Alcohol-related medicosocial problems and their prevention

Alcohol-related medicosocial problems and their prevention D. Walsh Medico-Social Research Board Dublin, Ireland 1111111 11111 11111 111111111111111111 11 1111111111111 .. 0 0 0 7 8 S l 8 .. REGIONAL OFFI CE FO R EU ROP E World Heal th Organization Copenhagen 1982 ISBN 92 890 1153 X © World Health Organization 1982 Publications of the World Health Organization enjoy copyright protection in accorda nce with the provisions of Protocol 2 of the Universal Copyright Conven- tion. For rights of reproduction or translation , in part or in toto, of publications issued by the WHO Regional Office for Europe application should be made to the Regional Office for Europe, Scherfigsvej 8, DK-2100 Copenhagen 0, Denmark. The Regional Office welcomes such applications. The designations employed and the presentation of the material in this publica- tion do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorit ies , or concerning the delimitation of its frontiers or boundaries . The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organiza- tion in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The views expressed in this publication are those of the author and do not necessarily represent the decisions or the stated policy of the World Health Organization . PRINTE D IN DENMARK ISSN 0300-4880 CONTENTS Page AUTHOR'S INTRODUCTION CHAPTER I. CHAPTER II. CHAPTER III. CHAPTER IV. HISTORICAL BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 The nineteenth century and after . . . . . . . . . . . . . . . . . . . . . 5 Alcoholism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Distribution of consumption . . . . . . . . . . . . . . . . . . . . . . . . . 14 Alcoholism and alcohol-related problems . . . . . . . . . . . . 17 ALCOHOL CONSUMPTION AND ALCOHOLISM IN EU ROPE SINCE 1950 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Consumption data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Changes in drinking patterns . . . . . . . . . . . . . . . . . . . . . . . . . 20 The prevalence of alcoholism . . . . . . . . . . . . . . . . . . . . . . . . . 24 SOCIAL FACTORS AND ALCOHOL CONSUMPTION . . . . . . 27 Cultural factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Economic factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Women and the young ........................ ..... . . . 30 The unemployed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 The criminal subculture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Migrants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Increased leisure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 The temperance movement . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 The trade and promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 ALCOHOL-RELATED PROBLEMS ............ . .... . ..... 35 Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Alcohol-related social morbidity . . . . . . . . . . . . . . . . . . . . . 36 Alcohol-related mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Alcohol-related somatic morbidity . . . . . . . . . . . . . . . . . . . 49 Impact of alcohol-related problems on public hea lth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 The cost of alcohol to society . . . . . . . . . . . . . . . . . . . . . . . . . 56 111 CHAPTER V. CHAPTER VI. References iv PREVENTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Historical background .......................... 61 Alcohol control policies . . . . . . . . . . . . . . . . . . . . . . . . 64 State monopoly and control . . . . . . . . . . . . . . . . . . . . . 67 Control of availability . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Control of advertising . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Price control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Education and information . . . . . . . . . . . . . . . . . . . . . . 72 Legal sanctions ... .. ........................... 73 Early diagnosis and intervention . . . . . . . . . . . . . . . . . 73 Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 CONCLUSIONS AND RECOMMENDATIONS .......... . 77 ............... . . . ...... . ..................... 83 Author's introduction The history of attitudes to alcohol abuse is an interesting case study in the evolution of thought on a major social issue. Although the concept of "alcoholism" and alcohol problems as a manifestation of a "disease pro- cess" already existed in the nineteenth century (]) , prior to 1900 excessive drinkers or "inebriates" were viewed predominantly from a moral stand- point. Such views were tied, in the main, to a particular type of sociopolitical philosophy that saw much of late nineteenth century social misery as the result of alcohol abuse. (Some twentieth century commentators regard this view as a rationalization, and believe that the nineteenth century attitude was determined by the pragmatic consideration that a drunken workforce interfered with industrial productivity.) In addition, public drunkenness , particularly in large towns and cities, was unsightly, led to crime, and was costly to control. Matters were seldom seen the other way round - that the poor and socially deprived turned to drink for relief, however temporary , from the misery of their everyday existence. With the diminution of alcohol consumption in Europe, and presumably of alcohol-related problems also, towards the end of the nineteenth century and the outbreak of World War I, public preoccupation with alcohol prob- lems diminished. Rising alcohol consumption following World War II and the growth of Alcoholics Anonymous gave added impetus to the perception of alcohol problems as a manifestation of a disease process. In general, this is the view that predominates in contemporary European medical thought , and also influences the planning of health services for those with alcohol problems. The advantages and disadvantages of this approach will be discussed later. For the moment it is sufficient to indicate the generally rising consump- tion of alcohol and its related problems as causing major concern to those working in the health and social fields. Rising rates of mortality from cirrhosis of the liver, increasing frequency of hospitalization for alcoholism and alcoholic psychosis , which now constitutes the principal reason for admission to psychiatric hospital in many countries, the extent of alcohol- related family violence and increasing alcohol-linked road traffic offences, all underlie the serious concern to which alcohol-related problems have given rise. This was clearly expressed in 1979 by resolution WHA32.40, adopted by the Thirty-second World Health Assembly, which states that "problems related to alcohol, particula rl y to its excessive consumption, rank among the world's maj or public health problems". WHO's co ncern with alcohol problems da tes back to 1966, when an Expert Committee on Mental Health was convened to consider se rvices for the preventio n and treatment of dependence o n a lcoho l and other drugs. More recentl y, a number of ac tiviti es have been ca rri ed o ut under the medium-term mental hea lth programme 1975- 1982. As far as the Regio nal Office for Europe is concerned , a projec t entitled "Alcohol and drug dependence in the European Region" was sta rted in 1978 a nd will continue until 1983. The Regio na l Office is a lso collaborating with the Finnish Founda ti o n for Alcohol Studies in the Interna ti o nal Study of Alcohol Control Experiences. WHO's main soc ial target is the attainment by all ci ti zens of the wo rld by the year 2000 ofa leve l of health that will permit them to lead a soc ia ll y a nd econo micall y productive li fe. This necessarily involves the promo tion of hea lthy lifesty les, since much mortalit y a nd mo rbidity is the consequence of man's o wn se lf-da maging behavio ur. The use of alcohol in a moderate a nd responsible fashion is therefo re a major heal th priorit y. It is in this co nte xt that th e present report has been produced. The development of th o ught about alcoho li sm and alcoho l problems, in hi stori- ca l perspective, will first be considered . This will be followed by an examina- tio n of trends in alcohol co nsu mptio n a nd in alcohol-related problems in the countri es of the Europea n Regio n since 1950, and by a brief discussion of the factors underlying and associa ted with these trends. The poss ibility of introducing a nd deve loping preventive meas ures in the field of alcohol- related problems will then be exa mined , toge ther with the strategies tha t may be used in preventio n . AC KNOWL EDGEMENTS This study is part of the project of the WHO Regio na l Office fo r Europe on alcohol and drug dependence in the Europea n Region , a nd I am most gra teful to the Regiona l Director, Dr Leo A. Kaprio, a nd hi s ex-co lleague Dr M. Pos tigli one, for asking me to carry it o ut. I am a lso gratefu l to Mr J. Hannibal, Technical Officer, Menta l Health unit , for hi s adv ice during the planning and prepara ti on of the study a nd to o ther WHO s taff who have read a nd commented on the draft, in particular Dr J. Henderson , Regio na l Officer for Mental Hea lth , Regional Office for Europe, a nd Mrs J . Mose r, Scientist, Division of Menta l Healt h , WHO headquarters . Beca use of the recent developments in the prevention of a lcoho l-rela ted problems in France, I visited that country in la te 1980. The a rrange ments for thi s visi t were kindly made by Mr J. Hanniba l a nd my programme in Fra nce was prepared by Miss P. Cource lle, Ministry of Hea lth and Social Security, Pari s. I wish to thank in particular Mi ss M.R. Ma melet , Ministry of Hea lth and Social Security, Professor J . Be rnard , Chairman, Wo rking 2 Group on Alcoholism, and Dr J . Godard, Comite national de Defense cont re I' Alcoolisme, for receiving me and giving me their time. I also received information and help from Mrs Boisset of the Haut Comite d'Etude et d'I nformation sur I' Alcoolisme and from the staff of the Centre d'H ygiene alimentaire at Soissons . A number of other people concerned with alcohol problems in France also gave me information and help. They are too numerous to thank individually but to all of them I would like to convey my gratitude. 3 I Historical background It is impossible to say with any degree of certainty when man first discovered the use of alcohol with food and for fun . Clearly it was a long time ago and it came almost certainly from the observation that the fermentation of ripe grapes gave a liquid that was pleasurable to drink by reason of its taste and its euphoric effects. Wine was widely used in biblical times , a the Old Testament recounts. There is documentary evidence that the older pre- Christian civilizations also used wine and experienced drunkenness . The recognition of the chemical substance and its properties appears to have been an Arab discovery , as the word "alcohol" is Arabic in origin. The widespread European use of wines , particularly in areas not originally suitable for wine-growing, may have been the consequence of Roman con- quest. The Romans, like the Greeks, were prolific growers of grapes and consumers of wine. It seems likely, therefore, that as the Romans marched northwards they brought their wine with them and introduced indigenous populations to wine consumption and grape cultivation . Other sources of alcohol were also known in early times, one example being mead, obtained by the fermentation of honey. From the middle ages onwards beer and cider became increasingly known and used. Spirit alcohol, obtained by the process of distillation, seems to have been discovered before the middle ages, but was not in widespread use until several centuries later. It seems clear that the recognition of problems related to excessive consumption of alcohol , in whatever form, is almost as old as alcohol itself. Early writers condemned the abuse of alcohol through excessive drinking and one Roman Emperor in the first century after Christ ordered the destruction of Roman vineyards to curb the vice of drunkenness . In more recent times abuse of alcohol by the upper strata of society appears to have been widespread in the eighteenth century. Although this was felt to be generally undesirable it never evoked the same reaction of moral concern that was to follow the more widespread use of alcoholic beverages by broader sections of the community in the next century. The nineteenth century and after Data on alcohol consumption in European countries became generally avai lable in the nineteenth century. They showed both a general increase in total alcohol consumption and a per capita increase. Coincident with this 5 increase were numerous reports of public drunkenness, particularly among the poorer sections of society. This led to governmental action and enquiry in certain European countries. Because the findings and conclusions of these enquiries tell us much about the origin and growth of attitudes towards excessive alcohol con- sumption and alcohol problems, it is worth quoting one example of such an enquiry, namely the Report of the Select Committee of the House of Commons of the United Kingdom on Drunkenness, published in 1834. This indicated that the "vice of intoxication" could be laid at the door of "remote" and "immediate" causes. Foremost among the remote causes was the tendency of the lower classes to emulate the upper classes, who gave such a bad example in their misuse of alcohol. Among the immediate causes were temptations, such as the establishment of places at which drink was placed in the path of the humbler classes of society and a reduction in the price of spirits. The report also distinguished between consequences to individuals and consequences to national welfare. From the point of view of individuals , drunkenness was seen to lead to "destruction of health , disease in every form and shape, premature decrepitude in the old, stunted growth and general debility and decay in the young, loss of life by paroxysms, apoplexies , drownings, burnings and accidents of various kinds, delirium tremens ( one of the most awful afflictions of humanity), paralysis, idiotcy (sic), madness and violent deaths , destruction of mental capacity and vigour and extinction of aptitude for learning as well as of disposition for practising any useful art or industrious occupation, irritation of all the worst passions of the heart, hatred, anger, revenge , with the brutalisation of disposition that breaks asunder and destroys the most endearing bonds of nature and society, extinction of all moral and religious principles, disregard of truth, indiffer- ence to education, violation of chastity, insensibility to shame and indescrib- able degradation". This dire recital of the evil consequences of excessive drinking for the individual was matched by the consequences to the nation. "The conse- quences of intoxication and intemperate habits among the people are as destructive of the general welfare of the community as they are fatal to the happiness of individuals." They affected the "wealth, resources, strength, honour and prosperity of the country". They led to destruction of grain, loss of production and labour, loss of property, damage to the national repu- tation abroad, an increase in pauperism, the spread of violence, and the retardation of all improvements. In proposing remedies, the Committee hinted at the cause when it spoke of drunkenness being "so deeply rooted, so long established, so widely spread and so strongly supported by selfish indulgence, ignorance, preju- dice, custom and pecuniary interests" . It saw remedies as falling into broad groups, of which the first was legislative and the second moral. The legisla- tive measures would "direct, restrain and punish the vicious and contami- nating propensities of the evil-disposed in society who promoted or engaged in the evil of drunkenness". Among the more specific remedies of a moral kind proposed were temperance societies and "a national spirit of education 6 which should embrace, as an essential part of the instruction given to every child in the Kingdom, accurate information as to the poisonous and invari- able deleterious nature of spirits ... ". We see, therefore, that as early as the beginning of the nineteenth century there was a clear recognition tha t socia l and cultural factors (the example given to the poor and less intelligent members of society by those whom they presumably regarded as their superiors) were important in moulding both attitudes towards alcohol abuse a nd methods of preventing it. At the sa me time, concern was ex pressed a bout the ava ilability of a lcoho l a nd the met hods used by its ma nufacturers a nd distributors to increase sa les. There was a lso concern about the low price of spirits which, it was felt , led to increased consumptio n. Drunkenness and intemperance, it see med , led to every conceivable ph ys ical , menta l a nd moral infirmity. There was a strong indication that intemperance and drunkenness led to poverty, that the y interfered with national pros perit y, a nd hindered a pro- gressive and economically a mbitio us society. It is not apparent th at the Committee differenti a ted between "drunkenness" a nd "inebriety", a l- tho ugh the inference is tha t "drunkenness" may have referred to iso lated incidents a nd "inebriety" to ha bitua l a buse. It is interesting to note that, a mo ng the remedies proposed were the use of legislation to int roduce what is now called hea lth educat io n, i.e., "a na tio na l system of educa tion for every child as to the deleterious na ture of spirits" a nd , in additio n , the estab lishment o f temperance socie ti es, which were to be so cha racteristi c a part of the life of the rest of the nineteenth centu ry. It is a lso interesting that the thinking about the origins of excessive drinking a nd the remedies proposed for it are similar to those of our own day, a century and a half later, a lthough often in different guise. Artists a nd writers, too, were concerned abou t the problems associa ted with excess ive drinking. For exa mple, William Hogarth , the ce lebra ted English painter, depicted the miseries of working-class degradation through a lco ho l in a fa mous series of pictures entit led Gin Lane. In France, Emi le Zola portrayed, in the novel/' Assommoir, the gradual decline into a lcoholic misery of a Pa ris family. Nineteenth century commentators believed that the increas ing avai l- ab ilit y a nd cheapness of spirit s, in particular, were among the most potent econo mic and social forces leading to increased a lcohol consumpt ion in most Euro pea n countries at that time. The production of wine and the manufacture of bee r and spirits became increasingly important, both com- mercially and politica ll y. In beer and sp irit countri es the fiscal importance of di stilling and brewing increased enormously . Indeed, in so me Euro pean countri es, dependence on revenue from alcoho l, which had grad uall y been increasing during the century, became of enormous importance , so much so that in those countries little short of one ha lf of a ll exchequer revenue came from alcoho l taxes. In some European count ri es the peak of a lcohol consu mptio n was reached in the last quarter of the nineteenth century; in o thers it cont inued right up to the outbreak of World War I in 1914. For exa mple, in England in 1900, 25 623 000 proof ga llons of sp irits we re "retained for consumption" . 7 This had fallen to 17 891 000 in 1914, 6 646 000 in 1918 but was still 7 187 000 in 1933 (2). The reasons for the decline in those countries where the increase had continued up to 1914 were fairly obvious. However , in those countries where consumption had begun to fall earlier the reason is more difficult to see. No doubt there was no single cause, but many interacting and inter- dependent factors. Among ot her things , the level of consumption in some countries had been so high that little further growth could occur. There is also some evidence to suggest that, in the more affluent European countries, a wider range of general consumer goods had come within the reach of the poorer classes so that for the first time they were able to envisage saving for, and purchasing, a wide variety of household and other articles that had hitherto been beyond their means. They responded accordingly and in the process found alternatives to purchasing and drinking alcohol. No doubt other influences were also important , such as the increasing price of al- coholic beverages, at least in the beer and spirit countries, and the more restrictive legislation on availability. The demands of full-scale war in 1914 inevitably saw precipitous falls in a lcohol production and consumption. Most European countries, and not only the combatant ones , introduced emergency legislative measures to preserve grain for essential foodstuffs and to restrict hours of sale in cafes and public houses , so that the war effort could be maintained. At the same time as consumption decreased as a result of these measures, there were dramatic falls in such alcohol-related conditions as cirrhosis of the liver. The lesson of the war was that changes in sociocultural conditions, albeit of an extreme kind, could modify and control consumption. However , there could be no question that such changes were both undesirable and generally resented, as presumably was the diminished availability of alcohol. After the war there was a temporary relaxation of legislative controls on the production and supply of alcohol, and consumption rose. However, throughout the inter-war years of the 1920s and 1930s a lcohol consumption in Europe was generally low, with some exceptions in wine-producing countries. Many of the wartime controls, although they had been relaxed , were not abolished and furthermore the price of alcohol remained relatively high in relation to incomes, which continued to be low throughout this period. World War II saw much the same pattern of decreases in consumption and related problems that had existed from 1914 to 1918. This situation could not last; change was inevitable, and has been quite dramatic since the end of the war. The wine-producing countries were the first to recover, as more and more vineyards were reclaimed and replanted. Consumption had reached peak heights in countries such as France by 1955. However , in the beer and spirit countries, where recovery was slower, consumption figures remained low throughout the 1950s. From 1960 onwards, however, growth in a lcohol consumption in Europe has been considerable (see Chapter II) . To explain why this should be so is not easy, and it is clear that no single explanat ion is, of itself, sufficient. 8 Alcoholism An understanding of the fundamental nature of alcohol-related problems and alcoholism is of crucial importance to any approach to prevention. Consequently, some little time will be spent in considering the growth and deve lopment of thought about the origins of such problems. The material presented above from early nineteenth century England makes it clear that the causes of intemperance were regarded as partly lying within the individ- ual, because of his natural "propensity to evil", but partly also in the social environment, particularly when it fostered easy availability of alcohol and when the individual was led astray by the bad example of his social su- periors. Here , then, in easily recognizable form is the familiar nature- nurture dichotomy as it relates to drunkenness. However, it is of interest that much of nineteenth century European thought on the problem stresses the moral aspect, i.e., the personal responsibility of the individual. In spite of the strong influence of the social environment, it was claimed that in- dividuals themselves were ultimately to blame for their excessive drinking. This was the dominant view of alcoholism in the nineteenth century. There were, nevertheless , as Wilson (2) has pointed out, the beginnings of a "disease" concept of alcoholism even at that time. It was at about the turn of the nineteenth century that physicians began to show an interest in alcohol-related problems and that the medical aspects of alcohol abuse began to receive attention. The reasons for this are not entirely clear, but the growth in urban populations at about this time and the greater visibility of social problems, whether of insanity, feeble-mindedness or the socially deviant behaviour to which alcohol abuse often led , may well have been responsible. It was also at about this time that institutions for the mentally ill began to appear all over Europe. Inevitably, doctors working within them found that drink played some part in a considerable proportion of admissions. At first , physic ians were more concerned with the conse- quences of excessive drinking than with its origins, and assiduously employed themselves in identifying and describing the types of insanity to which it led. However , at roughly the sa me period, as Bynum (3) points out, the terms, alcoholismus, dipsomanie, methysmus and Trunksucht first came into use in Europe. These words, from a moral point of view, were more or less neutral and did not have the opprobrium inherent in such words as "in- ebriate" and "drunkard" in English and "ivrogne" in French. Alcoholism as "disease" In all this we see the beginnings of a "disease concept" of alcoholism and a moving away from a rigidly moral standpoint. In the United States, Ben- jamin Rush was emphasizing the disease aspects of alcoholism. In an early nineteenth century publication ( 4), he suggested that habitual drunkenness was a disease. He stressed that the "disease" only began after many years of excessive drinking, for which the individual was fully responsible. Thus, he said "the use of strong drink is at first the effect of free agencies . From 9 habit it takes place from necessity". Trotter in his Essay on drunkenness and its effects on the human body (5) suggested that habitual drunkenness was a disease. Elsewhere in Europe, von Bruhl-Cramer (6) took the view that some people drank excessively because they liked being drunk. He recognized that in these cases the volitional element rather than the disease was uppermost. However, Henke ( 7), writing in 1829, strongly supported the earlier views of Trotter by emphasizing that in the early stages an excessive drinker was morally culpable. It was only at a later stage, he claimed, that it became impossible to stop drinking, and only then did alcohol abuse become a disease. This view foreshadows the modern concept of "loss of control" . In much more recent times Jellinek (8) examined Aristotelian ethics on the subject of self-restraint and applied them to excessive drinking. He concluded, like his forerunners a century and a half ago, that "the acqui- sition of the 'disease' (alcoholism) is in a limited way voluntary", that once the disease form is reached it is not different from other diseases, and that "it is not any more in the sphere of volition to terminate it, except through external means" . Most of the medical writers of the nineteenth century seem to have recognized the "craving" and "loss of control" aspects of habitual excessive drinking. Indeed, terms for the condition exist in most European languages, e.g. besoin obsedant in French and unwiderstehliches Verlangen in German. Many, such as von Bruhl-Cramer, felt that the craving and the inability to stop must indicate a constitutional predisposition . This could usually be brought to the surface by long periods of moderate drinking. It does not appear that these writers were able to confirm the existence of a "craving" for alcohol or for the state of mind that alcohol produced, in any satisfac- torily objective fashion. Instead, they appeared to rely on post hoc reason- ing. As will be seen later, the concepts of craving and loss of control have come in for serious criticism in more recent times. Rush, in recognizing the disease characteristics of alcoholism, proposed that alcoholics should be treated medically. With the passage of time the emphasis on the need for such treatment became increasingly stronger. Indeed, in England, for much of the nineteenth century, it became a live political issue. This movement was given its impetus by experience in the USA, where several homes and hospitals for the treatment of alcoholism had been inaugurated around 1850. One of the most prominent agitators in England was a Dr Dalrymple, who later became a Member of Parliament and introduced a private bill to provide institutional care for the treatment of habitual drunkards. He was followed by others, backed by Parliamen- tarians, such as Lord Shaftesbury, and the British Medical Association . Their efforts culminated in the Inebriates Act of 1898, which made special provision, including the use of compulsion, for the treatment of chronic drunkenness in certain cases. This was an improvement on earlier legisla- tion, which had catered only for the wealthier class and not for the poor and the criminally inebriate. In all these activities the reformers had been assisted by the temperance movement, which had its origins in the early decades of the nineteenth 10 century and proved to be a considerable political social force in many European countries as the century wore on. This movement was committed to abstinence and saw alcohol as totally evil. It was therefore at odds with many European reformers, and even European medical men who, at least in the early part of the century, aimed at moderation rather than abstinence. Following the lead of physicians such as Trotter and others, however, many European psychiatrists later in the century moved towards abstinence as the goal of treatment for drunkenness , if not as the ideal for all members of society. The history of the temperance movements and the rise and decline of their sociopolitical power have been reviewed by several authors (9-11) (see also p. 32). Many of the nineteenth century physicians were concerned with the social origins of alcoholism . Some maintained that privation, warfare, and the like played their part in determining the prevalence of drunkenness . However, others acknowledged that the condition was not solely dependent on such adverse circumstances, since not all persons responded in this way, but must depend on an interplay of personal predisposition and social misfortune. Much of the nineteenth century physician's perception of alcoholism as a disease was the result of his awareness of the other diseases, both physica l and mental , associated with it. For example, he recognized that certain mental disorders occurred in association with alcoholism. There was also a feeling that alcoholism led to "degeneration", not only in the alcoholic but also in his family. Indeed , there was for a while , in the nineteenth century, a strong belief, amounting almost to a genetic theory, that alcoholism was associated with , yet not directly responsible for, such conditions as crimi- nality and mental subnormality. The association of liver disease with alco- hol goes back to the seventeenth century, although the word cirrhosis does not appear until much later , and delirium tremens only in 1831 . Finally, the word alcoholism was used by Huss (12) in I 851. The notion that alcoholism or excessive drinking may in some way be the consequence of genetic or strongly influential early life experiences is the predominant twentieth century view. It forms the cornerstone of the attitude of Alcoholics Anonymous towards the problem, which stresses the "power- lessness" of the individual in relation to his need for alcohol. The most formal theoretical presentation of this view appears in Jellinek's The disease concept of alcoholism, published in 1960 (8) . This is still the predominant view in Europe, particularly among those who treat alcoholics. Essentially, the concept emphasizes the special position of the alcoholic as a person who, either for genetic reasons or because of his early environment, is particularly liable to abuse alcohol as compared with individuals not sharing this hypo- thetical early environmental or genetic predisposition . Some of the evidence for this view may have come from the observation of the frequency of alcoholism within families and from the essentially chronic and recurrent character of much problem drinking. Some evidence for a genetic compo- nent in heavy drinking has come from twin and adoption studies by Kaij (13), Partanen et al. (/4), Bohman (15) and Goodwin (16). However, the evidence is not yet conclusive and further study is required. 