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ALCOHOL CONTROL AND THE PUBLIC INTEREST
Centre for Social Research on Alcohol and Drugs
beverages have been known to humankind for all of recorded history, and even
before the European expansion of the last half-millenium fermented beverages
were used in all parts of the world except
Recognition that drinking can bring pain and harm, as well as pleasure, also extends through recorded history. The spectrum of harms from drinking is broad, affecting public health, safety, welfare, and productivity. Alongside private and informal responses, governments have taken a wide spectrum of measures to reduce the harms from drinking. Such measures have often included laws regulating public drinking places, which can be found already in the Code of Hammurabi 3800 years ago (Babor et al., 2003:117).
In public health terminology, regulation of the production and sale of alcohol is often referred to as alcohol control (Room, 1984), by which is meant all regulation of the extent and conditions of alcohol availability, including a variety of measures such as excise taxation, licensing of premises and servers, and regulation of circumstances of sale such as permitted opening hours and days.
In the frame of public health and safety, alcohol
policymaking starts from a consideration of the extent of and trends in problems
related to drinking. These include
social problems as well as health problems, and acute problems as well as
chronic. Considering only the health consequences, and after subtracting out
protective effects on the heart, the World Health Organization’s study of the
Global Burden of Disease in 2000 found that alcohol is the third most important
risk factor for death and disability in developed societies such as the
The relation of drinking levels and patterns to consequences: the individual and the population level
Both the level of drinking over time and the pattern of drinking affect the risks for the individual drinker. The contribution of different aspects of drinking varies for different consequences. Thus risks of problems such as injuries and overdose deaths are primarily depend on drinking on a particular occasion. On the other hand, risks of liver cirrhosis or gastritis or other chronic health consequences of drinking reflect levels of drinking over time. A pattern of relatively frequent light drinking seems to be protective for heart disease for those who are middle-aged or older. Most of this benefit can be gained by drinking as little as one drink every second day. On the other hand, a pattern of recurrent bouts of heavy drinking seems to be bad for the heart (Britton & McKee, 2000).
In recent years, it has become more clearly recognized that these patterns as described at the individual level are only part of the picture when the effect of alcohol consumption on the population as a whole is considered. First, many of the problems from drinking do not occur to the drinker (Room, 1996). Drinking-driving potentially affects other drivers, passengers and pedestrians. Alcohol-fueled violence may hurt family members, acquaintances or strangers. Time and resources spent out drinking may adversely affect children’s upbringing and the quality of family life. Second, amounts of drinking in the population are heavily skewed, with less than 20% of the drinkers typically responsible for more than half of the consumption (Greenfield & Rogers, 1999). What happens among the heavier drinkers may have a disproportionate influence on consequences. Third, in thinking about the population as a whole there is a need to take into account that drinking is primarily a social behaviour. How I drink today is likely to affect how you drink today or tomorrow. If I buy you a round as part of a group at the pub, my expectation is that you will sooner or later buy one for me – and drink another one for yourself at the same time. If I bring a bottle of wine to your dinner-party, the chances are you will bring one to mine the next time. So there is a tendency for changes in drinking in a population to be linked. The result of these three factors is that the risk levels based on individual-level data are not always a good guide to what will happen in the population as a whole as the amount of drinking changes (Skog, 1996).
For many chronic health consequences of drinking, such as liver cirrhosis, what seems to matter most at the population level, in predicting cirrhosis mortality in a given year, is the level of drinking in the previous few years. For drink driving and violence, the dominant patterns of drinking in a population – how much of the consumption leads to intoxication – affects the rate of harm. But customary drinking patterns in a population change only slowly over time (Simpura, 2001). Thus, while dominant patterns of drinking matter for comparisons of one drinking culture with another, they do not make much difference in comparisons over time within a given population. In a given society, it seems that changes in rates of injuries track quite closely changes in the population’s overall level of consumption (Norström, 2002).
For the middle-aged or older individual, the
heart-protective effect is a relevant consideration in choices about
drinking. But the effect is apparently
not important for alcohol policy and controls.
At the levels of drinking which are current in
The conclusion is that, at the
population level, both the level of consumption and the dominant patterns of
drinking matter for problems from drinking.
In terms of patterns, an extra litre of alcohol per capita will have a
greater effect on homicide, for instance, in northern
The warrant for alcohol controls
It may well be asked, what warrant does a government have for acting to reduce rates of alcohol problems in the population? Views differ, for instance, on whether and to what extent it is appropriate for a government to intervene to prevent suicide or other actions impacting primarily on the actor him- or herself. Even for effects which are limited to the actor, however, society at large has an interest in what happens where there are health or welfare costs for society from the actions. Beyond this, many problems from alcohol involve effects on others than the drinker. In the case of such effects, there is wide social consensus that there is a warrant for action, including as needed governmental action. There is no accurate accounting of the harm to others brought by drinking, but it is clearly very substantial. As noted above, it includes very serious harms such as homicide, domestic violence and drink-driving casualties, but also a more broader penumbra of personal conflict and infringement and disturbance of the peace. In a Canadian study, 45% of the population reported that they had experienced a problem as a result of someone else’s drinking in the preceding year. This included 26% who had been disturbed by loud parties or the behaviour of people drinking, 21% who had been insulted or humiliated by someone who had been drinking, 17% who had been in serious arguments or quarrels as a result of someone else’s drinking, 8% with family problems or marriage difficulties due to someone else’s drinking, 7% physically assaulted by someone who had been drinking, and 3% who had had their property vandalized by someone who had been drinking (Eliany et al., 1992).
