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.
REFERENCES
Andréasson, S.,
Romelsjö, A. and Allebeck, P. (1991) Alcohol, social factors and mortality
among young men, British Journal of Addiction, 86, 877-887.
Anonymous (1996).
Europe unites in Paris. The Globe 1/1996, 1-22.
Anonymous (1997). Pressure on liquor
tax system mounts; U.S. files complaint against Korea with WTO. The Korea
Herald, 27 May.
Anonymous (1999). Tax rate on soju
still unresolved. The Korea Herald, 31 October
Apple, R.W. (1999).
Zinfandel by mail? New York Times, 19 May.
Babor, T.F. and
Grant, M., with 17 others (1994). Randomized clinical trial of brief
interventions in primary health care: summary of a WHO project (with
commentaries and a response). Addiction, 89, 657-678.
Baggott, R. (1990) Alcohol,
politics and social policy. Avebury, Aldershot, UK, etc.
Beck, J. (1998).
100 years of “just say no” versus “just say know”, Evaluation Review, 22,15-45.
Beauchamp, D.
(1976) Exploring new ethics for public health: developing a fair alcohol
policy. Journal of Health Politics, Policy and Law, 1, 338-354.
Blocker, J. (1989).
American temperance movements: cycles of reform. Twayne Publishers,
Boston.
Bondy, S.J., Rehm,
J., Ashley, M.J., Walsh, G., Single, E., and Room, R. (1999). Low-risk drinking
guidelines: the scientific evidence. Canadian Journal of Public Health, 90,
272-276.
Botvin, G.J.
(1995). Principles of prevention. In Handbook
on drug abuse prevention: a comprehensive strategy to prevent the abuse of
alcohol and other drugs (ed. R.H. Coombs and D. Ziedonis), pp. 19-44. Allyn
and Bacon, Boston.
Bruun, K., Edwards,
G., Lumio, M., Mäkelä, K., Pan, L., Popham, R.E., Room, R., Schmidt, W., Skog,
O-J., Sulkunen, P. and Österberg, E. (1975a) Alcohol control policies in
public health perspective. FFAS Vol. 25.
Finnish Foundation for Alcohol Studies, Helsinki.
Bruun, K., Rexed,
I., and Pan, L. (1975b) The gentlemen’s club. University of Chicago
Press, Chicago.
Carmona, M. and
Stewart, K. (1996). Review of
alternative activities and alternatives programs in youth-oriented prevention,
CSAP Technical Report 13. Center for
Substance Abuse Prevention, Rockville, MD.
Casswell, S.
(1995). Does alcohol advertising have an impact on public health? Drug and
Alcohol Review, 14, 395-404.
Casswell, S.,
Gilmore, L., Maguire, V. and Ransom, R. (1989) Changes in public support for
alcohol policies following a community-based campaign, British Journal of
Addiction, 84, 515-522.
Casswell, S., and
Zhang, J.F. (1998). Impact of liking for
advertising and brand allegiance on drinking and alcohol-related aggression: a
longitudinal study. Addiction, 93, 1209-1217.
Catlin, G.E.G.
(1931) Liquor control. Home University Library. Thornton Butterworth, London.
Chadwick, D.J. and
Goode, J.A., eds. (1998) Alcohol and cardiovascular diseases. John Wiley
& Sons, Chichester etc.
Cook, P. (1981)
Effect of liquor taxes on drinking, cirrhosis, and auto accidents. In Alcohol and public policy: beyond the
shadow of prohibition, (ed. M.H. Moore and D.R. Gerstein), pp.
255-285. National Academy Press,
Washington, DC.
Cook, P.J. and
Moore, M.H. (1993). Violence reduction through restrictions on alcohol
availability. Alcohol Health and Research World, 17, 151-156.
Criqui, M., et al.
(1998) [Discussion]. In Alcohol and cardiovascular diseases (ed. D.J.
Chadwick and J.A. Goode), pp. 122-124. John Wiley & Sons, Chichester etc.
Cross, J.N. (1968) Guide
to the Community Control of Alcoholism. American Public Health Association,
New York.
de Lint, J. and
Schmidt, W. (1968) The distribution of alcohol consumption in Ontario. Quarterly
Journal of Studies on Alcohol, 29, 968-973.
DeJong, W. and
Hingson, R. (1998). Strategies to reduce driving under the influence of
alcohol, Annual Review of Public Health, 19, 359-378.
