Government Options to Reduce the Impact of Alcohol on Human Health: Obstacles to Effective Policy Implementation

Evidence for effective government policies to reduce exposure to alcohol’s carcinogenic and hepatoxic effects has strengthened in recent decades. Policies with the strongest evidence involve reducing the affordability, availability and cultural acceptability of alcohol. However, policies that reduce population consumption compete with powerful commercial vested interests. This paper draws on the Canadian Alcohol Policy Evaluation (CAPE), a formal assessment of effective government action on alcohol across Canadian jurisdictions. It also draws on alcohol policy case studies elsewhere involving attempts to introduce minimum unit pricing and cancer warning labels on alcohol containers. Canadian governments collectively received a failing grade (F) for alcohol policy implementation during the most recent CAPE assessment in 2017. However, had the best practices observed in any one jurisdiction been implemented consistently, Canada would have received an A grade. Resistance to effective alcohol policies is due to (1) lack of public awareness of both need and effectiveness, (2) a lack of government regulatory mechanisms to implement effective policies, (3) alcohol industry lobbying, and (4) a failure from the public health community to promote specific and feasible actions as opposed to general principles, e.g., ‘increased prices’ or ‘reduced affordability’. There is enormous untapped potential in most countries for the implementation of proven strategies to reduce alcohol-related harm. While alcohol policies have weakened in many countries during the COVID-19 pandemic, societies may now also be more accepting of public health-inspired policies with proven effectiveness and potential economic benefits.     

Alcohol consumption and burden of disease in the Americas: implications for alcohol policy.

OBJECTIVES: To describe patterns of alcohol consumption in the Americas, to estimate the burden of disease attributable to alcohol in the year 2000, and to suggest implications for policies to reduce alcohol-related disease burden. METHODS: Two dimensions of alcohol exposure were included in this secondary data analysis: average volume of alcohol consumption and patterns of drinking. There were two main outcome measures: mortality (number of deaths) and disability-adjusted life years (DALYs) lost (number of years of life lost due to premature mortality and disability). Separate estimates were obtained for different sexes, age groups and WHO regions. RESULTS: Despite regional variations, alcohol consumption in the Americas averaged more than 50% higher than worldwide consumption. Patterns of irregular heavy drinking prevailed. Alcohol consumption caused a considerable disease burden: 4.8% of all the deaths and 9.7% of all DALYs lost in the year 2000 were attributable to drinking, with most of the burden occurring outside North America. Intentional and unintentional injuries accounted for 59.8% of all alcohol-related deaths and 38.4% of the alcohol-related disease burden. Of all risk factors compared here, alcohol accounted for the greatest proportion of risk, followed by smoking. CONCLUSIONS: Interventions should be implemented to reduce the high burden of alcohol-related disease in the Americas. Given the epidemiological structure of this burden, injury prevention including, but not restricted to, prevention of traffic injuries, as well as appropriate treatment options, should play an important role in comprehensive plans to reduce the alcohol-related public health burden.     

Evidence-based alcohol policy in the Americas: strengths, weaknesses, and future challenges.

The objectives of this article are to describe the evidence base for alcohol policy in the Americas, to evaluate the extent to which national policies are likely to have an impact on public health, and to identify areas where alcohol policies could be improved. The paper begins with a brief review of epidemiological surveys of the prevalence of alcohol problems in the Americas. This is followed by an analysis of 32 prevention strategies and interventions in terms of the evidence for their effectiveness, amount of research support, cost to implement, and other feasibility issues. Overall, the strategies and interventions with the greatest amount of empirical support are low blood alcohol concentration levels for driving while intoxicated, controls on alcohol availability, age limits on alcohol purchases, and relatively high alcohol prices. The implications of the evidence are next discussed in relation to alcohol policy initiatives in the Americas, based on an analysis of the extent to which strategies and interventions currently used in 25 countries of the Americas are likely to have a public health impact on alcohol-related problems. The countries that have adopted the policies with the highest expected impact overall are Colombia, Costa Rica, Venezuela, and El Salvador. Nevertheless, the analysis indicates that almost all the countries of the Americas could improve the likelihood of preventing alcohol-related problems. Policy efforts in the developing countries of Latin America should focus on improving countermeasures against driving while intoxicated, measures that alter the drinking context, and limits on physical availability. For the developed, high-income countries of North America the goal should be to prevent deterioration of current drinking patterns and to reduce the overall volume of drinking. Given the low to moderate cost of many of the policies reviewed in this article, it now seems possible for communities and nations to substantially reduce the alcohol-related burden of illness in the Americas.     

