Alcohol and its effects
Alcoholic beverages have been consumed in most, if not all, human societies since the beginning of recorded history. Beverages containing ethanol (C2H5OH) can be fermented from a large number of organic materials that comprise carbohydrates, and in one part of the world or another, these products are prepared from fruits, berries, various grains, plants, honey, or milk. Under most circumstances, such fermented beverages can contain up to 14 per cent ethanol. The most widely commercialized fermented beverages are beer prepared from barley or other grains (usually 3–7 per cent ethanol), apple and other fruit ciders (usually 3–7 per cent ethanol), and grape wine (usually 8–14 per cent ethanol). Other fermented beverages are also common in particular cultures, often from home production or in commercial form: for example, sorghum or millet beers in Eastern and Southern Africa, palm wine toddy in West Africa and the Indian subcontinent, pulque (prepared from the maguey cactus) in Mexico, and rice wine (sake) in Eastern Asia.
Distilled beverages, in which ethanol is concentrated by evaporation and condensation from a fermented liquid, came to Europe from Arabia in the Middle Ages. In Europe, at first, their use was primarily medicinal, but by the 1600s, popular use as a social beverage spread rapidly. Distilled beverages can be made up of almost-pure ethanol, but those sold for drinking usually contain between 25 per cent and 50 per cent ethanol. Distilled alcohol is also added to wine, producing ‘fortified wines’ with about 20 per cent ethanol. Because distilled beverages and fortified wines do not readily spoil, they could be shipped over long distances, even before refrigeration and airtight packaging became available, and played a particularly important part in commerce and exploitation in the age of the European empires. Different cultures consume varying strengths of alcoholic beverages, often with water or a ‘mixer’ being added to distilled beverages and, in some cultures, also to wine and other fermented beverages.
Use-values of alcohol
Ethanol has many uses in human life. These include non-beverage uses as a fuel and as a solvent. Important beverage-related use-values include use as a medicine, as a religious sacrament, as a foodstuff, and as a thirst-quencher (Mäkelä 1983). But, alcoholic beverages have received special attention as a public health hazard because of their psychoactive properties. These properties carry with them another set of use-values: in terms of psychopharmacology, ethanol is a depressant, and alcoholic beverages have long been used to affect mood and feelings. With enough consumption, alcohol becomes an anodyne and, indeed, an anaesthetic; distilled spirits were used as an anaesthetic in surgical practice before the mid-nineteenth century. Many drinkers seek and appreciate the levels of intoxication which lie between mild mood alteration at one end of the spectrum and being comatose at the other.
The decisions to drink and how much to drink are, however, often not made by the individual in isolation. Drinking is usually a social act, and the pace and level of drinking are frequently subject to collective influence, with drinking together being seen as an expression of solidarity and community. Although drunkenness may be sought to relieve misery or loneliness, it is more commonly associated with sociable celebration.
Alcohol consumption can have a variety of adverse effects, some of which are acute effects associated with the particular drinking event. Drinking progressively impairs physical coordination, cognition, and attention, resulting in an increased risk of accidents and injury. Above a threshold level, drinking can also affect intention and judgement, so intoxication potentially plays a causal role in violent behaviour and crime (Graham et al. 1998). This relation appears to be culturally mediated, because there is a substantial variation between cultures in the association of intoxication with violence and crime (Room 2001). A sufficient amount of alcohol may result in a potentially fatal overdose, by interrupting various autonomic bodily functions.
Other adverse effects of alcohol consumption are chronic effects related to a repeated pattern of drinking. Alcohol consumption can adversely affect nearly every organ of the body, although some effects are not common. Chronic conditions in which alcohol is implicated as an important cause include liver cirrhosis; cancers of the upper digestive tract, liver, and breast; cardiomyopathy; and gastritis and pancreatitis (Rehm et al. 2010). Through a variety of mechanisms, alcohol is also implicated in the incidence and course of infectious diseases (Parry et al. 2009).
Repeated heavy drinking can also adversely affect mental health; specific neurological disorders are associated with sustained heavy drinking. More common concomitants include depression and affective disorders. Alcoholism—the experience of loss of control over drinking, along with other psychological and physical sequelae—has also been considered a mental disorder in modern times. In current nosologies, alcoholism has been replaced by the terms alcohol use disorder (in Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM5) terminology) and the alcohol dependence syndrome (in the International Classification of Diseases, 10th edition (ICD-10)).
The impairment of coordination and judgement produced by drinking potentially affects bystanders and the drinkers’ acquaintances, friends, and family, as well as themselves: the effects can be through impairment of coordination or judgement during the drinking event, resulting in injury or distress, or through impairment of performance in family, friendship, work, and other social roles as a result of recurring drinking episodes (Laslett et al. 2011). The actual and potential adverse effects on others have historically been the primary justification for alcohol controls and other societal responses to problematic drinking (Room 1996); the effects on the adult drinker’s own health have been of much less importance in determining public policy on alcohol.
For the drinker, and sometimes for those around, alcohol consumption can have positive effects. We have already mentioned the different use-values of alcohol—which mean that drinkers are usually willing to pay more than just the cost of production and distribution of the beverage. Apart from its valued effects on mental state, alcohol use has some positive outcomes on health. By far the most important of these, in terms of public health, is its potential for preventing cardiovascular disease (CVD). A fairly consistent finding in studies in several societies is that drinking at moderate levels protects against CVD (Klatsky 1999), although controversy about the existence and extent of this effect remains (e.g. Fillmore et al. 2006). The findings on the upper limit of drinking for such protection vary. Taken together, it appears that most of the protective effect can be gained with as little as one drink of an alcoholic beverage every second day (Maclure 1993). About half of this effect seems to come from inhibiting the build-up of plaque in arteries, whereas the other half seems to result from a relatively immediate effect of diminishing the likelihood of blood clots. To the extent this is true, irregular or occasional drinking is likely to have less protective effect.