11 Types of alcoholism Although there was no particular concern, in the nineteenth century, with typologies of drinking patterns and drinking problems, some progress was nevertheless made in this direction. For instance, the condition manie a potu, in which there is an acutely disruptive, noisy and destructive state of mind and behaviour following minimal alcohol consumption, was recognized and identified well over a century ago. Observers have recognized different drinking patterns in different countries. It has also been known for a long time that spirit drinkers behave differently in terms of the periodicity of their drinking bouts and the quantities consumed, as compared to wine drinkers. However, it was Jellinek who produced the most detailed classification of types of alcoholism, which he divided into five major groups (8) . The first is what he calls alpha-alcoholism, which is simply "psychological depen- dence" on alcohol in situations of emotional or physical discomfort or pain . There is no inability to abstain and no loss of control, although there may be certain undesirable social consequences. This condition is sometimes recog- nized as being a precursor of forms of physical dependence. The second type, beta-alcoholism, exists when physical damage results from alcohol intake, usually long established, in the absence of physical or psychological dependence. Thus, persons with this condition may suffer from cirrhosis, brain damage, or chronic gastrointestinal damage from prolonged alcohol intake. The third of Jellinek's types is gamma-alcoholism where both psychological and physical dependence exist. Physical depen- dence involves loss of control of drinking. It is implicit in this definition that, although the individual decides to take the first drink, once he begins he tends to continue drinking and does not stop until he is drunk. This type of drinking seems to be more typical of the spirit- and beer-drinking countries than the wine-drinking countries. The fourth type is delta-alcoholism, in which both psychological and physical dependence exist and there is an incapacity to abstain from alcohol. The individual drinks continuously though without loss of control and with little overt drunkenness. This type of alcoholism is commoner in the wine-drinking countries. Finally, there is what Jellinek called epsilon-alcoholism, where periodic drinking of short duration occurs interspersed with long periods of abstinence. Dependence It is appropriate, because of its controversial nature, to look more closely at the crucial concept of "dependence" or the "alcohol dependence syn- drome". This arises from long-standing excessive alcohol intake that, although not producing acute conditions such as delirium tremens, does lead to certain physiological changes. As a result , withdrawal symptoms appear when the customary alcohol intake is reduced or discontinued altogether. The syndrome can result in chron ic disabilities, such as brain damage and liver cirrhosis, and is often associated with socia l problems. Thus the alcohol dependence syndrome is the equivalent of what used to be called alcoholism, and sufferers from it are what the public usually calls alcoholics. 12 Various attempts have been made to define "dependence". Thus, accord- ing to Keller & McCormack (17), physical dependence on alcohol is "an overwhelming need for alcohol to relieve stress or tension felt by the alco- holic particularly in a period of abstinence, when he seeks to ward off tension by familiar effective means, i.e. by drinking". The same authors also define physical dependence as "a need or craving for alcohol felt by an alcoholic during or subsequent to drinking, arising sometimes from his loss of control (over drinking) and sometimes from his wish to avert or deviate the physical stress of hangovers". It is presumably initiated by the presence of alcohol in the organism. This hypothetically causes a metabolic or other change in the cellular environment and may therefore be the cause of withdrawal symptoms. In effect , then , the only objective validation of the existence of the physical dependence syndrome can be the presence of withdrawal symptoms. The concept of physical dependence, however, implies an incapacity to abstain or even reduce alcohol intake to non- dependent levels . There is ample evidence nevertheless that many indi- viduals who may be drinking at the dependent level, i.e. at the level at which withdrawal symptoms would occur, can and do reduce intake to levels at which stopping does not lead to such symptoms. In this sense the concept of dependence as an inevitable endpoint breaks down and must be seriously criticized. In fact, the concept of "dependence" has been much criticized, both philosophically because of its tautological character, and practically. Other key terms in relation to dependence, such as "craving" and "loss of con- trol", have been the subject of serious criticism by Pattison (18) . Much experimental evidence runs counter to the notions of craving and loss of control. In addition, these concepts are unacceptable to many because they imply the abolition or ineffectiveness of personal choice in situations encountered by alcoholics in daily life. Many would claim that it is im- possible to order and consume drink without making a personal choice. In that sense, the use of the phrase "loss of control" is misguided. They would also point out that , for many excessive drinkers, there comes a time when physical withdrawal symptoms become intolerable. For others, family or employers will no longer tolerate their drinking, or a prosecution may be pending for some alcohol-related offence. For any of these reasons , they may make a positive decision to enter treatment facilities. The decision to stop drinking for these totally intelligible reasons, many would maintain, hardly represents loss of control but rather a deliberate act, rationally related to circumstances whose unpleasantness outweighs the pleasure of continuing to drink . These concepts, then , of"craving", "dependence" and "loss of control" imply that an alcoholic is somehow qualitatively different from other people in his behaviour towards alcohol. He is, therefore, believed to differ radi- cally from other, and even heavy, drinkers . It follows that there is an inevitability about his behaviour in relation to alcohol that cannot be changed or modified and can be "cured" only by total abstinence. This is the current view of many engaged in the treatment of alcoholics and is also the view propounded by the drink industry. 13 However, in 1962, a report by Davis (19) showed that some "dependent" alcoholics were capable of returning to levels of drinking that were "non- dependent". Further evidence of the possibility of returning to "social" drinking by former alcoholics has appeared since then. Another consider- ation is that there is no information as to the numbers of those who, after drinking excessively, have by their own efforts returned to social drinking, because all the available data relate only to persons who have come into treatment. A further objection, from a therapeutic point of view, to the disease concept, is that the alcoholic under treatment becomes indoctrinated with the idea that he is unable to abstain. Some must undoubtedly become infected by this "self-fulfilling prophecy" . Distribution of consumption The disease concept of alcoholism, then, sees alcoholism as dichotomous and discontinuous , i.e. a curve describing drinking populations must be bimodal (Fig. I) . In this curve, the first part represents the distribution of alcohol intake among non-dependent people and the second its distribution among alcoholics or the dependent. I'.! Cl) .,,_ C ·;:: "O 0 8, !'l C ~ Cl) 0.. Low Fig . 1. The disease concept of alcoholism " Normal drinkers" High Alcohol intake The first substantial objection to such a view of the distribution of alcohol intake within communities was made by Ledermann, who examined the distribution of consumption in samples from six groups of people (20). These samples were not representative of general populations , but were drawn from: (a) persons hospitalized in a general medical ward; (b) persons hospitalized for cancer of the digestive and respiratory tract; (c) drivers 14 randomly stopped for blood alcohol samples in the United States; (d) per- sons seen at a social security office in France who were suffering from occupational illnesses; (e) French and Italian populations; and (j) citizens ofltalian descent in the United States. In some cases estimates of intake were based on replies to questionnaires, in others on blood alcohol content measured at the time of investigation . Ledermann claimed provisionally that, on the basis of his investigations, the "decimal logarithm of mean alcohol consumption is distributed normally". The practical implications of Ledermann's results are that the distribu- tion of alcohol intake in populations is a variant of the log-normal distri- bution curve, which is continuous and unimodal but differs from the normal distribution curve itself in that the tail of high alcohol intake extends further away from the mean. This tail represents the heavy or "alcoholic" drinking end of the distribution . It follows that there is a constant relation between per capita or mean intake and the prevalence of heavy drinking. In other words, when the mean intake within a community increases, the size and extent of the tail that extends beyond some hypothetical danger point of alcohol intake increases (Fig. 2). Quite simply, when mean consumption increases so does "alcoholism". It follows that the prevalence of alcoholism can be reduced by reducing per capita consumption . The extent to which this may be brought about by reducing the number of new problem drinkers recruited or the number of established alcoholics is problematical. Much criticism has been levelled at Ledermann's work , some resting on the inappropriateness of the samples used in his early study. The validity of a single blood alcohol measurement as indicating the usual drinking behav- iour of those investigated in some of the surveys has also been questioned. Other criticisms are of a more technical statistical nature and will not be dealt with here. However, Schmidt & Popham (21) have pointed out, in relation to the first objection, that Ledermann later carried out other surveys of drinking behaviour and drinking practices based on more repre- sentative population samples. On common-sense grounds it would seem that the mean per capita consumption of alcohol in a community does not say very much about the distribution of consumption within that commun- ity ( different distributions can exist around the same mean). There are, however , those who would argue that there is a constancy in the measure of distribution (22). Likewise, mean consumptions and distributions around them must necessarily conceal very widely differing consumption patterns of specific demographic and social subgroups within a community. Never- theless, the general thesis that alcoholism , in as far as it can be measured, rises and falls with mean alcohol consumption, has scarcely been refuted by any data that have been produced (23) . The unimodal distribution theory of alcohol consumption, which owes much to Ledermann, is that there is no discontinuity in alcohol intake in a community, as between the heaviest and the lightest consumers. There is, however, some hypothetical transition point between a non-injurious con- sumption level and one that is injurious. Obviously, the personality does not change fundamentally, in terms of ability to control or decrease intake in passing from one level to the other. It follows that individuals can pass as 15 °' 12 10 ~ 8 ., _,,_ C :§ 0 ., 6 CJ) i'l C ., ~ ., 4 a.. 2 0 0 3 6 Source: Ledermann (20) Fig . 2. Dist ribution of alcohol intake -S,. ~1 "o ..,., <o 'i. ~~ '<)~() -? "o ..,., ~~ • '0~ . "'o.-, 9 12 15 18 Alcohol intake (ml absolute alcohol per day) PROBLEMS 21 24 27 readily from the injurious level of intake to the non-injurious as vice versa, and also that the number of people in any given community who are on the wrong side of the boundary between these levels is related to the mean consumption of alcohol within that community. This unitary distribution model of alcohol consumption is that currently espoused by epidemiologists and public health workers concerned with prevention, and has influenced national health policies in the alcohol field (24). Thus, countries and communities have devised strategies to control alcohol consumption in an effort to halt the rise in national per capita consumption or, even better, to reduce it. Alcoholism and alcohol-related problems As already pointed out, little attempt was made in the nineteenth century to differentiate between various types of problem drinking. Terms such as "drunkenness", "inebriety" and more recently "alcoholism" have been used to cover all types of problem arising from excessive drinking. More recently, Jellinek attempted to subdivide dependent drinking into a number of types (seep. 12), but at the present time the word "alcoholism" is the one most commonly employed to describe problems of excessive drinking. It is now apparent that excessive drinking gives rise to a multiplicity of problems and that their range is much wider than that encompassed by the word "alcoholism". Increasingly, in this century, "alcoholism" has come to imply levels of alcohol intake associated with physical dependence. The resulting problems may roughly be divided into those causing social conflict and those affecting the individual's physical and psychological health , the latter involving both mortality and somatic morbidity and including the alcohol- dependence syndrome. Thus, the traditional view of"alcoholism" has been expanded to include a whole variety of alcohol-related problems, from wife-beating to suicide. Support for this approach is provided by the Ninth Revision of the International Classification of Diseases, Chapter V, Mental Diseases, in which the alcohol-dependence syndrome is given a separate rubric (303). The physical complications of alcohol consumption, such as cirrhosis and gastritis, are to be coded in other sections dealing with the appropriate physical conditions. The shift in thinking, from a specific condition of "alcoholism" to the broader concepts of"alcohol-related problems and the alcohol-dependence syndrome", is in general fairly recent. This also applies to the notion that alcohol problems in an individual are as much related to community con- sumption and behaviour towards alcohol as to the genetic and constitu- tional make-up of that individual himself. These more recent points of view have arisen from the studies of alcohol researchers, epidemiologists and public health workers . Their acceptance by clinicians and the general public has been slow and the belief in "alcoholism" and "alcoholics" in the traditional sense is deeply ingrained in many sections of society. As a recent report of a Task Force on Public Education and Social Policy of the Ad- diction Research Foundation of Toronto (22) has pointed out "popular 17 conceptualisations about alcohol (i.e., widely held beliefs and attitudes) appear to have lagged behind researchers' conceptualisations by 20 or 30 yea rs". In a different context, the perception of what is and what is not an alcohol-related problem is socially and culturally st ructured and deter- mined . This is true even within a region as apparently homogeneous as that consti tuting the majority of European countries. Thus , in northern Europe , the " Protestant et hic" , which traditionally disapproves of excessive drink- ing and any public manifestat ion of it, made prohibition possible, even if only for a limited time, in ce rtain parts of northern Europe and northern America. In contrast , some European societies with different drinking patterns have taken a different view of matters and are far less restrictive. Both traditional and contemporary approaches have made a clear ethi- cal difference between drinking that is self-destructive and drink-related behaviour that violates the social order. The former may be considered permissible, but drinking that interferes with, or disrupts, established socia l mores or impinges on members of society outside the family of the person concerned has always been punished . More recently , violence within the family, often hitherto tolerated and regarded as being a private matter, has now attained greater visibility. Intervention, whether by social or legal agencies, in cases of wife-beating or child-battering has become much commoner in European societies in recent years. Nineteenth century thinking was intimately preoccupied with the inter- action of social factors and the extent of alcohol abuse. In general terms, it was felt that much of the human misery a mong the lower socioeconomic classes was the consequence of over-indulgence in alcohol. This was particu- larly the attitude of right-minded people concerned with the increasing embarrassment to an orderly industrial and social life of large numbers of drunken people . The response was often predominantly the moral one of apportioning blame for drunkenness , and the solutions were those of con- trol and restraint. However, some writers were quick to point out that the relationship was not as sim ple as thi s: it was just as logical to see indulgence in alcohol as a means, for the miserable and poor of European society, of mitigating the rigours of working-class life by the warmth and cheer of drinking. In other words, they argued, the case could equally as well be made that people drank because they were poor, rather than that they were poor because they drank . The factors underlying the need to legislate for the control and prosecution of the inebriate, as well as the criminal and the lunatic, have been criticall y analysed by socio logists such as Foucault (25). The fashioning of public and legislative attitudes towards drink problems and the development of instruments of social control in this field have been the subject of two recent publications (26,27). 18 Consumption data II Alcohol consumption and alcoholism in Europe since 1950 Both use and abuse of alcohol exist in the great majority of European countries. In almost all of them there has been a considerable growth in per capita alcohol consumption since 1950. In general, the growth has been greatest where the consumption level was lowest in 1950 and least in those where it was highest; indeed, in France, a country with a very high 1950 per capita consumption, there has actually been a decrease. Alcohol consumption, in practical terms, means national authorized alcohol production for home consumption plus alcohol imported for bever- age use. This is known with considerable accuracy for most European countries because of excise and taxation requirements. Unrecorded produc- tion exists, but is now of small extent: illicit production, usually by distilla- tion, has fallen substantially in most European countries since the end of World War I. In some wine-drinking countries the bouil/eur de cru conces- sion exists whereby farmers who grow fruit are allowed to distil a certain amount of spirit from this fruit for their own consumption. Some home- brewing and home wine-making activity, through the sale of home manu- facturing kits, goes on in certain countries. However, the overall impact of these unrecorded manufacturing activities is likely to be slight. Other sources of unrecorded national alcohol consumption include liquor bought abroad and imported duty-free. Alcohol products are not always consumed at the time of production, e.g. vintage wines are kept for maturation . Furthermore, alcohol products are not always consumed immediately following purchase, as bulk-buying may occur under certain conditions, e.g. before a budget or in a nticipation of a strike. The assumption will, however, be made here that production represents consumption. Alcohol consumption data may be presented in a variety of different ways, e.g. in total amounts of the products consumed (barrels of beer, bottles of wine, etc.), in total amounts of each particular beverage con- sumed, in total amounts of I 00% alcohol consumed per capita total popula- tion, and total amounts of 100% alcohol consumed per capita by the population aged 15 and over. Several international compilations of national data exist in which these data are brought together, e.g. those published by the Produktschap voor Gedistilleerde Dranken in the Netherlands and by the Brewers' Association of Canada. 19 Data are presented in Table I for the alcohol consumption per person aged 15 and over. It is believed that this is a more accurate assessment of per capita consumption than consumption per head of total population because of the great disparity between European countries in the proportions of persons aged under 15 years. It is, of course, assumed that little or no consumption is accounted for by persons of that age. The table gives annua l per capita consumption in litres of absolute alcohol for the population aged 15 and over for those European countries for which it is available for the years 1950, 1960, 1970 and 1979. Between 1950 and 1979 every country for which data are presented in Table I has increased its consumption, except France. The increases have sometimes been substantial: of the order of 300% in the Federal Republic of Germany, and more than 500% in the German Democratic Republic. Whereas in 1950, figures ranged from 1.6 litres for the German Democratic Republic to 22.1 in France, this range had contracted considerably by 1979, with Norway the lowest at 5.7 litres and France still highest at 20.5 litres. The countries with highest figures in 1960, namely France and Italy, have shown little increase since then; in the case of France there has actua ll y been a decrease (French consumption had risen to 27.4 litres per capita aged 15 and over by 1955 and then declined). In the case of Italy, consumption rose between 1960 and 1970, but then fell again to a figure in 1979 below that for 1960. On the other hand , some countries with very low initial values, such as the Netherlands, the Federal Republic of Germany, the German Demo- cratic Republic and Finland, have increased their consumption consider- ably. Between 1970 and 1979 there were decreases in Austria, Italy and Switzerland . Changes in drinking patterns It has been customary to classify countries by the type of beverage tradition- ally drunk, so that there are wine countries , spirit countries and beer countries. However, there have been considerable changes in the period under study in the proportions of alcohol consumed by beverage type within countries. This is illustrated in Table 2, which shows the total amounts of alcohol consumed by beverage type and the percentage that each beverage type contributes to total consumption (28). It is evident from Table 2 that there has been a marked movement away from traditional beverage consumption patterns to one that is more inter- nationalized, standardized and homogenized. In other words, in most coun- tries, traditional beverages have been losing ground to "foreign" types of alcohol. In some cases it can be assumed that these changes in the type and style of drinking (e.g. with food, without food, etc.) are the substitution of an international drinking style for a more indigenous type. This would appear to be the case where shifts in proportions of beverages consumed have occurred without any great increase in total consumption. However, in the majority of cases it appears that the process is one of addition of an extraneous type and pattern of consumption to the more traditional type, as shown by both shifts in proportions of alcohol types and a greatly increased 20 Table 1. Alcohol consumption per capita at age 1 5 and above in Europea Alcohol consumption Percentage change Country (litres of pure alcohol) 1950 1960 1970 1979 1950/ 1979 1950 / 1960 1960 / 1970 1970/ 1979 I • I'- Austria 6.5 11 .2 15 .8 14 .3 +120 + 7 + 4 - 1 ,.... Belgium 8 .0 8 .3 11 .6 14.4 + 80 + 0.4 + 4 +3 Czechoslovakia 5.3 7.5 10.9 13 .5b +155 + 4 + 5 +3 Denmark 4 .9 5.6 8 .8 12 2 +149 + 1 + 6 +4 Fin land 2.4 2.6 5.7 8 .1 +238 + 0 .8 +12 +5 .,.. Fr ance 22 . 1 23.4 20 .5 20 .5 7 + 0 .6 - 1 0 7" German Dem . Rep . 