In: Strategic Task Force on Alcohol, Interim Report: May 2002, pp. 30-35. Dublin: Department of Health and Children, 2002.



Alcohol Policy Effectiveness[1]


Robin Room

Centre for Social Research on Alcohol and Drugs

Stockholm University

Sveaplan, S-106 91 Stockholm, Sweden



            All governments have de-facto alcohol policies, even if the term is never used.  To a greater or lesser extent, there will be rules about the purity and form of alcoholic beverages, about the conditions of their sale as a commodity, and about how drinkers can and cannot behave while drinking.

            Alcohol policies can affect rates of alcohol problems.  This effect operates in both directions: policies which are oriented to public health and order can reduce rates of problems, while policies which are oriented otherwise can increase rates of problems.   Decisions made by governments at every level -- local, regional, national, and supranational – thus have the potential both the reduce and to increase rates of alcohol-related problems.


The target of policies and prevention: drinking, intoxication, or harm from drinking?

            We may think of alcohol policies as having three possible goals (Bruun, 1971; Moore and Gerstein, 1981).  One possible goal is to affect decisions about drinking at all.  A minimum purchasing-age law, for instance, is intended to discourage younger teenagers from drinking at all.  A second possible goal is to affect the manner and circumstances of drinking.  A policy may aim to discourage drinking in inappropriate circumstances -- for instance, the school or the workplace -- or to discourage getting intoxicated.  If a policy could successfully prevent intoxication, many serious alcohol-related problems would be prevented.  A third possible goal is to insulate the drinker – and those around the drinker – from harm.  Again, the crucial issue here is often intoxication.  Policies can help to protect others from the intoxicated person, as well as to protect intoxicated persons themselves from harm.

            In a public health perspective, these three goals are not alternatives to one another. Rather, they are in most cases complementary.  The third goal, to reduce the harm when drinking or intoxication occurs, will be an appropriate public health goal in all circumstances.  Keeping drinking from becoming hazardous or out of hazardous situations is an appropriate goal in most societies concerning all who choose to drink and are of legal drinking age.  When efforts to prevent hazardous drinking fail, strategies to limit the harm from drinking need to kick in.  Keeping drinking from happening at all may be an appropriate goal for children or teenagers under legal drinking age, as well as for others in particular circumstances.  But if and when drinking nevertheless occurs, there is a need for measures to prevent hazardous drinking, and, as a back-up, measures to insulate the hazardous drinking from actual harm.


Strategies of alcohol prevention

            Simplifying somewhat, there are seven main strategies which have been used by governments to minimize alcohol problems (Room, 2000).  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 alcohol or the conditions of its use.  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.  Apart from the help it provides to the individual drinker, treatment provision could possibly reduce the overall rates of alcohol-related problems in a society. 


The research literature on the effectiveness of different alcohol policies

            There is by now a very substantial literature on the effectiveness of different alcohol policies.  The literature is uneven in coverage: some policies have been intensively studied, while others have received very little research attention.  And the results, even from the good studies, are not always the same for a given policy, presumably reflecting variations in the  social context and implementation of the policy.

            Despite these limitations, the research literature is sufficient for us to make judgements about the degree of effectiveness of a number of alcohol policy measures. I have grouped 19 different kinds of measures into four degrees of effectiveness: policy measures which are of proven high effectiveness; policy measures of proven effectiveness, but with a moderately strong effect; policy measures which probably have some effect, but where the research findings are still limited; and policy measures were the research literature suggests they are not effective, at least in the relatively short run for which effects can best be measured.

            Three of the policy measures of proven high effectiveness have to do with the market availability of alcoholic beverages.  The research literature strongly supports the effectiveness of well-enforced minimum drinking ages in holding down harm to teenagers.  However, most of this literature, it should be mentioned, is from north America, where mixing drinking with automobile-oriented teenage cultures creates a particularly lethal combination.  Enforcement of alcohol control laws, and holding servers liable for damages when they serve an already intoxicated patron, is another set of policy measures which seem to have high effectiveness.  These measures can also be seen as a harm reduction strategy.  The evidence is also quite strong that higher rates of taxes, and thus of prices for alcoholic beverages, are effective in reducing rates of alcohol-related problems.

            The drinking-driving countermeasures evaluation literature identifies three policy measures as having high effectiveness. One is reduced maximum blood-alcohol levels for driving.  A study from Sweden, where the BAL has been reduced to 0.2 per mille (.02%), shows that there was a measurable reduction in traffic accidents even when the reduction was from the already low rate of 0.5 per mille to 0.2 per mille.  A second measure, well evaluated particularly in Australia, is the institution on a regular basis of random breath testing (RBT) traffic check-points.  And a third measure of proven effect, at least in jurisdictions where decisions on drinking-driving arrests can be delayed in the courts, is immediate administrative license suspensions, which greatly strengthen the celerity dimension in the general deterrence of drinking-driving.

