In: Strategic Task Force on Alcohol, Interim Report: May 2002, pp. 24-29. Dublin: Department of Health and Children, 2002.






Robin Room

Centre for Social Research on Alcohol and Drugs

Stockholm University



Alcohol-related harms and their measurement

Drinking is causally related to a long list of both social and health problems.  These problems are both short-term -- primarily related to a particular intoxication occasion -- and long-term -- primarily reflecting levels of drinking over time.  Alcohol-related problems occur to many others besides the drinker him- or herself: to those hurt in a drinking-driving crash, to family members in the form of neglect or abuse, to strangers, friends and family in the form of alcohol-fuelled violence.

            The statistics we have on alcohol-related social and health problems primarily come from the community agencies charged with responding to the problems -- from the health system, the police, and welfare and employment agencies.  The statistics are affected, to a greater or lesser degree, by the social attention being paid to the problems they reflect, as well as by the behaviour and events they record.  The statistics least affected by these are the records of death; deaths are usually a matter of concern everywhere.   For that reason, mortality data is the most widely available data on alcohol-related harm.

            While there is no adequate comparative measure of the relative magnitude of social and health problems attributable to drinking, some comparisons can be made. These comparisons are, however, incomplete; estimates of the relative burden of alcohol problems in social and health services, for instance, do not take account of private costs and problems, such as disruption of family life or work roles, except as they come to the attention of public agencies.

Cost-of-illness studies of the economic costs attributable to alcohol include estimates of the “direct costs” of health and social services used by those with alcohol-related problems.  Typically, the ongoing costs to society for handling these cases is estimated to be larger in the social welfare and criminal justice sectors than in the health sector.  For instance, an estimate for 2001/2002 for Scotland (Catalyst, 2001:3) estimated alcohol-attributable health care costs of  95.6 million pounds (GBP), social work service costs of 85.9 million pounds, and criminal justice and fire services costs of 267.9 million pounds.

In a mixed urban, suburban and rural county in northern California, from a series of surveys of those seen by different social and health systems, the proportions were estimated of those reporting “problem drinking” (defined as having at least two of having heavy drinking occasions, a serious social consequence of drinking, or a dependence symptom) who came for services to one or another system, though not necessarily concerning their alcohol problems. Of those with “problem drinking” thus defined, 41.0% were seen by the criminal justice system, 8.0% by the social welfare system, 42.1% by the general health system (primary health clinics and emergency rooms, both private and public), 3.1% by the public mental health system, and 5.9% by public alcohol or drug treatment agencies (Weisner, 2001)  In that county, thus, the resources devoted to dealing with social problems related to drinking are at least as extensive as those devoted to health problems related to drinking.    

            A third way of estimating the relative burden of health and social harm is from survey research responses, where the attribution is by the drinker or those around the drinker.  In terms of experiences reported as occurring during the previous year in a Canadian survey, for instance, 7.2% of Canadians reported that they had been pushed, hit or assaulted by someone who had been drinking, 6.2% had had friendships break up as a result of someone else’s drinking, and 7.7% reported they had had family problems or marriage difficulties due to someone else’s drinking.  In the same study, 2.3% reported their own drinking had had a harmful effect on their home life or marriage in the past year, and 3.7% that it had harmed their friendships or social life, while 5.5% reported that it had harmed their physical health (recalculated from pp. 258, 274 of Eliany et al., 1992).  Social problems due to someone’s drinking thus seemed to extend more broadly in the population than health problems due to drinking.     

            These three probes into the issue of the scope and relative size of alcohol-related problems all point to the conclusion that social problems from drinking, and problems for others besides the drinker, are at least as important as health problems for the drinker him/herself.  It should be borne in mind, then, that the problems covered in the discussion which follows are only a part of the whole range of alcohol-related problems.


What happens to problem rates when there are changes in consumption?