1.6 5 .8 7.9 10.6c +563d +26 + 4 +6e l"-- Germany. Fed . Rep o f 3 .8 8 .7 13 .5 16 .0b +321 +13 + 6 +2 Hungary 6.4 8 .3 11 5 15 .7 +145 + 3 + 4 +4 Ireland 4.6 4 .9 7.8 11 .3 +1 46 + 0 .7 + 6 +5 -,. ' Italy 12.4 16 .3 18 .0 16 .1 + 30 + 3 + 1 - 1 Luxembourg 8.5 10.5 12 .9 16 .8c + 98d + 2 + 2 +5e Netherlands 3.0 3 . 7 7.5 1 2 2 +307 + 2 +10 +7 T' Norway 2.9 3.4 4 . 7 5.7 + 97 + 2 + 4 +2 r. Po land 4.3 5.8 7.0 10.8 +151 + 3 + 2 +6 Portugal - 15 .3 16 .3' 19 .6c + 289 - + 0 .7 h +5' Spain - 11 .6 14 .9 19 .6 + 69-' - + 3 +4 .,. Sweden 4.7 4 . 7 7.2 7.6 + 62 0 + 5 +0 .6 Switzerland 10.4 1 2. 7 13 .6 13 .5 + 30 + 2 + 0 .7 - 0 .1 '- United Kingdom 6 .3 6 .6 8.4 10.3b + 63 + 0 .5 + 3 +3 Yugoslavia - 6.8 9 .1 12 .0* + 76 1 - + 3 +6m - 8 For each cou ntry. population data have been taken from the United Nations Demographic yearbook at the census year closest to the relevant year 1n the table b Estimate C 1976 d 1950/1976 8 1970/ 1976 f 1972 g 1960/ 1976 h 1960/ 1972 ' 1972/1976 1 1960 / 1979 k 1975 / 1960/ 1975 m 19701 1975 ....., N .... ' -. N Table 2. A lcohol co nsumptio n in Europe: sp ir its. bee r and wine N Sp1r1ts (%) Beer(%) Wine(%) Country 1950 1960 1970 1979 1950 1960 1970 1979 1950 1960 1970 1979 Austria 23 .0 28 .8 13 .6 1 5.3 41 5 41.4 46 .1 45 .5 35 .5 29 .8 40 .3 39 .2 Belgium 13 .0 12.4 14 .8 26 .8 74.4 72.4 66 .5 51 .2 12 .6 15.2 18. 7 22 .0 Czechoslovakia 27.4 15.1 25 .0 29 8• 59 .3 59 .9 56.4 51.2• 13 .3 25 .0 18.6 19 _0• Denmark 15 .9 14 .6 18.5 15.6 72.2 74 .5 69.4 64 .5 11 .9 10.9 1 2.1 19 .9 Fin land 60 .5 54 .9 38 .6 43 .8 36 .3 37 1 48 .8 41 .6 3 .2 8 .0 12 .6 14 .6 France 14 .6 10.6 13 .2 15.8 5.6 9.1 11 .6 14 .0 79 .8 80.3 75 .2 70 .2 German y. Fed . Rep . of 34.4 25.7 25 .8 26 .38 49 .5 56 .9 55 .3 51 . 1 • 17 .0 17.4 18.9 22 .68 Hungary 15 .2 21.6 27 .8 36 .3 7.5 25.4 2 7 .5 31 2 77 .3 53 .0 44 .7 32 5 Ireland 20 .0 20.4 25.0 29 .5 72.4 73 .0 67 .8 62.9 7.6 6 .6 7.2 7.6 Ita ly 7.4 8 .0 1 2. 7 16.4 1.8 2 .1 4.1 7.0 90 .8 89 .9 83 .2 76 .6 Neth erland s 71.0 44 .0 36.4 36 .8 25 .6 46 .0 51 .1 45 .8 3.4 10.0 12 5 17.4 Norway 56 2 49 8 43 7 41 6 36 9 43 1 4 7 1 4 7.1 6 .9 7.1 9 .2 11 .3 Poland 74 .0 58 .8 58 .8 66 .9 22 .5 2 7 .9 28 .9 18.9 3 .5 13 .3 12 .3 14 .2 Spain - 23 .1 21 .3 1 5.9 19.1 61.0 59 .6 Swed en 66.0 58 .1 45.4 50.2 29.4 30 .1 40 .3 29.4 4 .6 11.8 14 .3 20.4 Switzerland - 35 .2 30 .8 43 .0 4 7 7 3 .7 2.7 United Kingdom 13 .2 17 .6 17 .3 24 . 1 • 79.7 72 7 69.4 57.4• 4.1 6.9 10.0 1 5.1 • a Estimate Source · Brown & Wallace (2 8 ) overall consumption. In general terms, the more total consumption in- creases the more likely it is that addition rather than substitution is taking place. Makela (29) has described in some detail the phenomena of substitu- tion and addition and the effects of the grafting of new drinking patterns on to traditional ones in increasing overall consumption. In certain countries, such as the United Kingdom and Ireland, there is evidence of the substi- tution of spirits for beer and of an increase in total consumption. In this context, it appears that incomes and wages as well as, or even to a greater extent than, prices may have a decisive influence. Spirit consumption appears to be very sensitive to prevailing economic conditions, increasing in times of affluence and decreasing in recessions. In some countries, at least, spirit consumption has shown a certain responsiveness to changes in prices and incomes but beer consumption has not, i.e., spirits are seen as a luxury but beer as a necessity (30). What is perhaps one of the most striking examples of "addition", where "substitution" was intended, comes from Finland. In that country a policy of liberalization favouring, or so it was intended, the consumption of "medium" beer in an effort to reduce spirit consumption, led to the expected increase in beer consumption but no concomitant decrease in spirit con- sumption (29). There is nevertheless some evidence to suggest that severe restrictions on a beverage type, because it is perceived as more harmful or undesirable, may reduce its consumption thanks to replacement by a less noxious drink (31). This is, of course, a different strategy from that employed in Finland in the example just cited, where decreased consumption of spirits was promoted by reducing controls on the desired substitute, beer. Accurate data on alcohol consumers, how much they consume, and when and where, are not easy to come by. Most information in this field comes from survey data from individual countries, with the usual difficulties inherent in all self-report data in the alcohol field. Most drinking surveys concerned with estimating quantities of alcohol consumed are based on questionnaires and tend to underestimate actual consumption, as indicated by liquor sales, etc., considerably. Furthermore, there is evidence to suggest that the heaviest consumers are the greatest under-reporters (32). Indirect methods of estimating consumption patterns are available, but their ac- curacy is questionable. The general impression, however, is that the overall consumption increase in most countries is the result of more people drink- ing, a fall in the number of abstainers, increased consumption by each individual drinker, and an increase in the number of drinking occasions for each drinker (33). Both the objective and the impressionistic evidence appears to suggest that more young people and women, and the less affluent socioeconomic classes, for whom the price of drink had formerly been a deterrent, have been recruited to the number of drinkers. In addition, former social and even heavy drinkers would appear to have increased their intake, like everybody else (34). There is some evidence to suggest that the proportion of abstainers is higher in spirit-drinking countries than in those where beer and wine are the main beverages consumed (35). 23 A few countries have data discriminating between alcohol consumption "on the premises", i.e . where it is bought (in a pub, cafe, restaurant, etc.) and alcohol bought at a retail outlet and consumed at home. For those countries, such as Finland, which do have such data, the evidence shows a greater relative increase in home consumption as compared to public drinking. Impressionistically, the considerable growth in supermarket and other "off- premises" sales suggests similar trends in other countries. The prevalence of alcoholism Much thought has been expended on various attempts to measure the "prevalence of alcoholism" in different communities. This, however, is no easy exercise, as definitions of what constitutes "alcoholism", and the methods used to identify and count those suffering from it , are nonstandard and subject to considerable variation from one community to another. They even vary with time in the same community. The data used include treatment data, self-report data on individual intake, and data on deaths from alcohol-related causes ; all are inexact to some extent. Treatment data are obviously influenced by the availability of facilities. Even if it is argued that facilities expand to meet need, such data must still be highly suspect because need is itself "soft" and determined by whether or not facilities are provided . Self-report data are notorious for under-reporting actual consumption, particularly among heavy consumers. Consumption data, or rather sales data, are useful in indicating trends but say little about the dispersion of consumption and, therefore , the proportion of that consumption accounted for by heavy and problem drinkers. Never- theless, Schmidt & de Lint examined four different methods of estimating the number of alcoholics in Ontario and found that the results did not differ greatly (36). However, there are obvious anomalies: countries such as the United Kingdom and Ireland show high admission rates for alcoholics to inpatient facilities but low cirrhosis mortality rates; other countries, such as Spain and Italy, show high cirrhosis mortality rates but low figures for admissions to treatment facilities. The most time-revered method of estimating the prevalence of alco- holism is that of the Jellinek formula (37) . This requires a knowledge of the number of deaths from liver cirrhosis per year in a given area (D); the proportion of such deaths that may be considered attributable to alcoholism (P); the annual death rate from liver cirrhosis among alcoholics with com- plications (K); and the ratio of all alcoholics to alcoholics with complica- tions (R). The prevalence of alcoholism (A) is then calculated from the formula: A (PD/K)R The accuracy of the formula obviously depends on that of the observa- tions, estimates or merely guesses on which the values of P, K and R are based. This must be open to doubt and, in addition, the values will vary greatly from country to country and from time to time within the same 24 country. This method of assessing the prevalence of "alcoholism" has been cr iticized by Seeley (38) and Popham (39). Perhaps the most fundamental of all criticisms of the Jellinek formu la is its concentration on the physical complications of excessive alcohol intake and its conceptua li zation of "alcoholism" in this light. It therefore fails to take into account such a lcohol-related problems as those leading to social deviance, which in some societies are of even greater importance than physical damage. Other methods of assessing the prevalence of alcoholism, based on multiple indices of alcohol-re lated problems, also have their shortcomings. Ultimately, from a pragmatic point of view, there may be little point in pursuing the elusive question of the prevalence of alcoholism , which so far appears to evade enquirers. It would seem more valuable to concentrate on recording the incidence of individual alcohol-related problems in a more standardized fashion than is now the case. In the last analysis, such prob- lems are operationally and culturally defined in time and place, and to that extent everlastingly changing. 25 Cultural factors III Social factors and alcohol consumption Cultural factors mould the behaviour and responses in given situations of the component members of a society, but culture itself is difficult to define. Williams ( 40), in fact, suggests that "culture is one of the most complicated words in the English language". Here, culture will be taken to mean the way in which society prescribes and determines a given individual's behaviour in relation to alcohol: whether or not he drinks it, where, how much, how often, and how he behaves when he has done so. This is not to say that within a given society there may not be a number of contradictory cultural attitudes to alcohol, including abstinence. There may, therefore, be ambivalent, even contradictory, responses within the community. One factor that must be considered is the purpose for which particular peoples use alcohol. Some would contrast the infrequent heavy spirit drink- ing of certain nations, in which the objective appears to be to get drunk, with the constant wine drinking of other peoples, where drunkenness is rare. The beverage clearly serves different functions in these two groups of people. The "psychological" functions, including the relief of anxiety or tension , appear to be most important in the first group. Studies of "primitive" or remote societies indicate the societal uses to which alcohol can be put. It may sublimate aggression, for example, or may mobilize it and lead to its open expression. A discussion of these issues is outside the scope of this report; they have been reviewed by Heath ( 41). On a more elementary level, societal attitudes can be summed up as being permis- sive in the case of the wine-drinking countries, restrictive in the case of some Nordic countries, and ambivalent in the case of other countries where beer is the predominant beverage. Such attitudes and their origins have been dis- cussed by Pitman ( 42) . Even if our understanding of the meaning and development of "attitudes" to alcohol is limited, it is here that many of the hidden, poorly perceived determinants of collective national behaviour towards alcohol are to be found. When Norwegian attitudes to alcohol, on the one hand, are contrasted with those of a permissive country like France, on the other, it is clear that the differences observed must have originated many generations ago, if not in antiquity. Nothing in recent history is adequate as a complete explanation of alcohol consumption per capita levels in 1978 ranging from 4.0 litres of absolute alcohol in Norway to 16.5 in France. 27 Whether specific cultures within Europe are more likely to foster exces- sive drinking than others is a highly relevant , but difficult question to answer. Much depends on patterns of alcohol usage and the visibility, type and character of alcohol-related problems determined by specific types of drinking behaviour. Particular national groups with a low alcohol con- sumption may be labelled as "drunken" by comparison with others simply because of extroverted and sometimes aggressive behaviour on iso lated occasions. Similarly, groups of poorly housed immigrants and lower paid manual workers , given to extravagant behaviour when drinking, are often condemned as "drunken" by the more orderly indigenous society . The actual alcohol consumption of the latter may be higher, but is less apparent because social deviance when intoxicated is much lower; somatic conse- quences may nevertheless be much more serious. Although there are differ- ences in the way European peoples behave when they take alcohol and in the amounts of alcohol they consume, these differences are beginning to dim- inish and become less marked. The cultural d ifferences in relation to alcohol consumption among European countries may therefore become less import- ant as time goes on and affluence increases, thus leading to a standardization of beverage types , quantities consumed and behaviour when intoxicated. Broad cultural differences in attitudes to alcohol will nevertheless remain, as will such differences between generations in a given country. The increas- ingly homogeneous social and cultural influences on the younger genera- tions of European peoples puts them in a very different situation, as com- pared with that of their predecessors of several generations ago. Economic factors From the point of view of the consumer, two considerations would seem to be of prime importance in determining his intake - income and price. Economists would argue that there is nothing special about alcohol as a market commodity; its consumption trends are therefore explicable in terms of the economics of the marketplace. It is true that legislators and others have, over the centuries, regarded it as a potentially dangerous product and have therefore placed legislative restrictions on its availability. To that extent, at least , alcohol does differ from many , though not all, consumer goods. In addition, in some countries, it is made to carry a considerable burden of taxation. In general terms, the view of alcohol, as determined by marketplace behaviour, held by contemporary European society is that it is a luxury. Within the range of alcoholic beverages some are clearly identified as being more luxurious than others. Champagne, for example, is synonymous with special occasions and celebrations; beer is more mundane. With the increas- ing demand for "quality of life" , alcohol as a luxury has performed very similarly to other luxury goods. From this point of view, at least, alcohol has not shown any special characteristics. Just as the consumption of motor cars, colour television sets and the like has risen inexorably in recent years, so too has that of alcohol, and because Europeans have enjoyed rapidly 28 rising incomes generally during the last 20 years or so, purchases of luxury goods have steadily increased. European personal incomes increased dramatically between 1950 and I 980. Up to 1960 the rate of increase was relatively slow in some countries but has accelerated considerably since then. The devastation of World War II with the subsequent industrial depression and large-scale un- employment took many years of rebuilding and effort to overcome. During this time of redevelopment the populations of many formerly wealthy European countries were at first unable to afford luxury goods. Others who had enjoyed no great pre-war prosperity were in a similar position. Gradu- ally the position improved, incomes rose and purchasing power increased. However, the rate of increase in alcohol consumption varied consider- ably and was not linked solely to income increases. This was because the price factor was also of considerable importance, particularly in the early post-war period of slow economic growth. In general terms, those countries where the tax imposed on alcohol was considerable showed slower rates of growth in alcohol consumption than those where such taxation was low. In effect, the former are the beer and spirit countries , though the level of taxation varies from one country to another, while the latter are the pre- dominantly wine-producing countries. Of course, the matter was not quite as simple as that. For example, the tradition of consuming alcohol with meals was much more deeply ingrained in the wine-drinking countries. In some of them wine was not necessarily perceived as alcohol and was regarded as a normal constituent of the diet. Nevertheless, wine was cheaper in the decade 1950-1960, in terms of incomes and prices, in wine-drinking countries than beer and spirits were in beer- and spirit-drinking countries, and this is still the case. Such considerations probably explain the much earlier consumption increases in wine countries in the I 950s. It is entirely intelligible, therefore, that the greatest consumption increases should be seen in those countries where post-war levels had been lowest and where income increases had been greatest. The other factor affecting purchasing power is that of prices. In general, prices of alcohol in real terms have tended to decline in Europe since 1960. In other words, even if incomes had not increased, alcohol would have become cheaper simply as a consequence of the decline in its real price. In some countries the fall has been of substantial proportions, particularly for spirits. In Ireland , for example, the price of spirits in real terms at the end of 1980 was only 82% of its 1969 price (30). Nevertheless, the fall in real prices appears to be less relevant to rising consumption than the increase in real incomes. Thus, in many European countries the amount of working time required to purchase a given quantity of alcohol has declined enormously in recent years. With the proceeds of one hour's industrial wage it is now possible to buy the amount of alcohol that would have required a whole day's pay some years ago. The effect of real per capita income as a determinant oft he consumption of alcoholic beverages is most apparent when the initial level of con- sumption has been low. Interesting price elasticities have been demon- strated between beverage types and between different countries for different 29 beverage types (43). In the United States and Canada, for example, spirits are much more sensitive to changes in incomes and prices than beer. Spirits therefore perform in the market much more as luxury goods , their sales dropping when incomes fall during a recession or prices increase substan- tially. Beer, on the other hand, shows much smaller fluctuations of this type; from the economic point of view, it behaves more like a market necessity . Such effects can often be seen when taxation policies favour one or other beverage type. Further evidence of the importance of incomes in determining levels of demand for alcohol comes from the minor economic recessions which occurred around 1974-1975. Some countries had zero growth in alcohol consumption at about this time. For example, the growth in beer consump- tion in the United Kingdom, which had been quite rapid since 1959, slowed down very considerably in the middle I 970s, and spirit consumption actu- ally declined between 1974 and 1975. This illustrates both the effect of the recession on consumption overall and the much more sensitive response of spirits to the situation, as compared with beer. Economic factors other than incomes and prices must also have played an important part , since not all the consumption changes of the past century can be explained on that basis. Reference has already been made to the decline in alcohol consumption occurring in the United Kingdom and other European countries towards the end of the nineteenth century, a time when alcohol was becoming cheaper and real disposable income was increasing. A similar situation has existed in France since the late I 950s. The increasing availability of other luxury goods and more favourable changes in their prices relative to alcohol prices may have played a role, but lack of data makes serious examination of this suggestion impossible. Changes in consumption patterns may also have been affected by per- sonal taste and by social pressures, including pressures from the manu- facturing interests in the form of advertising or other promotional activities. Women and the young None of the factors mentioned operates independently; the reasons why people drink or increase their consumption are multiple and complex. Increases in disposable income in Europe in recent years have not affected all subgroups of society equally. Previously disadvantaged groups, such as young people, women and lower paid workers, have benefited most. Their relative purchasing power in relation to alcohol has increased correspond- ingly, and their behaviour has conformed to the predictions of market economics. In virtually every European country, evidence from market survey material and from scientific research (33) has identified the "new drinkers". They are, predominantly , groups that formerly would have been either abstainers or light consumers. Perhaps the most important develop- ment has been the change in the social position of women. Mention has already been made of their improved economic position , but this has not come about in a vacuum of cultural change. Greater financial indepen- dence has meant greater social independence , and a lessening of the social 30 restrictions on public drinking by women, either by themselves or in mixed groups. Similarly, the much greater freedom enjoyed by young people has meant greater independence from parental control at an earlier age, so that much more of teenage and youth leisure time is spent out of the home and away from parents. Finally, the 1960s and the 1970s saw the arrival onto the drinking market of the generation resulting from the ear ly post-war fertility explosion. In numbers as well as in changed socia l customs, therefore, this group has made a significant contribution to the recent increase in alcohol consumption. Indeed, in Finland in 1976, the highest a lcohol consumption was recorded by those aged 20-29 years ( 44). Will the present drinking patterns of the young generation of new drinkers, the so-called "wet generation", remain with them as their genera- tion ages? It seems likely that, although the amount and sty le of their drinking may change as they mature, they will be a wetter genera tion in later life than were their ancestors (33). The unemployed Rece nt years have seen an increase in unemployment in Europe, as a result both of the economic recession and of increasing automation. Unfortu- nately, this situatio n does not appear likely to improve in the short term. For the young who are unable to find employme nt on completing their edu- cation, the psychological consequences may be serious. Cynicism, boredom and frustration are quite likely to find expression in deviant antisocial behaviour involving misuse of alcohol and drugs. In the newly redundant middle-aged worker similar consequences may ensue. The criminal subculture Families in whom alcohol problems seem particularly frequent are found in most large urban areas. The same is true of crime and other deviant be- haviour, and the two are often interrelated. This social heritage of fa milial misuse of a lcohol, mostly in males , in such subcultures is related to more genera l psychosocial disturbance. The precise significance of the role of alco ho l in the behaviour of such families, where evidence of wider mal- adaptation is abundant and where social problems arise concomitant ly with alcohol abuse rather than as a consequence of it, is not clearly understood. Migrants Migration in Europe can be directed towards European countries from cou ntries o utside Europe, from country to country within Europe, and from rural to urban areas within European countri es. Many migrants earn rela- tively high wages, particularly in relation to their previous income levels, and have little to spend them on. Not surpr isingly, some members of this group become heavy consumers and often display a high level of social conflicts. Furthermore, as urban rates of alcohol consumption are generally 31 higher than those of rural areas, within-country rural / urban migration often leads to increased consumption leve ls by migrants. Increased leisure Increased leisure , in combination with increased income , has been a major factor in determining increases in alcohol consumption, especially among younger people. In addition, leisure activities have become international- ized, so that the lifestyles of young people in different countries have become more uniform. Increased international contact of young people with one another, through tourism, the mass media and even sport, has led to a further standardization of their way of life, in which alcohol plays a secure and definite role. Increasingly, leisure time is spent in settings where alcohol is consumed, and this is accepted as the norm for an ever wider range of soc ial transactions. In this sense, as an accompaniment to social interaction , alcohol has taken on, in recent years, a sy mbolic as well as a merely pleasurable significance. Many social activities among older people also occur increasingly in alcohol settings. The type and quality of these soc ial activities are strongly related to social class and income; in addition, as incomes increase, the type of social activity becomes more middle-class or bourgeois. The role of home drinking, at least for the middle-aged , has also become increasingly im- portant ; this is why the demand for "off-premises" sales outlets has become such a feature of the post-war years. Home drinking in social settings is generally seen as "more civilized" than public drinking, at least for the mature , but whether any reduction in consumption results is doubtful. Indeed, the reverse may be true, since "respectable" drinking of this type is more closely linked to long-term consequences than to the acute problems more usual with public drinking. The temperance movement One traditional moderating influence on alcohol consumption, namely the temperance movement , has declined considerably in importance in the twentieth century. In most European countries such movements were at their height in the mid to late nineteenth century. It is no coincidence that these movements exercised their greatest influence at a time when social disadvantage and deprivation were considerably more marked than they are today. Under such conditions, the further burden of alcohol-related prob- lems was seen by many politically active and concerned working-class people as an abomination. The social preco nditions for such movements were thus considerable at that time. Temperance movements therefore had strong working-class roots; the inexpensiveness of alcohol relative to other goods was seen by temperance workers as a tool used by capitalist society to exploit the poor. A contemporary analogy is the recent attitude of Polish workers towards the role of alcohol in their country, which has led to tighter controls on availability, including price increases . Women's influence was particularly strong in certain European temperance movements, no doubt 32 because women were often at the receiving end of many alcohol-related problems. The decline in alcohol consumption in the early twentieth century and its virtual collapse during World War I made such movements almost superfluous. Nevertheless, strong temperance movements still exist today in certain European countries, notably in Norway and Sweden. As a vocal minority in those countries they exert considerable influence and bring political pressure to bear on matters relating to alcohol availability. In recent years both government and workers in Poland have been increasing their control on the availability and consumption of alcohol ( 45). The trade and promotion It is often said that the promotional activities of manufacturers, wholesalers and retailers are important in increasing alcohol consumption. The means employed may be direct, e.g. advertising, or less immediately obvious, e.g. the control of outlets, the ownership of recreational facilities that also promote and sell alcohol, and the manipulation of prices through the control of competitor products such as soft drinks. There is apparently no convincing evidence, however, that advertising increases consumption . Recently, McGuinness (46) has claimed to show a positive influence of advertising on alcohol consumption, but the validity of his results has been questioned by Walsh ( 47). Advertising does appear to have a definite im- pact on brand consumption and preference. There is thus no conclusive evidence that advertising increases alcohol consumption nor that it deter- mines shifts in consumption from one beverage type to another. The main value of advertising to the trade is monopolistic, i.e. its enormous cost deters new competitors from entering the arena. This is shown by the increasing monopolization of the alcohol trade in Europe by fewer but larger manufacturers . Increasing internationalization, either through increased exports or the establishment of plants under licence in other countries, has been a con- spicuous feature of the post-war alcohol trade. Furthermore, the trade has largely moved away from traditional product types and into substitute alcohol fields. Thus, many chiiteaux in the Bordelais have been bought by breweries to take advantage of the rapidly growing, although still relatively small, wine trade in northern European countries. Such activities have been facilitated by common marketing arrangements, such as those of the Euro- pean Economic Community. The harmonization of taxation has tended, in general, to remove differential and protective tariff barriers. Inevitably, this leads to a lowering of tariffs overall . The consequence has been a diffusion of alcohol products throughout the European Economic Community. Further- more, overproduction of wine in the wine-producing countries has led to increasing pressure from wine growers to stimulate consumption . The com- mercial provisions of the Treaty of Rome that provide for the free passage of goods can only do so. Nevertheless , the Treaty also contains a clause providing that such free passage must not be detrimental to health . The influence of EEC commercial policies has been reviewed by Sulkunen ( 48). 