            For three other availability measures, there is a substantial literature which on balance finds them effective. One of these is limiting the hours and days of sale of alcoholic beverages.  A second measure is running retail outlets for alcoholic beverages as a government responsibility.   And a third effective measure, inconceivable as it may be in our era of consumer sovereignty, is rationing the availability of alcoholic beverages, which targets in particular the heavier drinkers who are most at risk of alcohol problems.

            A fourth drinking-driving measure for which the evidence of effectiveness is now accumulating is to restrict the driver’s license of novice drivers, including requiring no drinking before driving for young drivers.

            Then there are a set of four alcohol policy measures for which the research evidence is still limited, but which probably have some effect.  These include another availability measure with a harm reduction orientation, server training and tavern management policies.  Limiting the number and concentration of sales outlets also seems to have an effect at least in some circumstances.  Outright bans on alcohol advertising also seem likely to have some effect, as can well-considered community mobilization approaches.

            Lastly, let us turn to the alcohol policy measures for which there is considerable evidence of non-effectiveness.  Alcohol education in schools has probably the best-developed evaluation literature in the alcohol problems prevention field; the overall result is a finding that this measure has little or no measurable effect on drinking behaviour and problems (Paglia and Room, 1999).  For the other measures listed, the evidence is not so strong.  But the general finding is that for such measures as voluntary codes of bar practice, providing alcohol-free activities as an alternative to drinking, regulating the content of alcohol advertising, and putting warning labels on alcoholic beverage containers, there is little evidence of any effect on drinking behaviour and problems.       


The effectiveness vs. the political popularity of the strategies

            While the whole range of strategies may be seen as an appropriate part of public health-oriented alcohol policies, they are, then, not all equally effective.  The list of the most effective approaches, in terms of demonstrated effects on rates of alcohol problems in the population as a whole, are alcohol control measures such as taxes and regulating availability, some harm reduction approaches that insulate use from harm, and deterrence, particularly in the context of drinking-driving.

            If we compile a list, on the other hand, of the approaches which are most popular with the general public and with politicians, in many countries the most popular approaches tend to be education, particularly education of schoolchildren; providing alternatives to drinking; and providing treatment.  Deterrence for drinking-driving also has some popularity.  As we can see, there is a real conundrum: what is most effective generally is not what is politically popular.

            We may well ask, why is there such a lack of correspondence between what is popular and what is effective?  One simple answer, of course, is that effective strategies are opposed because they will hurt economic interests. The alcoholic beverage industry has learned that it can live quite comfortably with school education.  Some educational messages, indeed, may even help its interests.  “Drinking is an activity for grown-ups, so don’t do it until you are an adult”, for instance, cements in the symbolic meaning of drinking as a claim for adult status.  But the lack of correspondence reflects other factors as well. Strategies which are effective but unused are often unused because they conflict with competing values and ideologies in the society or in the spirit of the times. 


Controlling the conditions of sale

            In the remainder of this presentation, I will focus on one particular set of alcohol policy measures: controls on the conditions of sale of alcohol, including alcohol taxes, limits of the time and place of sale, and restraints on the seller.  These controls generally affect the availability of alcohol, but also include strategies to separate the drinking from harm.


            Who is affected how much by alcohol controls?

            One can still find uninformed statements that heavy drinkers will not be affected by alcohol controls -- they will find a way to get their alcohol anyway, and it is only lighter drinkers who will be affected.  But in reality, it is often the opposite which happens -- that the drinkers of heavy drinkers will be disproportionately affected by alcohol control measures.  This can be illustrated by what happened in four big alcohol policy changes in European countries during the last century.  We take as our indicator of the effects of the policy changes on heavy drinkers what happened to the number of cases of delirium tremens (DTs), or to deaths from alcohol-specific causes, in the year after the policy change.  We compare the size of these changes among heavy drinkers with the overall change in the total alcohol consumption of the population (see Table 1).

            The first case is the huge increase in spirits taxes, accompanied by some increase in beer taxes, in Denmark in 1917.  Alcohol consumption overall fell by 76%, but the rate of DTs fell by 93% and the rate of chronic alcoholism deaths by 83% (Bruun et al., 1975).