Although it has been argued that this protection comes primarily from red wine constituents (particularly resveratrol) rather than from the ethanol, the balance of evidence favours an ethanol effect (Klatsky 1999). However, relatively little is known about how this effect interacts with or overlaps other risk and protective factors for chronic heart disease (CHD), such as regular exercise, diet, or taking aspirin (acetylsalicylic acid) or other pharmaceuticals (Criqui et al. 1998). The protective effect of alcohol appears to be higher for cigarette smokers than for non-smokers (Kozlowski et al. 1994).
Drinking is also often bad for the heart (Chadwick and Goode 1998; Poikolainen 1999). Studies have found that a pattern of intermittent heavy drinking, such as getting drunk every weekend, is associated with an elevated rate of coronary death (Kauhanen et al. 1997; Bagnardi et al. 2008), probably through mechanisms such as heart arrhythmias (Kupari and Koskinen 1998; McKee and Britton 1998). Data from countries in the former Soviet Union, where a pattern of intermittent intoxication is common, support the strong adverse effect of binge drinking on heart disease mortality (Rehm and Room 2009; Zaridze et al. 2011). During a period of deliberate restriction of alcohol supplies, the estimated per capita consumption in Russia, including the illicit alcohol market, fell from 14.2 L in 1984 to 10.7 L in 1987 (Shkolnikov and Nemtsov 1997)—a fall of 25 per cent. The death rate from ischaemic heart disease among males fell by 10 per cent in the same period (Leon et al. 1997). This rate rose again when the restrictions lapsed, although this time, unlike between 1985 and 1988, other risk factors also changed.
Research on cumulative effects of alcohol
Effects on the drinker’s health
In most studies, the relationship between amount of drinking and overall mortality is a J-shaped curve, with abstainers, and often, very light drinkers showing a higher mortality than those drinking a little more. This may be because, in these findings, a substantial part of the study population were older adults, and thus were at risk of mortality from CVD. Studies limited to younger cohorts typically found a monotonic relationship between amount of drinking and mortality (Andréasson et al. 1991; Rehm and Sempos 1995). Such an association might also be expected in any population, such as in some developing countries, that has a low rate of CVD.
The pattern of drinking is also a potentially important factor in mortality due to alcohol. Although this has long been obvious in casualty deaths, there is growing recognition of its significance in other causes of death, as implied by the earlier-mentioned Russian data. However, until recently, there have been only few measurements of this pattern in studies on alcohol and overall mortality. Variations among cultures in drinking habits may partly explain why the J-curve relation of volume of drinking to mortality shows different low-points in different cultures.
The risks and potential benefits associated with a given level of drinking, thus, vary with the age and sex of the drinker, and possibly with other sociocultural characteristics, as well as with the pattern and circumstances related to drinking. This variation has posed a considerable challenge because of political demand in a number of countries for advice on ‘low-risk drinking’ or ‘safe drinking’ guidelines. Whereas earlier guidelines were inclined to be stated only in terms of the volume of drinking, in line with the measurement methods of medical epidemiology literature, more recent guidelines have also emphasized limits on the amount consumed on a given occasion or day (Stockwell and Room 2012).
Current literature on the cumulative effects of drinking on health relies substantially on summations of prospective epidemiological literature, following the tradition set up by English et al. (1995). Using meta-analysis on studies of the relationship between volume of drinking and specific causes of death in which alcohol was either a risk or protective factor, the studies following this tradition derive attributable fractions for different levels of the volume of drinking and apply these fractions to segments of the population at each level in order to arrive at estimates on total lives and life-years lost and gained, subtracting the projected protective effects of alcohol from the negative burden. In addition to life-years lost, the study’s most comprehensive indicator, disability-adjusted life years (DALYs), includes a projection of the burden of disability attributable to alcohol.
According to estimates for 2010, 3.9 per cent of the total burden of disease globally (as measured in DALYs) is attributable to alcohol (Lim et al. 2012). This compares with 6.3 per cent for tobacco and 1.0 per cent for illegal drugs. As earlier estimates showed (Ezzati et al. 2002), the alcohol share of the burden is highest in high-income societies, including Eastern Europe and Northern Asia, as well as in Latin America. The relative position of alcohol among risk factors is actually highest in middle-income countries, where it ranks first; although the alcohol share of all DALYs is lower in other developing regions, this fraction is calculated on the basis of a higher total burden of disease and disability in these countries.
Effects at the population level
So far, we have dealt with estimates of alcohol’s effects at the individual level. The methodological difficulties in the studies underlying these estimates extend beyond those we have already discussed (Edwards et al. 1994). The estimates rely primarily on prospective epidemiological studies in which alcohol consumption is measured at one point in time; such a measurement is, at best, a poor surrogate for either of the main aspects of alcohol consumption as a risk factor—chronic effects of cumulated alcohol consumption or acute effects of intoxication at a specific event. In these studies, the effects of possible confounders are dealt with by statistically controlling for them in the analysis. But this can be problematic if drinking and the potential confounder are causally intertwined, as is true in the case of hypertension or tobacco smoking. Consider, for instance, a person who only smokes when under the influence of alcohol; controlling for that person’s smoking behaviour potentially obscures some of the alcohol effect.
From a public health perspective, it is the effects at the population level, rather than the individual level, that are the main concern. If drinking was entirely a matter of individual choice and behaviour, and if the effects of drinking happened only to the drinker, then effects at the population level would be a simple aggregation of the effects at the individual level. But neither of these conditions is applicable. Drinking is by and large a social activity, and the drinking behaviour of a person is likely to influence and be influenced by those around that person. In a given population, the amounts drunk by infrequent or light drinkers and by heavy drinkers tend to move up and down in concert. Thus, if there is some health gain when those at the lower end of the spectrum increase their consumption, there will also be health losses from an increase in consumption for those at the top end of the spectrum. In view of this, it has been argued that the level of per-drinker consumption where the balance of health benefits and losses is optimized in a population is likely to be considerably lower than the optimum level of consumption for the individual drinker (Skog 1996). For instance, Skog (1996) argued that the optimum level of alcohol consumption with respect to mortality was likely to be lower than the present-day per-capita consumption of any nation in Western Europe. His argument is supported by findings of a generally positive relationship of the level of alcohol consumption with total mortality in time-series analysis of differenced data in a number of high-income countries (Norström and Ramstedt 2005).
