Prevention of alcohol-related problems.
- Education and persuasion
- Evidence on effectiveness
- Evidence on effectiveness
- Providing and encouraging alternative activities
- Evidence on effectiveness
- Insulating use from harm
- Evidence on effectiveness
- Regulating the availability and conditions of use
- The effectiveness of specific types of regulation of availability
- Social and religious movements and community action
- Evidence on effectiveness
- Treatment and other help
- Evidence on effectiveness
- A note on brief interventions
- Building an integrated societal alcohol policy
In most developed societies and many developing societies, alcohol consumption is widely distributed in the population, with abstainers in a minority among adults. Those qualifying to be diagnosed with an alcohol use disorder are a minority of drinkers in such societies.
On the other hand, alcohol is causally implicated in a wide variety of health and social problems. The Global Burden of Disease study estimates that alcohol accounts for 10.3 per cent of the total health-related loss of disability-adjusted life-years in developed societies. (1) In terms of where this burden appears in the health system, while psychiatric conditions (including dependence) and chronic physical disease are both important, casualties often play a predominant role. A recent study in Canada calculated that injuries and other acute causes of death accounted for 66 per cent of all potential years of life lost due to alcohol. (2)
The public health importance of acute effects of a particular episode of intoxication underlies what is often described as the ‘prevention paradox'. In many societies, a fairly substantial proportion of the population (particularly of males) gets intoxicated at least occasionally, and by that fact is at risk of experiencing and causing social and health harm from drinking. (3) Preventing alcohol problems thus requires looking beyond the considerably smaller segment of the population diagnosable with an alcohol use disorder, or the even smaller segment receiving treatment for such a disorder.
A complication in preventing alcohol problems is that there is also evidence of a health benefit from drinking in terms of reduced cardiovascular disease. This benefit is, however, important mainly for men over 45 and women past menopause, and can be attained with a pattern of very light regular drinking, as little as a drink every second day. (4) There is thus little potential conflict between taking alcohol as a preventive heart medication and any prevention policy short of total prohibition.
Simplifying somewhat, there are seven main strategies to minimize alcohol problems:
- educate or persuade people not to use or about ways to use so as to limit harm;
- deter drinking-related behaviour with the threat of penalties—a kind of negative persuasion;
- operating in the positive direction, provide alternatives to drinking or to drink-connected activities;
- somehow insulate the use from harm;
- regulate availability of the drug or the conditions of its use—prohibition of supply may be regarded as a special case of such regulation;
- work with social or religious movements oriented to reducing alcohol problems;
- treat or otherwise help people who are in trouble with their drinking.
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 which 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 about information, and leaves it to the listener to draw conclusions concerning beliefs and behaviour. However, most alcohol education programmes go beyond this. A commonplace of the North American evaluative literature on alcohol education is that ‘knowledge-only' approaches do not result in changes in behaviour. (5) 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 persuasion can be pursued also through other media and modalities.
In most societies, public-health-oriented persuasion about alcohol must compete with a variety of other persuasional 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. (6,7) Even where alcohol advertising is not allowed on the mass media, these messages are 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 from the United States on school-based education. This means that the alcohol education has usually been in the context of drug and tobacco education, and that the emphasis has been on abstention, (8) or at least on delaying the start of drinking, in cultural circumstances where the median age of actually starting drinking is about 13, while the minimum legal drinking age is 21. In general, despite the best efforts of a generation of researchers, this literature has had difficulty showing substantial and lasting effects. (9) There is a good argument from general principles for alcohol education in the context of consumer and health education, but there is little evidence from the formal evaluation literature at this point of its effectiveness beyond the short term.
Persuasional media campaigns have also been a favourite modality in many places in recent decades for the prevention of alcohol problems. In general, evaluations of such campaigns have been able to demonstrate impacts on knowledge and awareness about substance use problems, but can show only modest success in affecting attitudes and behaviours. As with school education approaches, there are hints in the literature that success may come more from influencing the community environment around the drinker—in terms of attitudes of significant others, or popular support for alcohol policy measures—than from directly persuading the drinker him- or herself. Thus, media messages can be effective as agenda-setting mechanisms in the community, increasing or sustaining public support for other preventive strategies.(10)
In its broadest sense, deterrence means simply the threat of negative sanctions or incentives 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. (11) A law tends to have a greater preventive effect and to 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. (12) In many societies there have also been laws 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
Drink–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. (11,13,14) 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 its quickness and certainty). Drink–driving is an ideal area for applying general deterrence, since the gains from breaking the law are limited, and 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, but the trend has been to decriminalize public drunkenness. Though there are few specific studies, criminalizing public drunkenness may not be very effective in changing the behaviour of those 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 which are an alternative to drinking or to activities closely associated with drinking. This includes such initiatives as making soft drinks available as an alternative to alcoholic beverages, providing locations for sociability as an alternative to public houses and bars, 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' nothing else to do' are certainly among the reasons some drinkers give for drinking. There are many good reasons for a general social policy of providing and encouraging alternative activities. However, as has been noted, ‘the problem with alternatives to drinking is that drinking combines so well with so 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 range of societies, have generally not shown lasting effects on drinking behaviour, (15,16) although they undoubtedly often serve a general social purpose in broadening opportunities for the disadvantaged. (17)
Insulating use from harm
A major social strategy for reducing alcohol-related problems in many societies has been measures to separate the drinking, and particularly heavy drinking, 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. (18)
A variety of modifications of the driving environment 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 road 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
Drink–driving countermeasures are a prime example of an approach in terms of insulating drinking behaviour from harm, since they seek to reduce alcohol-related traffic casualties without necessarily stopping or reducing alcohol use. (19) There is substantial evidence of the success of a range of such countermeasures, including environmental change approaches as well as deterrence. (20,21) Some environmental measures which reduce road casualties in general, for example requiring that seat-belts be worn in cars, providing pavements 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 harms 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 which nevertheless occur, and there are no legal sales interests, controlled through licensing, to co-operate with the state in the market's regulation.