Edwards, G.,
Anderson, P., Babor, T.F., Casswell, S., Ferrence, R., Giesbrecht, N., Godfrey,
C., Holder, H.D., Lemmens, P., Mäkelä, K., Midanik, L.T., Norström, T.,
Österberg, E., Romelsjö, A., Room, R., Simpura, J., and Skog, O.-J. (1994) Alcohol
policy and the public good. Oxford University Press, Oxford, etc.
Emerson, H., ed.
(1932) Alcohol and man: the effects of alcohol on man in health and disease.
Macmillan, New York.
English, D.R.,
Holman, C.D.J., Milne, E., Winter, M.G., Hulse, G.K., Codde, J.P., Bower, C.I.,
Corti, B., Dawes, V., de Klerk, N., Knuiman, M.W., Kurinczuk, J., Lewin, G.F.
and Ryan, G.A. (1995). The quantification of drug caused morbidity and
mortality in Australia, in 2 parts. Australian Government Publishing
Service, Canberra.
Evans, L. (1991). Traffic
safety and the driver. Van Nostrand
Reinhold, New York.
Ferris, J., Room,
R., and Giesbrecht, N. (1993). Public health interests in trade agreements on
alcoholic beverages in North America. Alcohol Health and Research World,
17, 235-241.
Finney, J.W. and
Monahan, S.C. (1998). Cost-effectiveness of treatment for alcoholism: a second
approximation. Journal of Studies on Alcohol, 57, 229-243.
Forsyth, I. (1996). Alcohol and drugs: the role of insurance
in promoting effective countermeasures.
In Proceedings of the Conference, Road Safety in Europe and Strategic
Highway Research Program (SHRP). VTI
Conferens No. 4A, part 3, pp. 45-63.
Swedish National Road and Transport Safety Institute, Linköping, Sweden.
Giesbrecht, N.,
Conley, P., Denniston, R., Gliksman, L., Holder, H., Pederson, A., Room, R.,
and Shain, M., eds. (1990). Research, action and the community: experiences
in the prevention of alcohol and other drug problems. DHHS Publication No.
(ADM) 89-1651. Office of Substance Abuse Prevention, Rockville, MD.
Graham, K.,
Leonard, K.E., Room, R., Wild, T.C., Pihl, R.O., Bois, C. and Single, E. (1998)
Current directions in research on understanding and preventing intoxicated
aggression, Addiction, 93, 659-676.
Grant, M. and
Litvak, J. (1998) Introduction: beyond per capita consumption. In Drinking patterns and their
consequences (ed. M. Grant & J. Litvak), pp. 1-4.Taylor and Francis,
Washington DC.
Greenfield, T and
Zimmerman, R., eds. (1993) Experiences with community action projects: new
research in the prevention of alcohol and other drug problems. DHHS
Publication No. (ADM) 93-1976. Center for Substance Abuse Prevention,
Rockville, MD.
Grover, P.T., ed..
(1999). Preventing problems related to alcohol availability: environmental
approaches: reference guide. DHHS Publication No. SMA 99-3298. Center for Substance Abuse Prevention,
Washington, DC. Available on the web at:
http://text.nlm.nih.gov/ftrs/dbaccess/csap
Hawks, D. (1993)
The formulation of Australia’s National Health Policy on Alcohol. Addiction,
88 (Supplement), 19S-26S.
Hawks, D. (1994) A
review of current guidelines on moderate drinking for individual consumers. Contemporary
Drug Problems, 21, 223-237.
Hemström, Ö.
(2000). Per capita alcohol consumption and ischaemic heart disease mortality,
presented at a meeting of the European Comparative Alcohol Study,
Stockholm,12-14 January.
Her, M.,
Giesbrecht, N., Room, R. and Rehm, J. (1999). Privatizing alcohol sales and
alcohol consumption: evidence and implications, Addiction, 94,
1125-1139.
Her, M. and Rehm,
J. (1998). Alcohol and all-cause mortality in Europe 1982-1990: a pooled
cross-section time-series analysis. Addiction, 93, 1335-1340.
Herd, D. (1992)
Ideology, history and changing models of liver cirrhosis epidemiology. British
Journal of Addiction 87, 179-192.
Hingson, R. (1996).
Prevention of drinking and driving, Alcohol Health and Research World, 20,
219-226.
Holder, H. (1997).
Can individually directed interventions reduce population-level
alcohol-involved problems? Addiction, 92, 5-7.
Holder, H.D. (1998)
Alcohol and the community: a systems approach to prevention. Cambridge, UK:
Cambridge University Press, Cambridge etc.
Holder, H.D. and
Cunningham, D.W. (1992). Alcoholism treatment for employees and family members:
its effect on health care costs, Alcohol Health and Research World, 16,
149-153.
