In: Strategic Task Force on Alcohol, Interim Report: May 2002,
pp. 24-29. Dublin: Department of Health and Children, 2002. http://www.doh.ie/pdfdocs.stfa.pdf
WOULD REDUCING THE LEVEL OF
ALCOHOL CONSUMPTION REDUCE RATES OF
ALCOHOL-RELATED HARM?
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.
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
|
|
Males |
Females |
|
Deaths from all causes |
12% |
7% |
|
alcohol-specific causes |
56% |
52% |
|
accidents and violence |
36% |
24% |
|
pneumonia |
40% |
32% |
|
other respiratory diseases |
20% |
22% |
|
infectious and parasitic diseases |
25% |
23% |
|
circulatory diseases (including heart disease) |
9% |
6% |
(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 http://www.geocities.com/Colosseum/5585/mprev.html
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 |
|
Males: Cirrhosis |
31.7* |
9.1* |
9.8* |
|
Accidents |
9.0* |
3.4* |
2.3* |
|
Homicide |
17.7* |
10.5* |
7.1* |
|
Females: Cirrhosis |
16.9* |
5.2* |
10.6* |
|
Accidents |
9.6* |
2.8* |
1.9* |
|
Homicide |
8.1 |
6.7* |
1.8
|
* 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)
|
|
Males |
Females |
|
Cirrhosis |
6.7* |
4.8 |
|
Accidents |
7.5* |
7.6* |
|
Homicide |
20.6* |
4.8 |
|
Suicide |
3.1
|
1.1 |
|
Alcohol-specific causes |
13.7
|
14.8
|
* 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 1998-99 |
Unrecorded consumption estimate |
Total
consumption estimate |
|
Ireland |
14.21* |
1.0 |
15.21 |
|
France |
14.62
|
1.0 |
15.62 |
|
Portugal |
14.06
|
1.0 |
15.06 |
|
Spain |
12.28
|
1.0 |
13.28 |
|
Greece |
9.39
|
2.0 |
11.39 |
|
Italy |
8.84
|
1.5 |
10.34 |
*
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.
Conclusions
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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