Addiction 92 (Supplement):S7-S11, 1997.
Drinkers derive both pleasure and pain from drinking, but harm may come also to others. Through religious or secular rules, societies have sought to limit these "externalities" of drinking. Societal reactions have primarily focused on social harms from drinking; policy attention to casualties and chronic health effects is fairly recent. Drinking behaviour varies greatly according to the cultural framing of alcohol; societal policies tend to vary accordingly.
Ecological constraints and social norms on preparation and use meant that
alcohol was often available only sporadically in tribal and village societies.
Alcohol production has been increasingly industrialized and marketing increasingly
globalized in the modern era. Now, free trade agreements and the doctrine of
consumer sovereignty increasingly limit the scope of national alcohol control
policies. On the other hand, modern society demands exacting standards of
attention and care incompatible with intoxication, for instance when driving a car
or minding children. Managing the conflict between these and alcohol's ready
availability is seen as a wholly individual rather than a societal responsibility.
Those who fail the task are defined as alcoholics, and modern western states have
increasingly provided treatment for them. While there is a renewed public health
concern about the externalities of drinking, substantial reductions have historically
often required the mobilization of strong popular movements of remoralization.
Throughout the thousands of years of human experience with alcoholic beverages, it has been recognized that drinking is a source of both pleasure and harm. The pleasure is mostly experienced by the individual drinker, or collectively by the members of a sociable drinking group. The harm may also be experienced by the drinker, whether in the form of a short-term effect like a hangover, an injury, or an overdose, or a long-term effect like liver cirrhosis, throat cancer, or an encephalopathy. But a person's drinking can also bring harm to others; for example:
the members of the drinking group may get into an argument, and the occasion may end in a fight or even a death;
the drinker's family finances may be harmed by the money spent on drinking;
others may be injured by a drinker made clumsy or quarrelsome by drinking;
drinking may lead the drinker to perform major family or work roles badly or not at all, thus harming other members of the family or those depending on or sharing in the work; or
too many people drinking too much may have harmful effects on a society as a whole, resulting in such effects as a loss of productivity, an endemic neglect of children's upbringing, or a neglect of rituals central to the culture.
To use an economist's term, drinking thus carries with it externalities -- costs which do not accrue to the drinker, and which thus may not be taken into account when the drinker makes cost/benefit decisions about drinking.
From the time of the first records we have of laws and customs, societies have endeavoured to redress this balance, to limit drinking so as to limit the harm, or to forbid particular drinking patterns or behaviours while drinking that are seen as likely to lead to harm. These limits or disincentives on individual choice with respect to drinking have been both religious and secular. Most of the major world religions -- those with hundreds of millions of adherents -- urge abstention on believers. Christianity is of course the major exception, though a number of Christian denominations do require abstinence. Secular controls are as much in the form of social customs and norms as in the form of laws and regulatory controls. They may be quite stringent and severely applied -- like the death penalty in ancient Rome for any drinking by wives -- or they may be subtle and enforced by a lifted eyebrow -- like the look from a spouse when a drinker contemplates ordering one too many for the road.
Examining the historical ethnographic record, we find that alcoholic beverages were known and used in most traditional societies, though not in some aboriginal cultures in North America and Oceania (Marshall, 1979). In many societies, particularly in temperate rather than tropical zones, alcoholic beverages were only available sporadically or as luxury goods. In agrarian societies, preparing alcoholic beverages depended on the existence of an agricultural surplus, and in a warm climate beverages like ale or beer had to be consumed within a few days of preparation. Traditional drinking patterns in many societies thus took on a "fiesta" pattern, where the year was marked off with periodic communal festivals of drinking and often of drunkenness. In wine-drinking cultures, there was less incentive to drink up the supply before it spoiled, since wines could be stored and used throughout the year. But constraints on availability and of resources limited the drinking of most people in most traditional societies.
Cultural norms and customs around preparation and drinking have also often served as limits on consumption. In many African village societies, for instance, the preparation of alcoholic beverages was women's work, while the drinking of them was the men's prerogative (Colson and Scudder, 1988; Partanen, 1991), an arrangement which tended to set limits on availability. Drinking has often been culturally limited to particular occasions and to particular statuses. In many societies, drinking or heavy drinking has been limited to adult men, and sometimes to particular age-grades or statuses within this group (Roizen, 1986). Generally speaking, drinking has been a prerogative particularly of the powerful, and has often been forbidden to those in subordinate statuses -- women, children, slaves, or prisoners (Knupfer & Room, 1964). Except with regard to children and prisoners, such sumptuary laws are mostly absent in modern industrial societies. These societies tend to have a formal norm of universality with respect to rules on consumption, although there are persistent normative expectations, for instance, that women will drink less than men.
