Drugs and Society 11:11-23, 1997.

VOLUNTARY ORGANIZATIONS AND THE STATE IN THE PREVENTION OF ALCOHOL PROBLEMS⁽¹⁾

Robin Room

Addiction Research Foundation

33 Russell Street

Toronto, Ontario M5S 2S1, Canada

Don Cahalan and alcohol policy issues

An essay on issues in alcohol policy and the community prevention of alcohol problems seemed an appropriate contribution to a journal issue in honor of Don Cahalan. In the first place, during the years we worked together, Don taught me many things about myself; one of these was that my fundamental metier is as an essayist. In the second place, in the later phases of his career, Don himself turned increasingly to concerns with community prevention and with alcohol policy issues. As initiator of the evaluation of the California Prevention Demonstration program (Wallack and Barrows, 1982), Don led the way in applying a community trial design, loosely modeled on the Stanford Heart Disease project, in the alcohol field. After his retirement, Don came into his own as a writer on alcohol and drug policies, both in terms of their development in the United States and in terms of laying out public health approaches to their prevention (Cahalan, 1987; 1991). This essay is offered in the spirit of these concerns.

The diversity of voluntary organizations

Our focus here is on the role of voluntary organizations⁽²⁾ in the prevention of alcohol problems. In discussing voluntary organizations, our frame of reference is bounded so as to exclude on one side the individual, the family, and other primary-group collectivities; and on the other side the state and its various organs. This frame of reference, of course, encloses within it a wide variety of types of organization. Let me enumerate some of the types:

* churches and other religious organizations;

* corporations and other business enterprises;

* professional societies and organizations and labor unions;

* mutual-help organizations;

* charitable, service and educational organizations;

* interest-groups, political parties, and social movement organizations;

* recreational organizations and social clubs.

In the context of a small village or tribal society, this intermediate sphere between families and the state may be little developed. In some large and complex societies, the state has endeavored to assume command of some or all of such types of organization. In others, such organizations are often supported by state revenues, and to a greater or lesser extent may become coopted by the state. In general, however, the arena of voluntary organizations, roughly that referred to by such concepts as "civic culture" or "civil society", is a highly developed and important feature of complex industrial societies.

In such societies, nongovernmental organizations have crucial roles to play in the prevention of alcohol-related problems. The importance of these roles has been reemphasized by the experience of recent decades, which saw first a rediscovery of the potential role of governmental actions, and more recently a dawning recognition that most modern states cannot or will not act alone in these matters.

The Potential and the Limits of Governmental Action

This experience starts from an era in which the prevention of alcohol problems was not on the public agenda at all. In the period after the Second World War, alcohol issues were redefined in many industrial societies in terms of a governing image of alcoholism -- of a mysterious disease which singled out foreordained individuals, and which thus had very little to do with general patterns of drinking and of responses to drinking in the society. As the great wave of temperance thinking and legislation of the first decades of the century receded, alcohol problems were redefined from being a public issue to being a matter only of private anguish and concern, a matter between the drinker, his or her family, and doctors or other professionals providing treatment. Prevention, in this framework, becomes a matter of early detection and casefinding, and perhaps of genetic counseling.

Starting in the 1960s, there were tentative moves beyond this constricted frame to a broader consideration of issues of prevention. The change was signalled by a shift in terminology, from the prevention of alcoholism to the prevention of alcohol problems (see Cahalan, 1970). By the end of the 1970s, it was recognized that there was a diversity of alcohol-related problems, and a correspondingly broad palette of possible prevention approaches (Room and Sheffield, 1976).

One outcome of this shift in thinking was a rediscovery of the possibilities of governmental action in the prevention of alcohol problems. An important aspect of such potential actions is the operation of alcohol controls -- of government intervention in the market to influence the availability of alcoholic beverages and the conditions of their use. In 1975, an international group of scholars led by Kettil Bruun published a report on Alcohol Control Policies in Public Health Perspective which laid out the basic argument: the level of alcohol consumption in a population appeared to affect the level at least of physical health consequences of drinking, and controls of availability (notably price) often had some effect on the level of consumption (Bruun et al., 1975). In the intervening years, we have learned a great deal more about the kind of relationships involved, but the book's fundamental argument has not been shaken. It was an argument that governments could influence the rates of alcohol problems in their societies, and that diminishing the effective availability of alcoholic beverages was one way of doing that.