By their design, the prospective studies typically used for investigations of alcohol’s effects on mortality or morbidity do not measure the effects of drinking on others. Other types of individual-level studies, such as studies of the effects of drinking–driving (Perrine et al. 1989) or studies of homicide and other crimes (Wolfgang 1958), document the importance of such effects in terms of death or injury. But the strongest evidence of the magnitude of these effects comes from aggregate-level studies of the covariation of changes over time in a given society or place. Differenced time-series analyses in European societies have suggested that a 1 L change in per capita alcohol consumption produces about a 1 per cent change in the overall mortality rate (Her and Rehm 1998; Norström 1996). Here again, however, drinking patterns and social circumstances are likely to make a difference. For instance, the drop in Russian total mortality during the alcohol restrictions of 1985–1988 implies a decline of about 2.7 per cent in age-standardized mortality for each 1 L drop in per capita consumption (calculated from Shkolnikov and Nemtsov (1997) and Leon et al. (1997)). Even specifically for heart disease, any protective effects from changes in low-level drinking seem to be outbalanced in the population as a whole by negative effects from changes at high-consumption levels, levels of consumption typical in high-income societies. Thus, time-series analyses of differenced data on alcohol consumption and on CHD mortality in 14 European countries found no evidence of net protective effects and some evidence of net adverse effect (Hemström 2001; Ramstedt 2006).
Alcohol as an issue in public health
Shifting societal responses to problematic drinking
Efforts to control problematic drinking date back to the beginning of recorded history. These efforts have been many-sided, including informal responses in the family and community, as well as governmental controls. Religious teachings and movements have often been directed against drinking or intoxication: Moslems are forbidden by their faith to drink at all, and drinking is also discouraged or forbidden in at least some branches of all the major world religions.
In the last few centuries, European and Europe-derived societies have been hosts to conflicting trends in terms of alcohol issues. The production of alcoholic beverages became an important part of European economies and of imperial domination and trade in the age of European colonization. Alcohol production and exports took on political importance not only in the wine cultures of Southern Europe, but also in such countries as the Netherlands and Britain. In America, in the late-eighteenth century, distilled spirits was the only profitable way to get grain to market (Rorabaugh 1979). In recent decades, alcohol beverage industries have become increasingly internationalized and concentrated (Jernigan 2010), and multinational companies, mostly based in Europe or North America, have pressed with considerable success to open up global markets for alcohol.
Starting in the early 1800s, there were substantial waves of popular, and eventually, governmental response to the problems that were resulting from the very heavy consumption of alcoholic beverages in English-speaking and Northern European societies (Blocker 1989; Levine 1991). As a culmination of decades of popular temperance movements, in the early twentieth century, alcohol prohibition was adopted in 13 countries (Schrad 2010) and imposed on indigenous people in colonial territories, and stringent controls were placed on the availability of alcohol in some other countries. Although alcohol’s impact on public order and morals and on family life were more central to the temperance movement thinking than the public health issues, mainstream thought in medicine and public health acknowledged the substantial adverse impacts of alcohol on health (Emerson 1932), and prohibition or an alternative, stringent controls on the availability of alcohol (Catlin 1931), were often identified with the public health interest.
In the United States, and some other societies which had prohibited or greatly restricted alcohol availability, there was a strong reaction against it by the early 1930s, with middle-class youth in the lead (Room 1984a, 1984b). In this cultural–political context, as the new generation moved into professional and research positions, adverse effects of alcohol were downplayed or denied (Herd 1992; Katcher 1993), and alcohol issues almost disappeared from public health textbooks and discourse. Any problems with drinking were seen as attributable to a relatively small cadre of alcoholics, unable to control their drinking because of a mysterious predisposing factor. As late as 1968, the main emphasis of the American Public Health Association was on building treatment capacity for alcoholism (Cross 1968).
The ‘new public health’ approach
The last three decades of the twentieth century saw the rise of what has been termed in the alcohol literature the ‘new public health’ approach (Beauchamp 1976; Tigerstedt 1999) to alcohol issues. This approach brought together several strands of research and philosophy. In contrast to a concept in terms of ‘alcoholism’, the approach was premised on a disaggregated approach: there was a diversity of alcohol-related problems, fairly widely distributed among the drinking population (Knupfer 1967; World Health Organization (WHO), Expert Committee on Problems Related to Alcohol Consumption 1980). It was noted that for many problems, the heaviest drinkers accounted for only a minority, because there were so many more drinking at somewhat lower levels (Moore and Gerstein 1981); picking up Rose’s (1981) phrase, Kreitman (1986) termed this the ‘preventive paradox’. Attention was, therefore, paid not only to the heaviest drinkers, but also to the whole range of drinking levels, and indeed, to the distribution of consumption in the population (Ledermann 1956; De Lint and Schmidt 1968). What happens with moderate drinkers, it was argued, influences the social climate for heavy drinking, because drinking is largely a social activity, marked by mutual influences and norms of reciprocity (Bruun et al. 1975a; Skog 1985). In a given population, it was found that rates of alcohol-related problems tend to rise and fall with changes in the level of consumption (Seeley 1960). Controls on the availability of alcohol, including taxes, affect the level of consumption, and thus, also the rates of alcohol-related problems (Seeley 1960; Terris 1967; Popham et al. 1976). The level of alcohol consumption in a population, and controls on alcohol availability, is thus seen as a public health concern, and part of a society’s overall ‘alcohol policy’ (Bruun et al. 1975a).
In enumerating the elements of the new public health approach, we have given references for early statements of each element. It will be seen that the strands of this approach were woven together gradually over a period of some years. A 1975 report by an international group of researchers (Bruun et al. 1975a) became a pivotal document for the approach. A few years later, the approach was given an authoritative endorsement in the United States by a committee of the National Academy of Sciences (Moore and Gerstein 1981). The most recent restatement of the approach by an international group of scholars appeared in 2010 (Babor et al. 2010), with a somewhat parallel analysis oriented to the developing world (Room et al. 2002).