Until recently, it has been rare for any society to focus on alcohol's effects on health as a criterion of state policy. Typically, it has been social harms from drinking which have been the main consideration (besides revenue generation) in alcohol policy. This has been the case, for instance, in European states in recent centuries. The concerns have included public disorder and violence, the labour supply and productivity, and role functioning in family and parental roles. Serious societal concern about the role of alcohol in accidents is a matter only of the last 60 years, focused of course around drunken driving (Aarens et al., 1977). Concern over the physical health of drinkers and their families was only a secondary concern in the societal response to the English gin epidemic of the 18th Century and in the great temperance movements of the 19th and early 20th centuries. The French government campaign symbolized by Mendès-France's famous glass of milk in 1954 (Prestwich, 1988:269) may be regarded as the beginning of a public concern by the modern state specifically with the long-term health effects of heavy drinking.
As a psychoactive and potentially intoxicating substance, alcohol affects our feelings and cognitions. Due to the build-up of tolerance, these effects are weaker for daily regular drinkers than for occasional drinkers. How the psychoactive changes are expressed in behaviour is also subject to cultural framing and expectations (Room & Collins, 1983). In Northern European cultures and in many developing societies -- where drinking has mostly been intermittent rather than daily -- alcohol is regarded as a powerful substance able to transform behaviour, while drinkers in Southern European wine cultures -- where daily drinking is common -- are expected to display as few changes as possible in their behaviour and demeanour after drinking. Particular cultural expectations about drinking behaviour are often longstanding and resistant to change, although apparently not always immutable.
Cultural expectations about the effects of alcohol tend to be reflected in societal policies on alcohol availability. In Southern European cultures, wine is banalized as an everyday beverage, taxes on it are low or nonexistent, and media discussions tend to look elsewhere -- to youthful beer-drinking, for instance -- for the location of any alcohol problems. At the opposite extreme, some aboriginal villages or groups in North America and elsewhere, viewing customary drinking behaviours as extremely disruptive of social life and the community, endeavour to prohibit all alcohol in the community. Many societies take positions between these extremes. What might be called a "harm reduction" approach has been common: societies often try to limit heavy consumption with high tax policies and with restrictions on sales, and to limit harm by structuring the circumstances of drinking and by forbidding dangerous behaviours like driving after drinking.
While societies differ in the cultural position of drinking and in their definitions of and responses to alcohol-related problems, the production and marketing of alcohol has become more uniform, more industrial, and more global. At an accelerating pace over the course of the past several centuries, alcoholic beverages have moved from being products produced locally by specialized crafts in small batches to being products of large-scale industries and distributed through a wide network. With the shift of distilled spirits in early modern Europe from a specialized status in medicines to regular use as an intoxicant, alcoholic beverages could be produced and distributed more cheaply, and could be stored or transported without spoiling. Distilled spirits were indeed a chief instrument of trade and exploitation at the frontiers of the European colonial expansion (see, for example, Pan, 1975; MacAndrew & Edgerton, 1969). With fortification and eventually with pasteurization, wine also took on some of the same functions. Where full-strength wine had been an unaffordable luxury for everyday use even by those who produced it in Southern Europe, the agricultural revolutions of the 19th and 20th centuries brought large increases in wine consumption as standards of living rose; accordingly, wine consumption in France rose dramatically in the course of the 19th century (Prestwich, 1988). In the 20th century, pasteurization and innovations in refrigeration and in packaging turned beer, too, from a perishable to a stable commodity, capable of being transported long distances to market (Fogarty, 1985).
The production of alcoholic beverages has thus become increasingly industrialized, not only in developed countries but all over the world. Control of alcoholic beverage production and consumption is increasingly in the hands of multinational corporations. European-style beverages -- particularly lager-style beers -- have increasingly replaced traditional indigenous beverages such as pulque in Mexico, opaque beers in Africa, and shochu in Japan. The concentration of control of alcoholic beverage markets, and the push of multinational corporations into new markets, has been greatly assisted by the growth of free-trade areas and agreements and of an ideology of free trade. In this ideological perspective, local alcohol control structures which may limit the harm from drinking are attacked as impediments to free trade, and free-trade agreements have been instruments for producers and governments from elsewhere to break down local controls (Ferris et al., 1993).