The book, then, and the literature of the years since its appearance, offered to governments levers for action on the prevention of alcohol-related problems. By and large, however, it must be said that governments in the ensuing years have failed to grasp and work those levers. In California, for instance, it would be hard to point to any state action which has directly reduced alcohol availability. In the U.S. as a whole, the main new restrictions on availability in the last 20 years have been raising the minimum drinking age or stronger enforcement of the minimum-age laws. There has been a considerable flurry of preventively-oriented measures which might be described as educational or symbolic: public service advertisements, warning labels on liquor bottles, warning signs about alcohol and pregnancy, and so on. But meanwhile, in the U.S. and in many other countries, there has been a continuing erosion of long-established alcohol control structures. In Britain, opening hours have been lengthened, in southern U.S. states taverns have been legalized, in the U.S. and Canada many state and provincial alcohol stores have been privatized, and in Finland and Canada alcohol stores have moved to self-service. The most serious governmental initiative in the opposite direction -- in the Soviet Union in 1985 -- was largely abandoned after three years.

With respect to alcohol controls, then, in the current era the state has turned out to be largely a paper tiger. The problem is not that the state does not have tools to reduce the rate of alcohol problems through alcohol control measures, but rather that these tools are not used. In complex societies, the state cannot or will not move alone, without substantial parallel and supportive efforts in the public sphere, to take effective actions to reduce the rate of alcohol problems. This has so far remained true in an era when public opinion polls on alcohol issues have often been quite supportive of measures to reduce alcohol problems (Room et al., 1995). Even in the area of drinking-driving, the one area of alcohol policy where many states have taken effective countermeasures, voluntary organizations like Mothers Against Drunk Driving have often been the necessary catalysts for state action.

We may conclude that the lesson of recent years is that in complex societies state action to reduce alcohol problems is unlikely to happen in the absence of substantial activity by voluntary organizations, and in fact is often more an adjunct to or byproduct of such activity than a catalyst for it. Part of the reason for this inaction by the state is the vested interest of commercial organizations in the market for alcohol, an interest which opposes any new and effective state controls of the market. Even where these commercial interests are state-owned rather than nongovernmental, they tend to find expression in defense of the state's fiscal and production interests.

Forms of Action of Voluntary Organizations

Voluntary organizations exist for a variety of purposes, take a variety of forms, and act in many different ways. Without exhausting the topic, let us consider three general forms of action of voluntary organizations, and their potential application in the prevention of alcohol problems.

Interest representation and political action: One form of action of voluntary organizations is interest representation and political action. The aim here usually is to influence the actions of a governmental or supragovernmental entity. Organized action in the political realm to reduce rates of alcohol problems has a long history in many societies. Certainly in the period after the Maine Prohibition Law of 1851, a great deal of the energy of the American temperance movement was directed at influencing governmental actions, whether at local, state or national levels (Blocker, 1989). In addition to interest and pressure groups with a specific alcohol focus, a wide variety of other interest groups came to define alcohol issues as within their scope of interest and thus were drawn into political activity in the temperance era. By the turn of the century, in one or another society, medical and other professional organizations, labor unions and working-class organizations, church denominations, nationalist movements, and women's interest groups had all defined alcohol issues as within their field of political action. In the U.S. and elsewhere, many of these organizations eventually came to feel "burned" by their involvement, as societies turned decisively against Prohibition, and thus were for long after resistant to any involvement in alcohol issues.

In recent years, alcohol issues have come back onto the political agenda of various interest groups in North America. Included are public health and consumer protection organizations, as well as medical and other professional organizations. Long-established organizations specifically in the alcohol field, such as the National Council on Alcoholism and Drug Dependence (formerly the National Council on Alcoholism), have broadened their policy agenda to include prevention policy issues. In addition, single-interest political organizations have emerged specifically oriented around alcohol policy issues. The best known of these are Mothers Against Drunk Driving (MADD) and Remove Intoxicated Drivers (RID). Coalitions of dozens of organizations of all of these types have been formed around pressing particular alcohol policy initiatives.

Economic interests are usually at stake, sometimes on both sides, in political action around alcohol issues. But other interests are often at least as much at stake. The constituencies of grassroots political action groups in the alcohol field are often motivated by personal experience or moral or ideological commitment, and do not usually have an economic stake in the changes they seek. Symbolic Crusade, Gusfield's classic interpretation (1963) of the politics of temperance at the turn of the century, proposed that status politics -- a conflict over the relative legitimacy of different ways of life in the U.S. -- was also at stake in the struggle over prohibition.