Factors influencing GPs' decisions regarding screening for high alcohol consumption: a focus group study in Swedish primary care

OBJECTIVE: The aim of this study was to explore factors that influence general practitioners' (GPs') decisions regarding screening for high alcohol consumption. METHODS: GPs working at three primary healthcare centres in Sweden participated in focus group interviews. The interviews were recorded and transcribed verbatim, and a deductive framework approach was used for the analysis. RESULTS: The majority of the participating GPs did not believe in asking all patients about their alcohol consumption. Reported factors that influenced how many and which patients were questioned about alcohol consumption were time, age of the patient, consultation setting, patient-physician relationship, what symptoms the patient presented with, and knowledge of measures if patients appear to have a high alcohol consumption. Thus, alcohol screening and intervention were not performed in all patient groups as was originally intended, but were performed in limited groups of patients such as those with alcohol-related symptoms. CONCLUSIONS: Although the number of participants in this study was small and the conclusions cannot be generalized, the results provide some valuable insights into why GPs are hesitant to engage in screening for high alcohol consumption. Since prevention of alcohol-related health problems is an important public health issue, many different screening and intervention strategies have to be formulated and evaluated in order to reach patients with both hazardous and harmful alcohol consumption within the healthcare system. Screening all consecutive patients for a limited period or screening patient groups known to include a fairly high frequency of high alcohol consumers are two ways of limiting the time requirements and increasing role legitimacy. Still, there is a need for a broader public health strategy involving many players in the community in alcohol preventive measures, especially in more primary preventive approaches.     

The effectiveness of alcohol control policies in Europe

This paper examines the relationship between alcohol control measures, alcohol consumption and selected indicators of alcohol related harm in fifteen countries of Europe and in Israel. A public health perspective on alcohol problems is developed in which alcohol related consequences, both positive and negative, are seen as emerging from the interaction of alcohol itself, the individuals who consume it and the physical and social environment. Consequently, a range of alcohol control and prevention measures is examined, some aimed at the availability of alcohol, other at those who drink alcohol and yet other at the environments in which drinking takes place and problems emerge. A rudimentary scale of alcohol control policy is presented, from which a classification of European countries in terms of alcohol control status is possible. Per capita alcohol consumption and liver cirrhosis mortality data in these countries are examined cross-sectionally and over time. These indicate that cross-sectionally there is, in general, a clear relationship between the alcohol control status of European countries and both per capita alcohol consumption and liver cirrhosis mortality. However, from a time series view there are some interesting exceptions to this general observation. Nonetheless, there is sufficient evidence to suggest that alcohol control and prevention measures are effective at controlling alcohol consumption and preventing the adverse consequences of drinking. Some considerations about alcohol control policy in Europe other than the control of availability are presented.     

Alcohol-related problems and public hospitals: defining a new role in prevention

Application of the public health model of primary prevention to the prevention of alcohol-related problems suggests that public hospitals can be significant partners in community-based prevention efforts. Injury and illness related to alcohol use place a high level of demand on public hospital resources, and their participation in prevention efforts is a promising and underutilized way of reducing this demand. Avenues of participation in prevention include improved data collection and reporting, identification and referral of problem-drinking patients, greater dissemination of data on alcohol-related problems to the general public, liaison with victim assistance groups and community-based alcohol-problem prevention organizations, involvement in public policy regarding alcohol use, and the development of prevention messages from a medical perspective. Implementing some or all of these approaches can be done with little extra cost, through using local government alcohol program staff and resources, integration of alcohol-related problem prevention issues into staff training, liaison with professional educational institutions with expertise on alcohol, networking with alcohol policy organizations, incentives for staff participation in health-related professional organizations giving alcohol policy issues higher priority, and the development of a permanent on-site prevention component.     