            The second case is the abolition of the individualized alcohol ration-book system in Sweden in 1955.  Alcohol consumption rose by 25% in the following year, but cases of DTs increased by 438% (Norström, 1987).

            The third case is when Finland greatly increased the availability of alcohol in 1969 by allowing beer to be sold in grocery stores.  While alcohol consumption went up by 46%, deaths from alcohol-related causes went up by 58% (Mäkelä et al., forthcoming).  

            The fourth case is the anti-alcohol campaign in the Soviet Union in 1985-1988.  Alcohol consumption in Russia in 1987, including unrecorded consumption, was estimated to be down 34% from 1984.  But deaths from alcohol-specific causes were down by 54% (Shkolnikov & Nemtsov, 1997; Leon et al., 1997).  Although in political terms, the campaign was a failure, in public health terms, it had substantial positive effects for as long as it lasted.       These four cases are of especially dramatic changes in alcohol controls. But it is clear from careful studies of more limited changes that here, too, it is often drinkers who are most at risk of harming themselves or others who are affected by changes in alcohol taxes, in the number of alcohol sales outlets, or in days or hours of sale.  Often, even where there is no change in the overall level of consumption, there will be changes in such indicators as rates of domestic violence or of injuries treated in emergency hospitals (Mäkela et al., forthcoming).

            It is unlikely that any European society will soon repeat the package of anti-alcohol initiatives taken in the former Soviet Union in the mid-1980s.  The package, imposed as a last impulse of the command economy, rapidly became extremely unpopular, and was abandoned by 1988.  But even unpopular measures can teach us something about the operation of alcohol policy measures.  The lesson is that the drinking patterns of very heavy drinkers are not immune to alcohol control measures; such measures, in fact, often affect heavy and hazardous drinkers especially strongly. 


            Effects of controlling public drinking environments   

            While countries vary in how much of drinking is in public places like taverns or restaurants, commonly such public drinking places are the venue of much drinking by young persons (particularly those above the minimum drinking age).  A common finding in general-population surveys, also, is that heavy drinkers are disproportionately represented among the patrons of public drinking places (Clark, 1985).  Public drinking places, including particularly those frequented by young drinkers, are also a common source of trouble and disturbance in their neighborhoods (Hauritz et al., 1998).

            Reflecting these factors, and that in many countries those selling alcoholic beverages by the drink are licensed by the government, and thus can be made to take some responsibility  for what happens on their premises, there is now a growing literature on experiments in controlling the public drinking environment as a way of reducing alcohol-related problem (Graham, 2000).  In Graham’s words, from the results in the literature “it seems likely that the greatest effects will be achieved by combining training of bar staff, education of patrons, development of lower-risk policies [in the drinking place], and enforcement of regulations aimed at decreasing risks related to drinking in licensed premises”.



            The main goal of alcohol policies should be to reduce levels of alcohol-related harm, both to the drinker and to others.   The means to this end may be preventing drinking altogether, or limiting or shaping it, or buffering the drinking from harm.  The policies need to be based on the basis of an assessment of the dimensions of alcohol-related harm in the target population (taking into account delayed harm), and their effectiveness should be measured and monitored in terms of changes in rates of alcohol-related harm.

            Within the broader spectrum of alcohol policies, regulatory approaches to the alcohol market have shown considerable success in limiting and shaping potentially harmful drinking.  Regulatory authorities can efficiently enforce the rules as a condition of licences to sell.  Regulations can also shape public drinking environments, and the drinking within them, so as to minimize rates of alcohol-related problems.  The success of such regulatory approaches depends on active enforcement, with licensees held to account for their actions in selling alcoholic beverages and providing public drinking places, and with a popular consensus supporting regulation and enforcement.  Maintaining this consensus may require continuing efforts at public persuasion.

            Saltz et al. (1995) note that policy and other environmental approaches to prevention enjoy some natural advantages.  Such approaches are not dependent on persuading individual drinkers; and their effects may not decay over time.  Moreover, the approaches work directly and indirectly by reflecting social norms and reflecting what is and is not acceptable.  The positive impact of such policies on alcohol consumption as well as subsequent harm is supported by consistent scientific evidence (Edwards et al., 1994).

            Along with efforts to reduce drinking, there is a substantial need for well-evaluated trials of approaches which acknowledge the realities of drinking and intoxication in the society, and either attempt to shape the use so as to minimize the risk of harm, or attempt to shape the social and physical environment of use to insulate the use from harm.  There will often be a need for an accompanying campaign to explain the rationale for these initiatives.