In highlighting the symbolic aspect of the struggle over temperance, Gusfield pointed to the public educational aspect of political organization and action on alcohol issues. The current evaluative literature on legislative shifts in the alcohol field has reemphasized this role of political advocacy and action as public education and consciousness-raising. Some evaluations of the effects of anti-drunk driving legislation, for instance, have found that the main reduction in drinking-driving behavior occurred at the time of the public political debate about the changes, rather than after the law went into effect. In line with this, discussions of public health-oriented advocacy on such issues as warning labels and restrictions on alcohol advertising have argued that the consciousness-raising involved in the debate over the policies is more important than any likely practical effect of the proposed measures.

Mutual help and consciousness raising: A second form of action of nongovernmental organizations is through mutual help and consciousness raising. In the first phase of temperance as a mass movement in the U.S., in the 1830s and 1840s, the emphasis was much more on mutual help in local temperance groups than on political action in the larger society. In the short run, these efforts were remarkably effective in reducing heavy drinking in the society; the best estimates are that per-capita alcohol consumption levels fell in the U.S. between 1830 and 1845 by two-thirds, without substantial governmental action.

In recent decades, the primary alcohol-specific mutual-help organizations in many countries -- Alcoholics Anonymous and its analogues -- have been focused on accomplishing recovery from alcoholism, and not on the prevention of alcohol problems. But mutual-help organizations have probably also made a hidden contribution to the decline in alcohol consumption levels and the social acceptance of heavy drinking that have occurred in the U.S. in the 1980s (Mäkelä et al., forthcoming). In the first place, although AA as an organization has not been involved, some long-term AA members have moved into active roles in political activity and coalition-building around alcohol problems prevention. Certainly AA members, acting in a private capacity, have been instrumental in the emergence and growth of the alcohol-specific treatment system. And in the long run, those who manage this system have become an important constituency for efforts to push forward prevention agendas and programs.

In the second place, the 1980s have seen the emergence from nowhere of the Adult Children of Alcoholics (ACA) movement, a movement which draws both on the 12-step principles of AA and on psychotherapeutic traditions and terminology. This movement has raised the consciousness of its members about the drinking of other members of their family, and also about their own drinking. In the same period, the level of societal efforts to exert informal social controls on drinking has risen sharply. Our U.S. national survey data shows that between 1984 and 1990 the proportion of respondents making comments and suggestions about cutting down on a family member's or friend's drinking rose by 50% (Room, Greenfield and Weisner, 1991). It is likely that the problematization of family members' drinking from which the ACA movement starts underlies this substantial change in behavior in the larger society.

A third contribution to alcohol problems prevention may have come from the development of thought and organization of the modern women's movement. The picture is clearer for the classic temperance movement and women's movements of the turn of the century. At that time, the women's movement in fact emerged from the temperance movement; looking across societies, it seems that temperance was strongest precisely where women's emancipation was strongest, and vice-versa. By late in the 19th century, women's organizations had become the backbone of the American temperance movement. But while the political focus of the classic women's movement had been on "home protection", the initial focus of the women's movement of the last 20 years was on equal employment opportunity; to the extent alcohol came up at all, the leading issue was equal access for women to alcohol and drinking places, rather than the burden of men's drinking on women. More recently, though, as women's organizations have brought into public view and discussion issues of intimate violence -- for instance, wife battery and date rape -- the modern women's movement has been moving towards a concern with reducing rates of alcohol-related problems (see, for instance, Sheehy, 1995). So far, however, the modern women's movement has probably had its primary influence on alcohol problems prevention through the operations of the network of women's mutual support and discussion groups which has grown up since the 1970s. To some extent, the Adult Children of Alcoholics movement can be seen as an offshoot of this network.

Community organizing and action: A third form of action of voluntary organizations is through community organizing and action. Certainly there are overlaps between this frame of action and the two we have already discussed: community organizing may involve political action, and there are often elements of mutual support.