33 An increasing amount of duty-free alcohol is brought back from abroad, and sometimes even from short journeys, by travellers. Tourism has increased considerably since 1950 and has had a large effect on duty-free consumption. The laws controlling the availability of alcohol have been liberalized in many European countries as part of the general spread of the post-war "alcohol culture"; this has led to the banalisation of alcohol, as it has been called in France. The permitted legal times of "on-premises" consumption have been extended in England, Scotland, Ireland, and most notably in Finland in 1969. The effects of this extension have been studied most closely in Finland and have been presented in some detail by Makela (29). All alcohol production and distribution in Finland is in the hands of the State monopoly, but in 1969 the number of licences granted to restaurants and "off-premises" retail shops was greatly increased. Consumption increased at the same time, as did problems. The general consensus in this and other countries where such liberalization has occurred is that, although greater availability may have been a response to increased demand for alcohol, it also stimulated this demand. In some European countries the age limit for on-premises consumption, which is generally around age I 8, is rigidly adhered to and enforced. In others there is virtually no enforcement. Some countries , at least in theory , have rigidly enforced permitted hours of opening. In others, although premises must be licensed and registered, they are usually free to remain open for as long as they find it profitable to do so. Control of availability, as part of alcohol control policy, is considered later in Chapter V. 34 IV Alcohol-related problems The material presented in Chapter II shows that, except in France, overall alcohol consumption has risen in Europe between I 950 and I 979 - in many cases very sharply. Although national data are not easy to come by, survey data for many European countries suggest that this increase in overall consumption reflects an increasing number of consumers with a correspond- ing decrease in abstainers, an increase in drinking occasions per drinker, and an increase in the amounts consumed on each drinking occasion. What have been the consequences for alcohol-related problems? Definition The first step in answering this question must be to ask: what does "alcohol- re lated" mean? A recent WHO publication (49) states that:" ... as to the problem of determining the causal role of alcohol , there is often no satis- factory way in which the matter can be dealt with . The assumptions on which such a determination might be based would usually be so dubious that, wherever possible, a search for causes should be avoided". However, later on in the same publication , "alcoholic disability" is defined as follows: "any disorder ( condition, disease, illness, pathology) secondary to severe alcoholisation or to the alcohol dependence syndrome ( or alcoholism or alcohol addiction) which interferes with the capacity to function nor- mally in the economic or social sphere". It seems, therefore, as if it is well nigh impossible to define "alcohol-related" in the sense in which the term is used by hea lth workers . From a more general point of view it is apparent that what is usually implied is "alcohol-associated". At this purely descrip- tive level there can be few difficulties; these arise when we attempt to assess the extent to which the association implies responsibility for the problem, disability or conflict in question. Although it may be difficult, in individual cases, to assign a causal role to alcohol, epidemiological evidence points strongly to it as responsible for the increased incidence of certain social and medical problems: these problems increase as alcohol consumption in- creases and decrease when it decreases. In this chapter the conditions to be dealt with wi ll be those covered by the following quotation from the WHO publication previously men- tioned ( 49): - 35 "An alcohol-related disability is deemed to exist where there is an impairment in the physical, mental or social functioning of an individual of such nature that it may be reasonably inferred that alcohol is part of the causal nexus determining that disability." Alcohol-related social morbidity Every form of social interaction may be disrupted by alcohol abuse, just as alcohol has now become accepted, in moderate amounts, as facilitating some of these interactions and indeed has become an integral part of them. As with somatic damage, it is difficult to determine the role of alcohol in some of these social disruptions or disturbances. Even in the absence of alcohol, not all social interactions would function smoothly. The relation- ship between alcohol intake and some social problems traditionally as- sociated with it, such as family violence, is so very close, however, as to appear to make a cause-and-effect relationship fairly obvious. The question of interpretation nevertheless remains, and that of the importance to be assigned to alcohol as a catalyst and originator of such family violence. Since alcohol has its place in every aspect of social life it is naturally associated with many problems within the family. It is also associated with conflicts occurring in drinking locales and places of entertainment, in the street and on the factory floor , and with such conditions as public drunken- ness and offences against public order, absenteeism, industrial injuries and injuries to, or caused by, intoxicated pedestrians and drivers. The perception by different communities of what constitutes a "social problem" will vary from one community to another and may change with time in a given community and between social classes within it. Signifi- cantly, the "problem" content of any socially deviant behaviour may well be determined by community attitudes and responses as much as by the actual behaviour itself. The moral susceptibilities and preconceptions of certain social groups within a society may determine, for example, the amount of money that a man may legitimately spend on alcohol without being seen as causing his family to suffer economically and materially. Changing attitudes to such deviant and disruptive alcohol-related behaviour as public drunkenness have led, in some countries, to its de- criminalization and a move towards a more treatment-oriented system of dealing with it. For example, public drunkenness in Poland is now dealt with by police detention for treatment rather than trial and punishment. How- ever, in relation to more serious forms of behaviour, such as homicide, fatal traffic accidents, thefts, physical injuries and brawls, etc., committed under the influence of alchol, the approach is still punitive. It is paradoxical to some extent that those who commit the less serious alcohol-related offences are seen as excusable and given treatment, while for the more serious offenders punishment is seen as the only way of dealing with them. Social problems and consumption levels The dose-response relationship is even more arbitrary and idiosyncratic in the field of social problems and conflicts than with physical problems. It is 36 certainly true that the heaviest and most persistent consumers have a greater number of social difficulties. Nevertheless , much social disturbance and difficulty is created by persons with a relatively small intake, both in quantity and frequency. Since moderate drinkers far exceed excessive drinkers in numbers it is even conceivable that the former could create more problems than the latter. As already mentioned, idiosyncratic individual response to relatively minor doses of alcohol, resulting in serious social disturbances, has been recognized for over a century and designated by such terms as manie a potu. It would seem that personality characteristics and/ or physiological variations in absorption or response are the determining factor. Age, sex and social class are all related to the probability of social disturbance at any given level of alcohol intake. From this point of view, young people and persons belonging to the lower socioeconomic strata may be defined as "high-risk groups". Males as a sex are more likely to encounter alcohol-induced social conflicts than are women. Other groups at high risk of creating alcohol-related socia l disturbances are migrants and those engaged in occupations with unsocial hours of work. Different individuals or groups perceive the existence of problems at different levels of disordered socia l behaviour. For example, O'Connor, in a comparative study of Irish and English youths, found that the Irish believed that they had more problems at a substantially lower intake level than the English (50). For all these reasons it is hazardous to attempt to advocate any level of intake that would be "safe" in relation to social problems, just as it is in relation to physical damage (see p. 49). Indices of alcohol-related social problems All indices of alcohol-related social problems, at least at national level, are derived from secondary sources, i.e., they are provided by social and medi- cal agencies or facilities and are often variable in quality and sometimes incomplete. The data are not standardized and therefore generally unsuit- able for intercountry comparisons. At most, they may be of value in reveal- ing trends within countries. There is thus a great dearth of adequate stat ist ical data on alcohol- related socia l problems and disruptions. Furthermore, no serious efforts are being made to encourage the standardization in gathering and recording such material that is badly needed. Public drunkenness Among the indices of socially disruptive behaviour often submitted to statistical scru tiny is the number of arrests for drunkenness. To be useful , international comparisons of this index require a uniform definition of "public drunkenness" and uniform action by the police, based on this definition . What determines public drunkenness, however, depends as much on a person's social, ethnic and economic background as on the amount of alcohol that he has consumed. Thus, persons of lower socia l class are often likely to behave noisily and disruptively under the influence of alcohol. 37 Furthermore, because they usually drink publicly and have to go home afterwards, their exuberant behaviour is more likely to bring them to the notice of the police. Much the same is true of immigrants who, as well as sharing all the characteristic disadvantages just described, often have hous- ing problems . This leads to an increased possibility of fights and brawls in lodgings and a general reluctance to return to such unwelcoming homes. In addition, there is a particular behavioural pattern among certain social groups, such as immigrants and some young people, which may be of as much importance in determining their behaviour as the amount of alcohol they have consumed. Thus, "drunken behaviour" is not simply a matter of quantities drunk but is also associated with social position and social setting (including national group) (51). Even if the differences in behavioural responses to the same alcohol intake are ignored, international comparisons of numbers of arrests for drunkenness may still be invalid because of the inconsistencies in law enforcement on the part of the police. This may result from manpower shortages, for example, or the need to concentrate on other forms of crime. The number of offences of drunkenness proved in England and Wales rose from 47 717 in 1950 to 108 871 in I 974, and the rate per 10 000 popula- tion aged 15 years and over increased from 14.0 in 1950 to 21.2 in 1968 and from 27.9 per 10000 population aged 14 years and over in 1970 to 26.8 in 1974 (52). In Finland, arrests for drunkenness rose from 146 998 in 1950 to 276 206 in I 976; the corresponding rates per I 00 000 inhabitants aged I 5 and over are 5210 and 7485, respectively (53). The number of prosecutions resulting from these arrests has , however, continued to decline in the period under survey, suggesting an increasing "decriminalization" of drunkenness in Finland. Interestingly, the number of arrests for drunkenness relative to the amount of alcohol consumed nationally in Finland has also fallen over the same period. If the attitude of the police towards drunkenness has remained unchanged over the period, this indicates either that the Finns have greatly improved their social behaviour on consuming alcohol or that they consume more of it at home, where their drunkenness is less obvious. On the other hand, it may simply be that the amount of alcohol consumed in Finland on single drinking occasions has decreased whereas the number of drinking occasions has increased, although survey data from Finland do not support this latter possibility. In Sweden , the number of persons taken into custody for drunkenness increased from I 03 041 in 1971 to 110 187 in 1976, the rate per I 000 popula- tion aged 15 and over increasing from 16.2 in 1971 to 16. 9 in 1976. The numbers of convictions for drunkenness offences increased from 67 996 in 1971 to 75531 in 1975 (54). In Poland, the number of prosecutions for liquor offences per 100 000 persons aged 15 and over has decreased slightly from 1239 in 1953 to 717 in 1975 ( 45) . At the same time, per 100 000 population , the numbers of persons detained at sobering-up stations declined slightly from 1295 in 1959 to 1252 in I 975 . In the case of both prosecutions for liquor offences and persons detained in sobering-up stations, the numbers per I 00 000 litres of alcohol 38 consumed fell considerably between 1955 and 1975; this suggests that, as in Fin land, if the police have behaved cons istently over the period , behaviour follow ing a lco hol consumption has improved. Alcohol-related violence Alcohol-related vio lence usually means, apart from public brawls , wife- beating a nd child injury. The number of prosecutions for wife-beat ing will depend on the number of persons charged and this, in turn , will depend mainly on police practice . In many countries, the police are reluctant to interfere in what they regard as fami ly quarrels. They know from experience that , even if they decide to charge a husband with injury to his wife or assau lt, they will not be able to obtain a conviction unless the wife comes to court and gives evidence. They have also learnt that , in many cases, wives who, in the heat of the moment, are ada mant in their determination to prosecute, fa il to appear to give evidence in the cooler light of the next morning or weeks later. In the absence of the wife's ev idence, the police fail to make their case a nd are understandably less ent husiast ic about further prosecutions of this type . Paediatric hospitals are now much more alert to non-accidental injury to chi ldren and refer such cases to social work departments , but these depart- ments seldom keep statistical records and cases are not reported to any authority. Data for non-family personal injury are available, but most national crime statist ics do not distinguish between alcohol-related and non-alcohol-related cases. Drinking/ driving offences The variation in community att itudes and response to socia ll y deviant behaviour is clearly shown by the fact that the maximum blood alcohol concentrations for drivers in Europe differ widely, namely from zero in some eastern European countries to I00mg/ IO0ml blood in Ireland, as shown in Table 3 (55) . This range of opinions and practices concerning blood alcohol levels permitted for driving not only indicates very varying attitudes to the topic throughout Europe, but also makes it almost impossible to compare drunken driving statistics cross-nationall y. Consideration should perhaps be given by some international organiza tion, such as WHO, or by WHO act ing in cooperation with national road safety organizations, to the stan- dardization of maximum permitted blood alcohol levels in Europe. Statistics on prosecutions for drinking/driving offences are strongly af- fected by the police approach to law enforcement; in addition, the number of vehicles and of miles travelled may change dramatically over a short period of time. Changes in absolute numbers of cases of drinking/ driving offences may therefore not reflect the incidence of such offences in relation to the numbers of miles travelled , nor the numbers of drivers and vehicles on the road. General improvements in road systems and in automobile design must a lso be taken into account. Factors outside the driver's control have tended 39 Table 3 . Statutory limits on blood alcohol concentrations for drivers in some European countries8 Country Ireland Austria Belgium Denmark France Germany. Federal Republ ic of United Kingdom Netherlands Norway USSR Con centration (mg / 100 ml) 100 80 80 80 80 80 80 50 50 0 a There is no statu to ry l1m1t in Italy. but in practi ce the limiting rang e 1s 1 50-230 m g / 100 m l . Source: M oser (55) . to diminish in importance as causes of accidents, but factors associated with the driver himself, including intoxication, have become more important. Although there can be little doubt epidemiologically that alcohol must play a material role in causing many driving accidents, its quantitative contribu- tion to overall traffic mortality is difficult to assess (56). While as many as 50% of drivers dying in road traffic accidents have blood alcohol levels above permitted limits, road deaths also occur in Moslem countries where no alcohol is consumed. Such personality factors as aggressiveness and impulsiveness also con- tribute to accidents. When allied to excess alcohol intake, as they often are in young people particularly, the combination can be disastrous. Conse- quently, certain groups are particularly at risk of road traffic accidents, even at relatively low alcohol consumption levels. Although no general trend can be discerned in European countries, alcohol-related accidents are probably increasing as a proportion of total road accidents. Prosecutions for drinking/driving offences are affected by many factors. The incidence of offences in most countries shows a fairly well-marked "shock" effect whenever new or more rigid legislation , or the threat of more rigid enforcement, is announced: there is an immediate fall in recorded offences and presumably of infractions. However, after a short time, as people calculate the risks of being caught, based on their own experience and 40 that of others, they incline to return to their former behaviour. Accordingly, prosecutions and convictions tend to climb back to previous levels. Other changes appear to be more long-lasting. For example, in some countries random "spot tests" of blood alcohol levels were formerly not permissible; when the law was changed to enable police to stop motorists and carry out such tests the result was apparently a more lasting decline in offences (57). Similar spot tests under "implied consent legislation" in certain states of the USA have had the same effect. It has not been possible to obtain time-series data on prosecutions for drinking/driving offences in a representative sample of European countries. However, the information that is available from some countries indicates a worsening situation. For example, in Norway in 1950, there were 710 con- victions for offences against driving and drinking laws; by 1976 the number had increased to 7156 (58). In Sweden, the number of convictions for drunken driving increased from 7052 in 1971 to 8482 in 1975, and those for driving under the influence of alcohol from 7722 in 1971 to 8755 in 1976. The total number of drinking/ driving offences (the two categories for which data have been given technically constitute different offences) therefore increased from 14 774 to 17 237, and the numbers of persons convicted from 13 497 to 15 382 (54). In France , the number of driving licences suspended for driving under the influence of alcohol rose from 8817 in 1966, accounting for 11. 7% of all suspensions, to 35 064 in 1975, or 13.1 % of all suspensions in that year. In Switzerland, the number of driving licences withdrawn for drunken driving increased from 2429 in 1954 to 9683 in 1977 (59). Thus, for those countries for which data are available there has been an increase in the total number of prosecutions for drunken driving. However, it remains uncertain whether the rate of conviction per driver and per mile driven has increased. Data suggest that, at least in Finland, this is not the case (53). It is calculated that, while the absolute number of cases of drunken driving "known to the police" increased considerably between 1950 and 1975, "the number of cases of drunken driving relative to the number of motor vehicles multiplied by the consumption of alcohol beverages dropped vigorously and at an even rate in the early 1950s and in the 1960s and remained remarkably stable during the 1970s". Crime A number of other criminal activities, apart from drinking/driving, public drunkenness, and violence within the family , are often associated with alcoholism. The relationship between crime and alcohol is complex, and again highlights the need for a multifactorial approach to the causation of many social disabilities. However, from the epidemiological evidence it is clear that the incidence of many forms of petty crime rises when alcohol consumption rises and declines when consumption declines. Crime against the person, ranging from minor assault to homicide, is sometimes alcohol- related. Personal knowledge of many cases indicates that they would not have taken place in the absence of the ingestion of substantial amounts of alcohol by one or both participants. Many chronic drinkers , particularly 41 of the "skid row" type (see p. 43) commit larceny or steal to be able to buy drink. Once again, however , the precise extent of the problem is difficult to define because adequate data are lacking. Problems at the workplace It is usually assumed that much sick leave, whether medically certified or not, in large industrial enterprises is due to absenteeism that is the result of alcohol problems. These may range from hangovers and their physical consequences to early-morning drinking that is continued throughout the day. In addition, it is believed that a great deal of inefficiency caused by alcohol leads to extensive production losses. No really satisfactory attempt has ever been made to measure the cost, in terms of lost output, caused by such behaviour but the matter has been discussed in a recent pub- lication (30). Serious industrial accidents, particularly in high-risk activities and pro- cedures, are often caused by heavy drinkers, and may result in personal injury or death , either for other workers or in the community generally. The damage caused by heavy drinkers in industrial settings may, however, be reduced by their high absenteeism. Here again, the difficulty of evaluating the role of alcohol in causation arises. A rare attempt to evaluate that role in connection with accidents at work has been made by Lahelma (60). Excessive drinking and the family Family health is particularly liable to social damage caused by alcohol. The overt results are common enough: separation, divorce and, as already discussed, family violence. The familial nature of many alcohol-related problems is well documented, although the relative contribution of genetic and environmental factors is debatable . However, there can be little doubt that many of the alcohol problems seen in the children , and particularly the sons, of alcoholic fathers must be related to the unsatisfactory environment created by those fathers. The subtler disturbances also exist in abundance: neurotic and personality disorders are much commoner in families of heavy drinkers than in control groups. The damage done by an alcoholic father to other family members is therefore well established. Excessive drinking by mothers may have even more serious conse- quences for the family. The traumatic effects of child neglect by mothers may, however, be impossible to assess. Inefficient mothering, caused by alcohol, may well become a growing problem among future generations of young women because of the changed status of women in relation to alcohol in our society. Attempted suicide A high proportion of suicide attempts are made under the influence of alcohol. In general, national data on the incidence of such attempts are not available but many centres in Europe have good data extending over many years (e.g. Edinburgh , Southampton and Vienna). A particularly 42 wide-ranging ep idemiologica l study has recently been concluded in France (61). Data from a ll these sources indicate a continuing and steepl y rising incidence of suicide attempts to near epidem ic proportions. It is est imated, for exam ple, that I out of every 100 females in Edinburgh aged 15-19 years ma kes a suicide attempt each year (62) . In add ition, inpatient data on hospi tal ad missions for se lf-poiso ning, virtually a ll of which in ad ults can be regarded as suicide attempts, indicate considerable increases in recent years. The extent to which a lcohol intake is responsible for these su icide attempts is another matter. It can be assumed that its contribution is greater among males than among females who , however, attempt su icide more frequently. "Skid row" drinkers A familiar sight in most large European cities, usually in the centre, is that of homeless , indigent and semi-destitute men (there may also be some women) who have obviously reached the lowest level of socia l functioning. Some of th em may be suffering from chronic mental illness , but man y are chroni c excessive drinkers who have sunk to this level because of uncontrolled drinking over many years. They now consume alcohol in the cheapest possible form and are no longer co ncerned with its quality . They make themselves a major nuisance to the rest of society by begging and often by engaging in petty crime, e.g. stealing money with which to buy drink, or, more comm o nly, public drunkenness. The extent of this problem is unknown and no data are avai lab le to show whether or not it is growing. It does see m clear, however, tha t attitudes towards it have changed, as a result of"decriminalization" . In o th er words , in many countries "skid row" drinkers are no longer prosecuted for public drunkenness, vagrancy or begging, but are more frequently directed to medical treatment centres or, in eastern European countries, to sobering-up sta tions. A similar development has taken place in the United States. As a rule, drinkers are not kept as long in medical treatment centres or sobering- up stations as they were in prison , serving jail sen tences. Since such people therefore spend longer periods living rough, there have been reports of a decline in their physical hea lth , as compa red with a similar population in earli er years (63). Alcohol-related mortality Cirrhosis of the liver The ca use of death most traditionally associated with alcohol intake is cirrhosis of the li ver; thi s association has been known for well over a century and a ha lf. Observers long ago noted the correla tion between national alcohol consumption and mortality rates from cirrhosis of the liver. This became particularly clear during World War I when, between 1914 and 191 8, in association with greatly diminished alcohol consumption, mortality from cirrhos is of the li ver fell correspond ingly. 