            The limiting case: A telling example of how much difference the level of alcohol consumption can make in a population is when there is a substantial and sudden shift in the consumption level. In March, 1985, the government of the former Soviet Union announced an anti-alcohol campaign, including a substantial reduction in alcohol availability (White, 1996).  The campaign lasted for about 3 years.  While there was a great deal of illegal distilling during the campaign, the best estimate is that there was a net reduction in consumption of about 25% (Shkolnikov & Nemtsov, 1997).  During that period, the age-standardized death rates in Russia were reduced as follows (calculated from Leon et al., 1997):


Table 1. Reduction in age-standardized death rates in Russian between 1984 and 1987




Deaths from all causes



alcohol-specific causes



accidents and violence






other respiratory diseases



infectious and parasitic diseases



circulatory diseases (including heart disease)



(Source: calculated from Leon et al., 1997)


The figures for deaths from all causes imply that, for each litre decrease in per-capita consumption of alcohol, the overall death rate dropped by 3.4% for males and 2.2% for females.


            The cross-cultural range of effects: It seems that Russian drinking patterns, and particularly the drinking patterns of Russian men, are especially harmful in terms of the amount of harm associated with each litre of alcohol consumed.  In this respect, Russia and a number of the other countries of the former Soviet Union are probably towards the upper limit.

            A recent study of 14 western European countries (the countries of the European Union excluding Greece and Luxembourg but including also Norway), the European Comparative Alcohol Study (ECAS), examined the evidence from the 46 years 1950-1995 of the relation between year-to-year increases or decreases in the alcohol consumption level and year-to-year increases or decreases in deaths from a variety of causes where alcohol often is involved (Norström, 2001a, 2001b). The analyses used ARIMA time series methods (Auto-Regressive Integrated Moving Average – see for explanation).   The researchers pooled the countries into three groups, a northern Europe group (Finland, Norway and Sweden), a southern Europe group with wine as the dominant beverage (France, Italy, Portugal and Spain), and a middle group of 7 countries, including Ireland.

            For liver cirrhosis mortality, for accidental deaths, and for homicide, the researchers found a significant effect from changes in alcohol consumption in all three country groups (Table 2).  They also found a systematic gradient in the size of the effects, with higher effects in northern and lower in southern Europe.  These results support the idea that cultures do vary in how much difference subtracting or adding a litre of per-capita consumption will make to rates of problems from alcohol, but that everywhere in western Europe reducing the per-capita consumption of alcohol does reduce the rates of harm from these three indicative causes of death (though not always for female deaths from homicide).


Table 2. Percentage change in mortality for a one-litre increase in per capita alcohol consumption. Pooled estimates for 3 regions of Europe from country-specific ARIMA analyses for 1950-1995. (Source: Norström, 2001b)


northern Europe                                               

mid-Europe (includes Ireland)

southern Europe

































* significant relationship (p<.05)


            The finding that the amount of harm from each litre of alcohol per-capita varies from one end of Europe to another underlines that characteristics drinking patterns in a culture are also important, along with the level of consumption.  This kind of finding often brings suggestions  and even campaigns to change a nation’s drinking culture, for instance to resemble the characteristic drinking patterns of southern European “wine cultures”.  In Scandinavia, this persistent “dream of a better society”, as Olsson calls it (Olsson, 1990), recurs from decade to decade.  But the experience has been, instead, that in a given culture the characteristic drinking patterns are deep-rooted and resistant to change; when new drinking habits are encouraged, they often add onto the old ones, rather than replace them.  Examples of a successful shift in a national drinking culture to less problematic drinking patterns are few indeed (Room, 1992).

            The ECAS findings in any case support the conclusion that, while attention to drinking patterns may be worthwhile, it is not a substitute for a focus on the general level of consumption in a population.  From one end of Europe to the other, alcohol-related death rates are affected quite strongly by changes in the general level of consumption.     


            Findings for Ireland.  The findings specifically for Ireland fit broadly into the patterns found by the ECAS researchers for what we have termed the “mid-Europe” group of countries (Table 3).  Males deaths from homicide seem to be particularly strongly associated with changes in the level of consumption in Ireland. On the other hand, any effects of changes in consumption on male and female suicide rates in Ireland were too weak to reach statistical significance.  Effects on alcohol-specific causes (explicitly alcohol-related deaths, from alcoholic psychosis, alcoholism or alcohol poisoning) appeared quite strong, but failed to reach statistical significance, perhaps reflecting a relatively small numbers of deaths recorded in these categories.  