Holder, H.D.,
Kühlhorn, E., Nordlund, S., Österberg, E., Romelsjö, A., and Ugland, T. (1998) European
integration and Nordic alcohol policies, Ashgate, Aldershot UK etc.
Holder, H.D., Lennox, R.D.L., and Blose, J.O. (1992).
Economic benefits of alcoholism treatment: a summary of twenty years of
research, Journal of Employee Assistance Research, 1, 63-82.
Holman, C.D.J. and
English, D.R. (1995). Improved aetiologic fraction for alcohol-caused
mortality. Australian Journal of Public Health, 19, 138-141.
Holmila, M., ed.
(1997) Community Prevention of Alcohol Problems. Macmillan, Basingstoke,
UK.
Hurst, W., Gregory,
E. and Gussman, T. (1997). International survey: alcoholic beverage taxation
and control policies. Brewers Association of Canada, Ottawa.
Järvinen, M.
(1991). The controlled controllers: women, men and alcohol. Contemporary
Drug Problems, 18, 389-406.
Jernigan, D.H.
(1997) Thirsting for markets: the global impact of corporate alcohol.
Marin Institute for the Prevention of Alcohol and Other Drug Problems, San
Rafael, CA.
Katcher, B.S.
(1993) The post-Repeal eclipse in knowledge about the harmful effects of
alcohol. Addiction, 88, 729-744.
Kauhanen, J.,
Kaplan, G.A., Goldberg, D.E., and Salonen, J.T. (1997) Beer bingeing and
mortality: results from the Kuopio ischaemic heart disease risk factor study, a
prospective population-based study. British Medical Journal, 315,
846-851.
Klatsky, A.L.
(1999) Moderate drinking and reduced risk of heart disease, Alcohol Research
and Health, 23(1), 15-23.
Knupfer, G. (1967)
The epidemiology of problem drinking. American Journal of Public Health,
57, 973-986.
Kozlowski, L.T.,
Heller, D.A., Pillitteri, J.L. and Rovine, M. (1994) Tobaccco use, the health
effects of moderate alcohol drinking, and the assessment of their interaction. Contemporary
Drug Problems, 21, 81-89.
Kreitman, N. (1986)
Alcohol consumption and the preventive paradox. British Journal of Addiction
81, 353-363.
Kupari, M. and
Koskinen, P. (1998) Alcohol, cardiac arrhythmias and sudden death. In Alcohol
and cardiovascular diseases (ed. D.J. Chadwick and J.A. Goode), pp. 68-79.
John Wiley & Sons, Chichester etc.
Ledermann, S.
(1956) Alcool, alcoolisme, alcoolisation. INED Cahier No. 29. Presses Universitaires de
France, Paris.
Leino, E.V.,
Romelsjö, A., Shoemaker, C., Ager, C.R., Allebeck, P., Ferrer, H.P., Fillmore,
K.M., Golding, J.M., Graves, K.L. and Kniep, S. Alcohol consumption and
mortality: II. Studies of male populations. Addiction, 93,
205-218.
Leon, D.A., Chenet,
L., Shkolnikov, V.M., Zakharov, S., Shapiro, J., Rakhmanova, G., Vassin, S. and
McKee, M. (1998). Huge variation in
Russian mortality rates 1984-94: artefact, alcohol, or what? Lancet, 350,
383-388.
Levine, H.G. (1991)
Temperance cultures: concern about alcohol problems in Nordic and
English-speaking cultures. In: The nature of alcohol and drug related
problems (ed. M. Lader, G. Edwards and D.C. Drummond), pp. 15-36.
Long, C.G.,
Williams, M. and Hollin, C.R. (1998).
Treating alcohol problems: a study of program effectiveness and cost
effectiveness according to length and delivery of treatment, Addiction, 93,
561-571.
MacAndrew, C. and
Edgerton, R.E. (1969). Drunken comportment. Aldine, Chicago.
Murray, C.J.L and
Lopez, A.D. (1996). Quantifying the burden of disease and injury attributable
to ten major risk factors. In: The
global burden of disease: a comprehensive assessment of mortality and
disability from diseases, injuries and risk factors in 1990 and projected to
2020 (ed. C.J.L. Murray and A.D. Lopez), pp. 295-324. Harvard School of Public Health, Cambridge,
Mass.
Maclure, M. (1993)
Demonstration of deductive meta-analysis: ethanol intake and risk of myocardial
infarction. Epidemiologic Reviews, 15, 328-351.
Mäkelä, K. (1983)
The uses of alcohol and their cultural regulation. Acta Sociologica, 26,
21-31.