43 Our knowledge of mortality from cirrhosis of the liver, as for all causes of mortality , is derived from national vital statistics based on death certifi- cates. These are generally fairly complete and accurate in the European Region. However, in the case of cirrhosis of the liver there are certain difficulties. Some countries produce cirrhosis mortality data that dis- tinguish between alcoholic cirrhosis, or cirrhosis with mention of alcohol, and non-alcoholic cirrhosis; others produce only total cirrhosis figures. In some of the latter the information may be given in the death certificates but not be used in coding. This problem would not be important if the propor- tion of alcoholic to non-alcoholic cirrhosis deaths was known and constant over time and place, but this is definitely not the case. For example, in 1975 in Switzerland , 88% of cirrhosis mortality was ascribed to alcohol as com- pared to 76% in 1950 (64); in Finland, in 1950 the figure was 7% as compared with 50% in 1975 (53); and in the Netherlands, in 1960, 7% as compared with 43 % in 1975 ( 65) . Furthermore, there is the question of the disproportion- ately high rates for female cirrhosis mortality relative to male , given the known differences in consumption by the sexes. This is usually explained by the high physiological vulnerability of the female liver to alcohol, but the validity of this explanation has yet to be substantiated . Cirrhosis mortality data for 1950-1975, expressed as rates per 100 000 population aged 15 years and over, are presented in Table 4 for a representa- tive group of European countries. In every case except Turkey (where the data do not cover the entire country), mortality has risen between 1950 and 1975, although in France, Spain and Switzerland there were falls between 1971 and 1974. The general picture is of a doubling of rates in most countries. These changes, when viewed in the context of the consumption increases shown in Table I, strongly support the close correlation between consumption levels and mortality from cirrhosis of the liver. In fact, it can be taken that the relationship is almost certainly causal. Alcohol poisoning and alcoholism Deaths from alcoholism and acute alcoholic poisoning are clearly related to alcohol and present little difficulty in interpretation but their overall numbers are small. They are , in addition, related to the manner in which people drink and, as European drinking behaviour has become more "civi- lized" with the passage of time, it may be anticipated that they will not necessarily rise as consumption increases. In Poland, the death rate per 100000 inhabitants aged 20 years and over from acute alcohol poisoning rose from 1.6 in 1951 to 4.0 in 1975 ( 45) . Data from the Netherlands show that numbers of deaths from alcoholism and alcoholic psychosis per 100 000 population in men and women aged 35-74 changed little between 1950 and 1975 . Male death rates declined in the age group 35-40 from 2 per 100 000 in 1950 to 3 per 100000 in 1975, and in the age group 55-74 increased from 3 per 100 000 in 1950 to 5 in 1975. For women there was an increase from zero deaths per 100 000 population in those aged 55-74 to 1 per 100 000 in 1975. In France, there was a perceptible decline in mortality from alcoholism 44 Table 4 . Deaths from cirrhosis of the liver : rates per 100 000 population aged 1 5 years and over8 Country 1950 1960 1970 1975 Austria 17 .8b 30.0 40.3 42.4 Belgium 7.5c 12.5 15.5 17 .9 Bulgaria 5.4d 8 .5 10.4 Czechoslovakia 12 .3 19.8 22 .6 Denmark 7 .9 8 11 .3 12.4 13 .6' Finland 3.6c 4.8 5.7 7.19 France 20 .8 39 .5 43 .9 German Dem . Rep . 15.8 15.9 Germany, Fed . Rep . of 12 9h 24 .6d 32 .0 35 .6 Greece 13.01 14.7 21 1 17 .7 Hungary 7 .6b 11 .9 16.3 22 .9 Iceland 1 0 8 2.6 5.0 1.3 Ireland 2.9 2.9 4.8 4.5 Italy 16 . 78 22.4 38 .2 42 .5' Luxembourg 9.4k 23 .4 28 .3 30.9 Malta 6 .oc 14.9 11 .91 12 .0' Netherlands 3 .6 5.1 5.5 6.5' Norway 4.6c 5.7 5.6 6 .5 Poland 5.2 11 .3 13.4 Portugal 25 .6k 28 .3 41 .0 47 .6 Romania 26 .6 28 .29 Spain 13.8c 20.6 29.4 31.1 9 Sweden 4.18 6 .5 10.2 15.4 Switzerland 15.8c 15.2 20.2 16 .5 Turkeym 4 .2d 3.9 2.4 United Kingdom 3.1 3 .8 4.0 5.3n Yugoslavia 2.4c 4.8 14.8 17 .6 8 For eac h cou ntry, popula tion data have bee n taken from th e United Nations Demographic yearbook at the census year closest to the relevant year 1n the table b 195 4 e 1951 . C 1952. 19 76. d 1961 9 19 74 . h 1952 for the Federal Republic of Germany. 1953 for Bertin (W est) I 1955 1 1972 k 1953 1971 m Provm c1al cap ita ls and distric t ce ntres . n Engl an d & Wales. 19 76 45 between I 960 and I 975: from 5074 deaths in I 960 to 4 I 92 in I 975 . 0 This decline is accounted for exclusively by the drop in female deaths; male deaths actually increased slightly in numbers over this time period . In Norway the death rate from alcoholism rose from 0.59 per 100 000 popula- tion in I 970 to 1.64 in I 975 ; for alcoholic psychosis a fall was recorded between 1970 and 1975 from 0. 7 per I 00 000 to 0.17, and the respective rates for deaths from accidental poisoning by alcohol were 1.56 in 1970 and I. 74 in 1975 (58). In Finland total alcohol poisoning fatalities were 89, or 2.2 per JOO 000 population, in 1951 and 205 , or 4.3 per JOO 000 population, in 1975. In the same country there were 3 fatalities from alcoholic psychosis in 1951 and I I in 1975 (53). The precise degree of reliance to be placed on the numbers of deaths certified as being from these causes is difficult to determine because, as Sundby (66) has pointed out, there is a certain arbitrariness about the manner in which deaths are assigned to "alcoholism" and "alcoholic psy- chosis". Indeed, the substantial differences between the numbers so certified in various countries are unlikely to be due solely to the differences in consumption and mortality in those countries. Alcohol-related road traffic mortality Whereas all countries produce data for the number of persons killed in road traffic accidents and some for the numbers of injuries , the majority of countries do not provide data on the number of deaths attributed to alcohol. Indeed, in a recent review of the matter, only eight countries could be identified which produced data on traffic fatalities related to alcohol ( 67). Such data are produced in Switzerland, however, and, in 1954, 111 deaths of persons killed in road traffic accidents were considered to be alcohol- related. By 1977 this figure had risen to 270, and the percentage of road traffic deaths that were alcohol-related increased from 11.5 in 1954 to 20. 7 in I 977. Data on "road accidents involving alcohol registered by the police" are also available in Poland ; such accidents resulted in 332 deaths in I 954 and 169 I in 1975. The number of fatal accidents involving alcohol, expressed as a percentage of the total number of road accidents resulting in fatalities, increased from 23.2% in I 950 to 30.0% in I 975 in Poland. The number of road traffic deaths classified as being related to alcohol known to the police in Finland rose from 83 in I 950 to 194 in 1975; as a proportion of all fatal road traffic accidents they accounted for 22. 7% in 1950 and 23.0% in I 975 . In those countries (the majority) where no distinction is made between alcohol-related and non-alcohol-related road traffic morta lity - at least in official statistics - the fatality rate per I 00 000 inhabitants from road traffic accidents has generally increased in the 25 years between 1950 and 1975. We can reasonably assume that in most countries the proportion of such acci- dents that are alcohol-related is at least 25% and may be even more ( 68). It a Unpublished data . 46 must therefore be concluded that alcohol-related road traffic mortality has increased considerably and is substantial in absolute term in most Euro- pean countries. Cancer Certain cancers, and particularly those of the upper gastrointestinal tract, are suspected of being alcohol-related. Thus, Tuyns ( 69) has shown the close association between oesophageal cancer and calvados consumption in northern France. In Norway, mortality rates per 100000 population for cancer of the larynx increased from 0.5 in 1964 to 0.8 in 1974, but no change was observed in mortality rates either for cancer of the oesophagus or the buccal cavity and pharynx. Little change was observed over a similar period in Sweden, mortality from laryngeal cancer increasing from 0.6 per 100000 population to 0. 7, buccal cavity and pharyngeal cancer from 3.1 to 3.5, and oesophageal cancer from 3.1 to 3.7. Over the same 10 years, from 1966 to 1975, mortality from these three causes of death decreased in the United Kingdom. Similarly, in Switzerland, falls were observed for all these causes of cancer deaths. In Finland , over the same period , falls were registered for laryngeal and oesophageal cancer, with a slight rise in buccal cavity and pharynx cancer deaths. McMichael (70) believes that trend in laryngeal cancer mortality reflect increased alcohol consumption . Cancers at other sites, such as the large bowel , pancreas, etc., have also been suspected of being alcohol-related ( 71). The possible etiological agent, or carcinogen, in alcohol beverages has so far not been clearly identified , nor is the manner of its action clear. It is likely that the effect is mediated through interaction with other ingested or imbibed susbstances, which may result in a "multiplicative" effect, such as is suspected of existing between cigarette smoking and alcohol and cancer of the larynx and possibly oesophagus. Suicide Suicide is often thought to bear so me relationship to alcohol consumption and close relationships certainly existed between the rise and fall of suicide and that of alcohol consumption in nineteenth century Europe. Data on suicide rates for European countries are presented in Table 5, but fail to show any overall general trends: some countries show increases , some decreases, over the years under consideration; and the rank order of coun- tries for suicide mortality does not conform very closely to that for alcohol consumption. Clinical impressions and a number of investigations indicate , however, that a high proportion of people who kill themselves have taken alcohol beforehand. This, of course , does not constitute the necessary causal link nor does it indicate that these people would not have killed themselves had the y not taken alcohol. Nevertheless, although the epidemiological evidence may not be compelling, experience of individual cases does tend to reinforce the impression of a definite relationship. 47 48 Tabl e 5. Sui cide and self - inflicted injuries death rates per 100 000 total population8 Country 1950 19 75 Austr ia 23 .8 24 .1 Belg iu m 13.1 b 16.2 Bul ga ria 7.4c 12 9 Czechoslovakia 21 .9 Denmark 23 .3 24.1 Finland 15.6 25 .1 d France 15.2 15.4• Germ an Dem . Rep . 30.5· Germany. Fed . Rep . of 1 g 8' 20 9 Greece 3 .69 2.8 Hungary 17 .8h 38.4 Iceland 11 9 10.1 Ireland 2.6 5.0 Italy 6 .5 5.8' Luxembourg 11 01 10.6 M alta 14.9k 0 .61 Neth erland s 5.5 8 9 Norway 7.4 9 9 Po land 5.4h 11 .4 Portugal 10.0 8 .5 Roman ia 59 gm Spain 5.4 4 .0 d Sweden 14 9 19.4 Switze rland 23 .5 22 .on Turkey0 0.4 0 .3 United Kingdom 9 5 7.8P Yugoslavia 55 3q 13.4 8 For each co untry. population data have been taken from the United Nati ons Demo - graphic yearbook at the census year closest to the relevant year 1n the Iable b 1952 1 Beriln (West). l 95 1 1972 C 1953 1 1951 d 1974 g 1955 • 1970 h 1954 1952 This figure includes all other accid ents. su ici de and sel f-1nfhcIed 1niur1es 1973 m 197 4 This figure includes all other accident s. su1c 1de and self -,nfllcted InIunes. all other external causes n l 976 P England & Wal es. 1974 Q 1 9 52 . Thi s figu re includes motor vehicle acc idents. all oth er acc idents. suicide and self-1nfl1cted 1n1ur1es Other causes of alcohol-related mortality An unknown number of deaths from causes other than those specifically dealt with above may, with varying degrees of uncertainty, also be attributed to alcohol. Foremost among these must be non-traffic accidents, i.e. deaths from falls and other forms of accident either in the home or outside it. At the same time a number of homicidal deaths, usually in drunken brawls, can be ascribed to alcohol with reasonable certainty, but in any one country these are small in number. Deaths from such somatic conditions as acute pan- creatitis, cardiomyopathy, etc., can also, in varying degrees, be alcohol- ascribed. Heavy drinkers may be particularly liable to develop atherosclero- sis and heart disease. Alcohol-related somatic morbidity As well as killing people , alcohol can seriously damage health and bring about long-standing somatic disability in early life . As with mortality, the type of disability resulting will differ depending on whether alcohol is taken on high-dosage occasions at irregular intervals or is consumed regularly. In the first instance the damage may be the result of a road accident or a fight; in the second, chronic pancreatitis or brain damage. Somatic morbidity and consumption levels As European populations turn to more regular intakes of alcohol without serious excesses on single occasions, many workers in the alcohol field now consider that there is a need for some guidance and information to be given to the public on the quantities of alcohol that they may consume on a regular basis without causing physical damage to themselves. It is not a simple matter of setting any hard-and-fast daily limits since so much ignorance surrounds this area , and there may be great individual variation in the threshold limits for damage. Nevertheless, in one country - the United Kingdom - the professional body responsible for psychiatry has been concerned to lay down daily amounts that should not be exceeded (52) . A good review of what limits are felt to be consistent with moderate drinking has been given by Lelbach (72). What is startling is the great variation in the daily intakes regarded by different authors as being "con- siderable", "excessive", "immoderate", or "heavy". Thus, McDonald et al. ( 73) considered 21-45 g of ethanol per day as "excessive consumption" , while Hallen & Krook (74) regarded 320-400 gas "the intake of a heavy drinker". With such a bewildering range of intakes it is obviously not easy to decide on what is moderate and what is excessive. Some workers refine the figures somewhat by relating them to body weight and other physiological measures . One of the most outstanding contributors in this field, Pequignot , considered an average daily intake of between 40 and 60 g as potentially cirrhogenic ( 75). On the basis of evidence available to them from published data, Turner et al. ( 76) concluded that risk of serious liver damage rises rapidly at daily consumption levels above 150 g. They note that chronic 49 relapsing pancreatitis patients "seem to have been consuming 150 grams ethanol or more over long periods", and consider a similar level of intake to be necessary for serious risk of the fetal alcohol syndrome; other congenital abnormalities have been observed, however, at lower intakes. Serious neuro- logical damage, including brain damage, generally occurs in patients whose levels of intake are higher still. On the basis of the evidence available it is therefore reasonable to conclude that a continuous daily intake over a number of years of 150 g of 100% alcohol is often associated with severe physical damage, whether to the liver or elsewhere. This, of course, says nothing about the proportion of people with such an intake who develop such damage nor does it tell us what proportion of people with lower levels of intake develop disease. In practical terms, 150 g of ethanol is equivalent to 4. 7 litres of beer at 4% by volume, 1.9 litres of wine at 10%, 0.53 litres of spirits at 40%, and 0.38 litres of spirits at 50%. This, then, is the level of daily intake that should not be exceeded if clinical complications are to be avoided with any degree of confidence. It must be realized that the daily figure of 150 g is derived from work on male patients exclusively and, because of the suspected lower threshold for liver damage among females, considerably lower levels of intake will, until the contrary is proven, be applicable to women. The fallacy inherent in attempting to fix "safe limits" is that the pro- cedure presupposes a discontinuity between "risk" and "non-risk". The reality is that "risk" is a graded phenomenon or concept. As a recent report of a WHO Expert Committee put it: "Convenient as it might be to determine a level of alcohol consumption below which one could freely drink without apprehension, discontinuities of this kind are rare in biological systems. Below a certain level of exposure, the increase in risk is so small that it does not reach significance . This artificial threshold, once considered to be about 80 g of I 00% ethanol per day, was later lowered to 40 g; there is now evidence that above the level of 20 g an effect on rates of damage can be observed. Under such circumstances, an 'acceptable level of risk' can be defined only arbitrarily" ( 77). Some studies apparently showing low ischaemic heart disease mortality for light alcohol users compared with abstainers have recently appeared ( 78). It has been pointed out that this finding does not necessarily mean that "alcohol in moderation is good". Abstainers may represent a very atypical group of people in relation to mortality . For example, they may contain a high proportion of people who have given up alcohol or who have never drunk because of poor health . It may be their poor health , rather than their abstinence from alcohol , that accounts for their excess mortality as com- pared to moderate drinkers . Alcohol-dependence syndrome ( alcoholism) As European health services have developed and expanded, medical and social service provision for alcohol-related physical morbidity has in- creased. Nowhere is this more apparent than in the provision of facilities for 50 the "alcohol-dependence syndrome". Most individuals who present for treatment for this condition are still treated as inpatients, usually in psychi- atric hospitals. For that reason, data from such hospitals on admissions for "alcoholism" are one of the main sources of comparative data for alcohol- related physical disability. The great majority of admissions to psychiatric hospitals designated as being for "alcoholism" are of persons who are physically dependent on alcohol and who wish to be withdrawn or "dried out" painlessly. For many of these , continuing to drink has become physically or socially too painful or unacceptable and so they seek relief from their discomfort. This, of course, does not mean that they wish to stop drinking altogether or even to moder- ate their intake. Rather, many wish to return to a less disagreeable physical and mental state so that they can begin to drink again with enjoyment. Data from psychiatric facilities throughout Europe confirm the increas- ing use being made of them by persons having a heavy alcohol intake. For example, admissions to mental hospitals and units in teaching hospitals in England and Wales with the primary diagnosis of alcoholism increased in number from 439 in 1949 to 12 751 in I 975 (52) . In Ireland in I 966 there were 1750 admissions for alcoholism to psychiatric hospitals; by 1978 the number had risen to over 6000 (79). In Switzerland the first admission rate to specialized inpatient institutions for alcoholics per 100 000 population aged 20 years and over rose only slightly from 8.3 in 1950 to 8.6 in 1976 (64) . In Poland, however, numbers of first admissions to hospitals of patients with alcoholism and alcoholic psychosis behaved in a fashion more in keeping with general experience than was the case in Switzerland, increasing from 7.8 per I 00 000 inhabitants aged 20 and over in 1956 to 36.0 in 1975 ( 45) . The total number of admissions for alcoholic psychosis to psychiatric hospitals in Rome almost doubled between 1950 and 1962. However, as a percentage of total admissions they amounted to just under 10%.0 The impact on inpatient facilities, and the time and expertise of those who work in them, of the ever-increasing admission rates for alcoholism can be considerable. In some, e.g. France and Ireland, they constitute the largest single reason for admission to psychiatric hospitals and account for almost 40% of all first admissions. Indeed, for males only, the figure is well over 50%. In addition to formal psychiatric admission, another arrangement for dealing with alcoholics exists in Norway and Sweden. This involves the temperance organizations which, in the case of a problem drinker, may intervene, either on their own initiative or on request, on behalf of a person abusing alcohol or narcotics . They are empowered by legislation to "try to influence the person concerned to improve his/her way of life". These temperance bodies may try to persuade an individual to abstain from the use of alcohol and assist him to obtain work or change his environment. They a Unpublished data. 51 also try to get him to accept an arrangement whereby someone else looks after his income, at the same time endeavouring to get him to consult a doctor or seek admission to an institution for his alcohol problems. If persuasion fails, they have statutory powers of compulsory commital to hospital. The numbers of such persons dealt with in Norway increased, among males, from 10 388 in 1970 to 21 334 in 1976, and among females from 498 in 1970 to 1697 in 1976 (58) . In Sweden , however , the numbers of persons "investigated" by temperance bodies increased slightly from 36 071 in I 970 to 36 854 in 1975. In terms of rates per 1000 inhabitants aged I 5 years and over there was actually a fall from I 1.0 in 1970 to 9.3 in 1975 (54) . A few countries provide data on outpatient attendances for alcohol problems. Thus, the first admission rates per I 00 000 population aged 20 years and over to specialized outpatient institutions for alcoholics in Switzerland increased for females from 8.1 in 1959 to 16.7 in 1977. On the other hand, the equivalent rates for males fell from 111. 7 in 1959 to 91.4 in 1977 (64). Non-fatal road traffic injuries Many European countries supply useful data on alcohol-related road injur- ies; these show a general trend for such injuries to increase. For example, in Poland, the number of road traffic accidents involving alcohol and resulting in injury increased from 1152 in 1954 to 8993 in 1975, but as a proportion of all road accidents there was a decline from 21.0% in 1954 to 19.4% in 1975 ( 45). In Finland, the number of road traffic accidents, classified as being related to alcohol and known to the police, resulting in non-fatal injury rose from 385 in 1950 to 1404 in 1975 (53). However, expressed as a proportion of total road accidents, the percentages have hardly changed - 14. 7% in 1950 and 14.8% in 1975. In Switzerland the numbers of persons injured in alcohol-related traffic accidents rose from 2002 in 1963 to 3823 in 1977, and as a proportion of persons injured in all traffic accidents from 6.4% in 1963 to 12.2% in 1977 ( 64) . Other alcohol-related somatic conditions Non-fatal physical damage from alcohol is d istributed over a wide range of conditions. Some, as indicated earlier, is the direct result of tissue damage by alcohol; some is due to accidents or assaults . Causes of morbidity are recorded at various depths of enquiry. In the first place they may become apparent through information coming from treating agencies . Thus, hospital admission or discharge records will indi- cate the number of people entering general hospitals with alcohol-induced cirrhosis, or other alcohol-related physical conditions, and also the number of persons injured in brawls , falls, etc., that are not specifically alcohol- linked and may not be so recorded even when they are. Figures are available from Finland concerning the numbers of persons treated in hospital for cirrhosis of the liver and similar information is available from the Hospital 52 Inpatient Enquiry in England and Wales. More detailed information may come from general population community health surveys. For some specific conditions reporting systems may already be in existence. For example, cancer registers are supplied with regular information on the incidence and prevalence of cases of various cancers believed to be alcohol-related. In- formation on suicide attempts, where alcohol is implicated in such a high proportion of cases, is also available from psychiatric case registers such as that operating in Mannheim, Federal Republic of Germany (80). Alcohol intake during pregnancy, even in moderate amounts, is now known to be associated with an increased risk of congenital malformation in the infant. The most obvious, usually associated with heavy intake, is the character- istically recognizable fetal alcohol syndrome. In other cases the malforma- tion is nonspecific but more frequently encountered than in control series of non-drinking pregnant women. There can be little doubt that many young people suffer injury and disability from alcohol-related accidents or fights. Severe irreversible brain damage, spinal injuries and other major physical incapacities, though prob- ably infrequent, are very serious and costly in their effects and consequences. The interpretation of data based on returns from treatment facilities inevitably emphasizes the number of treatment events. These, in turn, are directly related to the provision and adequacy of facilities, and may reflect their extent and development rather than the frequency of the particular morbid condition being studied. The emotional and psychiatric damage suffered by heavy drinkers and their families must be considerable. Presumably severe withdrawal symp- toms and delirium tremens are subjectively extremely unpleasant experi- ences, apart altogether from the physical risks associated with them. Indeed, in many cases heavy drinking may precipitate severe psychotic disorder, even if only temporarily, including severe affective disturbances. The toll of permanent and irreversible alcohol-related brain damage is probably in- creasing everywhere, although data cannot be adduced in support of this contention . There is also ample evidence from many psychiatric services of the extent and severity of depressive illnesses in the wives of alcoholics . This makes a misery of their days more effectively than any amount of physical violence, which is also often present. The burden of psychiatric disturbance in the drinker' s children, with implications for the likelihood of psychological disturbance and possibly alcoholism itself in these children, particularly the sons, should also not be forgotten. Many other somatic conditions are believed to be alcohol-related, among them acute and chronic pancreatitis, gastritis, peptic ulcer, various diseases of the nervous system, such as avitaminoses, beriberi, etc. No very adequate data exist on some of the conditions enumerated above and believed to have some relationship with alcohol intake. However, the general impression is strong that alcohol plays a considerable role in contributing to these causes of ill health. 