Table 3. Percentage change in mortality for a one-litre increase in per capita alcohol consumption. Estimates for Ireland from ARIMA analyses for 1950-1995. (Source: Norström, 2001b)
















Alcohol-specific causes



 * significant relationship (p<.05)


            Some of the ECAS analyses went on to specify the relative strength of the relationship for different age and gender categories (Ramstedt, 2001; Skog, 2001). Among males, the effect of an increase in consumption in the population as a whole was strongest on cirrhosis mortality for those aged 45-64, and on deaths from accidental injury for those aged 50-69.  Among females, the effect was greatest for cirrhosis on those aged 15-44, and for accidents also for those aged 50-69.  

            A limitation of these kinds of analyses is that the per-capita consumption data is only available for the population as a whole.  Since males typically account for two-thirds or more of the consumption, for instance, this means that changes in male consumption tend to dominate what happens to overall consumption.  It is thus to be expected that relations with male death rates are more often significant than relations with female deaths, as in Table 3.


Ireland’s alcohol consumption level in an international perspective

            A focus on the public health implications of the general level of consumption makes particular sense in the Irish context, given that per-capita consumption has risen by 41% in ten years.

            Table 4 shows the consumption per person aged 15 and above in Ireland and in the five main “Mediterranean wine cultures”.  In recent years, old assumptions about where drinking is heaviest in Europe have been overturned by the continuing drop in per-adult consumption in the traditional wine cultures (Simpura, 1998).  At this point, only France, still on its long slow glide down from its consumption levels in the early 1950s, exceeds Ireland in per-adult drinking levels.  In fact, among the EU countries only it and Luxembourg now exceed Ireland’s per-adult consumption level, and the total list of countries in the WHO Global Database with an estimated total consumption level per adult higher than Ireland’s is just 11: Argentina, Croatia, France, Hungary, Latvia, Luxembourg, Mauritius, Moldova, Romania, Russia and Slovakia.


Table 4.  Ireland and the European wine cultures: estimated alcohol consumption per person aged 15 and above, in litres of pure ethanol (figures for 1998-99, except Ireland’s is for 2000)


Recorded consumption


Unrecorded consumption estimate

Total consumption estimate

























                        * data for 2000.

                        (Source: WHO Global Alcohol Database, current data; see WHO, 1999)


            Factors involved in the sharp growth in alcohol consumption levels in Ireland presumably include increased affluence, the relative decline in alcohol taxes, and increased availability.  In a way, the new situation in Ireland sheds light on an old puzzle.  In a book originally published in 1976, Richard Stivers (2000) analyzed the reputation and the reality of high rates of alcohol consumption and problems in the Irish-American community, already marked in the 19th century (Room, 1968), both in the U.S. and wherever the Irish diaspora settled and prospered.  But, Stivers pointed out,  there seemed to be a much lower level of problems with drinking in Ireland.  While there was some dispute within Ireland about the national problems rates (Walsh and Walsh, 1973), by international standards the consumption and problems seemed low.  In the 1950s, for instance, per-adult consumption levels in Ireland were about one-third what they are today in Ireland, and only 3 of the current EU member countries had lower consumption levels (Leifman, 2001).

            Perhaps the experience of the diaspora in past generations was a pointer to what might happen in Ireland itself, if and when Ireland might become, as it has now, an affluent society. 



Recent time-series analyses for Ireland and for other Western European countries confirm previous findings that mortality rates for a range of chronic health problems and casualties are affected, often quite strongly, by the overall level of alcohol consumption in a population.  The fact that patterns of drinking in a population can also affect these relationships does not alter this fundamental finding.

            Data is much scarcer concerning rates fo social problems from drinking, but these, too, are likely to be affected by the overall level of alcohol consumption. 

            Per-capita consumption rates have risen quite sharply in Ireland in recent years.  If the  upward trend of 1995-1999 continues, Ireland will shortly have the highest level of consumption in Western Europe.  While alcohol problems rates generally respond quite quickly to rises or falls in consumption, the incidence of chronic health problems such as liver cirrhosis undoubtedly has a longer-term component, since it often takes a drinking career of 20 years to destroy a liver.  An effective strategy to reduce the overall level of consumption now is thus likely to have a special impact in forestalling the build-up of cirrhosis and other chronic illnesses and problems brought on by sustained heavy drinking.



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