McKee, M. and
Britton, A. (1998) The positive relationship between alcohol and heart disease
in eastern Europe: potential physiological mechanisms. Journal of the Royal
Society of Medicine, 91, 402-407.
Moore, M.H. and
Gerstein, D.R., eds. (1981) Alcohol and public policy: beyond the shadow of
Prohibition. National Academy Press, Washington, DC.
Moskalewicz, J.
(1993). Privatization of the alcohol arena in Poland. Contemporary Drug
Problems, 20, 63-275.
Moskowitz, J.M.,
Mailvin, J., Schaeffer, G.A., and Schaps, E. (1983). Evaluation of a junior
high school primary prevention program, Addictive Behaviors, 8,
393-401.
Mott, G. (1991) The
anti-alcohol network, Moderation Reader, 5(5), 6-20.
NIAAA (1997).
Alcohol and the immune system. In Ninth
special report to the U.S. Congress on alcohol and health, pp. 163-169. NIH
Publication No. 97-4017. Rockville MD: National Institute on Alcohol Abuse and
Alcoholism.
Neves, P., de Pape,
D., Giesbrecht, N., Kobus-Matthews, M., Kruzel, E., Abbott, D., Cusenza, S.,
Gliksman, L., Hyndman, B., Oliver, R., and Single, E. (1998) Communities
take action! A practical guide for municipalities, enforcement agencies,
community groups and others concerned about the impact of alcohol on public
health and safety. Addiction Research Foundation, Toronto.
Norman, E., Turner,
S., Zunz, S.J. and Stillson, K. (1997)
Prevention programs reviewed: what works? In Drug-free youth: a compendium for
prevention specialists (ed. E. Norman), pp. 22-45. Garland Publishing, New York.
Norström, T.
(1987). Abolition of the Swedish rationing system: effects on consumption
distribution and cirrhosis mortality. British Journal of Addiction, 82,
633-641.
Norström,
T.(1996). Per capita consumption and
total mortality: an analysis of historical data. Addiction, 91,
339-344.
Norström, T.
(2000). Per capita alcohol consumption and all-cause mortality in 14 European
countries, presented at a meeting of the European Comparative Alcohol Study,
Stockholm, 12-14 January.
Olsson, B. (1990)
Alkoholpolitik och alkoholens fenomenologi: uppfattningar som artikulerats i
pressen [Alcohol policy and the phenomenology of alcohol: conceptiosn
articulated in the press]. Alkoholpolitik, 7, 184-195.
Paglia, A. and
Room, R. (1999). Preventing substance use problems among youth: a literature
review and recommendations, Journal of Primary Prevention, 20,
3-50.
Peele, S. (1987)
The limitations of control-of-supply models for explaining and preventing
alcoholism and drug addiction. Journal of Studies on Alcohol, 48,
61-77.
Perrine, M.W.,
Peck, R.C. and Fell, J.C.(1989). Epidemiologic perspectives on drunk driving.
In: Surgeon General’s Workshop on Drunk Driving: background papers, pp.
35-76. U.S. Department of Health and
Human Services, Washington, DC.
Plant, M., Single, E.,
and Stockwell, T., eds. (1997) Alcohol: minimizing the harm -- what works? Free
Association Books, London & New York.
Poikolainen, K.
(1998) It can be bad for the heart, too -- drinking patterns and coronary heart
disease. Addiction, 93, 1757-1759.
Popham, R.,
Schmidt, W., and de Lint, J. (1976) The effects of legal restraint on drinking.
In The biology of alcoholism: vol. 4.
Social aspects of alcoholism, (ed. B. Kissin & H. Begleiter), pp.
579-625. Plenum, New York & London.
Rehm, J.T. (1999)
Draining the ocean to prevent shark attacks? Nordic Studies on Alcohol and
Drugs, 16 (English Supplement), 46-54.
Rehm, J. and
Sempos, C.T. (1995) Alcohol consumption and all-cause mortality. Addiction,
90, 471-480.
Room, R. (1983).
Alcohol and crime: behavioral aspects. In Encyclopedia of crime and justice,
vol. 1. (ed. S. Kadish), pp. 35-44. Free
Press, New York.
Room, R. (1984a)
Alcohol control and public health. Annual Review of Public Health, 5,
293-317.
Room, R. (1984b). A
‘reverence for strong drink’: the Lost Generation and the elevation of alcohol
in American culture. Journal of Studies on Alcohol, 45, 540-546.
Room, R. (1984c).
Former NIAAA directors look back: policymakers on the role of research. Drinking
and Drug Practices Surveyor, 19, 38-42.
Room, R. (1993).
