In: Strategic Task Force on Alcohol, Interim Report: May 2002,
pp. 30-35. Dublin: Department of Health and Children, 2002. http://www.doh.ie/pdfdocs/stfa.pdf
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”.
Conclusions
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.
References
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 |
|
|
|
indicator |
change in next year |
Denmark, 1917: huge increase in spirits taxes, some increase in beer taxes |
-76% |
cases of DTs (Delirium Tremens) chronic alcoholism deaths |
-93% -83% |
Sweden, 1955: abolition of motbok (alcohol rationing) |
25% |
cases of DTs |
438% |
Finland, 1969: beer into grocery stores |
46% |
deaths from alcohol-specific causes |
58% |
Russia, 1985-88: less availability in anti-alcohol campaign |
-25%* |
deaths from alcohol-specific causes |
-54%* |
*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.