A grouped data regression approach to estimating economic and social influences on individual drinking behaviour

General Household Survey (GHS) data sets, covering the period 1978-1990, are pooled to investigate the relationship between the riskiness of individuals' self-reported drinking behaviour and a wide range of personal characteristics and economic factors. A grouped data regression approach is used to reduce problems with the inaccuracy of self-reports of alcohol consumption and clustering of observations in the consumption data. Results for males aged 18 to 24 years are presented, and possible methods for interpreting the results of grouped data regression are illustrated. Controlling for other factors, current smokers are estimated to be at a 75% higher risk of drinking over recommended levels than non-smokers. Particular attention is paid to the interactions between the price of alcohol, income and heavy drinking. At average levels of income, a 5% increase in the real price of alcohol is predicted to reduce the probability of 'at-risk' drinking by 1.5%. At lower initial levels of income, drinking patterns are found to be more responsive to both price and income changes. Grouped data regression is proposed as a way of focusing policy analysis on individual risks of alcohol-related health and social problems.     

Towards a global alcohol policy: alcohol, public health and the role of WHO

In 1983 the World Health Assembly declared alcohol-related problems to be among the world's major health concerns. Since then, alcohol consumption has risen in developing countries, where it takes a heavy toll. Alcohol-related problems are at epidemic levels in the successor states of the Soviet Union and are responsible for 3.5% of disability-adjusted life years (DALYs) lost globally. Substantial evidence exists of the relationship between the levels and patterns of alcohol consumption on the one hand and the incidence of alcohol-related problems on the other. Over the past 20 years, research has demonstrated the effectiveness of public policies involving, for example, taxation and restrictions on alcohol availability, in reducing alcohol-related problems. In the wake of rapid economic globalization, many of these policies at national and subnational levels have been eroded, often with the support of international financial and development organizations. Development agencies and international trade agreements have treated alcohol as a normal commodity, overlooking the adverse consequences of its consumption on productivity and health. WHO is in a strong position to take the lead in developing a global alcohol policy aimed at reducing alcohol-related problems, providing scientific and statistical support, capacity-building, disseminating effective strategies and collaborating with other international organizations. Such leadership can play a significant part in diminishing the health and social problems associated with alcohol use.     

The emergence of the foetus: discourses on foetal alcohol syndrome prevention and compulsory treatment in Finland

The scientific discovery of foetal alcohol syndrome (FAS) in the early 1970s made pregnant women's heavy alcohol consumption problematic. A growing concern over prenatal alcohol intake has made FAS a major public health issue in the developed western countries and led to the proliferation of practices that aim to prevent it. This article provides a Nordic perspective on the existing and largely North American literature on the politics of FAS prevention. This article analyses how the proposal to use the compulsory treatment of pregnant women as an FAS prevention tool emerged and became a disputed political issue in Finland. The analysis is qualitative and the data consists of medical journals and political documents between the end of the 1970s and the 1990s. This article depicts how the foetus was constructed as a subject needing protection and how the prominence of the foetus served as justification for the demands for compulsory measures. This article argues that the strong professional status of the medical advocates of compulsory measures and the position of the foetus as an ‘ideal victim’ gave weight to demands for compulsory treatment. However, it is suggested that the public health approach that characterised Finnish alcohol and welfare policy made the compulsory care of pregnant women a controversial issue. This article concludes that during the study period, the Finnish FAS prevention discourse became increasingly individualised and focused on the foetus.     

Alcohol consumption and alcohol-related mortality in Canada, 1950-2000

OBJECTIVE: To describe trends in overall alcohol consumption and alcohol-related mortality in Canada, and to test regional associations between per capita alcohol consumption and alcohol-related mortality. METHOD: Alcohol sales for 1950-2000 were used to measure total alcohol consumption; alcohol-related mortality consisted of nine different alcohol-related causes of death for 1950-1998. Alcohol consumption and alcohol-related mortality were described for 1950-2000, and measures of dispersion were calculated to assess the homogeneity across regions. FINDINGS: Both alcohol consumption and alcohol-related mortality increased in all regions up to 1975-80 and then underwent a decline until the 1990s. Since 1996, consumption began to increase. Beer represented more than half of the total consumption throughout the study period, although overall, the share of wine increased, particularly in the larger provinces. Over time there have been fewer differences in per capita consumption and alcohol-related mortality rates across the regions. A strong positive cross-regional relationship was observed between explicitly alcohol-related mortality and per capita consumption, whereas cirrhosis showed only a weak geographical association with consumption. CONCLUSIONS: Since 1950, there has been a general trend toward national homogenization, especially with respect to drinking levels but also to alcohol-related mortality. A strikingly close regional relationship between alcohol consumption and alcohol-related mortality suggests that consumption is an important marker of alcohol-related harm in Canada.     

