical coordination, cognition and attention, resulting in an increased risk of accidents and injury. Above a threshold level, drinking also potentially affects intention and judgement, so that intoxication potentially plays a causal role in violent behaviour and crime (Graham et al., 1998).  This relation appears to be culturally mediated, since there is substantial variation between cultures in the association of intoxication and violence and crime (MacAndrew and Edgerton, 1969).  Enough drinking may result in a potentially fatal overdose, by interrupting various autonomic bodily functions.

            Other adverse effects of alcohol consumption are chronic effects of a repeated pattern of drinking.  Alcohol consumption potentially adversely affects nearly every organ of the body, although some effects are not common.  Chronic conditions in which alcohol is implicated as an important cause include liver cirrhosis, cancers of the upper digestive tract, liver and breast, cardiomyopathy, gastritis and pancreatitis (English et al., 1995).  Through a variety of mechanisms, alcohol is also implicated in the incidence of infectious diseases (NIAAA, 1997).

            Repeated heavy drinking can also adversely affect mental health.  There are specific neurological disorders associated with sustained heavy drinking.  More common concomitants include depression and affective disorders.  Alcoholism -- the experience of loss of control over drinking, along with other psychological and physical sequelae -- has also been considered a mental disorder in modern times.  In current nosologies, alcoholism has been replaced by the terms alcohol dependence (in DSM-IV terminology) or the alcohol dependence syndrome (in ICD-10).

            The impairment of coordination and of judgement produced by drinking potentially affects bystanders and the drinker’s acquaintances, friends and family, as well as the drinker him/herself.   The effects can be through impairment of coordination or judgement in the drinking event, resulting in injury or distress, or through impairment of performance in family, friendship, work and other social roles, from recurring drinking episodes.  It is the actual and potential adverse effects on others which have historically been the primary justification for alcohol controls and other societal responses to problematic drinking (Room, 1996).  Effects of drinking on the adult drinker’s own health have been much less important in determining public policy on alcohol.

 

POSITIVE EFFECTS

             For the drinker, and sometimes also for those around the drinker, alcohol consumption also potentially has positive effects.  We have already mentioned the different use-values of alcohol -- effects which mean that drinkers are usually willing to pay more than the cost of production and distribution for the beverage.  Apart from its valued effects  on mental state, alcohol also potentially has some positive health effects.  By far the most important of these, in terms of public health, is its potential effect in preventing cardiovascular disease (CVD).  A fairly consistent finding in studies in several societies is that drinking at moderate levels is protective against CVD (Klatsky, 1998).  Studies vary in findings of the upper limit of drinking for such protection; for that matter, not all studies find the protective effect (e.g., Leino et al., 1998).  Taking the studies together, it appears that most of the protective effect can be gained with as little as one drink of an alcoholic beverage every second day (Maclure, 1993).  While about half of the effect seems to come from inhibiting the build-up of plaque in arteries, the other half seems to result from a relatively immediate effect in diminishing the likelihood of blood-clots.  To the extent this is true, an irregular or occasional drinking pattern is likely to have less of a protective effect. 

            While it has been argued that the protective effect comes primarily from red wine constituents, particularly resveratrol, rather than from the ethanol, the balance of evidence presently favours an ethanol effect (Klatsky, 1999). But relatively little is known about how the ethanol effect interacts or overlaps with other risk and protective factors for CHD, such as regular exercise, diet, or taking aspirin (ASA) or other pharmaceuticals (Criqui et al., 1998).  The protective effect of alcohol appears to be higher for current cigarette smokers than for nonsmokers (Kozlowski et al., 1994).

            Drinking is not always good for the heart (Poikolainen, 1998; Chadwick and Goode, 1998).  Some studies have found that a pattern of intermittent heavy drinking, such as getting drunk every weekend, is associated with an elevated rate of coronary death (Kuhanen et al., 1997), probably through such mechanisms as heart arrhythmias (Kupari and Koskinen, 1998; McKee and Britton, 1998).  Recent data from countries of the former Soviet Union, where a pattern of intermittent intoxication is common, support a strong adverse effect of binge drinking on heart disease mortality.  In a period of deliberate restriction of alcohol supplies in 1985-1988,  the estimated per-capita consumption in Russia, including the illicit alcohol market, fell from 14.2 litres in 1984 to 10.7 litres in 1987 (Shkolnikov & Nemtsov, 1997) -- a fall of 25%.   The male rate of deaths from ischemic heart disease in the same period fell by 10%.  The rate rose again when the restrictions lapsed, although in this period, unlike 1985-1988, other risk factors were also changing. 

 

NET EFFECTS OF DRINKING ON THE DRINKER’S HEALTH

            In most studies, the relationship of amount of drinking to overall mortality is a J-shaped curve, with abstainers -- and often also very light drinkers -- showing a higher mortality than those drinking a little more.  In studies with these findings, a substantial part of the study population is older adults, and thus at risk of CVD mortality.  Studies limited to younger cohorts typically find a monotonic relation of amount of drinking with mortality (Andréasson et al., 1991; Rehm and Sempos, 1995). Such a relation might be expected, too, in any population, such as in some developing societies, which has a low rate of CVD.