Recent years have seen a substantial upsurge in several countries in organizing and action on alcohol issues at the local community level. Many of the burdens of alcohol problems are borne at local rather than national levels -- in the family, in the neighborhood, and by local government -- so that it is not accidental that temperance organizing in the classic era tended to support "local option", while alcoholic beverage industry interests have tended to want issues to be settled at national levels. Alcohol issues around which local community groups have organized in recent years in the United States include teenage drinking, overconcentrations of and problems around alcohol sales outlets, protests against new alcohol outlets, drinking driving and casualties, and obtrusive public drunkenness. Sometimes the issue has been taken up by existing community groups or neighborhood associations; sometimes new organizations have emerged, or new chapters of multicommunity organizations; and sometimes coalitions of existing community groups have formed around alcohol-related issues. In California, at least, organizing around such issues has emerged both in middle-class suburbs and poor urban neighborhoods. The actions of the community groups have taken a variety of forms, including: constituency-building parades; petition circulation; attendance and testimony at public hearings; picketing and other demonstrations at problem sites; and support for alternative recreations and activities.

Often these efforts at community organization emerge spontaneously from lay community members. Government-funded county or local alcohol problems agencies have frequently become involved relatively early in the process, often offering some logistical support. Sometimes, the efforts at community organization have been initiated and led by professional community organizers supported from outside the community. We tend to know more about community organizing efforts which are professionally directed, since professionals have a greater incentive to record and publish their activities. We are particularly likely to know about such efforts which have received direct government support, since involving a researcher to conduct a written evaluation is often a condition of that support. Thus the experiences with community organizing collected in two recent volumes (Giesbrecht et al., 1990; Greenfield and Zimmerman, 1993) primarily relate to efforts with government funding and a good deal of professional intervention. We know far too little about what happens when communities organize themselves on a grassroots basis around alcohol issues in the modern era.

Voluntary Organizations and the State

In each of their forms of action, voluntary organizations sooner or later come into relation with various levels of government. By definition, the relation between a voluntary organization and the state is asymmetrical: in a democratic society, the state is responsible to all the people, whereas a voluntary organization is primarily responsible only to its constituents. Through its police and other coercive powers, the state collects its resources through involuntary exactions, while nongovernmental agencies must rely on voluntary contributions, unless they borrow the power of the state.

By their nature, voluntary organizations thus lack the enormous resource base of the state, but have a considerable advantage in flexibility of action. Much that they can do is completely independent of the state. In most democratic polities, as representatives of a constituency or interest, they may also appropriately seek openly to influence state action and contribute to the political debate.

But in the modern state, most voluntary organizations are not in fact completely divorced from the state. Resources tend to be a continuing problem for a nonmarket-oriented voluntary organization, and most such organizations will gladly accept, for instance, an offer from the state for tax-exempt status for money donated to them. Quite properly, since the offer relates to the state's coercive taxation powers, it usually carries strings: for instance, that the tax-exempt organization refrain from political or lobbying activity.

The state's involvement with voluntary organizations frequently goes much further. In most industrial societies, it is quite usual, and increasingly typical, for the state to carry out important functions through direct subvention of voluntary organizations. There are often fiscal benefits to parties on both sides of this relationship. Those in leadership or functional roles in a voluntary organization drift into regarding their work as a profession, and the prospect of assured funding for their work from a single client is very attractive. From the state's perspective, a contract with a nongovernmental organization is often a cheaper and more flexible arrangement than operating a government agency subject to civil service regulations.

For the state, there are also other benefits from this process of cooptation. Its responsibility for the actions it supports is somewhat veiled and detached. And frequently the state is also seeking greater legitimacy for itself: by acting through or in concert with the voluntary organization, it seeks to borrow the credibility of the voluntary organization with the organization's constituency.

For the voluntary organization, cooptation by the state offers the prospects of closer contact with the corridors of power, and of a more stable organizational base (both these prospects may turn out to be illusory). But the organization gives up substantial freedom of action. Even more importantly, over the long run it is putting at risk its credibility with its constituency, its bottom-up organizational form, and its grassroots base of support.

So far I have been describing issues in the relationship of voluntary organizations and the state in general. But the issues I have been describing have a special resonance in the field of the prevention of alcohol problems. As I have noted, in the modern era, the state has turned out to be largely a paper tiger in terms of actions to reduce alcohol problems. Like Gulliver waking up in Lilliput, it has great powers, but it is effectively hindered in using them by a myriad of constraints and interests. The solution so far, in country after country, has been to steer a path which gives the symbolism to public health interests but the substance to economic and fiscal interests and to the doctrine of consumer sovereignty (Room, 1990).