The approach has had considerable influence on WHO programmes in the field of alcohol (Room 2005; WHO 2007). For instance, action on the availability and marketing of alcohol and on pricing policies are key elements of WHO’s Global Strategy to Reduce the Harmful Effects of Alcohol, adopted in 2010 (WHO 2010). At national levels, there has been a considerable variation in its influence on policy. In Sweden, where it is known as the Total Consumption Model, it attained dominance as the basis for official policy (Sutton 1998). However, policies based on this approach have been eroded as a consequence of Sweden’s accession to the European Union (Holder et al. 1998). The approach also has had considerable backing in other Nordic countries.
In English-speaking countries, it has encountered substantial resistance in the cultural–political realm. Those allied with the alcoholic beverage industry have strongly attacked the approach, both in analyses and polemics (e.g. Mott 1991; Grant and Litvak 1998) and through direct political action to remove official proponents (Room 1984c). An approach that contemplates government regulation and influencing of private consumer choices is also unwelcome to those committed to consumer sovereignty and the primacy of individual choice (e.g. Peele 1987). Often, proponents of approaches seeking to ‘domesticate’ drinking—to reduce problems from drinking by integrating it into everyday life—have portrayed the new public health approach as antithetical to this (Olsson 1990), although some researchers have noted that there is no necessary antithesis (Whitehead 1979).
In terms of its influence on policy, the approach has undoubtedly had some effect in strengthening the defence of existing control structures and regulations. But efforts to get the approach adopted as the practical base for policy have met with resistance and failure in a number of countries (Hawks 1993; Room 2004). One response to this resistance has been some calls for an alternative approach (Stockwell et al. 1997), arguing that policy measures directed at heavy and problematic drinkers are more politically acceptable than measures directed at all drinkers.
The policy approach offered as an alternative is a focus on harm reduction, primarily by reducing instances of intoxication or insulating the drinkers from harm (Plant et al. 1997; Stimson et al. 2007). However, there is in fact usually no conflict between approaches aimed at total consumption and approaches aiming to reduce harm from heavy drinking. As Stockwell et al. (1997) noted, ‘aggregate consumption levels are in fact likely to fall if effective [harm reduction] strategies are introduced’ (p. 6). Conversely, many measures that affect the whole drinking population—taxation being a good example—are especially hard on heavier drinkers. Nor are targeted harm reduction measures necessarily more politically acceptable than measures that affect all drinkers. Old systems of rationing and individual buyer surveillance (Järvinen 1991), which were directed specifically at restraining heavy drinking, are now politically unacceptable in any high-income society, although rationing, at least, was highly effective as a targeted prevention measure (Norström 1987). Thus the first act of a new government elected in Australia’s Northern Territory was to dismantle a new system requiring electronic identification to purchase alcohol, which had put into effect a ban on alcohol purchases by specific problematic drinkers (Room 2013).
Beyond its specific features, the controversy over the new public health approach replicates familiar patterns of controversy over public health approaches in general, particularly when those approaches impinge on familiar and valued patterns of behaviour, with substantial economic interests at stake. At the level of the knowledge base, the approach has had considerable success: The empirical evidence underlying the approach has considerably strengthened since the approach was first put forward. At a political level, however, the approach has had only limited success, and primarily in areas peripheral to its main focus—that is, in drinking–driving and minimum-age limits for drinkers.
Strategies of prevention and control and their effectiveness
Simplifying them, there are seven main strategies to minimize alcohol problems. One strategy is to educate or persuade people not to use alcohol or about ways to use it 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, in the positive direction, is to provide alternatives to drinking or to drink-related activities. A fourth strategy is in one way or another to insulate the user from harm. A fifth strategy is to regulate availability of alcohol or the conditions of its use; prohibition of supply may be regarded as a special case of such regulation. 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 have trouble with their drinking habits. We will consider, in turn, these strategies and the evidence on their effectiveness.
Education and persuasion
In principle, education can be offered to any segment of the population in a variety of venues, but it is usually education of youth in schools that first comes to mind in the prevention of alcohol problems. Community-based prevention programmes, which are often also directed at adults, also may include an educational component.
Education offers new information or ways of thinking and leaves it to the listener to draw conclusions concerning beliefs and behaviour. However, most alcohol education programmes go beyond this. A common theme in North American evaluative literature on alcohol education is that ‘knowledge-only’ approaches do not result in changes in behaviour (Botvin 1995). School-based alcohol education has, thus, usually had a persuasional element, aiming to influence students in a particular direction.
Persuasion is directly concerned with changing beliefs or behaviours, and may or may not also offer information. Mass media campaigns aimed at persuasion have been a very common component of prevention programmes for alcohol-related problems, but this can also be pursued through other media and modalities.
In most societies, public health-oriented persuasion about alcohol must compete with a variety of other persuasive messages, including those intended to sell alcoholic beverages. The evidence that alcohol advertising influences teenagers and young adults towards increased drinking and problematic drinking is becoming stronger (Casswell et al. 2002). Even where alcohol advertising is not allowed in the mass media, these messages are often conveyed to consumers and potential consumers in a variety of other ways.
Evidence on effectiveness
The literature on effectiveness of educational approaches is dominated by studies on school-based education from the United States. This means that alcohol education has usually been in the context of drug and tobacco education and that the emphasis has been on abstention (Beck 1998) or at least on delaying the start of drinking, in cultural circumstances where the median age of actually starting to drink is about 13 years although the minimum legal drinking age is 21 years. In general, despite the best efforts of a generation of researchers, this literature has had difficulty showing substantial and lasting effects (Foxcroft et al. 2003; Gorman et al. 2007). There is a good argument from general principles for alcohol education in the context of consumer and health, but there is little evidence from the formal evaluation literature at this point of its effectiveness beyond the short term (Babor et al. 2010).
Persuasive media campaigns have also been a favourite modality in many places in recent decades. In general, evaluations of such campaigns have been able to demonstrate impacts on knowledge and awareness about substance use problems, but show little success in affecting attitudes and behaviours (Babor et al. 2010). As with school education approaches, there are hints in literature that more success may come from influencing the community around the drinker—in terms of attitudes of significant others or popular support for alcohol policy measures—than from directly persuading the drinker himself or herself. Thus, media messages can be effective as agenda-setting mechanisms in the community, increasing or sustaining public support for other preventive strategies (Casswell et al. 1989).