            The pattern of drinking is also potentially important in mortality.  While this has long been obvious for casualty deaths, there is growing recognition of its potential importance also for other causes of death, as the Russian data just cited implies.   But pattern of drinking has been little measured in the studies of alcohol and overall mortality.  Variations between cultures in patterns of drinking may well partly explain why the J-curve relation of volume of drinking with mortality shows different low-points in different cultures.

            The risks and potential benefits associated with a given drinking level thus vary with the age and sex of the drinker, and potentially with other sociocultural characteristics, as well as with the pattern and contexts of drinking.  This has posed a considerable challenge when the political demand has arisen in a number of countries for guidance on “low-risk drinking” or “safe drinking” guidelines (Hawks, 1994).  While earlier guidelines tended to be stated in terms of volume of drinking, in line with the measurement methods of the medical epidemiology literature, more recent guidelines have also emphasized limits on the amount on an occasion or day (Bondy et al., 1999).

            The current literature on the net effects of drinking on health relies substantially on summations of the prospective epidemiological literature such as English et al. (1995).  Using meta-analyses of studies of the relation of volume of drinking to specific causes of death where alcohol was a risk or protective factor, English et al. derived attributable fractions for different levels of volume of drinking, and applied these to proportions of the population at different volumes of drinking to arrive at estimates of total lives and life-years lost and gained (Holman and English, 1995).  Reflecting the underlying literature the study meta-analyzes, the resulting estimates are based on a relatively narrow range of societies, and take no account of patterns of drinking.  The method relies on an assumption which is thus problematic, that there is a single invariant mortality effect for a given range of volumes of drinking.

            Drawing on the work of English et al., but factoring in the estimated effects of intoxication as well as volume of drinking, Murray and Lopez (1996) have estimated the share attributable to alcohol of the Global Burden of Disease (GBD).  In these estimates, the projected protective effects of alcohol are subtracted from the negative burden.  In addition to  years of life lost, the study’s most comprehensive indicator, Disability-Adjusted Life-Years (DALYs), includes a projection of the burden of disability attributable to alcohol.

            According to the GBD estimates, 3.5% of the total burden of disease globally, as measured in DALYs, is attributable to alcohol (Murray and Lopez, 1996).  This compares with 2.6% for tobacco and 0.6% for illicit drugs. The alcohol share of the burden is highest in developed societies, and high also in Latin America and eastern Europe. Although the alcohol share in all DALYs is lower in other developing regions, this fraction is calculated on the base of a higher total burden of disease and disability there.  While the GBD estimates must be regarded as a first rough cut that will be refined in future, they do indicate  that the global health burden attributable to alcohol is very substantial.

 

NET EFFECTS ON THE POPULATION LEVEL

            Thus far we have been dealing with estimates of alcohol’s effects based on individual-level data.  The methodological difficulties in the studies underlying these estimates extend beyond those we have already discussed (Edwards et al., 1994). The estimates rely primarily on prospective epidemiological studies with alcohol consumption measured at one time-point; such a measurement is at best a poor surrogate for either of the main aspects of alcohol consumption as a risk factor -- chronic effects of cumulated alcohol consumption or acute effects of intoxication in a specific event.  In these studies, the effects of possible confounders are dealt with by statistically controlling for them in the analysis.  But this can be problematic, if drinking and the potential confounder are causally intertwined, as for instance is true for hypertension or tobacco smoking.  Consider, for instance, a person who only smokes when under the influence of alcohol: controlling for that person’s smoking behaviour potentially controls out some of the alcohol-effect.

            From a public health perspective, it is the effects on the population level rather than the individual level which are the main concern.  If drinking were entirely a matter of individual choice and behaviour, and if the effects of drinking happened only to the drinker, then effects at the population level would be a simple aggregation of effects at the individual level.  But neither of these conditions are applicable.  Drinking is in large part a social activity, and the drinking behaviour of one person is likely to influence and be influenced by those around the person.  In a given population the amounts drunk by infrequent or light drinkers and by heavy drinkers tend to move up and down in concert.  Thus, if there is some health gain when those at the bottom of the consumption spectrum increase their consumption, there will be health losses from an increase in consumption, too, at the top of the consumption spectrum.  In view of this, it has been argued that the level of per-drinker consumption where the balance of health benefits and losses is optimized in a population is likely to be considerably lower than the optimum level of consumption for the individual drinker (Skog, 1996). Skog argued, for instance, that the optimum level of alcohol consumption with respect to mortality was likely to be lower than the present-day per-capita consumption of any nation in western Europe.  His argument has recently been supported by the finding of a generally positive relationship with total mortality in time-series analysis of differenced data in 14 European countries (Norström, 2000).