            The lesson of the research literature on the effects of alcohol policy measures is that governments and other social actors can take measures which substantially reduce the rates of alcohol problems in their society. Conversely, there is also ample opportunity to take actions which sound good, but which the research literature suggests have little or no effect.  While much research remains to be done, we already know quite a lot about the strategies and measures which are needed to have an effective alcohol policy.



Bruun, K. (1971) Implications of legislation relating to alcoholism and drug dependence: government policies, pp. 173-181 in L.G. Kiloh and D.S. Bell., eds., 29th International Congress on Alcoholism and Drug Dependence. Australia: Butterworths.

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. (1975) Alcohol Control Policies in Public Health Perspective. Helsinki: Finnish Foundation for Alcohol Studies, Volume 25.

Clark, W. (1985) Alcohol use in various settings, pp. 49-70 in: E. Single and T. Storm, eds., Public Drinking and Public Policy.  Toronto: Addiction Research Foundation.

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., Romesljö, A., Room, R., Simpura, J. & Skog, O.-J. (1994) Alcohol Policy and the Public Good. Oxford: Oxford University Press.

Graham, K. (2000) Preventive interventions for on-premise drinking: a promising but underresearched area of prevention, Contemporary Drug Problems 27:593.668.

Hauritz, M., Homel, R., McIlwain, G., Burrows, T., and Townsley, M. (1998) Reducing violence in licensed venues through community safety action projects: the Queensland experience, Contemporary Drug Problems 25:511-551.

Leon, D.A., Chenet, L., Shkolnikov, V.M., Zakharov, S., Shapiro, J., Rakhmanova, G., Vassin, S. and McKee, M. (1997) Huge variation in Russian mortality rates 1984-94: artefact, alcohol, or what? Lancet 350:393-388.

Mäkelä, P., Rossow, I., and Tryggvesson, K. (forthcoming) Who drinks more and less when policies change? Evidence from 50 years of Nordic studies.  In: The Effects of Alcohol Policy Changes on Different Classes of Drinkers: Analyses of Changes in the Nordic Control Systems. Helsinki: Nordic Council on Alcohol and Drug Research.

Moore, M.H. and Gerstein, D.R., eds. (1981) Alcohol and Public Policy: Beyond the Shadow of Prohibition.  Washington, DC: National Academy Press.

Norström, T. (1987). Abolition of the Swedish alcohol rationing system: effects on consumption distribution and cirrhosis mortality, British Journal of Addiction 82:633-641.

Paglia, A. and Room, R. (1999). Preventing substance use problems among youth: a literature review and recommendations, Journal of Primary Prevention 20:3-50.

Room, R. (2000) Prevention of alcohol-related problems, pp. 514-519 in: M.G. Gelder, J.J. López-Ibor and N. Andreasen, eds., New Oxford Textbook of Pychiatry. Oxford, etc.: Oxford University Press.

Saltz, R. F., Holder, H. D., Grube, J. W., Gruenewald, P. J., & Voas, R. B. (1995). Prevention strategies for reducing alcohol problems including alcohol-related trauma. In R. R. Watson (Ed.), Drug and Alcohol Abuse Reviews: No. 7. Alcohol, cocaine, and accidents (pp. 57-83). Totowa, NJ: Humana Press.

Shkolnikov, V.M. and Nemtsov, A. (1997) The anti-alcohol campaign and variations in Russian mortality, pp. 239-261 in Bobadilla, José Luis, Costella, Christine A., and Mitchell, Faith, eds., Premature Death in the New Independent States. Washington, DC: National Academy Press.




Table 1.  Differential effects of dramatic alcohol policy changes

 on problematic drinkers


Country, date, policy change

change in total consumption in next year

change in alcohol problem indicators




change in next year

Denmark, 1917:

huge increase in spirits taxes, some increase in beer taxes


cases of DTs (Delirium Tremens)


chronic alcoholism deaths





Sweden, 1955:

abolition of motbok (alcohol rationing)


cases of DTs






Finland, 1969:

beer into grocery stores


deaths from alcohol-specific causes


Russia, 1985-88:

less availability in anti-alcohol campaign


deaths from alcohol-specific causes



*comparison 1987 vs. 1984. Change in total consumption includes estimated change in unrecorded consumption.


Sources:    Denmark: Bruun et al., 1975

                   Sweden: Norström, 1987

                   Finland: Mäkela et al., forthcoming

                   Russia: Shkolnikov & Nemtsov, 1997; Leon et al., 1997



[1]Prepared for presentation at an international conference, Alcohol Policy: A Public Health Perspective, Dublin Castle, Dublin, Ireland, 20 November 2001.