In its broadest sense, deterrence means simply the threat of negative sanctions or disincentives for behaviour—a form of negative persuasion. Criminal laws deter in two ways: by general deterrence, which is the effect of the law in preventing a prohibited behaviour in the population as a whole; and specific deterrence, which is the effect of the law in discouraging those who have been caught from doing it again (Ross 1982). A law will have a greater preventive effect and be cheaper to administer to the extent it has a strong general deterrence effect.
Prohibitions on driving after drinking more than a specified amount are now in effect in most nations (WHO 2004). In many societies, there have also been laws against drinking in public places, against public drunkenness (being in a public place while intoxicated) and against obnoxious behaviour while intoxicated. Other common prohibitions are concerned with producing or selling alcoholic beverages outside state-regulated channels and with aspects of drinking under a specified minimum age.
Evidence on effectiveness
Drinking–driving legislation, such as ‘per se’ laws outlawing driving while at or above a defined blood-alcohol level, has been shown to be effective in changing behaviour and reducing rates of alcohol-related problems (Ross 1982; Hingson 1996; Babor et al. 2010). The effect is through both general and specific deterrence. The quickness and certainty of punishment as well as its severity are important in the deterrent value (too much severity tends to undercut the quickness and certainty). Drinking–driving is an ideal area for applying general deterrence, as the gains from breaking the law are limited and automobile drivers typically have something to lose by being caught.
Many English-speaking and Scandinavian countries have had a tradition of criminalizing drinking in public places or public drunkenness as such. The trend in the 1970s and following was to decriminalize public drunkenness, although in many places it remains illegal. In the 1990s and following, there has been some trend to criminalize drinking in specific public places (Pennay and Room 2012). Criminalization of such behaviours has some effect in moving behaviour around, but is not very effective in changing the behaviour of marginalized heavy drinkers who have little to lose.
Providing and encouraging alternative activities
Another strategy, in principle involving positive incentives, is to provide and seek to encourage activities that are an alternative to drinking or to activities closely associated with drinking. This includes initiatives such as making soft drinks available as an alternative to alcoholic beverages, providing locations for sociability as an alternative to taverns, and providing and encouraging recreational activities as an alternative to leisure activities involving drinking. Job creation and skill development programmes are other examples.
Evidence on effectiveness
‘Boredom’ and ‘because there’s nothing else to do’ are certainly among the reasons given by some for drinking. And, there are often good reasons of general social policy for providing and encouraging alternative activities. But as has been noted, the problem with alternatives to drinking is that drinking combines so well with many of them. Soft drinks are indeed an alternative to alcoholic beverages for quenching thirst, but they may also serve as a mixer in an alcoholic drink. Involvement in sports may go along with drinking as well as replace it. The few evaluation studies of providing alternative activities, again from a restricted number of societies, have generally not shown lasting effects on drinking behaviour (Moskowitz et al. 1983; Norman et al. 1997), although they undoubtedly often serve a general social purpose in broadening opportunities for the disadvantaged (Carmona and Stewart 1996).
Insulating use from harm
A major social strategy for reducing alcohol-related problems in many societies has been measures to separate the drinker, and particularly heavy drinkers, from potential harm. This separation can be physical (in terms of distance or walls), it can be temporal, or it can be cultural (e.g. defining the drinking occasion as ‘time out’ from normal responsibilities). These ‘harm-reduction’ strategies, as they are called in the context of illicit drugs, are often built into cultural arrangements around drinking, but can also be the object of purposive programmes and policies (Moore and Gerstein 1981), such as promotion of ‘designated drivers’, where one person in a social group is chosen to abstain and drive in the particular social situation (DeJong and Hingson 1998).
A variety of modifications to the driving environment positively affect casualties associated with drinking and driving, along with other casualties. These include mandatory use of seat belts, airbags, and improvements in the safety of vehicles and roads. Many other practical measures to separate intoxication episodes from casualties and other adverse consequences have been put into practice, although usually without formal evaluation.
Evidence on effectiveness
Drinking–driving countermeasures are a prime example of an approach in terms of insulating drinking behaviour from harm, as they seek to reduce alcohol-related traffic casualties without necessarily stopping or reducing alcohol use (Evans 1991). There is substantial evidence on the success of a range of such countermeasures, including environmental change approaches as well as deterrence (DeJong and Hingson 1998; Babor et al. 2010). Some environmental measures that reduce traffic casualties in general—such as requiring the wearing of seat belts in cars or providing sidewalks separated from the road—may prevent casualties associated with intoxication even more than other casualties.
Regulating the availability and conditions of use
In terms of the substantial harm to health and public order they can cause, alcoholic beverages are not ordinary commodities. Governments have, thus, often actively intervened in the markets for such beverages, far beyond usual levels of state intervention in markets for commodities.
Total prohibition can be viewed as an extreme form of regulation of the market. In this circumstance, where no one is licensed to sell alcohol, the state has no formal control over the conditions of the sales that occur nevertheless, and there are no legal sales interests, controlled through licensing, to cooperate with the state in market regulation.
With a general prohibition, typically, the consumption of alcohol does fall in the population, and there are also declines in the rates of the direct consequences of drinking such as cirrhosis or alcohol-related mental disorders (Moore and Gerstein 1981; Teasley 1992). But prohibition also brings with it characteristic negative consequences, including the emergence and growth of an illicit market and the crime associated with this. Partly for this reason, alcohol prohibition at a national level is now a live option only in Islamic societies, where the law reflects religious belief, which helps to sustain compliance. Local-area alcohol prohibitions are more widespread.