            By their design, the prospective studies typically used for studies of alcohol’s effects on mortality or morbidity do not measure the effects of drinking on others.  Other types of individual-level studies, for instance of the effects of drinking-driving (Perrine et al., 1989) or studies of homicide and other crimes (Wolfgang, 1958), document the importance of such effects in terms of death or injury.  But the strongest evidence of  the magnitude of such effects comes from aggregate-level studies of the covariation of changes over time in a given society or place.  Differenced time-series analyses in European societies have suggested that a one-litre change in per-capita alcohol consumption produces about a 1% change in the overall mortality rate (Norström, 1996; Her and Rehm, 1998).  Here again, however, drinking patterns and social circumstances are likely to make a difference.  The drop in Russian total mortality during the alcohol restrictions of 1985-1988, for instance, imply a decline of about 2.7% in age-standardized mortality for each one-litre drop in per-capita consumption (recalculated from Shkolnikov & Nemtsov, 1997, and Leon et al., 1998).  Even specifically for heart disease, any protective effects from changes in low-level drinking seem to be outbalanced in the population as a whole by negative effects from changes at high consumption levels, at levels of consumption typical in developed societies.  Thus a time-series analysis of differenced data on CHD mortality in 14 European countries found positive and mostly significant relationships (Hemström, 2000).

 

ALCOHOL AS AN ISSUE IN PUBLIC HEALTH

SHIFTING SOCIETAL RESPONSES TO PROBLEMATIC DRINKING 

            Efforts to control problematic drinking date back to the beginning of recorded history. These efforts have been many-sided, including informal responses in the family and community, as well as governmental controls.  Religious teachings and movements have often been directed against drinking or intoxication. Thus Moslems are forbidden by their faith to drink at all, and drinking is also discouraged or forbidden in at least some branches of all the major world religions.

            In the last few centuries, European and Europe-derived societies have been hosts to conflicting trends in terms of alcohol issues.  On the one hand, the production of alcoholic beverages became an important part of European economies, and of imperial domination and trade in the age of European colonization.  Alcohol production and exports took on political importance not only in the wine cultures of southern Europe, but also in such countries as the Netherlands and Britain.  In the British colonies in America, too, in the late 18th century distilled spirits was the only profitable way to get grain to market (Rorabaugh, 1979).  In recent decades, alcohol beverage industries have become increasingly internationalized and concentrated (Jernigan, 1997), and multinational companies, mostly based in Europe or north America, have pressed with considerable success to open up global markets for alcohol.

            Starting in the early 1800s, there were substantial waves of popular and eventually governmental response to the problems which were resulting from the very heavy consumption of alcoholic beverages in English-speaking and northern European societies (Blocker, 1989; Levine, 1991).  As a culmination of decades of popular temperance movements, in the early 20th century alcohol prohibition was adopted in many of these countries, and stringent controls on the availability of alcohol in others.  While alcohol’s impact on public order and morals and on family life were more central to temperance movement thinking than public health issues, mainstream thought in medicine and public health acknowledged substantial adverse impacts of alcohol on health (Emerson, 1932), and prohibition or an alternative, stringent controls on the availability of alcohol (Catlin, 1931), were often identified with the public health interest.

            In the U.S. and other societies which had adopted alcohol prohibition, there was a strong reaction against it by the early 1930s, with middle-class youth in the lead (Room, 1984a; 1984b).  In this cultural-political context, as the new generation moved into professional and research positions, adverse effects of alcohol were downplayed or denied (Herd, 1992; Katcher, 1993), and alcohol issues almost disappeared from view in public health textbooks and discourse.  Any problems with drinking were seen as attributable to a relatively small cadre of alcoholics, unable to control their drinking because of a mysterious predisposing factor.  As late as 1968, the main emphasis of the American Public Health Association in the alcohol field was on building treatment capacity for alcoholism (Cross, 1968).

 

THE “NEW PUBLIC HEALTH” APPROACH

            The last three decades of the 20th century have seen the rise of what has been termed in the alcohol literature the  “new public health” approach (Beauchamp, 1976; Tigerstedt, 1999) to alcohol issues.  The approach brought together several strands of research and thinking.  In contrast to a concept of the field in terms of “alcoholism”, the approach was premised on a disaggregated approach: there were a diversity of alcohol-related problems, fairly widely distributed among the population of drinkers (Knupfer, 1967; WHO, 1980).  It was noted that for many problems, the heaviest drinkers accounted for only a minority of the instances of problems, since there were so many more drinking at somewhat lower levels (Moore and Gerstein, 1981:30-32; picking up Rose’s phrase [1981], Kreitman [1986] termed this the “preventive paradox”). Attention was thus paid not just to the heaviest consumers, but to the whole range of drinking levels, and indeed to the distribution of consumption in the population (Ledermann, 1956; de Lint and Schmidt, 1968).   What happens with moderate drinkers, it was argued, influences the social climate for heavy drinking, since drinking is largely a social activity, marked by mutual influences and norms of reciprocity (Bruun et al., 1975a:39; Skog, 1985).  In a given population, it was found that rates of alcohol-related problems tend to rise and fall with changes in the level of alcohol consumption (Seeley, 1960). Controls on the availability of alcohol, including taxes, affect the level of consumption, and thus also rates of alcohol-related problems (Seeley, 1960; Terris, 1967; Popham, Schmidt & de Lint, 1976). The level of alcohol consumption in a population, and controls on alcohol availability, thus are seen as a public health concern, and part of a society’s overall “alcohol policy” (Bruun et al., 1975a).