53 Impact of alcohol-related problems on public health The total burden on public health resulting from alcohol is difficult to assess quantitatively. Questions such as how much longer we would live if alcohol did not exist, and how much happier we and our families would be, are not easy to answer. In overall terms it is possible to say that heavy drinkers have considerable excess mortality as compared with non-drinkers and moderate drinkers, but this is not to say that such heavy drinkers would show mor- tality rates similar to non-drinkers or moderate drinkers if they abstained or drank moderately. Comparisons of the life expectancies of heavy drinking with non-drinking populations show markedly higher figures for the latter. Thus, if the State of Utah is compared with Nevada, for example, different lifestyles appear to lead to very different life expectancies (81). However, self-selection may operate to some extent in attracting particular individuals to particular habitats, so that the abstemious prefer Utah and the risk- taking, gambling population, Nevada. Such differing personality types may also have different predispositions in terms of survival. Some information is available on the mortality experiences of heavy drinkers as compared to moderate drinkers or abstainers. Sundby (66) followed up a cohort of persons hospitalized for alcoholism in Norway and compared their mortality experience with that of the Norwegian population as a whole. He found mortality rates tha t were twice those of the general population at every age group, particularly for such specific causes of death as ci rrhosis, and cancer of the buccal cavity and oesophagus. A further study confirming these general results was carried out in England and Wales, where Adelstein & White (82) reviewed the death certificates of persons hospitalized for alcoholism some years earlier. Their results confirm those of Sundby in finding a mortality rate that was approximately twice the normal. However, an analysis of their findings by cause of death gave somewhat different results from those of Sundby. Almost all the excess mortality of their cohort could be explained by mortality from violent causes of death (accidents , suicide, etc.) rather than general systemic medi- cal conditions. This raises the question whether these persons were not, because of personality characteristics, highly susceptible to mortality from vio lent causes and brings into question the causal role of alcohol in their deaths . Of course, had these people not died violent deaths it could well be that their subsequent mortality experience might have been more typical of lifetime heavy drinkers , so that they would be found to have died of cirrhosis , etc. The results of these two studies may be unrepresentative in a number of ways . Firstly, the individuals comprising the samples may be atypical of heavy consumers generally. Secondly, the fact that they had been admitted to hospital may reflect greater social deprivation, greater susceptibility to dependence , perhaps at a lower level of alcohol intake than those not hospitalized , and more general physical disability or impairment because of malnutrition, etc. Both the samples are of persons hospitalized 20 or more years ago when general sociomedical progress had not reached the level of 54 today. It may be, therefore, that the persons forming these series of cases do not reflect the mortality experience of contemporary heavy drinkers. Interpretation of time trends in mortality for an alcohol-related con- dition, at a time when general mortality trends are changing rapidly, is subject to certain pitfalls. Thus, to take a rather obvious example, at the time when tuberculosis mortality was high, mortality from cirrhosis might have been obscured by the coexisting tuberculosis condition, so that many heavy consumers might have died of tuberculosis before their liver damage had reached fatal levels. Similar distortions might be expected to have occurred at the time of great epidemics, now virtually unknown in Europe. Poi- kolainen has highlighted some other problems in interpreting data from studies on alcoholic intake and mortality (83), but nevertheless concludes that "Mortality related to alcohol correlates closely with the average con- sumption of alcohol in a population. Therefore, the increases in alcohol consumption in industrialized countries during the last decades imply that the use of alcohol has become a notable determinant of mortality". Specific causes of death for which mortality can be closely related to alcohol, viz., cirrhosis of the liver, alcoholism and alcoholic psychosis, and road traffic fatalities in adults or in young people, account for a variable proportion of mortality in different European countries. Assuming that all were alcohol-precipitated and that no mortality from these causes of death would occur in the absence of alcohol, their overall contribution to mor- tality in many countries is small; for example, even in France, the proportion of all deaths to be ascribed to cirrhosis of the liver in 1977 was 3% and a substantial proportion of them occurred after the age of60 years . Likewise, the contribution of road traffic deaths to overall mortality can be gauged by reference to a study in the United States, in which the difference in life expectancy with this cause of death present on the one hand and absent on the other, was calculated (84). The authors found that, when all road traffic mortality (of which not more than one half at most could be ascribed to alcohol) was eliminated, less than 0.5 years was added to life expectancy. This may be compared with the 14 years that would have been added if mortality from cardiovascular diseases had been removed. Admittedly, the data related to 1964 but, on the other hand, alcohol consumption in the United States has not grown at the same rate as in Europe since then. The comparison, however, is with such considerable causes of death as heart disease and cancer that, between them , account for the bulk of mortality in the western world, the remainder being accounted for by many other con- ditions. Most of these causes are responsible for relatively few deaths but, nonetheless, each has to be tackled individually and brought under control. The causes of death to which alcohol makes a major contribution belong to this category. The numbers of deaths from alcoholism and alcoholic psychosis, as already indicated, are very small indeed and make no appreciable impact on overall mortality data . Similarly, the numbers of deaths from cancers that are believed to be alcohol-related are generally quite small and , as we have seen, are in some cases declining. They, too , do not make any appreciable impact on overall mortality data, although an exception must presumably 55 be made for areas, such as Normandy in France, where the evidence link- ing high oesophageal cancer death rates to alcohol consumption is very strong (85). The precise contribution of alcohol to suicide mortality is not clear, but even if one third of suicides occurred in people actually under the influence of alcohol and in heavy alcohol consumers, this is probably the upper limit of attributability. It is impossible even to begin to speculate on the extent of alcohol-related mortality from non-traffic accidents or from homicide, but it is probable that deaths from falls, etc., are likely to kill the elderly, the debilitated and the "skid row" alcoholic more than the "less expendable". If it is assumed that 80% of all deaths from liver cirrhosis around 1976 in Europe were caused by alcohol and one quarter of all road traffic accidents were similarly caused, the total number of deaths per annum would be approximately 200 000. These two causes of death are those that can be most confidently assumed to be alcohol-related and to the extent indicated. The minute numbers of deaths from "acute alcoholic poisoning, alcoholism and alcoholic psychosis" have been neglected . The numbers are substantial and in themselves justification for an uncompromising commitment to preven- tion and its resolute implementation. The cost of alcohol to society It is customary to speak in a very general and imprecise way of the "cost of alcohol abuse" . Some statements of this kind are simplistic and emotional in tone, rather than based on hard economic data. The fact is that the so-called "cost" of alcoholism must necessarily be extremely variable from country to country. In those countries where alcohol is very highly taxed, i.e., in general, the spirit and beer countries, relatively little employment is pro- vided by the drink industry. In comparison, in the predominantly wine- producing and wine-drinking countries, taxation is low but employment considerable. In the first group of countries, State revenue can be very considerable and can substantially outweigh State expenditure on treatment facilities for alcoholism, compensation to those injured in road accidents, social security benefits to widows of alcoholics, and so on. In like manner, unqualified statements concerning the "loss to industry caused by absentee- ism" have never been adequately objectified. A discussion of the economic aspects of alcohol consumption in a predominantly beer and spirit culture is provided by Walsh (30). In wine-drinking countries, on the other hand, the old adage that "wine gives a living to more than it kills" cannot be lightly dismissed. What no accounting procedure can ever quantify is the unhappiness suffered by families as a result of excessive drinking and the violent physical behaviour that it leads to , nor is it possible to express in financial terms the isolation of widowhood and the sufferings of excessive consumers them- selves during withdrawal or delirium tremens, or the tragedy of permanently injured and brain-damaged personalities. 56 In summary, "efforts to estimate a lcohol-related costs and benefits are problematic because of data and conceptual difficulties. The studies that have been completed suggest that alcohol abuse is one of the most costly single health problems, but at the same time the production and sale of alcohol generate substantial income for both industry and government" (22). It is clear , then, that the case for prevention cannot be scient ifically made on an economic basis alone or, at least, not so stridently as has frequently been the case. Rather must we cons ider the mortality, the morbid- ity and the pain and suffering that alcohol abuse brings in its wake. 57 V Prevention In Chapter I, the measures advocated for the prevention of alcohol-related problems in the nineteenth century in the United Kingdom were considered; they do not differ substantially from those advocated today . Past and current thinking about the origins of alcohol problems was also reviewed, and it was concluded that there was a need to reduce alcohol consumption or keep it within acceptable limits , since the evidence indicates that when it rises so does the incidence of alcohol-related problems. As instruments to be used towards this end there are available a whole range of measures for controlling the availability of alcohol on the one hand, and, on the other, an educational approach that takes it as given that there are cultural and social reasons for the rise in alcohol consumption . Individual preferences are important , and people do not , at least consciously or in large measure, do things they do not want to do , including drinking alcohol. The strength of commercial interests and the multiplicity and diversification of these in- terests in society, and the political and economic importance of alcohol in European countries must be recognized , and it is therefore necessary to be realistic in terms of what can be expected of prevention in the field of alcohol problems. Nevertheless , the mounting consumption of alcohol and the increase in alcohol-related problems in post-war Europe, although not yet reaching nineteenth century levels, is seen by those in the health and social care field as one of the major problems of our time. The question may be asked why anyone should want to interfere with the consumption of a substance that brings great pleasure to many millions of people, that in some countries provides as much as 3% of the population with employment and that in others yields as much as 10% of State revenue. Furthermore, it may be argued, this is a substance that people freely make individual decisions to consume. Nobody is forcing it on them and, even though some of the publicity or advertising may be persuasive, they are sti ll free agents and can choose not to consume or to consume in moderation if they wish. As pointed out in Chapter III, there are considerable individual ethnic differences in behaviour towards alcohol : in some countries per capita consumption may be as much as three times that in others. In the case of high-consumption societies, either people are unaware of the health risks involved or they accept them as the price to be paid for liberal alcohol policies. Some societies have resigned themselves to a policy of "acceptable levels of damage" . In contrast, other countries have, at some time or other, 59 decided that alcohol consumption should be reduced or stopped altogether. There have thus been measures directed towards reducing consumption and limiting alcohol availability as well as periods of total prohibition of manu- facture, distribution and importation . However, one by one, attempts at prohibition have been abandoned as being either economically undesirable, politically unacceptable, or legally unenforceable . The preoccupations of preventive medicine have changed drastically in the past century. The disappearance from the developed world of the major epidemics and the infectious fevers , the virtual elimination of mortality from tuberculosis , and the remarkably successful campaigns against neonatal and infant mortality have shifted the emphasis from these conditions to the cardiovascular diseases and cancer. Above all, there has been the recog- nition that our own lifestyles are often inju rious . To put it another way, one of the major preoccupations of contemporary medicine is to ensure that we die less often and less prematurely as a consequence of our own health- damaging behaviour. Among the types of behaviour that are now seen as life-threatening and life-damaging is abuse of the most widely circulating drug in our society, ethanol. Despite the fact that it is virtually impossible to quantify the extent of the mortality and disabling morbidity that is caused by it, there can be no doubt in anyone's mind of the important contribution that it makes to death and chronic illness. It is easy, of course, to be the devil's advocate, and to point out that the majority of fatalities from liver cirrhosis are among relatively old people, that many of the people who die violently following alcohol consumption might have died violently anyway because their life- style, even without alcohol, was orientated towards risk-taking, and that in countries where alcohol is banned and is not consumed, people still die from these causes of death. Within the European Region, however , there is a close correlation between the level of alcohol consumption per capita in a country and, for example, road traffic deaths. Unfortunately, there is also co- variation of both of these indices with income levels . An important aspect of such co-variation is that some countries experience low consumption and low accident rates, due to an ethnic and cultural orientation directed to- wards responsible and less risk-taking lifestyles. Perhaps the question is wrongly put and should no longer be oriented towards the quantitative contribution of alcohol to various causes of mor- tality and morbidity. Rather should there be a general acceptance of the multifactorial causality of all these causes of death. With this acceptance comes the realization that knowledge of any of the contributing factors should lead to the elimination of each individually. As progress is made in other areas of prevention, the role of alcohol becomes correspondingly greater. Better roads, better street lighting, im- provements in car design leading to a safer vehicle, the increasing insistence on the wearing of seat belts and the enforcement of stricter speed limits, reduce the proportional contribution of non-alcohol factors to road acci- dent mortality and injury and simultaneously increase the relevance and importance of alcohol. Similarly, the more effective treatment of depressive illness by psychopharmacologically active antidepressant drugs may render 60 the proportional contribution of alcohol to suicide more important. It has been noted, too, that between 1950 and 1975 the relative importance of alcohol in total liver cirrhosis mortality increased considerably. Thus, as public health measures in other areas have advanced, the role of alcohol as a contributing factor in certain forms of mortality and morbidity has become greater. With the approach of the close of the twentieth century, health priorities have changed; people are now expected to take greater responsibility for their own behaviour, to be more responsible in their reproductive behaviour and in interpersonal relations, and to provide for and take greater responsi- bility for the handicapped. In particular, they are expected to ensure, by their own behaviour, that they do not handicap and disable themselves. This means that they must avoid self-damage by the use of dangerous drugs , including nicotine and alcohol, not just so that they themselves may live longer and enjoy happier and unimpaired lives, but so that they may set an example to the next generation . These are the considerations underlying the justification for designing preventive programmes aimed at halting the growth of problems associated with an increased alcohol consumption. Historical background Attempts and endeavours at reform and prevention in the alcohol field are not new: since 1800 and before, reformers have been active, spurred on by all types of motivation . Often the reasons for reform were complex and embedded in the political and social matrix of the time. The subject has been reviewed by Longmate (JO) and by Harrison (J J). Genuine concern for the sufferings associated with alcohol abuse in the working classes led to active campaigns for abstinence. No doubt some of the movements towards a soberer working class were determined by the philosophy of a growing capitalist ethic, which saw industrial expansion as the legitimate goal of purposeful human activity. Since inebriety and a disorderly workforce, particularly in the growing industrialized urban societies of Europe, was an increasing problem, it was in the capitalist interest to curb or eliminate it. Despite these sentiments, the use of legislative controls to bring about prevention was extremely limited. Indeed, the availability of alcohol during the nineteenth century was almost unrestricted. Licensing hours were ex- tremely permissive and liberal and it was possible to drink in shops and other legal "on-premises" locations, virtually around the clock. Nevertheless, the strength of the movement in favour of abstinence increased . Abstinence societies flourished throughout Europe. Reformers , such as Father Matthew in Ireland, became widely known, as did organ- izations like the Salvation Army and the Band of Hope. Pressure came not just from the working class itself but also from the ranks of the bourgeoisie and the middle class. Medical sentiment and organization lent its support early to such endeavours, and in France the Comite national de Defense contre I' Alcoolisme was established in 1872, though under a different name. "Dry" sentiment was very strong in certain parts of Europe, particularly in Scandinavia, and in the southern part of the United States. These feelings 61 were translated in many areas into total prohibition, which lingered on well into our own time before finally capitulating in the face of economic and social considerations. That some of these efforts were effective may be gauged from the fall in consumption in Ireland in the early 1840s, when Father Matthew's cam- paign was at its highest. Indices of alcohol-related damage fell during the Franco-Prussian war of 1870, in Denmark in the early 1900s (86), in most of Europe in World War I, and in the United States during the period of prohibition . All of these , except the latter, were times of national emergency and of severe restriction of alcohol availability. Supporting evidence of problem decreases during short-term restrictions comes from such situ- ations as strikes affecting the manufacture or sale of alcoholic beverages. a For most of the early reformers, prevention was seen as synonymous with total abstinence. It seems to have been universally believed that the only way to discourage abuse was to shun alcohol altogether and to advocate its avoidance, rather than campaigning to reduce its consumption, although there were, in different European countries, organizations whose policy was the avoidance of spirits while permitting beer and wine. As the nineteenth century progressed , taxes , which had always been levied on alcohol, became more important and higher in many European countries. The consequence was that a sizeable trade in illegally produced beverages, almost exclusively spirits, developed . These were marketed and sold near their point of manu- facture to avoid the hated government tax . One of the consequences of this change was a gradual shift in European countries from an almost exclusive spirit economy to one in which beer became of greater importance. As far as the drink industry is concerned, it had, by 1800, become of very considerable economic importance in most European countries. In the wine-producing countries there had, during the mid eighteenth century, been a considerable expansion of the export trade, particularly of high- quality wines from Bordeaux, but also of fortified wines from Spain and Portugal. Many of the great, and some small, breweries had their roots in the mid eighteenth century, while the distilleries came somewhat later. In most European countries there were, by 1850, a considerable number of such enterprises, many of them functioning and distributing on a local rather than a national basis . As time went on they tended to diminish in numbers and the monopolistic or oligopolistic situation that exists today began to develop. As the need for revenue taxes of all kinds intensified during the latter half of the nineteenth century, governments turned increasingly, particularly in the beer- and spirit-producing countries, to alcohol as a source of revenue. Thus, alcohol production became important economi- cally on two counts: firstly, because the numbers engaged in the alcohol trade, from producers to distributors, represented a sizeable proportion of the national workforce; and secondly, because governments became in- creasingly dependent on the alcohol trade for revenue as the industry gradually increased in importance. The situation now is that, in some European a Unpublished data. 62 countri es, up to 10% of a ll revenue to the Sta te is deri ved fro m ta xes levied o n alcoho l. Consequentl y ta xes, in so me cases, co nstitute mo re tha n 50% of the retail price o f drink . In oth ers, a nd particula rl y in the wine-producing countries, the ta x revenue is less impo rta nt and in so me cases wine is not ta xed a t a ll. This has meant that both the brewers and distillers, toge th er with the wine-producing interes ts, have become ex tremely impo rta nt indus- tria ll y, have form ed protective assoc ia tio ns o f their own , and co mma nd a n impo rta nt po litica l lo bby. Since Wo rld Wa r II there has been furth er ra tio n- a lizatio n a nd mergers within the alco ho l trade so that smaller brewing a nd di stilling interests have become pa rt o f much la rge r internat ional co mbines. Similarly, large groups o f iso la ted sma ll wine growers have jo ined together to form la rge wine coo perati ves that so metimes suppl y majo r entrepreneurs possessing extensive nati ona l a nd internatio na l outl ets a nd distr ibutio n networks. Furthermore, ra tio naliza tion a nd di ve rsification within the a lco- hol trade has led to ma ny fo rmerl y exclusive bee r a nd spirit p roducers buying into and develo ping interests in the wine trade, just as wine pro- ducers have tended to di ve rsify into bee r and spirits. In a ll these ways, the size and po wer o f the a lco ho l industry and , mo re impo rta ntl y, its effi ciency, have tended to grow sin ce Wo rld Wa r II . At the po litica l leve l, the majo r industri a l concerns a re of considera ble importance. They a re backed up at na tio na l po litica l level by trade unio ns and by o rganizatio ns of reta ilers a nd o f employees in di stributio n and retai ling outlets. At the same time, the a lco hol-producing interest is ex- tremely strong at loca l leve l, where the industry is of parti cula r impo rta nce eco nomica ll y. The trade is a lso represented a t the supra na tiona l leve l by various co mmittees, fo r example in the EEC. At natio na l level it is quit e comm o n in some countries fo r acti ve po liticia ns to accept pos itio ns as chairmen or boa rd members in brewing o r distilling co mpa nies. In additio n, many members of gove rnments have direct or indirect interests in the drink industry. This is o ne se t of rea lit ies th a t a ny po licy of preventio n must conce rn it self with . While the red uctio n o f na tio na l a lcoho l co nsumptio n is a legiti- mate public hea lth objecti ve, it runs counter to commercia l interests whose a im is to increase natio nal co nsumptio n o f a lcoho l. At first sight there wo uld seem to be little poss ibility of co mprom ise between such widely oppos ing a ims. Perha ps even mo re constra ining fro m the po int of view of preventive po licies is the ge nera l o utlook a nd sentiment tha t has develo ped in Euro pe. The growth in in co mes and the di ffusio n a nd ava il abilit y of co nsumer goods o f a ll types to virtually the tota l po pula ti o n, has ensured a dema nd fo r a nd expecta ti o n of " the good li fe " denied to success ive ge nera tio ns of Euro- peans during the mise ri es of two Wo rld Wars a nd the econo mic depress io ns o f the imm edia te pos t- wa r a nd inter-war periods. First a mo ng the po litical considera ti ons a ffecting p reve ntio n must be the mos t impo rt a nt of a ll , the will o f the people. Time a nd aga in histo ry has shown that it is ex tremely difficult to enforce a po li cy decisio n in a ny a rea o f soc ia l concern if it runs counter to what people wa nt. Prohibitio n was only pa rti a ll y successful a nd eventua ll y b ro ke down in ma ny places fo r th is simple reaso n. Where 63 prohibition is contrary to the will of a large section of the community then that section will devise methods and techniques of evasion. There is ample evidence of this in the alcohol field . As already pointed out, when taxation on spirits reached a sufficiently burdensome level, illicit distillation began to flourish. The extent to which any people wish to be free to drink alcohol is strongly culturally determined (see Chapter III). Accordingly, what may be appropriate in terms of sanctions on alcohol production, distribution and retailing in one area may be totally unacceptable in another, and not just on theoretical grounds but al so because of basic practical difficulties. In the non-wine-producing countries, some measure of control of alcohol con- sumption is more feasible than in areas where wine is produced. Differences in cultural attitudes to what is permitted and permissible in various Euro- pean countries can be exemplified, as pointed out on p. 39 , by the permitted blood alcohol levels in relation to driving. In particular, it was possible in Norway, without public opposition, to introduce a blood alcohol limit of 50 mg/ I 00 ml in 1936, whereas there is still no limit at all in some European countries and others have only recently introduced a limit of l00 mg - double the Norwegian figure. It becomes apparent , therefore, that cultural attitudes to what is desirable and what the public wishes or will allow, in relation