With a general prohibition, typically the consumption of alcohol does fall in the population, and there are declines also in the rates of the direct consequences of drinking such as cirrhosis or alcohol-related mental disorders. (18,22) 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, prohibition is not now a live option in any developed society, although it is in some other societies.
The features of alcohol control regimes, regulating 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. Many societies have minimum age limits forbidding sales to underage customers, and regulating 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 shops 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 beverage products. Such regulations potentially complement education and persuasion efforts. State monopolization of sales of some or all alcoholic beverages at the retail and/or wholesale level has also commonly been used as a mechanism to minimize alcohol-related harm. (23)
The effectiveness of specific types of regulation of availability
The last 25 years have seen the development of a burgeoning literature on the effects of alcohol control measures. Specific types of regulation of the alcohol market, and the evidence on their effectiveness, are discussed below.
Minimum age limits
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. (13) However, this literature is North America based, focuses mostly on youthful driving casualties, and mostly evaluates reduction from and increases to age 21 as the limit, a higher minimum age limit than in most societies. The applicability of the literature's findings in other societies and where youth cultures are less car focused has been little tested.
Taxes and other price increases
Generally, consumers show some response to the price of alcoholic beverages, as of all other commodities. If the price goes up, the drinker will drink less; data from developed societies suggests this is at least as true of the heavy drinker as of the occasional drinker. (13) Studies have found that alcohol tax increases reduce the rates of traffic casualties, of cirrhosis mortality, and of incidents of violence. (24,25)
Limiting sales outlets, and hours and conditions of sale
There is a substantial literature showing 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. (13) Enforced rules influencing ‘house policies' in drinking places on not serving intoxicated customers etc. have also been shown to have some effect. (26)
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. (27) From a public health perspective, it is the retail level which is important, while 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. (28,29) But while 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 developed societies.
Advertising and promotion restrictions
Many societies have regulations on advertising and other promotion of sales of alcoholic beverages. (12) While it is well accepted that advertising can strongly affect consumer choices between products on the market, it has proved difficult to measure the effects of advertising on demand for alcoholic beverages as a whole, in part 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 stronger in the recent literature. (30)
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, there have also been efforts 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. (31,32,33 and 34) 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. (9)
While some of the largest historical reductions in rates of alcohol problems 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. (35) 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 one-half in the first flush of temperance enthusiasm in 1830 to 1845. (18) 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. (36) The enthusiasm which sustains such movements tends to decay over time, although they often leave behind new customs and institutions with 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.
Treatment and other help
Providing effective treatment or other help for these 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.
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. (37,38) Positive results from such interventions in a primary health care settings were shown in a World Health Organization study including a number of countries. (39)
Evidence on effectiveness
In terms of the effects of treatment on those who come for it, there is good evidence of effectiveness of treatment for alcohol problem. 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 health care is not self-paid), as well as improving the quality of life. (40,41) 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-related treatment provision and mutual-help group membership in recent decades has contributed to reducing alcohol problems rates. (42) But the strength of the evidence for this contention is disputed. (43,44) 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 probably not cost-effective.
A note on brief interventions
As noted above, alcohol treatment evaluations have often found that briefer interventions are as effective as longer ones in clinical populations. This finding has fuelled substantial efforts to encourage non-specialists to apply brief interventions to broader populations of problematic drinkers, not only in the context of primary-care medical practice but also in such contexts as college counselling (45) and on-site in public houses and bars. (46) In such contexts, brief interventions may be viewed as a form of targeted persuasion. Results in these expanded frames have been somewhat mixed. Evaluations of brief interventions by medical general practitioners have not always found effects. (47) Persuading general practitioners to use the methods on a sustained basis has not proved easy, (48) and their patients are often unreceptive(49) or recalcitrant.(50) It remains to be seen whether and in what sociocultural circumstances making brief interventions for problematic drinking a routine part of general medical practice is a feasible and effective strategy.
Building an integrated societal alcohol policy
Often the different strategies for preventing alcohol problems appear to be synergistic in their effects. (51) Controls of availability, for instance, 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 which 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 terms of strategies we have reviewed for managing and reducing the rates of alcohol problems in society, there is clear evidence for effectiveness and cost-effectiveness of measures regulating the availability and conditions of use, and measures that insulate use from harm. With respect to some aspects of alcohol problems, notably drink–driving, deterrence measures also fall in the same category. Despite their perennial popularity, evidence of the effectiveness of education/persuasion and treatment strategies in reducing societal rates of problems is limited at best. Education and treatment are worthy activities for a society and a government to be doing, but they do not constitute in themselves a public health policy on alcohol. These strategies will nevertheless be pursued in most societies, and they can be best pursued with attention to using cost-effective methods, and to integrating targets and messages with other aspects of alcohol policy.
Physicians and other health workers observe the adverse effects of alcohol in their daily practice, and are well-positioned to argue for public health approaches to reducing the burden of alcohol problems. Reports by colleges of psychiatrists and other physicians have played an important role in such countries as the United Kingdom(52) and Sweden(53) in putting a public health response to alcohol problems on the societal agenda.
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