            In enumerating the elements of the “new public health approach”, we have given references for early statements of each element.  It will be seen that the strands of the approach were woven together gradually over a period of some years.  A 1975 report by an international group of researchers (Bruun et al., 1975a) became a pivotal document for the approach. A few years later, the approach was given an authoritative endorsement in the U.S. by a committee of the National Academy of Sciences (Moore and Gerstein, 1981).  The most recent restatement of the approach by an international group of scholars appeared in 1994 (Edwards et al., 1994).

            The approach has had considerable influence in World Health Organization programs in the alcohol field, particularly in the European Region (WHO, 1980; Anonymous, 1996).  At national levels, there has been considerable variation in its influence on policy.  In Sweden, where it is known as the “total consumption” model, it attained hegemony as the basis of official policy (Sutton, 1998).  However, there is now considerable antipathy to the model in Swedish public discourse, and high-tax and other alcohol control policies based on it are being eroded as a consequence of Sweden’s accession to the European Union (Holder et al., 1998).  The approach also has had considerable currency in other Nordic countries.

            In English-speaking countries, the approach has encountered substantial resistance in the cultural-political realm.  Those allied with alcoholic beverage industry interests have strongly attacked the approach, both in analyses and polemics (e.g., Mott, 1991; Grant and Litvak, 1998) and through direct political action to remove official proponents (Room, 1984c).  An approach which contemplates government regulation and influence of private consumer choices is also unwelcome to those committed to consumer sovereignty and the primacy of individual choice (e.g., Peele, 1987). Often, proponents of approaches seeking to “domesticate” drinking -- to reduce problems from drinking by integrate the drinking into everyday life -- have portrayed the new public health approach as antithetical to this (Olsson, 1990), although some researchers have noted that there is no necessary antithesis (Whitehead, 1979).

            In terms of the influence of the approach on policy, it has undoubtedly had some effect in strengthening the defense of existing control structures and regulations.  But efforts to get the approach adopted as the practical base for policy have met resistance and failure in a number of countries (e.g., Baggott, 1990; Hawks, 1993). One response to this resistance has been some calls for an alternative approach (Stockwell et al., 1997), arguing that policy measures directed at heavy and problematic drinkers are more politically acceptable than measurers directed at all drinkers.

            The policy approach offered as an alternative is a focus on harm reduction, primarily by reducing instances of intoxication or insulating them from harm (Plant et al., 1997).  An approach to prevention in terms of reducing total consumption is likened to “draining the ocean to prevent shark attacks” (Rehm, 1999).  However, there is in fact usually no conflict between approaches aimed at total consumption and approaches aiming to reduce harm from heavy drinking.  As Stockwell et al. (1997:6) note, “aggregate consumption levels are in fact likely to fall if effective [harm reduction] strategies are introduced”.  Conversely, many measures which affect the whole drinking population -- taxation is a good example -- bear especially hard on heavier drinkers.  Nor are targeted harm reduction measures necessarily more politically acceptable than measures which affect all drinkers.  Old systems of rationing and individual buyer surveillance (Järvinen, 1991), which were directed specifically at restraining heavy drinking, are now politically unacceptable in any developed society, though rationing, at least, was highly effective as a targeted prevention measure (Norström, 1987).

            Beyond its specific features, the controversy over the “new public health” approach in the alcohol field replicates familiar patterns of controversy over public health approaches in general, particularly when those approaches impinge on familiar and valued patterns of  behaviour, with substantial economic interests at stake.  At the level of the knowledge base, the approach has had considerable success: the empirical evidence underlying the approach has considerably strengthened since the approach was first put forward.  At a political level, however, the approach has had only limited success, and primarily in areas peripheral to its main focus -- that is, in drinking-driving and minimum age limits for drinkers.

 

STRATEGIES OF PREVENTION AND CONTROL AND THEIR EFFECTIVENESS

            Simplifying somewhat, there are seven main strategies to minimize alcohol problems.  One strategy is to educate or persuade people not to use or about ways to use so as to limit harm.  A second strategy, a kind of negative persuasion, is to deter drinking-related behaviour with the threat of penalties. A third strategy, operating in the positive direction, is to provide alternatives to drinking or to drink-connected activities.  A fourth strategy is in one way or another to insulate the use from harm.  A fifth strategy is to regulate availability of the drug or the conditions of its use.  Prohibition of supply may be regarded as a special case of such regulation.  A sixth strategy is to work with social or religious movements oriented to reducing alcohol problems.  And a seventh strategy is to treat or otherwise help people who are in trouble with their drinking.  We will consider in turn these strategies and the evidence on their effectiveness.

 

EDUCATION AND PERSUASION

            In principle, education can be offered to any segment of the population in a variety of venues, but it is usually education of youth in schools which first comes to mind in the prevention of alcohol problems.  Community-based prevention programs, which are often also directed at adults, also may include an educational component.