The features of alcohol control regimes that regulate the legal market in alcohol vary greatly. Special taxes on alcohol are very common, imposed often as much for revenue as for public health considerations. Most societies have minimum-age limits forbidding sales to underage customers and many have regulations forbidding sales to the already intoxicated. Often, the regulations include limiting the number of sales outlets, restricting hours and days of sale, and limiting sales to special stores or drinking places. Rationing of alcohol purchases—limiting the amount individuals can buy in a given time period—has also been used as a means of regulating availability. Regulations restricting or forbidding advertising of alcoholic beverages attempt to limit or channel efforts by private interests to increase demand for particular alcoholic beverages. Such regulations potentially complement education and persuasion efforts. State monopolization on sales of some or all alcoholic beverages at the retail and/or wholesale level has also been commonly been used as a mechanism to minimize alcohol-related harm (Room 1993).
Effectiveness of specific types of regulation on availability
The decades since the 1970s have seen the development of a burgeoning literature on the effects of alcohol control measures. Reference guides for communities, summarizing the research evidence and attuned to particular national or regional conditions, are becoming available (e.g. Neves et al. 1998; Grover 1999). Specific types of regulation of the alcohol market, and the evidence on their effectiveness, are discussed as follows:
A minimum-age limit is a partial prohibition, applied to one segment of the population. There is a strong evaluation literature showing the effectiveness of establishing and enforcing minimum-age limits in reducing alcohol-related problems (Babor et al. 2010). However, this literature is mostly based on North America, focusing mostly on youthful driving casualties and evaluating reduction from and increases to age 21 years as the limit, a minimum-age limit higher than in most societies. There is limited evidence on the applicability of the literature’s findings in other societies and where youth cultures may be less automobile-focused (but see Møller 2002; Kypri et al. 2006).
Taxes and other price increases
Generally, consumers show some response on the price of alcoholic beverages, as on all other commodities. If the price goes up, the drinker will drink less; data from high-income societies suggests this is at least as true of the heavy drinker as of the occasional drinker (Babor et al. 2010). Studies have found that alcohol tax increases reduce the rates of traffic casualties, of cirrhosis mortality, and of incidents of violence (Cook 2007).
Limiting sales outlets and hours and conditions of sale
A substantial body of literature shows that levels and patterns of alcohol consumption, and rates of alcohol-related casualties and other problems, are influenced by such sales restrictions, which typically make the purchase of alcoholic beverages slightly inconvenient or influence the setting of and after drinking (Babor et al. 2010; Livingston 2013). Enforced rules influencing ‘house policies’ in drinking places on not serving intoxicated customers, for example, have also been shown to have some effect (Saltz 1997).
Monopolizing production or sale
Studies of the effects of privatizing retail alcohol monopolies have often shown some increase in levels of alcohol consumption and problems, in part because the number of outlets and hours of sale typically increase with privatization (Her et al. 1999) and partly also because the new private interests typically exert political influence for further increases in availability. From a public health perspective, it is the retail level that is important, although monopolization of the production or wholesale level may facilitate revenue collection and effective control of the market.
Rationing the amount of alcohol sold to an individual potentially directly impacts on heavy drinkers and has been shown to reduce levels both of intoxication-related problems such as violence and of drinking-history-related problems such as cirrhosis mortality (Schechter 1986; Norström 1987). But, although a form of rationing—the medical prescription system—is well accepted in most societies for psychoactive medications, it has proved politically unacceptable nowadays for alcoholic beverages in high-income societies.
Advertising and promotion restrictions
Many societies have regulations on advertising and other promotion of sales of alcoholic beverages (WHO 2004). Although it is well accepted that advertising can strongly affect consumer choices on products in the market, it has proved difficult to measure the effects of advertising on demand for alcoholic beverages as a whole, partly because the effects are likely to be cumulative and long-term, making them difficult to measure. However, the evidence on the effects of advertising and promotion on overall demand has become somewhat stronger in recent literature (Casswell 1995; Casswell and Zhang 1998; Babor et al. 2010).
Social and religious movements and community action
Substantial reductions in alcohol-related problems have often been the result of spontaneous social and religious movements, which put a major emphasis on quitting intoxication or drinking. In recent decades, efforts have also been made to form partnerships between state organizations and non-governmental groups to work on alcohol problems, often at the level of the local community. There has been an active tradition of community action projects on alcohol problems, often using a range of prevention strategies (Giesbrecht et al. 1990; Greenfield and Zimmerman 1993; Holmila 1997; Holder 1998). School-based prevention efforts have also moved increasingly to try to involve the community, in line with general perceptions that such multifaceted strategies will be more effective (Paglia and Room 1999).
Although some of the biggest historical reductions in alcohol problem rates have resulted from spontaneous and autonomous social or religious movements, support or collaboration from a government can easily be perceived as official co-optation or manipulation (Room 1997). Thus, there is considerable question about the extent to which such movements can or should become an instrument of government prevention policies.
Evidence on effectiveness
In the short term, movements of religious or cultural revival can be highly effective in reducing levels of drinking and of alcohol-related problems. Alcohol consumption in the United States fell by about half in the first flush of temperance enthusiasm in 1830–1845 (Moore and Gerstein 1981). Rates of serious crime are reported to have fallen for a while to a fraction of their previous level in Ireland in the wake of Father Mathew’s temperance crusade (Room 1983). The enthusiasm that sustains such movements tends to decay over time, although they often leave behind new customs and institutions of much longer duration. For instance, although the days when the historic temperance movement in English-speaking societies was strong are long gone, the movement had the long-lasting effect of largely removing drinking from the workplace in these societies.
Particularly in the developing world, religious or cultural renewal movements oriented to reducing or prohibiting drinking are often a strong avenue of preventive action (Room et al. 2002). A reform movement among poor indigenous people in a region of Ecuador touched off in 1987 by religious renewal movements and an earthquake appears to have had lasting effects on popular sobriety (Butler 2006).
Providing effective treatment or other help for drinkers who find they cannot control their drinking can be regarded as an obligation of a just and humane society. The help can take several forms: a specific treatment system for alcohol problems, professional help in general health or welfare systems, or non-professional assistance in mutual-help movements. To the extent such help is effective, it is also a means of preventing or reducing future alcohol-related problems in the person helped, although its effectiveness at a population level is less clear.