For other commodities which potentially threaten public health or order, international agreements exist by which nations control exports and support each other's market controls. This is notably the case for psychoactive drugs under international control. But for alcohol (as for tobacco) no such agreements exist (Bruun et al., 1975), and it is considered appropriate and indeed a source of national pride for nations to seek to maximize exports, thus reaping the revenues while imposing on the importing society the costs and harm associated with actual consumption of alcoholic beverages. The drift towards an ethic of free international trade in alcoholic beverages particularly threatens one of the most effective public health tools for limiting alcohol-related harm, since smuggling or duty-free cross-border transportation can effectively undercut taxes designed to discourage heavy consumption (Tigerstedt, 1990).
The ethic of free trade at the international level is a reflection of the doctrine of consumer sovereignty in modern industrial societies. With the application of this doctrine to alcoholic beverages, they become just another set of commodities on the supermarket shelf, with purchase and consumption by the adult customer limited only by the ability to pay. Hours of sale are extended and places of sale multiplied on the rationale of maximizing consumer convenience. Controlling consumption and any harms related to it becomes a responsibility solely of the individual consumer, rather than also a societal responsibility.
On the other hand, modern societies also impose increased responsibility on the individual for clear-minded and rational behaviour -- behaviour, in other words, that does not result in externalities. In many developed societies, a majority of adults regularly perform exacting tasks -- driving an automobile, operating heavy machinery -- where a few drinks are a threat to safety. Parents are expected to mind their small children carefully, and couples are expected to settle their disagreements without physical violence; heavy drinking threatens both of these expectations. In many societies, a strict sobriety is expected of workers when they are on the job.
For an intoxicating commodity like alcoholic beverages, there is an obvious conflict in modern societies between the doctrine of consumer sovereignty and these increasingly exacting standards of care and attention. The solution to this cultural dilemma has been to place the burden of managing the conflict (and the blame for failure) on the individual. Drinkers are conceptually divided into two classes: "normal drinkers", able to drink without externalities, and "alcoholics", who cannot. The concept of inebriety (later renamed alcoholism) as a mysterious disease which afflicted those unable to manage their drinking first became popular in the nineteenth century, in the wake of the distilled spirits "epidemics" of the 18th century and of the advent of the industrial revolution (Levine, 1978). The disease concept of alcoholism gained new favour with the decline of temperance movements and the failure of national alcohol prohibition policies. In the last forty years, many societies in Europe and elsewhere have built substantial provision for alcoholism treatment (Klingemann et al., 1992). Mutual-help movements centring on alcohol problems, such as Alcoholics Anonymous, have taken on a global significance (Mäkelä et al., 1996; Room, 1995). With their emphasis on identifying the problems of alcohol with the defective individual rather than with dilemmas in social policy, the disease concept of alcoholism and the growth of alcoholism treatment provide a rationale for applying the doctrine of consumer sovereignty to alcohol and dismantling controls on alcohol availability; "in this way, the expansion of the treatment system may be seen as a kind of cultural alibi for the normalization of drinking and the relaxation of controls" (Mäkelä et al., 1981:65).
Ironically, those who staff the new treatment services for alcoholism have eventually in many places moved towards advocacy for alcohol policies that accept societal as well as individual responsibility for limiting the harm from drinking. As this conference exemplifies, a renewed concern about alcohol problems and about prevention strategies at a societal level has emerged in the discourse of public health (Room, 1984).
But the historical record suggests that the task of limiting the damage from drinking will
not be accomplished only by mobilizing experts and technological solutions, nor by focusing only
on the chronic illnesses of heavy drinking. In the great "long waves of consumption" (Mäkelä et
al., 1981) and of alcohol-related harm which have characterized trends in drinking in the last
couple of centuries in many countries, there have been periodic downturns in consumption and
in rates of alcohol-related problems. But accomplishing a substantial downturn of trends in harm
has often required the mobilization of strong popular movements over a substantial period of time
(Blocker, 1989). However uncomfortable it may make us as rationalist experts, we should
recognize that a strong moral tone has marked these movements -- often indeed a tone of religious
revivalism. This should not surprise us, since the "externalities" of drinking often involve
fundamental issues with strong moral dimensions -- not only the more public issues such as safety
in the streets or national productivity, but also issues more in the private sphere such as power
relations between the genders, the duties which family members owe each other, and parents'
hopes and fears for their children.
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