            Education offers new information or ways of thinking about information, and leaves it to the listener to draw conclusions concerning beliefs and behaviour.  However, most alcohol education programs go beyond this.  A commonplace of the North American evaluative literature on alcohol education is that “knowledge-only” approaches do not result in changes in behaviour (Botvin, 1995).  School-based alcohol education has thus usually had a persuasional element, aiming to influence students in a particular direction.

            Persuasion is directly concerned with changing beliefs or behaviours, and may or may not also offer information.  Mass-media campaigns aimed at persuasion have been a very common component of prevention programs for alcohol-related problems, but persuasion can be pursued also through other media and modalities.

            In most societies, public-health-oriented persuasion about alcohol must compete with a variety of other persuasional messages, including those intended to sell alcoholic beverages.   The evidence that alcohol advertising influences teenagers and young adults towards increased drinking and problematic drinking is becoming stronger (Wyllie et al., 1998a; 1998b).   Even where alcohol advertising is not allowed on the mass media, these messages are often conveyed to consumers and potential consumers in a variety of other ways.

            Evidence on effectiveness   The literature on effectiveness of educational approaches is dominated by studies from the United States on school-based education.  This means that the alcohol education has usually been in the context of drug and tobacco education, and that the emphasis has been on abstention (Beck, 1998), or at least on delaying the start of drinking, in cultural circumstances where the median age of actually starting drinking is about 13, while the minimum legal drinking age is 21.  In general, despite the best efforts of a generation of researchers, this literature has had difficulty showing substantial and lasting effects (Paglia and Room, 1999).  There is a good argument from general principles for alcohol education in the context of consumer and health education, but there is little evidence from the formal evaluation literature at this point of its effectiveness beyond the short term.

            Persuasional media campaigns have also been a favourite modality in many places in recent decades for the prevention of alcohol problems.   In general, evaluations of such campaigns have been able to demonstrate impacts on knowledge and awareness about substance use problems, but can show only modest success in affecting attitudes and behaviours.  As with school education approaches, there are hints in the literature that success may come more from influencing the community environment around the drinker -- in terms of attitudes of significant others, or popular support for alcohol policy measures -- than from directly persuading the drinker him/herself. Thus, media messages can be effective as agenda-setting mechanisms in the community, increasing or sustaining public support for other preventive strategies (Casswell et al., 1989).

 

DETERRENCE

            In its broadest sense, deterrence means simply the threat of negative sanctions or incentives for behavior -- a form of negative persuasion.  Criminal laws deter in two ways: by general deterrence, which is the effect of the law in preventing a prohibited behavior in the population as a whole, and specific deterrence, which is the effect of the law in discouraging those who have been caught from doing it again (Ross, 1982).  A law tends to have a greater preventive effect and to be cheaper to administer to the extent it has a strong general deterrence effect.

            Prohibitions on driving after drinking more than a specified amount are now in effect in most nations (Hurst et al., 1997, pp. 555-556). In many societies, there have also been laws against public drunkenness (being in a public place while intoxicated), and against obnoxious behavior while intoxicated.  Other common prohibitions are concerned with producing or selling alcoholic beverages outside state-regulated channels, and with aspects of drinking under a specified minimum age.

            Evidence on effectiveness  Drinking-driving legislation, such as “per-se” laws outlawing driving while at or above a defined blood-alcohol level, has been shown to be effective in changing behavior and reducing rates of alcohol-related problems (Ross, 1982; Edwards et al., 1994, pp. 153-159; Hingson, 1996).  The effect is through both general and specific deterrence.  The quickness and certainty of punishment, as well as its severity, are important in the deterrent value (too much severity tends to undercut the quickness and certainty).  Drinking-driving is an ideal area for applying general deterrence, since the gains from breaking the law are limited, and automobile drivers typically have something to lose by being caught.

            Many English-speaking and Scandinavian countries have had a tradition of  criminalizing drinking in public places or public drunkenness as such, but the trend has been to decriminalize public drunkenness. Though there are few specific studies, criminalizing public drunkenness may not be very effective in changing the behavior of those who have little to lose.

 

PROVIDING AND ENCOURAGING ALTERNATIVE ACTIVITIES

            Another strategy, in principle involving positive incentives, is to provide and seek to encourage activities which are an alternative to drinking or to activities closely associated with drinking.  This includes such initiatives as making soft drinks available as an alternative to alcoholic beverages, providing locations for sociability as an alternative to taverns, and providing and encouraging recreational activities as an alternative to leisure activities involving drinking.  Job-creation and skill development programs are other examples.

            Evidence on effectiveness  “Boredom” and “because there’s nothing else to do” are certainly among the reasons that are given for drinking by some drinkers.  And there are often good reasons of general social policy for providing and encouraging alternative activities.  But as has been noted, the problem with alternatives to drinking is that drinking combines so well with so many of them.   Soft drinks are indeed an alternative to alcoholic beverages for quenching thirst, but they may also serve as a mixer in an alcoholic drink.  Involvement in sports may go along with drinking as well as replace it.  The few evaluation studies of providing alternative activities, again from a restricted range of societies, have generally not shown lasting effects on drinking behavior (Moskowitz et al., 1983; Norman et al., 1997), though they undoubtedly often serve a general social purpose in broadening opportunities for  the disadvantaged (Carmona and Stewart, 1996).  