The evolution of alcohol monopolies and their relevance for public health, Contemporary
Drug Problems, 20, 169-187.
Room, R. (1996)
Alcohol consumption and social harm -- conceptual issues and historical
perspectives, Contemporary Drug Problems, 23, 373-388.
Room, R. (1997).
Voluntary organizations and the state in the prevention of alcohol problems, Drugs
and Society, 11, 11-23.
Room, R. (1999) The
idea of alcohol policy. Nordic Studies on Alcohol and Drugs, 16
(English Supplement), 7-20.
Rorabaugh, W.J.
(1979). The alcoholic republic. Oxford University Press, New York.
Rose, G. (1981)
Strategy of prevention: lessons from cardiovascular disease. British Medical
Journal, 282, 1847-1851.
Seeley, J.R. (1960)
Death by liver cirrhosis and the price of beverage alcohol. Canadian Medical
Association Journal 83, 1361-1366.
Ross, H.L. (1982). Deterring
the drinking driver: legal policy and social control. Lexington Books,
Lexington, MA.
Saffer, H. (1998).
Economic issues in cigarette and alcohol advertising. Journal of Drug Issues,
28, 781-793.
Saltz, R.F. (1997).
Prevention where alcohol is sold and consumed: server intervention and
responsible beverage service. In Alcohol:
minimizing the harm: what works? (ed. M.Plant, E. Single and T. Stockwell),
pp. 72-84. Free Association Books, New
York.
Schechter, E.J.
(1986). Alcohol rationing and control systems in Greenland, Contemporary
Drug Problems, 13:587-620.
Shkolnikov, V.M.
& Nemtsov, A. (1997). The anti-alcohol campaign and variations in Russian mortality.
In: Premature death in the new independent states, (ed. J.L. Bobadilla,
C.A. Costello, & F. Mitchell), pp. 239-261.
National Academy Press, Washington.
Skog, O.-J. (1985)
The collectivity of drinking cultures: a theory of the distribution of alcohol
consumption. British Journal of Addiction, 80, 83-99.
Skog, O.-J. (1996)
Public health consequences of the J-curve hypothesis of alcohol problems. Addiction,
91, 325-337.
Smart, R.G. and
Mann, R.E. (1990). Are increased levels of treatment and Alcoholics Anonymous
large enough to create the recent reduction in liver cirrhosis? British
Journal of Addiction, 85, 1385-1387.
Smart, R.G. and
Mann, R.E. (1997). Interventions into alcohol problems: what works? Addiction,
92, 9-13.
Stockwell, T.,
Single, E., Hawks, D. and Rehm, D. (1997) Sharpening the focus of alcohol
policy from aggregate consumption to harm and risk reduction, Addiction
Research, 5, 1-9.
Sutton, C. (1998) Swedish
alcohol discourse: constructions of a social problem. Acta Universitatis
Upsaliensis, Studia Sociologica Upsaliensia 45, Uppsala.
Teasley, D.L.
(1992). Drug legalization and the “lessons” of Prohibition, Contemporary
Drug Problems, 19, 27-52.
Terris, M. (1967).
Epidemiology of cirrhosis of the liver: national mortality data. American
Journal of Public Health, 57, 2076-2088.
Tigerstedt, C.
(1990). The European Community and the alcohol policy dimension. Contemporary
Drug Problems, 17, 461-479.
Tigerstedt, C.
(1999). Alcohol policy, public health, and Kettil Bruun. Contemporary Drug Problems,
26, 209-235.
White, O.C., and
Batia, A. (1998) Privatization in
Africa. World Bank, Washington.
Whitehead, P.C.
(1979) Prevention of alcoholism. In: Alcohol problems (ed. D. Robinson).
Holmes and Meier, New York.
Wolfgang, M.E.
(1958). Patterns in criminal homicide. University of Pennsylvania
Press, Philadelphia.
World Health
Organization, Expert Committee on Problems Related to Alcohol Consumption
(1980). Problems related to alcohol consumption. Technical Report Series
650. WHO, Geneva.
Wyllie, A., Zhang, J.F. and Casswell, S. (1998a).
Positive responses to televised beer advertisements associated with drinking
and problems reported by 18- to 29-year-olds, Addiction, 93,
749-760.
Wyllie, A., Zhang,
J.F. and Casswell, S. (1998b). Responses to televised advertisement associated
with drinking behaviour of 10-17-year-olds, Addiction, 93:361-371.
Zajac, P.L.
(1997). Can technology be used to
intervene in behaviour in a human factors engineering approach to drunk driving
deterrence? Dissertation Abstracts International, 57(9),
4126A-4127A.