School matters: drinking dimensions and their effects on alcohol-related problems among Ontario secondary school students

AIMS: To test the hypotheses that average volume of alcohol consumption and patterns of drinking, each influence alcohol-related problems and that both act at individual and aggregate levels. METHODS: The 2003 cycle of the Ontario Student Drug Use Survey obtained self-administered questionnaires from a representative classroom-based survey of 2455 Ontario secondary school students (grades 9-12) from 74 schools, with a student completion rate of 72%. Average volume of alcohol consumption was assessed using a quantity-frequency measure. Heavy drinking occasions were operationalized by four dummy variables indicating less than monthly, monthly, weekly and daily consumption of five or more drinks per occasion, with never having a heavy drinking occasion serving as the reference group. Alcohol-related problems were measured by using seven items of the Alcohol Use Disorders Identification Test. RESULTS: As hypothesized, both the average volume of alcohol consumption and patterns of drinking influenced alcohol-related problems at the student level, independently of each other. At the school level, both determinants significantly influenced the problems, but not when simultaneously entered into the equation. CONCLUSIONS: Future prevention of alcohol-related problems in adolescents should consider both the average volume and patterns of drinking. Both prevention and research should also try to include environmental determination of alcohol-related problems.     

WHO Expert Committee on Problems Related to Alcohol Consumption. Second report

The disease burden attributable to alcohol consumption is significant and, in many countries, public health problems caused by harmful use of alcohol represent a substantial health, social and economic burden. Reduction of the alcohol-attributable burden is becoming a priority area for international public health. Alcohol-related harm can be reduced through the implementation of proven alcohol strategies, including at a global level. This report of a WHO Expert Committee reviews the health and social consequences of alcohol consumption and disease burden attributable to alcohol in the context of alcohol-related harm and recent trends in alcohol consumption worldwide. Based on the reviews of available evidence, including the latest data on the contribution of alcohol consumption to the global disease burden, the Committee makes several recommendations emphasizing WHO's role in coordinating a global response, and the need for global action to reduce alcohol-related harm through effective mechanisms of international action and country support. The Committee recommends a range of strategies and policy options that have a sound evidence base and global relevance for reducing alcohol-related harm, emphasizing that their adaptation and implementation at the national and sub-national levels should take into account specific cultural and legal contexts and the local configuration of alcohol problems. The Committee also recommends that WHO should support governments, particularly in low- and middle-income countries, in developing, implementing and evaluating national and sub-national evidence-based policies, action plans and programmes. The Committee's conclusions and recommendations have significant implications for future developments in this area.     

Effects of a School-Based Prevention Program on European Adolescents' Patterns of Alcohol Use

PurposeSchool-based substance abuse prevention programs are widespread but are rarely evaluated in Europe. We aimed to evaluate the effect of a new school-based prevention program against substance use on the frequency of alcohol consumption and alcohol-related problem behaviors among European students.MethodsDuring the school year 2004–2005, a total of 7,079 students aged 12–14 years from 143 schools in seven European countries participated in this cluster randomized controlled trial. Schools were randomly assigned to either control (65 schools, 3,532 students) or to a 12-session standardized program based on the comprehensive social influence model (78 schools, 3,547 students). Alcohol use and frequency of alcohol-related problem behaviors were investigated through a self-completed anonymous questionnaire at baseline and 18 months thereafter. The association between intervention and changes in alcohol-related outcomes was expressed as odds ratio (OR), estimated by multilevel regression model.ResultsThe preventive program was associated with a decreased risk of reporting alcohol-related problems (OR = .78, 95% confidence intervals [CI] = .63–.98), although this reduction was not statistically significant in the subgroup of 743 current drinkers at baseline. The risk for alcohol consumption was not modified by exposure to the program (OR = .93, 95% CI = .79–1.09). In the intervention group, nondrinkers and occasional drinkers at baseline progressed toward frequent drinking less often than in the control group.ConclusionsSchool curricula based on the comprehensive social-influence model can delay progression to frequent drinking and reduce occurrence of alcohol-related behavioral problems in European students. These results, albeit moderate, have potentially useful implications at the population level.     