 

INSULATING USE FROM HARM

            A major social strategy for reducing alcohol-related problems in many societies has been measures to separate the drinking, and particularly heavy drinking, from potential harm.   This separation can be physical (in terms of distance or walls), it can be temporal, or it can be cultural (e.g., defining the drinking occasion as "time out" from normal responsibilities).  These "harm reduction" strategies, as they are called in the context of illicit drugs, are often built into cultural arrangements around drinking, but can also be the object of purposive programs and policies (Moore and Gerstein, 1981, pp. 100-111 ), such as promotion of “designated drivers”, where one person in a social group is chosen to abstain and drive in the particular social situation (DeJong and Hingson, 1998).  

            A variety of modifications of the driving environment affect casualties associated with drinking and driving, along with other casualties.  These include mandatory use of seat belts, airbags, and improvements in the safety of road vehicles and roads.  Many other practical measures to separate intoxication episodes from casualties and other adverse consequences have been put into practice, though usually without formal evaluation.

            Evidence on effectiveness  Drinking-driving countermeasures are a prime example of an approach in terms of insulating drinking behavior from harm, since they seek to reduce alcohol-related traffic casualties without necessarily stopping or reducing alcohol use (Evans, 1991).  There is substantial evidence of the success of a range of such countermeasures, including environmental change approaches as well as deterrence (Forsyth, 1996; Zajac, 1997; DeJong and Hingson, 1998).  Some environmental measures which reduce road casualties in general -- e.g., requiring wearing of seat-belts in cars, providing sidewalks separated from the road -- may prevent casualties associated with intoxication even more than other casualties.

 

REGULATING THE AVAILABILITY AND CONDITIONS OF USE

            In terms of the substantial harms to health and public order they can cause, alcoholic beverages are not ordinary commodities.  Governments have thus often actively intervened in the markets for such beverages, far beyond usual levels of state intervention in markets for commodities.

            Total prohibition can be viewed as an extreme form of regulation of the market.  In this circumstance, where noone is licensed to sell alcohol, the state has no formal control over the conditions of the sales which nevertheless occur, and there are no legal sales interests, controlled through licensing, to cooperate with the state in the market's regulation.

            With a general prohibition, typically the consumption of alcohol does fall in the population, and there are declines also in the rates of the direct consequences of drinking such as cirrhosis or alcohol-related mental disorders (e.g., Teasley, 1992; Moore and Gerstein, 1981).  But prohibition also brings with it characteristic negative consequences, including the emergence and growth of an illicit market, and the crime associated with this.  Partly for this reason, prohibition is not now a live option in any developed society, although it is in some other societies.

            The features of alcohol control regimes which regulate the legal market in alcohol vary greatly.  Special taxes on alcohol are very common, imposed often as much for revenue as for public health considerations.  Many societies have minimum age limits forbidding sales to underage customers, and regulating forbidding sales to the already intoxicated.  Often the regulations include limiting the number of sales outlets, restricting hours and days of sale, and limiting sales to special stores or drinking-places.  Rationing of alcohol purchases -- limiting the amount individuals can buy in a given time-period -- has also been used as a means of regulating availability. Regulations restricting or forbidding advertising of alcoholic beverages attempt to limit or channel efforts by private interests to increase demand for particular alcoholic beverage products.  Such regulations potentially complement education and persuasion efforts.  State monopolization of sales of some or all alcoholic beverages at the retail and/or wholesale level has also been commonly been used as a mechanism to minimize alcohol-related harm (Room, 1993).

            The effectiveness of specific types of regulation of availability.  The last 25 years have seen the development of a burgeoning literature on the effects of alcohol control measures.  Reference guides for communities, summarizing the research evidence and attuned to particular national or regional conditions, are becoming available (e.g., Grover, 1999; Neves et al., 1998).   Specific types of regulation of the alcohol market, and the evidence on their effectiveness, are discussed below.

                        Minimum age limits:   A minimum age limit is a partial prohibition, applied to one segment of the population. There is a strong evaluation literature showing the effectiveness of establishing and enforcing minimum-age limits in reducing alcohol-related problems (Edwards et al., 1994, pp. 138-139).  However, this literature is North America-based, focuses mostly on youthful driving casualties, and mostly evaluates reduction from and increases to age 21 as the limit, a higher minimum-age limit than in most societies.  The applicability of the literature’s findings in other societies and where youth cultures are less automobile-focused has been little tested.

                        Taxes and other price increases:  Generally, consumers show some response to the price of alcoholic beverages, as of all other commodities.  If the price goes up, the drinker will drink less; data from developed societies suggests this is at least as true of the heavy drinker as of the occasional drinker (Edwards et al., 1994, pp. 118-119).  Studies have found that alcohol tax increases reduce the rates of traffic casualties, of cirrhosis mortality, and of incidents of violence (Cook, 1981; Cook and Moore, 1993).