This pattern of action -- or rather, inaction -- is especially problematic for voluntary organizations which wish to keep their credibility with their constituencies. Voluntary organizations are thus well advised to be wary of cooptive offers from the state. Activities of voluntary organizations are a crucial background to state action to reduce alcohol problems, and may indeed be a prerequisite for it. But they are most likely to play an effective role, in a terrain as contested as alcohol problems, if they maintain the ability to act independently of the state.

REFERENCES

Blocker, Jack. (1989) American Temperance Movements: Cycles of Reform. Boston: Twayne Publishers.

Bruun, Kettil, Griffith Edwards, Martti Lumio, Klaus Mäkelä, Lynn Pan, Robert E. Popham, Robin Room, Wolfgang Schmidt, Ole-Jørgen Skog, Pekka Sulkunen, and Esa Österberg. (1975) Alcohol Control Policies in Public Health Perspective. Helsinki: Finnish Foundation for Alcohol Studies, vol. 25.

Cahalan, Don. (1970) Problem Drinkers. San Francisco: Jossey Bass.

Cahalan, Don. (1987) Understanding America's Drinking Problem: How to Combat the Hazards of Alcohol. San Francisco: Jossey Bass.

Cahalan, Don. (1991) An Ounce of Prevention: Strategies for Solving Tobacco, Alcohol, and Drug Problems. San Francisco: Jossey Bass.

Giesbrecht, Norman, Peter Conley, Robert W. Denniston, Louis Gliksman, Harold Holder, Ann Pederson, Robin Room and Martin Shain, eds. (1990) Research, Action, and the Community: Experiences in the Prevention of Alcohol and Other Drug Problems, OSAP Prevention Monograph 4, DHHS Publication No. (ADM) 89-1651. Washington, DC: USGPO.

Greenfield, Thomas K. and Robert Zimmerman, eds. (1993) Experiences with Community Action Projects: New Research in the Prevention of Alcohol and Other Drug Problems, CSAP Prevention Monograph 14, DHHS Publication No. (ADM) 93-1976. Washington, DC: USGPO.

Gusfield, Joseph. (1963) Symbolic Crisade. Urbana: University of Illinois Press.

Mäkelä, Klaus, Ilkka Arminen, Kim Bloomfield, Irmgard Eisenbach-Stangl, Karin Helmersson Bergmark, Noriko Kurube, Nicoletta Mariolini, Hildigunnur Ólafsdóttir, John H. Peterson, Mary Phillips, Jürgen Rehm, Robin Room, Pia Rosenqvist, Haydée Rosovsky, Kerstin Stenius, Grayna witkiewicz, Bohdan Woronowicz, and Antoni Zieliski. (forthcoming) Alcoholics Anonymous as a Mutual-Help Movement: A Study in Eight Societies. Madison: University of Wisconsin Press.

Room, Robin. (1990) Thinking about alcohol controls, pp. 68-75 in: Ruth Engs, ed., Controversies in the Addictions Field. Dubuque, Iowa: Kendall-Hunt.

Room, Robin, Karen Graves, Norman Giesbrecht and Thomas Greenfield. (1995) Trends in public opinion about alcohol policy initiatives in Ontario and the US 1989-1991, Drug and Alcohol Review 14:33-45.

Room, Robin, Thomas K. Greenfield and Constance Weisner. (1991) "People who might have liked you to drink less": Changing responses to drinking by U.S. family members and friends, 1979-1990, Contemporary Drug Problems 18:573-595.

Room, Robin and Susan Sheffield, eds. (1976) The Prevention of Alcohol Problems. Sacramento: California State Office of Alcoholism.

Sheehy, Elizabeth. (1995) The Intoxication Defence in Canada: Why Women Should Care. Ottawa: Canadian Advisory Council on the Status of Women.

Wallack, Lawrence M. and David C. Barrows. (1982) Evaluating primary prevention: the California "Winners" alcohol program, International Quarterly of Community Health Education 3:307-335.

1. Revised from a plenary presentation at the International Institute for the Prevention and Treatment of Alcoholism, Stockholm, Sweden, June 2-7, 1991. Preparation was in part supported by a National Alcohol Research Center grant (AA 05595) from the U.S. National Institute on Alcohol Abuse and Alcoholism to the Alcohol Research Group, Medical Research Institute of San Francisco (ARG is now a unit of the Western Consortium for Public Health, Berkeley).

2. In the context of international governmental organizations such as the United Nations and the World Health Organization, the term "nongovernmental organizations" has come into use to cover much the same set of entities I am describing as voluntary organizations.