CO-MORBID DEPRESSION AND DRINKING OUTCOME IN THOSE WITH ALCOHOL DEPENDENCE

Depressed and non-depressed (pre-admission and post-detoxification)alcohol-dependent patients were followed-up on two occasionsover a period of 5 months following detoxification from alcohol.Detailed measures of alcohol consumption, alcohol-related problemsand abstinence status were taken throughout the follow-up period.No significant differences were found between those with a diagnosisof depression and those with alcohol dependence alone, regardlessof whether diagnosis of depression was made post-detoxificationor pre-admission, on any drinking outcome measure includingabstinence status, alcohol consumption, pattern of drinking,or alcohol-related problems. Neither a diagnosis of depressionin the post-detoxification period nor in the pre-admission episodewas related to drinking outcome at follow-up, which suggeststhat co-morbid depression does not confer a worse outcome inthose with alcohol dependence.     

College Students’ Drinking and Posting About Alcohol: Forwarding a Model of Motivations,Behaviors, and Consequences

College drinking continues to remain a public health problem that has been exacerbated by alcohol-related posts on social networking sites (SNSs). Although existing research has linked alcohol consumption, alcohol posts, and adverse consequences to one another, comprehensive explanations for these associations have been largely unexplored. Thus, we reasoned that students’ personal motivations (i.e., espousing an alcohol identity, needing entertainment, and adhering to social norms) influence their behaviors (i.e., alcohol consumption and alcohol-related posting on SNSs), which can lead to alcohol problems. Using structural equation modeling, we analyzed data from 364 undergraduate students and found general support for our model. In particular, espousing an alcohol identity predicted alcohol consumption and alcohol-related SNS posting, needing entertainment predicted alcohol consumption but not alcohol-related SNS posting, and adhering to social norms predicted alcohol-related SNS posting but not alcohol consumption. In turn, alcohol consumption and alcohol-related SNS posting predicted alcohol problems. It is surprising that alcohol-related SNS posting was a stronger predictor of alcohol problems than alcohol consumption. We discuss the findings within their applied applications for college student health.     

The economics of alcohol abuse and alcohol-control policies

Economic research has contributed to the evaluation of alcohol policy through empirical analysis of the effects of alcohol-control measures on alcohol consumption and its consequences. It has also provided an accounting framework for defining and comparing costs and benefits of alcohol consumption and related policy interventions, including excise taxes. The most important finding from the economics literature is that consumers tend to drink less ethanol, and have fewer alcohol-related problems, when alcoholic beverage prices are increased or alcohol availability is restricted. That set of findings is relevant for policy purposes because alcohol abuse imposes large "external" costs on others. Important challenges remain, including developing a better understanding of the effects of drinking on labor-market productivity.     

Differences in licensee, police and public opinions regarding interventions to reduce alcohol-related harm associated with licensed premises

Objectives: To determine the level of support by licensees, police and the general public for interventions to reduce alcohol-related harm associated with licensed premises and to identify differences between the three groups.
Methods: Participants were 108 licensees of premises licensed to sell alcohol; 132 police officers; 200 members of the public. Questionnaires were administered either through work settings or by mail. Respondents' levels of agreement with interventions to reduce alcohol-related harm associated with licensed premises: responsible service of alcohol; security and crowd control; policing; patron transport; and linking of alcohol-related harm to licensed premises and communication.
Results: Police and members of the public were significantly more likely than licensees to agree with strategies under licensee control, such as subsidising patron transport and training staff to deal with intoxicated patrons. Police were more likely than licensees and members of the public to agree with strategies requiring community action and changes to liquor licensing laws. Licensees had significantly lower levels of agreement than the other groups about licensees' responsibility to reduce alcohol-related harm as a consequence of drinking at their premises.
Conclusions: While there was good agreement between police officers and members of the public about strategies for reducing alcohol-related harm at licensed premises, licensees held divergent views about strategies within their control. Licensees were less likely than police and members of the public to agree they were responsible for reducing alcohol-related harm resulting from drinking at their premises.     