                        Limiting sales outlets, and hours and conditions of sale:  There is a substantial literature showing that levels and patterns of alcohol consumption, and rates of alcohol-related casualties and other problems, are influenced by such sales restrictions, which typically make the purchase of alcoholic beverages slightly inconvenient, or influence the setting of and after drinking (Edwards et al., 1994, pp. 125-142).  Enforced rules influencing “house policies” in drinking places on not serving intoxicated customers, etc., have also been shown to have some effect (Saltz, 1997).  

                        Monopolizing production or sale:  Studies of  the effects of privatizing retail alcohol monopolies have often shown some increase in levels of alcohol consumption and problems, in part because the number of outlets and hours of sale typically increase with privatization (Her et al., 1999), and partly also because the new private interests typically exert political influence for further increases in availability.  From a public health perspective, it is the retail level which is important, while monopolization of the production or wholesale level may facilitate revenue collection and effective control of the market.

                        Rationing sales:   Rationing the amount of alcohol sold to an individual potentially directly impacts on heavy drinkers, and has been shown to reduce levels both of intoxication-related problems such as violence, and of drinking-history-related problems such as cirrhosis mortality (Schechter, 1986; Norström, 1987).  But while a form of rationing -- the medical prescription system -- is well accepted in most societies for psychoactive medications, it has proved politically unacceptable nowadays for alcoholic beverages in developed societies.

                        Advertising and promotion restrictions: Many societies have regulations on advertising and other promotion of sales of alcoholic beverages (Hurst et al., 1997, pp. 552-554).  While it is well accepted that advertising can strongly affect consumer choices between products on the market, it has proved difficult to measure the effects of advertising on demand for alcoholic beverages as a whole, in part because the effects are likely to be cumulative and long-term, making them difficult to measure.  However, the evidence on the effects of advertising and promotion on overall demand has become stronger in the recent literature (Casswell, 1995; Saffer, 1998; Casswell and Zhang, 1998).

 

SOCIAL AND RELIGIOUS MOVEMENTS AND COMMUNITY ACTION

            Substantial reductions in alcohol-related problems have often been the result of spontaneous social and religious movements which put a major emphasis on quitting intoxication or drinking. In recent decades, there have also been efforts to form partnerships between state organizations and nongovernmental groups to work on alcohol problems, often at the level of the local community.  There has been an active tradition of community action projects on alcohol problems, often using a range of prevention strategies (Giesbrecht et al., 1990; Greenfield and Zimmerman, 1993; Holmila, 1997; Holder 1998).  School-based prevention efforts have also moved increasingly to try to involve the community, in line with general perceptions that such multifaceted strategies will be more effective (Paglia and Room, 1999).

              While some of the biggest historical reductions in alcohol problems rates have resulted from spontaneous and autonomous social or religious movements, support or collaboration from a government can easily be perceived as official cooptation or manipulation (Room, 1997).   Thus there is considerable question about the extent to which such movements can or should become an instrument of government prevention policies.              Evidence on effectiveness:  In the short term, movements of religious or cultural revival can be highly effective in reducing levels of drinking and of alcohol-related problems.  Alcohol consumption in the U.S. fell by about one-half in the first flush of temperance enthusiasm in 1830-1845 (Moore and Gerstein, 1981, p. 35).  Rates of serious crime are reported to have fallen for a while to a fraction of their previous level in Ireland in the wake of Father Mathew’s temperance crusade (Room, 1983).  The enthusiasm which sustains such movements tends to decay over time, though they often leave behind new customs and institutions with much longer duration.  For instance, though the days when the historic temperance movement in English-speaking societies was strong are long gone, the movement had the long-lasting effect of largely removing drinking from the workplace in these societies.

 

TREATMENT AND OTHER HELP

            Providing effective treatment or other help for these drinkers who find they cannot control their drinking can be regarded as an obligation of a just and humane society.  The help can take several forms: a specific treatment system for alcohol problems, professional help in general health or welfare systems, or non-professional assistance in mutual-help movements.  To the extent such help is effective, it is also a means of preventing or reducing future alcohol-related problems.

            Treatments for alcohol problems need not be complex or expensive.  The evaluation literature suggests that brief outpatient interventions aimed at changing cognitions and behavior around drinking are as effective in most circumstances as longer and more intensive treatment (Finney and Monahan, 1996; Long et al., 1998).   Positive results from such interventions in a primary health care settings were shown in a WHO study including a number of countries (Babor and Grant, 1994).

            Evidence on effectiveness  In terms of the effects of treatment on those who come for it, there is good evidence of  effectiveness of treatment for alcohol problem.  Typically, the improvement rate from a single episode of treatment is about 20% higher than the no-treatment condition.  Further treatment episodes are often needed.   Brief treatment interventions or mutual-help approaches usually result in net savings in social and health costs associated with the heavy drinker (at least where health care is not self-paid), as well as improving the quality of life (Holder et al., 1992; Holder and Cunningham, 1992).

            The effectiveness of providing treatment as a strategy for reducing rates of alcohol problems in a society is more equivocal.  In a North American context, it has been argued that the steep increase in alcohol problems treatment provision and mutual-help group membership in recent decades has contributed to reducing alcohol problems rates (Smart and Mann, 1990).  But the strength of the evidence for this contention is disputed (Holder, 1997; Smart and Mann, 1997).  A treatment system for alcohol problems is an important part of an integrated national alcohol policy, but as an instrument of prevention -- of reducing societal rates of alcohol problems -- it is probably not cost-effective.