The idea of establishing an evidence base for alcohol control is not new. For instance, a pioneer British study during the First World War of the effects of restricting the opening hours of pubs at the factory gates found that there were fewer accidents among men and during the first spell of work on a shift, since drinking before going to work had diminished (Collis, 1922). But the modern tradition of studies of the effects of alcohol controls is a product of the last 50 years. We here review briefly the evidence on particular strategies relevant to alcohol licensing and control. A more complete review of the literature can be found in Babor et al. (2003).
Taxation. As with other commodities, the consumption of alcohol is influenced by both price and income. A substantial economic depression is a very effective way of drinking alcohol consumption down, but no-one would argue for this as a deliberate strategy. Taxes on alcohol, which raise the price of alcoholic beverages relative to other choices for the consumer, are an effective strategy for reducing rates of problems from drinking – for instance, drink-driving casualties, cirrhosis and homicides (Cook, 1981; Cook and Moore, 1993). The tradition of relatively high alcohol taxes in Britain, recently considerably eroded (Academy of Medical Sciences, 2004), was not only a source of revenue for the Treasury but also effective in restraining the rates of alcohol-related problems.
Hours and days of sale. British studies of the effects of extending
hours of pub opening on health and drink-driving, which have been few and
rather weak in design, have shown mixed results (Raistrick et al. 1999,
pp. 134-136). Elsewhere, there are a
number of studies which demonstrate that changing either hours or days of
alcohol sale at a minimum redistributes
when alcohol-related crashes and other violent events related to alcohol take
place, which holds implications for rescheduling of police shifts and of public
transportation (e.g., Smith 1988;
Nordlund 1985). More recent studies in
Concentration and density of alcohol outlets. Cross-sectional studies suggest that alcohol-related problems, especially motor vehicle crashes, are more likely to occur where drinking places are more densely packed (Jewell & Brown 1995). These results appear to extend to other pedestrian injury collisions (LaScala et al. 2000) and violent assaults (Alaniz et al., 1998; Stevenson et al., 1998).
Studies of the density of outlets have also found an effect of increased
numbers of outlets on alcohol problem rates.
A time-series study of changes in the number of on-premise outlets
In general, it is clear that dramatic changes in the number of outlets can have a substantial influence on consumption and problem levels. But the overall effects of marginal changes where there are already a substantial number of outlets are much less clear.
Regulation of service. Responsible Beverage Service (RBS) programs focus on attitudes, knowledge, skills, and practices of persons involved in serving alcoholic beverages on licensed premises (Toomey et al., 1998). In the absence of institutional support and regulatory oversight, stand-alone training in RBS appears to have few lasting effects. But if supported by actual changes in the serving policies of licensed establishments and reinforced by local police, RBS training can reduce heavy consumption and high risk drinking (Howard-Pitney et al., 1991; Lang et al., 1998). A recent Swedish study found that a program combining stricter enforcement of alcohol sales laws and training in responsible beverage service had a significant effect in reducing the rate of violent crimes between 10 p.m. and 6 a.m. (Wallin et al., 2003). There are also promising results from a Canadian controlled trial of staff training in reducing pub-related violence (Graham et al., 2003).
In many jurisdictions in the U.S.
and Canada, alcohol sellers or suppliers are legally liable for damages caused
by patrons they served when already drunk or who are under age (“dram-shop”
laws), and such liability has been shown to be effective in reducing
drink-driving casualties (Wagenaar & Holder, 1991). It has the further advantage of encouraging
effective server training, and of making insurers deeply interested in house
policies and practices on unlawful serving. It has been argued that this
strategy could also be used as an extension of common law in
Drink-driving countermeasures. The evidence indicates that setting a low BAC
(blood-alcohol content) level significantly reduces alcohol-related driving
fatalities (Shults et al., 2001). The
present UK BAC level, 0.08%, is higher than the .05% level which applies in
In recent years the greatest emphasis has been placed not on catching and punishing drinking drivers but on deterring drinkers from driving in the first place. The most effective deterrence approach is through Random Breath Testing (RBT) (Shults et al., 2001; Henstridge et al., 1997), where motorists are stopped at random by police and required to take a preliminary breath test. The evidence shows that highly visible, non-selective testing on a regular basis can have a sustained effect on drinking-driving and the associated crashes, injuries, and deaths (Stewart & Conway, 1999).
There are a number of other drink-driving countermeasures which have also been shown to have effects (Babor et al., 2003).
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