Reducing drinking and related harms in college: evaluation of the "A Matter of Degree" program

OBJECTIVES: To examine the effects of a multisite environmental prevention initiative, the "A Matter of Degree" (AMOD) program, on student heavy alcohol consumption and resultant harms at ten colleges. METHODS: A quasi-experimental longitudinal analysis of alcohol consumption and harms was employed, using repeated cross-sectional survey data from the Harvard School of Public Health College Alcohol Study (CAS). Areas examined included seven measures of alcohol consumption, thirteen measures of alcohol-related harms, and eight measures of secondhand effects of alcohol use by others. Comparisons were conducted on self-reported behavior of students for the ten AMOD sites in aggregate and by level of program implementation, with students at 32 comparison colleges in the CAS, for each outcome. RESULTS: No statistically significant change was found in the overall ten-school AMOD program for outcome measures of interest from baseline (1997) to follow-up (2001). However, there was variation in the degree of environmental program development within AMOD during the intervention period. A pattern of statistically significant decreases in alcohol consumption, alcohol-related harms, and secondhand effects was observed, reflecting minor to more substantial changes across measures among students at the five program colleges that most closely implemented the AMOD model of environmental change. No similar pattern was observed for the low implementation sites or at 32 comparison colleges. CONCLUSIONS: While there was no change in the ten AMOD schools in study measures, significant although small improvements in alcohol consumption and related harms at colleges were observed among students at the five AMOD sites that most closely implemented the environmental model. Fidelity to a program model conceptualized around changing alcohol-related policies, marketing, and promotions may reduce college student alcohol consumption and related harms. Further research is needed over the full course of the AMOD program to identify critical intervention components and elucidate pathways by which effects are realized.     

Health for all by the year 2000: alcohol and the Nordic countries

One of the European targets in the "Health for all by the year 2000" programme is to reduce alcohol consumption significantly by the turn of the century. This article describes how this target, and especially the 25% goal included in it, has been adopted in the Nordic countries. With the exception of Denmark, alcohol has for a long time been regarded as a serious public health problem, and the reduction of total consumption of alcohol has been held as one of the most important ways of combating alcohol problems. In the 1980s Sweden and Norway have accepted the European 25% goal with the least reservations. In Finland the target has been regarded as unrealistic. Yet Finland, like Iceland, has accepted the goal of reducing total alcohol consumption but left the amount unspecified. In Denmark, controlling total alcohol consumption has been consistently held to be an irrelevant way to reduce alcohol problems. The alcohol policy measures suggested to reach the targets are the classical ones: price increases, restrictions in alcohol availability, and more efficient information and education. One cannot, however, avoid the observation that very few concrete measures have been taken so far and that many forces work against a reduction in alcohol consumption. The European alcohol target has affected alcohol policy in the Nordic countries in terms of target setting and programme design. It remains to be seen whether the forces advocating more restrictive alcohol control policy will be strong enough to generate concrete action plans and implement the accepted targets in actual alcohol policy measures.     

Alcohol policy impact on young risky drinkers and their support for proposed measures

Objective: To explore the impacts of existing policies on young Australian risky drinkers' access to alcohol and to gauge their support for proposed alcohol measures. Methods: The 16–19 year old participants were recruited from three Australian states using non‐random convenience sampling, for either a face‐to‐face or online quantitative survey (N=958). The sample was deliberately selected to represent drinkers whose consumption placed them in the riskiest drinking 20–25% of their age bracket. Results: Half (49%) the sample who were younger than the Australian legal purchase age reported it was ‘easy’ to buy alcohol from bottle stores, and 75% of those who had tried to purchase alcohol, said it was ‘easy’ the last time they tried. Half of those under 18, who had attempted to enter a licensed venue, reported they did not have their identification checked last time they gained access. Ninety per cent of all respondents drank within a private location at their last risky drinking session. Sixty‐five per cent supported ‘increasing the price of [alcohol by 20¢] a standard drink if the extra 20¢ was used to support prevention and treatment of alcohol problems'. Conclusions: Age‐ or intoxication‐based restrictions to alcohol were commonly bypassed. Implications: Point‐of‐sale alcohol controls require improvement to prevent under age access. Given that a significant proportion of drinking occasions for those under 18 were in private premises, prevention strategies need to target these locations. There were diverse levels of support for strategies to reduce harm, including potential community backing for an evidence‐based proposed price policy.