 

BUILDING INTEGRATED ALCOHOL POLICIES

ALCOHOL POLICY AT A COMMUNITY OR SOCIETAL LEVEL

            Often the different strategies for preventing alcohol problems appear to be synergistic in their effects (DeJong and Hingson, 1998).  Controls of availability, for instance, are more likely to be adopted, continued and respected when the public has been successfully persuaded of  their effects and effectiveness. But strategies can also work at cross-purposes: a prohibition policy, for instance, makes it difficult to pursue measures which insulate drinking from harm.

            In a society where alcohol is a regular item of consumption, in view of the resulting rates of alcohol-related social and health problems, there is a strong justification for adopting a comprehensive policy concerning alcohol, taking into account production, marketing and consumption, and the prevention and treatment of alcohol-related problems.  In recent years, the idea that there should be an integrated alcohol policy at community or national levels, reaching across the many sectors of government and civil society which deal with alcohol issues, has become a common public health aim, although accomplishing this in practice has often proved difficult (Room, 1999).  

            In terms of strategies we have reviewed for managing and reducing the rates of alcohol problems in the society, there is a clear evidence for effectiveness and cost-effectiveness of measures regulating the availability and conditions of use, and measures which insulate use from harm.  With respect to some aspects of alcohol problems, notably drinking-driving, deterrence measures also fall in the same category.  Despite their perennial popularity, evidence of the effectiveness of education/persuasion and treatment strategies in reducing societal rates of problems is limited at best. Education and treatment are good things for a society and a government to be doing about alcohol problems, but they do not constitute in themselves a public health policy on alcohol. These strategies will be nevertheless be pursued in most societies, and they can best pursued with attention to using cost-effective methods, and to integrating targets and messages with other aspects of alcohol policy.

 

ALCOHOL POLICY IN A GLOBAL PERSPECTIVE

            Apart from agreements a century ago among the European colonial powers about control of the spirits trade in Africa (Bruun et al., 1975b), there is little tradition of collaboration on alcohol policy at the international level.  It has been largely up to each nation to cope on its own with the serious social and health problems associated with drinking. Though alcohol smuggling has a long history, the nation-state could usually rely on distances and traditional trade barriers to keep alcohol issues largely a matter within its borders, in terms of the supply as well as of the problems.

            The last 15 years of the 20th century saw an accelerated rate of economic globalization that increasingly rendered obsolete the assumption that alcohol issues are local issues.  This globalization affected alcohol issues in three main ways.  The first of these was the influence of a global ideology of free markets.  In its sweep, this ideology caught up and dismantled a variety of market arrangements which served to hold down and to structure alcohol consumption.  State and provincial alcohol monopolies in North America were weakened or dismantled (Her et al., 1999).  In eastern Europe and the countries in transition, alcohol monopolies were swept away along with most other government intrusions in the market (Moskalewicz, 1993). Many of the municipally-run beerhalls in southern African countries were privatized (Jernigan, 1997).   In line with the general ideology, privatization of alcohol production and distribution was often suggested, abetted or imposed on developing countries by international development agencies (White and Batia, 1998).

            Secondly, trade agreements, trade dispute mechanisms and the growth of new sales media effectively reduced the ability of national and subnational governments to control their local alcohol markets.  The influence of trade agreements and trade dispute decisions in breaking down alcohol controls, including control of price through taxation, has been most fully documented for North America (Ferris et al., 1993) and Europe (Tigerstedt, 1990; Holder et al., 1998), but these mechanisms also operate in the developing world.  For instance, the average tax on alcoholic beverages in South Korea is likely to be pushed down early in the 2000s as a result of complaints to the World Trade Organization by the European Union and the U.S. (Anonymous, 1997; 1999).  Sales of alcoholic beverages through the internet have become a fast-growing threat to national or local control of alcohol markets (Apple, 1999).

            Third, alcohol production, distribution and marketing became increasingly globalized (Jernigan, 1997).  Transnational alcohol companies expanded rapidly into the developing world and the countries in transition in search of new markets, benefiting from weak policy environments and the sweeping tide of market liberalization. Though most alcoholic beverages are still produced in the country in which they are sold, industrially-produced beverages were increasingly produced in plants owned, co-owned or licensed by multinational firms.  To promote increased sales, these firms have been able to transform and step up the marketing techniques used in the national market, bringing to bear all the marketing resources and expertise they have developed in other markets.

            In light of these converging trends, there is a growing need for mechanisms to express public health interests in alcohol issues at the international level, both in trade agreements and settlements of trade disputes, and in creating mutual obligations for one nation to back up rather than subvert the alcohol regulations and policies of another.  If these needs are to be met, the public health interests may be expressed through the World Health Organization or through new international bodies.  

           

AUTHOR’S NOTE: Portions of this article are adapted from the article, “Prevention of alcohol-related problems”, in the New Oxford Textbook of Psychiatry.

                       

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