Treatments for alcohol problems need not be complex or expensive. The evaluation literature suggests that brief outpatient interventions aimed at changing cognitions and behaviour around drinking are as effective in most circumstances as longer and more intensive treatment (Finney and Monahan 1998; Long et al. 1998). Positive results from such interventions in primary healthcare settings were shown in a WHO study that included a number of countries (Babor et al. 1994).
Evidence on effectiveness
In terms of the effects of treatment on those who come for it, there is good evidence on the effectiveness of treatment for alcohol problems. Typically, the improvement rate from a single episode of treatment is about 20 per cent higher than the no-treatment condition: further treatment episodes are often needed. Brief treatment interventions or mutual-help approaches usually result in net savings in social and health costs associated with the heavy drinker (at least where healthcare is not self-paid), as well as improving the quality of life (Holder and Cunningham 1992; Holder et al. 1992).
The effectiveness of providing treatment as a strategy for reducing rates of alcohol problems in a society is more equivocal. In a North American context, it has been argued that the steep increase in alcohol problems treatment provision and mutual-help group membership in recent decades contributed to reducing alcohol problems rates (Smart and Mann 1990). But the strength of the evidence for this contention is disputed (Holder 1997; Smart and Mann 1997). A treatment system for alcohol problems is an important part of an integrated national alcohol policy, but as an instrument of prevention—of reducing societal rates of alcohol problems—it is unlikely to be very cost-effective (Chisholm et al. 2004).
Building integrated alcohol policies
Alcohol policy at a community or societal level
Often, the different strategies for preventing alcohol problems appear to be synergistic in their effects (DeJong and Hingson 1998). For instance, controls on availability are more likely to be adopted, continued, and respected when the public has been successfully persuaded of their effects and effectiveness. But strategies can also work at cross-purposes: a prohibition policy, for instance, makes it difficult to pursue measures that insulate drinking from harm.
In a society where alcohol is a regular item of consumption, in view of the resulting rates of alcohol-related social and health problems, there is a strong justification for adopting a comprehensive policy concerning alcohol, taking into account production, marketing, and consumption, and the prevention and treatment of alcohol-related problems. In recent years, the idea that there should be an integrated alcohol policy at community or national levels, reaching across the many sectors of government and civil society that deal with alcohol issues, has become a common public health aim, although accomplishing this has often proved difficult (Smart and Mann 1997; Crombie et al. 2007; WHO 2011).
In terms of strategies we have reviewed for managing and reducing the rates of alcohol problems in the society, there is a clear evidence for effectiveness and cost-effectiveness of measures regulating the availability and conditions of use, and for some of the measures which insulate use from harm. With respect to some aspects of alcohol problems, notably drinking–driving, deterrence measures also fall in the same category. Despite their perennial popularity, evidence of the effectiveness of education or persuasion and treatment strategies in reducing societal rates of problems is limited at best. Education and treatment are good things for a society and a government to be doing about alcohol problems, but they do not constitute in themselves a public health policy on alcohol (Babor et al. 2010). These strategies will nevertheless be pursued in most societies, and they can best be pursued with attention to using relatively cost-effective methods, and to integrating targets and messages with other aspects of alcohol policy.
Alcohol policy in a global perspective
Apart from lapsed agreements made a century ago among the European colonial powers about control of the spirits trade in Africa (Bruun et al. 1975b), there is little tradition of collaboration on alcohol policy at the international level. It has been largely up to each nation to cope on its own with the serious social and health problems associated with drinking. Although alcohol smuggling has a long history, the nation-state could usually rely on distances and traditional trade barriers to keep alcohol issues largely a matter within its borders, in terms of the supply as well as of the problems.
Since the 1980s, an accelerated rate of economic globalization has been seen, which has increasingly rendered obsolete the assumption that alcohol issues are local issues. This globalization affects alcohol issues in three main ways. The first of these is the influence of a global ideology of free markets. In its sweep, this ideology has caught up and dismantled a variety of market arrangements that served to hold down and to structure alcohol consumption. State and provincial alcohol monopolies in North America were weakened or dismantled (Her et al. 1999). In Eastern Europe and the countries in transition, alcohol monopolies were swept away along with most other governmental intrusions in the market (Moskalewicz 1993). Many of the municipally-run beer halls in Southern African countries were privatized (Jernigan 1997). In line with the general ideology, privatization of alcohol production and distribution has been often suggested, abetted or imposed on developing countries by international development agencies (White and Batia 1998). Where the market is organized in a state licensing system for private interests, free-market ideology has often overridden any concerns about public health risks or community need (Room 2004).
Second, trade agreements, trade dispute mechanisms, and the growth of new sales media have effectively reduced the ability of national and subnational governments to control their local alcohol markets. The influence of trade agreements and trade dispute decisions in breaking down alcohol controls, including control of price through taxation, has been most fully documented for North America (Room et al. 2006) and Europe (Tigerstedt 1990; Holder et al. 1998), but these mechanisms also operate in the developing world. For instance, average taxes on alcoholic beverages in South Korea were lowered in 2000 as a result of complaints to the World Trade Organization by the European Union and the United States (Kim 2000). In 2010–2012, the European Union and United States, joined by Australia, Canada, and five other countries, have argued that Thailand’s proposed warning labels on alcohol bottles would violate trade agreements, a first step towards seeking a trade court judgement (O’Brien 2013).
Third, alcohol production, distribution, and marketing became increasingly globalized (Room et al. 2002; Jernigan 2010). Transnational alcohol companies expanded rapidly into low- and middle-income countries in search of new markets, benefiting from weak policy environments and the sweeping tide of market liberalization. Although most alcoholic beverages are still produced in the country in which they are sold, industrially produced beverages were increasingly produced in plants owned, co-owned, or licensed by multinational firms. To promote increased sales, these firms have been able to transform and step up the marketing techniques used in the national market, bringing to bear all the marketing resources and expertise they have developed in other markets.
In light of these converging trends, there is a growing need for mechanisms to express public health interests in alcohol issues at the international level, both in trade agreements and settlements of trade disputes, and in creating mutual obligations for one nation to back up rather than subvert the alcohol regulations and policies of another.