to alcohol control, must differ a great deal throughout the European Region. It is thus a question of modifying public opinion be- fore legislation, any restrictions on availability, or other measures can be introduced. The possibilities of prevention must be thoroughly explored, evaluated and faced in the designing of any preventive programme. The political realities of what is possible and what is not possible, given the political muscle of the drink industry and, even more importantly, the wishes of the people, must be borne in mind . Legislative and other control measures in the alcohol field must have a political base in public sentiment that can only be established by setting the facts on alcohol-related damage before the people. Information and education is thus a fundamental ingredient of any preven- tive programme (see p. 72). Alcohol control policies From the public health point of view , as already indicated, the priority goal in halting the increase in alcohol-related problems must be the reduction of total national per capita consumption of a lcohol; failing this, a determined effort must be made to ensure that per capita consumption does not grow. A general review of policies for achieving this has been presented in a joint collaborative publication of the WHO Regional Office for Europe, the Finnish Foundation for Alcohol Studies, and the Addiction Research Foun- dation of Ontario (87) . The following were among the main conclusions: (I) "Theoretical considerations and empirical data indicate that a substan- tial increase in mean consumption (of alcohol) is very likely to be accom- panied by an increased prevalence of heavy users" ; (2) "A lowering of the total consumption of alcohol is likely to be accompanied by a reduction in 64 the prevalence of heavy users"; and (3) "The relationship between heavy con- sumption and excess mortality is manifested in the general population in a co- variation of liver cirrhosis mortality and per capita alcohol consumption". These and other considerations led to the main argument that "changes in the overall consumption of alcoholic beverages have a bearing on the health of people in any society. Alcohol control measures can be used to limit consumption, thus, control of alcohol availability becomes a public health issue" . In the last few years, in a number of European countries, reports have been submitted to governments on the prevention of alcohol-related prob- lems. In France, the report of Professor J. Bernard's working group states quite categorically that it is necessary to try to reduce progressively the quantity of alcohol consumed by the French people, and that this objective is of fundamental importance. Without a substantial decrease in alcohol consumption, no improvement in the present situation can be hoped for (57). In Finland, the Alcohol Committee reported in 1978 that "Some experience in Finland and abroad indicates that the detrimental effects [ of alcohol] are closely related to the overall level of consumption .. . ". The goal of Finnish alcohol policy" . . . must be achieved by reducing the level of consumption" ( 44). The report to the Storting (the Norwegian parlia- ment) on alcohol policy, prepared by a committee of the Under-Secretaries of State, is unambiguous: "The goal must, therefore, be to reduce the total consumption of alcohol in all groups of the population" (88). In the United Kingdom, the report of the Committee of the Royal College of Psychiatrists identified as a "first-level goal", "preventing the national per capita alcohol consumption from rising beyond the present level" (52). At the international level, a body such as the Commission of the Euro- pean Communities may impose rules governing the taxation of alcoholic beverages. These are enforceable under the various trade agreements and infringements may be brought before the Court of the European Parlia- ment. Narcotics have long been subject to strict international control but this has not been possible with alcohol products and may never be. Interna- tional bodies, though without any statutory powers, also exist in the alcohol field, one example being the International Council on Alcohol and Addic- tions . At national level, many countries have their own national councils on alcoholism and some local areas have their own bodies. An example from outside Europe is the National Institute of Alcohol Abuse and Addiction in the United States. As far as the alcohol policies of individual countries are concerned, it must be stressed that every government seriously concerned about health problems should have formulated such a policy and have formally pledged itself to the pursuit of the objectives of that policy. Without such a commit- ment there can be little hope of any effective control of alcohol problems. As was pointed out by the WHO Expert Committee, "The effectiveness of any specific type of control effort will depend in part on its integration into a clear governmental policy position that has been carefully defined and coherently expressed" ( 77). Given that such a policy exists and that that policy is aimed at preventing any increase in consumption, or even bringing 65 about a reduction in consumption, what types of State control systems exist? At its most general level, State intervention can be aimed at rectifying any adverse social conditions, such as poverty, unsuitable housing, etc., that may predispose to excessive drinking. Then it can control the production and distribution of alcohol, including its availability, an<;! regulate its taxa- tion and pricing. It can disseminate information concerning alcohol and its health-damaging effects with the aim of reducing consumption . Finally, it may set up early intervention programmes to decrease damage in persons identified as drinking excessively. It is clear that national policies aimed at restraining alcohol consump- tion must advance on many fronts simultaneously. As the WHO Expert Committee previously mentioned puts it : "The effectiveness of any single control measure probably depends on its being imbedded in a series of mutually supportive efforts that together constitute a comprehensive co- ordinated programme of intervention" ( 77). Such a multifocal medium- or even long-term strategy has been suggested in France in the Bernard Report (57). In any particular country, many government departments, such as those of health, social welfare , education, labour, industry and commerce, and many more, will be concerned with alcohol policy. It is essential, therefore, that any national policy should be defined and carried out by a body on which all of them are represented. France is a good example of a country where some progress in this direction has already been made. It was recommended that an inter-ministerial body should be set up, and the Haut Comite d'Etude et d'Information sur l'Alcoolisme was established in 1954 within the Department of the Prime Minister with the following responsibilities: (a) studying different aspects of alcohol problems and the measures necessary to combat them; (b) advising the Government so that it can direct the activities of differ- ent governmental departments on questions likely to influence the develop- ment of alcohol problems; and (c) undertaking all investigations , both social and economic, relating to alcohol problems as well as carrying out an information and education campaign. As far as the organization of coordinated, public health oriented, pre- vention programmes in the alcohol field is concerned, it is unfortunately true that what is apparent is a lack of coordination and integration of policy decisions and initiatives. Many countries have not yet even formally com- mitted themselves to a policy on alcohol. Many evade this critical issue and instead prefer to develop sectional rather than total approaches to the problem. Inevitably, this involves taking the soft options and evading the politically difficult decisions. It is in a sense paradoxical that representatives of the governments of Member States can come together at the World Health Assembly and subscribe to resolutions concerning the prevention of 66 alcohol-related problems and yet at the national level be unable to persuade their own governments to take the requisite steps to design and implement a national policy of prevention in the alcohol field. Apart from the general desirability of establishing national policies that make use, within the limits of public acceptance, of all the control and prevention measures discussed here, there is also a need to inform and educate the citizens of Member States within the European Region of the extent and growth of problems in the alcohol field, pending the development of such policies. It is for the specialist workers in the alcohol prevention field to explore, within the confines of their own culture and attitudinal struc- tures, the strategies most likely to be adopted and used in their own coun- tries and the methods of promoting and implementing them. State monopoly and control Some European countries, including Czechoslovakia, Finland, Hungary, Norway, Poland, Sweden and the USSR, have set up a State monopoly of alcohol production and distribution. In Finland, for example, following total prohibition between 1919 and 1931, legislation was introduced that vested all alcohol production in a State monopoly and excluded private enterprise. This device was an alcohol control policy, since its avowed aim was to ensure minimal consumption levels. At the same time, the monopoly was responsible for providing the outlets for drink sales, training monopoly personnel including bartenders, and collecting alcohol taxes for the Government. To many observers this multiplicity of roles seemed ambigu- ous and conflicting, particularly following the liberalization of Finnish liquor laws in 1969. Apart from Norway and Sweden, where prohibition, severe restrictions on availability , and rationing have been enforced at one time or another, few European countries have exercised such total control over alcohol manufacture and distribution as has just been described. In some countries, such as France and Switzerland, the State controls distribu- tion of spirits produced by private concerns. In France, in recent years, the areas cultivated for wine production have been subject to strict control. Government policy is to decrease the quantities produced and improve quality, and government grants and aid to producers are designed to favour this process. In other countries there are no restrictions on the production of alcoholic beverages as long as appropriate taxes are paid. Control of availability Rationing The most stringent method of controlling availability, apart from total prohibition, is rationing. In Sweden, in 1922, such a system of rationing was introduced, named after a certain Dr Bratt, one of its advocates. It con- tinued in force until the middle 1950s, and was mainly concerned with spirits and inter alia, the amounts that could be sold to customers in restaurants and cafes. In Finland, in the I 940s, a rationing procedure was also intro- duced, called the Linturi system. Both systems were abandoned with the 67 general liberalization of licensing legislation in Sweden and Finland. They both involved ration books or cards, and were administratively ponderous and open to abuse. On-premises sale and consumption Legislative control of premises for the sale and consumption of alcohol is universal in Europe. Such premises must be licensed and registered and, in addition, there are varying degrees of control over the manner in which they operate, i.e. the hours during which they are allowed to open, the types of drink they can serve, and to whom they may serve them. In some countries, such as Ireland and Italy, licences are granted on a strict population basis. One of the consequences, in the former country, where licences are corres- pondingly precious and usually only obtained by the extinction of an existing one, has been a growth in the size of public houses. Restrictions on on-premises consumption by type of drink is exemplified by the Belgian experience. The 1919 Van de Velde Law, which has been repeatedly amended, still remains the fundamental legislation. It prohibits the sale of drinks of more than 22° alcohol content in public places, including all drinking locations. This has led to the growth of private clubs, which may purchase licences to enable them to dispense spirits . Generally, in Europe, laws relating to availability apply to the country as a whole. However, in Switzerland, which has a federal structure, there is a certain degree of flexibility in that each canton has the power to regulate hours of opening and closing of licensed premises. In certain parts of the United States even smaller communities have the right to legislate auto- nomously, and this "local option" is an interesting development in local government. Historically, there has been a close association between econom ic growth and the availability of alcohol, so that causation in this area is complex and not easy to unravel. Alcohol was very widely available, in terms of places and times, in the nineteenth century. More restrictive licens- ing laws were introduced in certain European countries towards the close of the century and particularly before World War I, but it was during that war that alcohol availability was reduced very substantially. With the conse- quent reduction in alcohol consumption, there was a marked decline in alcohol-related problems . In about 19 I 9, however, restrictions on availabil- ity were gradually lifted and both consumption and problems increased, although neither reached pre-war levels . The inter-war years were times of economic depression for the most part and so disposable incomes did not, in most European countries, permit a very high consumption . Since the ability to consume was so restricted there was no demand for greater availability. This state of affairs was accentuated during World War II. In the post-war years, and particularly since 1960, there has been a widespread relaxation of restrictive measures, even in countries such as Finland, where previously availability had been very limited. It may be legitimately argued that the drive towards greater availability of alcohol, in terms of on-premises con- sumption, sprang from a general capacity and willingness to buy and 68 consume more alcohol. It was claimed by those who strove for more liberal opening hours that they would result in less drunkenness. They believed that restricted opening hours caused many people to drink quickly and heavily during the short period of time that bars and other drinking locations were open. This led, they claimed, to a greater incidence of social problems. This argument was used, for example, by the trade and others appearing before the Clayson Commission in Scotland (89). It was accepted and led to an extension of opening hours in Scotland. Sale for home consumption As, in many European countries, the drinking pattern has changed from on-premises consumption to home consumption, the opportunities for off- premises purchase of alcohol have increased enormously. The growth of supermarkets and other off-licence retail outlets has been one of the features of post-war Europe. In this way it has become possible for many groups of people, who previously would have had some reservations about purchasing alcohol, to buy drink in supermarkets along with their usual domestic shopping and bring it home for either convivial or solitary consumption . Once again it is difficult to disentangle the cause-and-effect relationships between this greater availability and increased home consumption. Age In virtually every country the law specifies the age at which drinking is permissible, the usual minimal age being 18 for on-premises consumption, although a distinction is sometimes made between consumption of spirits and beer consumption. European legislation in this area has tended to be more permissive than that of North America , where 21 was formerly the legal age in most states of the USA and Canadian provinces . Indeed, in many of these areas, there has been a demonstrable rise in alcohol-related problems among those aged 18-21 following the lowering of the permitted age from 21 to 18 years (90), and as a consequence, in some of them , it has been decided to return to the previous, more restrictive age limit. There are great practical difficulties, in the prevailing climate of late twentieth century European thought, in imposing these restrictions on young people. For one thing, young people now look older than they really are and also, more importantly, have far more money to spend on alcohol than the young had in the past. The degree to which the legal requirement is enforced by publicans, restaurant or cafe owners is very variable, but in some cases laxity is the rule. Control of advertising The role of advertising in relation to alcohol consumption has already been discussed in Chapter III. In spite of the lack of convincing evidence that it increases consumption, most countries have introduced some form of con- trol of the advertising of alcohol in the media. Some, such as France, have 69 developed elaborate codes of conduct, discriminating between different forms of beverage and applying the stricter sanctions to the stronger. Others, such as Finland and the socialist countries, have totally banned any media advertising of alcohol. It has been pointed out that the banning of alcohol advertising may be a double-edged weapon, in that the industry may thus save a great deal of money which can then be used to lower prices or to pay for some other method of sales promotion such as the purchasing of leisure facilities that supply alcohol. Indeed, some manufacturers have even anticipated the restrictions imposed by governments and health depart- ments by running campaigns in the media urging people to drink moder- ately. This is seen by some as covert advertising and as being promotional. Whatever the effectiveness or otherwise of the advertising of alcoholic beverages, there would probably be general agreement that, at least for the sake of consistency, there should be some restrictions on advertising in newspapers, on hoardings, and by radio and television, if only in view of the conflict between health education programmes, on the one hand, and alco- hol trade campaigns urging more people to drink more, on the other. The nature of the sanctions employed will be a matter of debate. Some countries may opt for total prohibition of any form of alcohol advertising or promotion; others may restrict the ban to spirits only, and some may be particularly concerned with the content of the publicity material. In par- ticular, it may be urged that young people should not appear in such material and that advertisements should not show alcohol in a romantic setting or contain anything that would imply that alcohol is in some way "good for you". The Bernard Report in France (57) recommended the closest surveil- lance of advertising material produced by the trade so as to ensure that it is neither misleading nor inaccurate. Statistics and other data should neither be presented out of context nor quoted only partially so as to convey an erroneous impression. Advertising material should not imply that any asso- ciation exists between alcohol and sport, appear in sports stadia or clubs, nor give the impression that any alcoholic drink is of medical value or in any way improves the quality of life . The Report stresses the growing astuteness of the trade in evading the advertising laws. One example quoted was that of a company manufacturing alcoholic drinks under a very well-known brand name. By buying into a company producing non-alcoholic drinks and giving the same brand name to the latter's products, it is able to evade all the controls on the advertising of alcoholic drinks. Price control The effect of prices on alcohol consumption has already been discussed in Chapter II I (p. 29); it is considered here from the point of view of the deliberate manipulation of prices as part of an alcohol control policy. It has often been assumed that increasing the price of alcohol will affect all drinkers equally, but precise information on this point is not as readily available as might be thought. According to the old disease concept model of alcoholism, price control measures should have less effect on heavy 70 consumers and particularly on those who are perceived as being "alcohol dependent" than on moderate consumers. Some would argue that it is the marginal drinkers, i.e. those who take alcohol relatively infrequently, who are most likely to respond by stopping drinking, whereas the heavy con- sumers will continue their intake at the previous level. Support for the contention that heavy drinkers will choose cheaper, but not less potent, beverages comes from the behaviour of"skid row" drinkers (seep. 43), who are adept at obtaining value for money in terms of alcohol content, if not in quality. Survey evidence from the cigarette field appears to indicate that it is the light consumers who have given up smoking since the cancer scares of the early I 960s and that those who continue to smoke are smoking as heavily as before . On the other hand, the evidence - now substantial - that decreases in consumption lead to a decrease in problems, suggests that heavy or problem drinkers also reduce their intake under such conditions, or that there is a reduction in recruitment to the ranks of such drinkers. Another consideration is of considerable importance here . Does raising the price, even if relatively ineffective in controlling the intake of heavy consumers, penalize their families more by reducing the proportion of a husband's income that eventually trickles through to them for spending on essentials? At certain periods upwards of 15% of personal expenditure has been on alcohol. Elasticity studies indicate that, in some cultures, people are prepared to pay the price of their need for alcohol simply by increasing the proportion of their income devoted to it , if price increases should make this necessary. Should there be any differentiation, from the point of view of price control, between the various beverage types? In other words, should spirits be more rigidly controlled than beers and wines? The general feeling for a very long period of time has been that spirits are more injurious to health and create more social problems than does the intake of alcohol in less concentrated forms. The evidence on this point, however, would seem to be mainly impressionistic rather than objectively scientific. Two points call for some comment in this connection. Firstly, in terms of somatic disability, the close association between oesophageal cancer and calvados intake in Nor- mandy reported by Tuyns (69) and by Pequignot & Tuynes (85) suggests that in this case, at least, spirits may be more carcinogenic than other forms of alcohol. Secondly, there is the time-honoured belief that acute social disturbances caused by alcohol, such as fights, brawls, homicides , etc., are more closely related to spirit consumption than to other forms of alcohol intake. However, the important point to be made here is that heavy con- sumers generally , but not always, tend to be spirit consumers and that it is the amount of alcohol consumed , rather than the form in which it is taken , that is the relevant factor. In any consideration of the usefulness of price control in the alcohol field, a number of issues must be taken into account. In the wine-drinking countries, because of low production costs and little or no taxation, alcohol is very cheap. In contrast, in the beer and spirit countries , where costs and taxes are both high, alcohol is dear. The usefulness of price increases as a deterrent must vary greatly between these two groups of countries. In 71 addition, the effectiveness of price increases in reducing the consumption of alcohol will depend on the relation between prices and incomes: where incomes are rising faster than prices , an increase in the price of alcohol may correspond to a decrease in real terms. In such a situation, the usefulness of price increases as a control measure in the alcohol field may be seriously reduced. To be effective, a price increase would have to be of sufficient magnitude to more than offset the rise in incomes, but such price increases may not be politically acceptable and very few governments would have the temerity to embark on what, from the political point of view, could be suicidal behaviour. Such price increases might, in addition, be counter- productive in that they could lead to inflation and demands for further wage increases. It could be argued that alcohol, as a luxury, should be excluded from the cost-of-living index used by trade unions for bargaining purposes, but the perception of what is a "luxury" is highly subjective. In most European societies, in any case, alcohol is a normal item of individual and family consumption. Although there is some evidence of the effectiveness of price increases in reducing alcohol consumption in earlier times, e.g. in Denmark in the early part of the twentieth century (86), this was under exceptional circumstances and the increase applied mainly to spirits. In more recent times, an econometric analysis of the effect of hypothetical price increases in relation to current expenditure in one European country where wages had been rising rapidly, showed the very limited usefulness of using price increases as a method of control (30). Indeed, it seems clear from the available evidence that a decrease in disposable income would be a far more effective way of reducing alcohol consumption, but this is obviously unacceptable. Nevertheless, in the majority of European countries, the price of alcohol in real terms has been allowed to fall substantially. (Finland is an exception, since the price of alcohol there is index-linked to the cost of living.) It may therefore be tentatively recommended that this fall in the real price of alcohol should not be allowed to continue. Finally, it has been suggested, e.g. in the Bernard Report (57), that taxes should be levied on alcohol to offset the cost of social security payments to those damaged by alcohol and their families. Education and information There is general agreement that an effective method of controlling alcohol consumption is by decreasing the demand for it through health education. Education and information programmes in relation to alcohol are therefore beginning to play an increasingly important part in the overall prevention strategies of many European countries, in spite of some disagreement as to the correct approach to be adopted. This is shown by the fact that, in a recent publication, some 50 such programmes in 28 countries were reviewed (91) . It was concluded that "as education of the young is accepted throughout the world as a fundamental human right, so education for health should be accepted as an integral part of the educational process", that "all educators, sta rting with health staff and teachers, should themselves be trained in 72 health education" and that it should be possible "to design and apply an adequate and relevant model for health education of the young today, in the countries of the WHO European Region". It is also generally agreed that certain groups in society, such as schoolchildren and young people, are more vulnerable than others in relation to alcohol, and should therefore be the subject of particular emphasis in information and education programmes. In addition, pregnant women should be made clearly aware of the risk to the fetus that drinking involves . It has been suggested that , since the children of known alcoholics are particularly at risk , special attention shou ld be given to them, but this may be easier in theory than in practice. Those holding positions of particular responsibility, such as drivers of public service vehicles, operators of heavy and potentially dangerous machinery, and workers in the drink trade itself, might be other target groups. The way in which professional groups, and particularly medical stu- dents , are taught about alcohol consumption and alcohol-related problems and their prevention and treatment is unsatisfactory. Thus, the Bernard Report (57) considers that, in France, the subject of alcohol-related prob- lems is inadequately taught and is dealt with in an unconnected and incoher- ent fashion within the medical curricul