Ways forward for the public health interest
At international levels
The comparative risk analysis in the WHO’s estimation of the global burden of disease (GBD) has underlined the substantial role of alcohol in death and disability, particularly in middle- and high-income countries. There are also substantial harms from drinking to others, and these harms are mostly not included in the GBD frame (Laslett et al. 2011). The high rates of harm reflect not only the levels of use and heavy use of alcohol, but also that current expert evaluations rate it as intrinsically among the most harmful of psychoactive substances that humans use (Nutt et al. 2010).
These findings contrast with the current omission of alcohol from international systems of control of psychoactive substances. International markets in most commonly used psychoactive substances are under strict control under the three drug treaties of 1961, 1971, and 1988. International markets in tobacco are also controlled, though more lightly, under a 2003 Framework Convention. Alcohol is thus unique as a commonly used and problematic psychoactive substance on which there is no current international control agreement. As noted, this has left the path open for international limits to be placed on national and local control policies through trade agreements and disputes (Ziegler, 2009; O’Brien 2013).
Apart from any specific treaty provisions, the lack of a treaty status for alcohol has also had implications for resources devoted to alcohol issues in intergovernmental agencies. In 2013, the number of posts at such agencies devoted to alcohol issues, almost all at the WHO, was in the single digits. In contrast, the number of posts in intergovernmental agencies devoted to tobacco was in the dozens, and to drugs in the hundreds. The treaty processes also mean that, both for drugs and for tobacco, there are regular meetings of parties to the treaties to review progress and consider further actions.
Symbolically, in the early 2010s there was increased recognition at the international level of the importance of alcohol control in public health. In 2010, The World Health Assembly (WHA) adopted a Global Strategy for the Reduction of Harmful Use of Alcohol (WHO 2010). In 2013, implementing United Nations decisions to put a global focus on preventing and controlling non-communicable diseases, the WHA acted to support a draft action plan (WHO 2013a) and a global monitoring framework (WHO 2013b) which included specific attention to alcohol as one of four main risk factors, although the targets and actions specified for alcohol were much less specific and ambitious than those for other risk factors such as tobacco. However, these actions were not accompanied by increases in resources for implementation concerning alcohol issues.
To remedy the deficit in alcohol control at the international level, there are growing calls for a framework convention on alcohol control to be negotiated under the WHO auspices or otherwise, on the model of the tobacco convention (Anonymous 2007; Room et al. 2008), although the advisability of this path has been contested (Taylor and Dhillon 2013, and commentaries). Another option was briefly discussed at the 2012 WHO Expert Committee on Drug Dependence: scheduling alcohol under one of the United Nations drug conventions. This was referred for consideration at a future Expert Committee meeting (WHO 2012, p. 16). It is clear that alcohol would qualify for scheduling under the treaties’ criteria. Scheduling alcohol under a drug treaty would provide de-facto insulation from trade treaty restrictions on control, and indeed provide mechanisms for countries to control imports. Such a step would presumably require amending at least one of the drug treaties to allow for regulated domestic markets for non-medical use of at least some scheduled drugs, but moves in the 2010s towards regulated cannabis markets point anyway toward such a development.
Apart from the sphere of intergovernmental action and agencies, there has also been a deficit in international activity in the sphere of non-governmental organizations (NGOs). At a global level, the main NGOs active have been the Global Alcohol Policy Alliance, the International Council on Alcohol and Addictions and the World Medical Association; at regional levels, there are such bodies as Eurocare and Forut. While the global alcohol industry is well organized to oppose effective alcohol policies, through such organs as the International Center on Alcohol Policy (Bakke and Endal 2010; Casswell 2013), the alcohol area lacks the dense networks of public health-oriented international NGO activity found in fields such as tobacco and drugs.
At national and subnational levels
As outlined earlier, over the last 40 years, a substantial literature has emerged which allows a differentiation of prevention strategies and policies in terms of their effectiveness. Some strategies—for example, school education, public information campaigns, and provision of alternatives—are often politically popular but have limited or no effect. A few strategies that have proved effective—notably, drinking–driving countermeasures—have been applied in a number of countries. Other effective strategies—especially controls on price and availability—have been widely resisted in the political process, and undercut by trade agreements. Ironically, our knowledge of the effectiveness of availability and price controls has often come from studies made possible by the fact that the stricter controls of the past were being dismantled (Olsson et al. 2002).
From the perspective of promoting public health, the lessons of this literature need to be applied. We now have much better evidence than formerly of the scope and distribution of the problems. We have a literature on policy impacts with good information on cost-effectiveness. The need is to focus policy attention, and to build public support for action. A wide range of government departments are responsible for the diversity of problems due to drinking. Police and justice agencies deal with drink-driving and with alcohol-related violence; welfare departments and agencies deal with family problems and immiseration when a parent drinks heavily; hospitals and health services deal with sickness and injury due to drinking. Typically, different levels of government each have some responsibility: for instance, taxes may be a national responsibility, hospitals a state or provincial task, welfare a local government task. Efforts to coordinate across departments and levels of government also run up against the issue that the State has mixed interests with respect to alcohol sales (Mäkelä and Viikari 1977), and are often impeded by alcohol not being a major priority for any of the players. Both at national and subnational levels, effective action will require that priorities be set in a situation where responsibilities are often divided and dispersed.
It is clear that, with sufficient political will, the difficulties can be transcended. For instance, in Victoria, Australia, the commitment to drive down the loss of lives—particularly young lives—from traffic crashes drove effective cross-department coordination and a series of policy and enforcement measures—some involving alcohol. Between 1989 and 2004, traffic deaths were halved (Johnston 2006), and they have since fallen further. The steady success of efforts to decrease the proportion of the population smoking cigarettes is another example of a good public health result with concerted action. Just such focused and coordinated attention and action will be required to drive down rates of alcohol-related problems.
‘Strategies of prevention and control and their effectiveness’ and ‘Building integrated alcohol policies’ sections have been adapted from Robin Room, ‘Prevention of alcohol-related problems’ pp. 467–471, in Michael Gelder et al. (eds.) New Oxford Textbook of Psychiatry, Oxford University Press, Oxford, UK, Copyright © 2012, by permission of Oxford University Press, http://www.oup.com.
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