um; it therefore argues the case for a comprehensive course in "alcohology". The role of national counci ls on alcoholism, which exist in a number of European councils have developed from voluntary bodies, but now receive governmental education is considerable. Most suchsupport and continue to grow in number and strength. They can also act as political pressure groups in inducing governments to review and tighten up their alcohol policies. In France, the Comite national de Defense contre I' Alcoolisme takes legal proceedings against advertisers and producers for infringements of the laws governing alcohol publicity. Finally, education and information must be seen as an essential part of overall policy on alcohol. Thus, education can prepare the ground for the introduction of other control measures and render them acceptable. Legal sanctions The legal sanctions, such as those concerning driving with high blood alcohol levels (see p. 39), can also be regarded as part of the education process. Their enforcement is the formalization of the commitment to national policies, but many excellent legislative provisions are current ly not being enforced. When enforcement is lax , compliance with the law will decrease as it becomes more widely realized that the chances of being apprehended are small. The probability of being caught while driving under the influence of alcohol has been calculated and shown to be relatively small (92) . Early diagnosis and intervention In France, the early detection of heavy alcohol intake, before problems develop, is an important part of preventive policy. This has been achieved 73 through the setting up of centres d' hygiene alimentaire throughout the country. They owe their origin to Dr Le Go, an industrial medical officer with the French National Railways, who was concerned by the extent of heavy drinking among the workers. He therefore devised a diagnostic screen or grid to be applied to each worker at the compulsory annual health examination (93) . He believed that the most judicious and diplomatic way to screen for heavy drinking among French workers was through a gastro- enterological clinic, because of the traditional perception of alcohol as an aliment or element of nutrition in the French diet. It was therefore logical to deal with any problems associated with it in a nutritional or gastroentero- logical setting. Those suspected by their general practitioners or by other agencies of drinking too much or beginning to have problems, or themselves worried about their drinking, can now go for examination, counselling and advice to a centre d'hygiene alimentaire. In addition, many of those who appear before the courts on charges of driving with raised blood alcohol levels are also advised to attend such a centre . If they do so and if the centre reports favourably to the courts, their chances of having their driving licences restored will be considerably improved. The impact of this approach to early diagnosis is not yet clear. So far, no other European country has committed itself in such a systematic way to early diagnosis as an essential element of preventive policy. Evaluation The effectiveness of every national policy and programme must be evalu- ated. Did it attain its objectives? Did it do so efficiently and at what cost? Were the objectives defined by the policy the correct ones? Were the pro- grammes developed in pursuit of the policy objectives the appropriate ones for the purpose? The infrequency with which such fundamental questions are asked has been pointed out in a recent Canadian publication (22) as follows: "The focus may be on the reduction in the incidence of alcohol problems, or a reduction in the rate of increase of alcohol problems, or a reduction in the prevalence of alcohol problems, or the promotion of health, or the promotion of health in order to reduce health problems, or the reduction of health problems in order to promote health, or the reduction of the spiralling costs of health care associated with alcohol problems, or the prevention of untimely deaths, or . . . Clear specification of the long-range, mid-range, and short-range objectives, and of the causal links between such objectives and policy measures, is essential; such planning is, however, frequently absent and can only be inferred from available evidence". It might be thought that evaluation should be easy, because total national per capita consumption of alcohol is readily available as an indi- cator of progress towards lower consumption levels. Similarly, data on mortality from cirrhosis of the liver will be the most useful single indicator of trends in the field of alcohol-related problems. In some countries, numbers of admissions to psychiatric hospitals for alcoholism may also serve as a useful indicator of alcohol-related morbidity, and there are also the data on prosecutions for drunken driving. 74 In most European countries such data are published annually so that there should be little difficulty in monitoring fairly accurately the success or failure of national policies. However, when the effectiveness of individual prevention programmes is examined in more ·ci"eta1l, the situation becomes a good deal more complicated . Data relating to the nation as a whole say very little about the changes in consumption or in somatic or social problems among particular population subgroups, so that more detailed data are required. There is therefore a need for regular survey data obtained from population samples representative for age, sex and social class and from both rural and urban areas. Such regular survey data are essential, even though the limitations of self-report data are well known . Only if such data are available will it be possible to deduce the changes taking place in particular population subgroups in relation to alcohol. Since some of the preventive and, particularly, the education programmes will be aimed at certain groups, such as the young, it is important for data to be available on the alcohol-related behaviour of those groups. The impact of pricing policies on alcohol consumption should be closely monitored; this applies not only to total consumption, but also to that of different beverage types . Because such monitoring is complicated by the large number of va riables involved, sophisticated econometric analyses are necessary; the skills of economists and others who can help in compiling and analysing the data are therefore necessary. Restrictions on alcohol availability, which may be used as control mea- sures, must also be subjected to critical scientific scrutiny. Here again, the need for data of adequate quality must be stressed. Since the effect of advertising in increasing consumption is so uncertain , the impact of restrictions on advertising calls for careful appraisal. This is no easy task, but it may be possible to carry out experiments in which a particular group or area is exposed to advertising of alcohol and another is not. Such experiments may be difficult to arrange nowadays, when national television and radio networks are almost universal, but local services and local newspapers do exist that might enable them to be carried out. Advan- tage might also be taken , where the occasion arises, of a prolonged media strike. Similar tactics might likewise be appropriate in evaluating the effects of health education programmes. Educational programmes confined to a par- ticular group of young people, or to young people in particular areas, whilst neighbouring populations are not subjected to them, may throw up valuable information as to their effectiveness or otherwise. Unfortunately, a proper evaluation of health education programmes in the alcohol field has so far been made in only a few cases; those that have been evaluated have not shown particularly striking results (94). The evaluation of the effectiveness of alcohol control measures is a difficult task involving many methodological complexities, and it is possibly for this reason that few serious attempts to do so have been made . Nevertheless , governments do have the obligation to evaluate pro- grammes in which they may have invested much public money. It can happen that governments may undertake prevention programmes merely in 75 order to rebuff the accusation that they are not doing enough in controlling alcohol; the programmes will then have been chosen, not because of their effectiveness, but simply because they are not controversial and will not give rise to objections on the part of industry or other vested interests . There is then little incentive to evaluate the effectiveness of such programmes, to examine them critically, to acknowledge their ineffectiveness and to bring about change. It is important, therefore, to press for critical, objective, systematic and continuing in-depth examination of the effectiveness of preventive policies and programmes in the alcohol field . 76 ------- -- -- - VI Conclusions and recommendations The following tentative conclusions may be drawn from the information presented here concerning alcohol and alcohol-related problems in the countries of the European Region of the World Health Organization . I . With the exception of France, there has been a substantial increase in alcohol consumption since 1950. 2. The magnitude of the increase in consumption has varied considerably from country to country ; in one it has risen to as much as five times the 1950 level, while in others the increase has been much smaller. In general, countries with the lowest consumption at the beginning of the period have shown the greatest increases. 3. There has been a tendency since 1950 for the differences between the amounts consumed in the different countries to become smaller, i.e. to- wards a greater uniformity of consumption. 4. There has been an "internationalization" of consumption, i.e. that of beer and spirits has increased in traditional wine countries and that of wine has increased in spirit and beer countries. The growth in the consumption of these "foreign" beverages seems to have been in addition to that of the more traditional types, rather than as a replacement for them . 5. There is some evidence to indicate that drinking in countries where the pattern was formerly one of episodes of high intake with intervening periods of abstinence is moving towards the more continuous intake characteristic of wine-drinking countries . 6. There is a good deal of evidence, so me impressionistic, some from survey data, to indicate that the increase in total consumption reflects both increased consumption by existing consumers and the recruitment of former abstainers. The increased consumption among existing consumers is believed to reflect a higher frequency of drinking occasions and a greater intake on each individual occasion . Former abstainers have been recruited particularly from young people, women and members of lower income groups who were formerly unable to purchase much alcohol. 77 7. Mortality data indicate an increase since 1950 in the mortality from causes of death that are believed to be alcohol-related. The most consistent and reliable of these indices appears to be mortality from cirrhosis of the liver. Other causes of death believed to be alcohol-associated, although the association is less direct than in the case of cirrhosis, have also generally shown increases since 1950. 8. Increases in morbid conditions known to be alcohol-associated have been recorded in most European countries since 1950. This is particularly true of admissions to psychiatric hospitals for alcoholism. 9. Data on social problems known to be alcohol-related show an increase, e.g. in prosecutions and convictions for drunken driving. Figures for other types of alcohol-related social deviance are neither so easily obtained nor as reliable and hence create difficulties of interpretation. IO. The association between increase in alcohol consumption and in alcohol-related mortality and morbidity in Europe since 1950 is generally believed to be causal for most of the conditions concerned. 11 . The reasons underlying the recent increase in alcohol consumption in Europe are complex and interrelated, but must include the considerable growth in prosperity since World War II , with an increase in disposable income and therefore in ability to indulge in expenditure on luxury goods such as alcohol and, particularly among the young, a raised expectation of what life should give in terms of pleasure, etc. 12. The reasons for the existence of a certain proportion of heavy con- sumers are poorly understood, but an interaction between personal and cultural factors, i.e. between personal and group pressures, must be involved. A direct relationship is believed to exist between the total number of alcohol consumers in a community and the number of individuals who will experience or cause problems as a result of drinking. 13. The distinction between "excessive" drinkers and "ordinary" drinkers is going out of use, as is the concept of alcoholism as a "steady state" and the belief that "alcoholics" are in some way fundamentally different from other drinkers . These changes in perception and emphasis have important impli- cations for prevention at all levels. 14. The cost, both to the individual and the community, of alcohol-related problems is difficult to quantify, but it is clear that abuse of alcohol makes a major contribution to disease and social problems in Europe. In the light of the foregoing, the following general recommendations are made that, it is hoped, will serve as guidelines in preventing, or at least in reducing, the harm caused by alcohol. 78 I . An unequivocal commitment should be given to primary prevention, which should take precedence over treatment in policy and funding. To quote the WHO Expert Committee : "In view of the wide diversity of the medical and social ills and human suffering resulting from the consumption of alcoholic beverages, the limited efficacy and high cost of the existing treatment or management of most of these problems, and their high preva- lence in many parts of the world, the Committee recommends that: (a) prevention should be given clear priority; (b) further investment in treatment should be concentrated on develop- ing inexpensive and cost-effective services" ( 77). 2. Because of the overwhelming evidence that consumption levels are closely related to the extent of alcohol-induced harm, the cornerstone of primary prevention must be the control and, where necessary, the reduction of national per capita alcohol consumption. Thus, the WHO Expert Com- mittee recommended that "governments: (a) should take immediate steps to prevent any further increases in consumption; (b) should begin to reduce per capita consumption by reducing the availability of alcoholic beverages and by taking educational and other measures to reduce demand" ( 77). 3. Every government should elaborate a national alcohol policy aimed at reducing alcohol-related problems by reducing, or at least preventing, any further increase in consumption. Such a policy must be imbedded in national development policy generally and must not be considered in isola- tion. This is all the more important since, as a widely consumed beverage and an important item in trade and taxation, virtually every government department or ministry is in one way or another concerned with alcohol; it s manufacture , marketing and consumption , and the policies to be adopted cannot therefore be the isolated responsibility of one government depart- ment only. At the same time, every individual ministry in formulating its own policies must bear in mind the effects that they may have on alcohol consumption. Since countries differ widely, each must shape its own alcohol policy in the light of its own particular cultural and administrative charac- teristics, its own alcohol problems, and the possibilities for prevention that its culture offers. 4. Once a firm political commitment has been made to a national alcohol policy, its implementation should be entrusted to a body that is both politically influential and representative of all government ministries con- cerned with alcohol in any way. This body should itself assume responsi- bility for developing the national policy for controlling alcohol consump- tion, and should then implement it in accordance with recognized health planning procedures, i.e. objectives and targets must be identified and 79 programmes developed to achieve them. In each programme, a particular effect or objective should be scheduled for achievement by a specified time. 5. Obstacles to the development of a national policy must be clearly identified, and strategies devised to overcome them . Such strategies must take into account the commercial importance of alcohol and the strength of the interests concerned in promoting increased consumption. 6. Where necessary, the appropriate administrative mechanisms should be established to facilitate the formulation and implementation of a national policy and the smooth operation of the programmes. This may call for the creation of a central inter-ministerial body or, in certain cases, new legisla- tion providing for suitable control measures . 7. In each country, data on alcohol consumption by age, sex, social class, and such other variables as may appear to be relevant, should be collected at regular intervals to allow the monitoring of consumption trends and to identify groups particularly at risk . 8. In each country, in addition , comprehensive information systems should be established, designed to collect data on changes in both physical and social alcohol-related problems with maximal efficiency and as rapidly as possible. At the international level , efforts should be directed towards the standardization of methods of data collection in this field; only if this is done can useful international comparisons and studies be made. Standardization is also essential to ensure the validity of time-series comparisons within individual countries , and in the monitoring and evaluation of the effective- ness of preventive programmes . 9. In line with the emphasis on prevention, governments are urged to place before their populations the fullest possible information relating to the extent of the harm caused by alcohol. The same applies to local authorities and to all who work in health, welfare and education services. Compre- hensive public information programmes with specified objectives must be developed and implemented; they must be carefully evaluated and, if found to be unsuccessful in achieving targets, must be appropriately modified . 10. Because incomes and prices play a substantial part in determining levels of alcohol consumption, an extensive study of their effects should be undertaken . 11 . The possibility of reducing consumption by manipulating prices and taxes should be fully investigated. In particular, in all countries, steps should be taken to ensure that the price of alcohol does not continue to fall in real terms. 12. Promotional activities by the alcohol trade should be subject to con- tinuous scrutiny and, if necessary, control. Since the effectiveness of adver- tising in increasing the consumption of alcohol is not yet clearly known, it is 80 essentia l to undertake appropriate research in this field. In the meantime, advertising should be discouraged in view of the inconsistency between health education programmes designed to reduce alcohol consumption, on the one hand, and alcohol advertising material, on the other. 13. Because newspapers, radio and television cross national boundaries, national legislation alone will be insufficient to curb undesirable advertis- ing. Accordingly, international legislation at the European level will be necessary in combating it, and should be considered, e.g. by the United Nations and the Commission of the European Communities. 14. Control of the availability of alcohol should be used to the maximum for prevention purposes. Legislation governing the minimum age at which alcohol may be supplied for on-premises consumption exists in many Euro- pean countries, but there is evidence to suggest that it is frequently not enforced and is therefore not effective in helping to reduce consumption by young people. Steps should be taken to correct this situation and, as a number of studies have shown that alcohol problems have increased among young people following a reduction in the minimum legal drinking age, no such reduction should be considered. 15. Control should be exercised over the provision of alcohol outlets at places of public recreation, and particularly those used by young people. Sports stadia should not be licensed for alcohol consumption and any attempt to associate sporting activities with alcohol should be prohibited. 16. The national and international activities of the alcohol trade, such as buying into the non-alcoholic or soft drinks industry so as to manipulate prices to the advantage of alcoholic beverages, should be carefully moni- tored by governments and international health agencies. 17. Legislation favouring the free passage of alcohol between countries should be carefully examined. The argument that alcohol is a commercial product like any other and needs no special legislative consideration must be rejected on health grounds. In particular, international agreements that permit reduced taxation of alcohol and lower its price should be avoided. The duty-free concession, which has increased the amount of cheap alcohol available to travellers even on short trips between adjacent countries, should be reconsidered. 18. Where serious damage to third parties and social distu rbances result from alcohol abuse, existing legislative sanctions should be enforced as part of prevention , not with the aim of "criminalizing" alcohol-related problems of this kind but rather of ensuring that they are detected early and dealt with appropriately. Every possible effort should be made to reduce consumption of alcohol by the persons concerned so as to minimize the possibility of a repetition. 81 19. Statutory limits on blood alcohol concentrations for drivers should be the same throughout Europe. They are too high in a number of European countries, and efforts should be made at the international level to see that they are reduced. 20. In each country, an attempt should be made to identify groups particu- larly at risk for alcohol-related problems. These include migrants to large industrial cities, whether from abroad or from rural areas within the coun- try , and more generally young people and women. For such groups, educa- tional programmes and community support are of particular importance, and should form part of any national alcohol policy. 21. Much alcohol research in many European countries is haphazard in approach , without concern for priorities or usefulness . In particular, there is still an overemphasis on biological reseach that may be of little practical va lue in preventive programmes. At the same time, little information is ava ilable , in many cases, on practices and the attitudes that determine them, in relation to alcohol consumption and the causation of alcohol problems. Research on the epidemiological and social aspects of alcohol consumption and alcohol-related problems should be initiated and expanded in the European Region, but its orientation should be determined by national alcohol po licies and it should contribute to the development of national prevention programmes. 22. Every research programme should be evaluated to determine whether it is useful and cost-effective, and if not, to define the type of research that should be carried out instead. 23. Notwithstanding the priority given to primary prevention, national health policies should also make provision for treatment programmes for alcohol abuse. In keeping with the Declaration of Alma-A ta (95), the health and social problems resulting from such abuse should be dealt with as far as possible by the extension of primary health care se rvices rather than the development of expensive, but not necessarily more effective, specialized facilities (96). 82 REFERENCES I. Levine, H.G. The discovery of addiction: changing conceptions of habitual drunkenness in America. Journal of studies on alcoholism, 39: 143-174 (1978). 2. Wilson, G.B. Alcohol and the nation. London, Nicholson & Watson, 1940. 3. Bynum, W.F. Chronic alcoholism in the first half of the 19th century. 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WHO Technical Report Series, No. 650, 1980 (Problems related to alcohol consumption: report of a WHO Expert Committee). 78. Kozararevic, Dj. et al. Frequency of alcohol consumption and morbid- ity and mortality . Lancet, 1: 6 I 3-6 I 6 ( 1980). 79. O'Hare, A. & Walsh, D. Activitiesoflrishpsychiatrichospita/sandunits 1978. Dublin , The Medico-Social Research Board, 1980. 80. Welz, R. Attempted suicide in Mannheim 1966-1977. Mannheim, Zentral- institut fiir seelische Gesundheit, 1978. 86 81. Fuchs, V.K. Some economic aspects of mortality in developed countries. In: Perlmam, M., ed. The economics of health and medical care. London, Macmillan , 1974. 82. Adelstein, A. & White, G. Alcoholism and mortality. Population trends, No. 6, pp. 7-13 (1976). 83. Poikolainen, K. Suomalaiset juomatavat ja kuolleisuus [Finnish drink- ing habits and mortality]. Alkoholi politikka, 43(2): 100-106 ( 1978). 84. Preston, S.H. et al. Causes of death: life tables for national populations. New York, Seminar Press, 1972. 85. Pequignot, G. & Tuyns, A.J. Rations d'alcool consommees "declarees" et risques pathologiques. In: Anglo-French Symposium on Alcoholism. Paris, INSERM , 1975, pp. 23-40. 86. Nielsen, J. Delirium tremens in Copenhagen. Acta psychiatrica scan- dinavica, Supplement 187 ( 1965). 87. Bruun, K. et al. Alcohol control policies in public health perspective. Helsinki, The Finnish Foundation for Alcohol Studies, 1975. 88 . Report to the Storting (the Norwegian parliament) concerning the policy on alcohol. Oslo , Ministry of Health and Social Affairs , 1980. 89. Report of the departmental committee on Scottish Licensing Law (The Clayson Report). London , H .M . Stationery Office, 1973. 90. Smart, R.G. & Schmidt, W. Drinking and problems from drinking after a reduction in the minimum drinking age. British journal of addiction, 70: 347-358 (1975). 91. Vuylsteek, K. Health education: smoking, alcoholism, drugs. Copen- hagen , WHO Regional Office for Europe, 1979 (EURO Reports and Studies, No. 10). 92 . Beitel, G.A. et al. Probabi lity of ar rest while driving under the influence of alcohol. Journal of studies on alcohol, 36: I 09 ( 1964). 93. Ozarin, L.D. Existing patterns of services for alcoholism and drug dependence. Copenhagen, WHO Regional Office for Europe , 1973 (unpublished document EURO 5437 IV), p. 74. 94. Blane, H.T. & Hewitt, L.E. Mass media, public education and alcohol, a state-of-the-art review. Report prepared for the National Institute of Alcohol Abuse and Alcoholism. Pittsburgh , PA, University of Pitts- burgh, 1977. 95. Primary health care: report of the International Conference on Primary Health Care, Alma-Ara, USSR. Geneva, World Health Organization , 1978. 96. Edwards, G. et al. Alcoholism: a controlled trial of "treatment" and "advice". Journal of studies on alcohol, 38: I 004-1031 ( 1977). 87 OTHER RELEVANT WHO PUBLICATIONS The influence of alcohol and drugs on driving: report on a WHO ad hoc Technical Group. Copenhagen , WHO Regional Office fo r Europe, 198 1 (EURO Reports and Studies, No. 38) . Changing patterns in mental health care: report on a WHO Working Group. Copenhagen , WHO Regional Office for Europe, 1980 (EURO Reports and Studies, No. 25). Road traffic accident statistics: report on a WHO ad hoc Technical Group . Copenhagen, WHO Regional Office for Europe, 1979 (EURO Reports and Studies, No. 19). Vuylsteek, K. Health education: smoking, alcoholism, drugs. Copenhagen, WHO Regional Office for Europe, 1979 (EURO Reports and Studies, No. IO). Public health aspects of alcohol and drug dependence: report on a WHO Conference . Copenhagen, WHO Regional Office for Europe, 1979 (EURO Reports and Studies , No. 8) . Tuyns, A. A/cool et cancer. Lyon, International Agency fo r Resea rch on Cancer, 1978. Edwards, G. et al., ed. Alcohol-related disabilities. Geneva, World Hea lth Orga niza tio n, 1977 (WHO Offset Publication, No. 32). The epidemiology of road traffic accidents. Copenhagen, WHO Regional Office for Europe, 1976 (WHO Regional Publications , European Series, No. 2) . \\ll\\llll\lll\111111 1111111111111111111111111111 .. 00078538"