consumption, drinking patterns, consequences and policy...

:

Consumption, drinking patterns,consequences and policy responses

in European countries

edited by Thor Norström

Stockholm

European Comparative Alcohol Study – ECAS

The project receives financial support from the European Commission (DG V), NationalInstitute of Public Health (Sweden), Swedish Ministry of Health and Social Affairs, andNational Research Centre for Welfare and Health, Stakes (Finland).

Neither the European Commission nor any person acting on its behalf is liable for anyuse made of the following information.

National Institute of Public HealthEuropean Commission

5

. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

by Thor Norström

. Trends in alcohol control policies in the EU member states and Norway, - . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

by Esa Österberg & Thomas Karlsson

. Trends in population drinking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

by Håkan Leifman

. European trends in drinking patterns and their socioeconomic background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

by Jussi Simpura, Thomas Karlsson & Kalervo Leppänen

. The ECAS-survey on drinking patterns and alcohol-related problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

by Örjan Hemström, Håkan Leifman & Mats Ramstedt

. Alcohol-related mortality in European countries in the postwar period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

by Mats Ramstedt

. Mortality and population drinking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

by Thor Norström, Örjan Hemström, Mats Ramstedt,Ingeborg Rossow & Ole-Jörgen Skog

. The contribution of alcohol to socioeconomic differentials in mortality – the case of Sweden . . . . . . . . . . . . . . . . . . . . . . . . . .

by Örjan Hemström

. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. Lessons from the ECAS study: comments and policy implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. Publications from ECAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. Participants of ECAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Contents

thor norström 7

ECAS – AIM AND SCOPE

The European Comparative Alcohol Study (ECAS) concerns, in very broadterms, alcohol policies, alcohol consumption, and alcohol-related harmwithin a comparative and longitudinal approach. The focus is on the timeperiod 1950-1995 in the member states of the European Union as of 1998.However, Luxembourg was not included for methodological reasons, whileNorway has been added to the set of study countries to broaden the repre-sentation of Northern Europe. The project was granted funding by theEuropean Commission, DG V/F in August 1998, and was completed in thesummer of 2001.

The project is structured into four interrelated but yet distinct areas:1. Analyses of alcohol control policies. These analyses comprise: a) a system-

atic description of different methods used to prevent alcohol-related harm,including price and tax policy, physical availability, licensing policy, adver-tisement regulations, and education and information; b) regulations andenforcement practises of public drinking, including drunk driving, on-licence outlets, and custody of drunk persons; c) the administrative structureof preventive policies and treatment; d) the feasibility of preventive policies,including an analysis of public opinion, pressure groups, and the effects ofinternationalisation and cross-border trade.

Introduction by Thor Norström

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2. Analyses of trends in overall consumption. This work is based on sales datafor alcohol beverages. Econometric analyses of price and income elasticitiesare performed in this context, and a natural continuation is to explore theextent to which variations in economic factors across time and countries canaccount for the variation in consumption. The issue of unregistered con-sumption is addressed as well.

3. Analyses of drinking patterns. Country specific studies were reviewed toassess trends in drinking patterns. This information was supplemented witha compilation of data on changes in living conditions, since drinking pat-terns reflect overall changes in culture and patterns of life. In the year 2000,a six-country survey on drinking patterns and some other alcohol-relatedissues was conducted to fill the gaps revealed in existing databases. The issuesaddressed by the survey include abstinence rates, frequency of drinking,binge drinking, age- and gender-differences in drinking, and contexts ofdrinking.

4. Analyses of alcohol-related harm. The only indicators that meet reason-able standards of comparability are mortality data, although these are farfrom unproblematic. The core list includes causes of death where alcohol isan established risk factor: alcohol poisoning, alcoholism, alcohol psychosis,liver cirrhosis, accidents, suicide, and homicide. A description of country dif-ferences and time trends in alcohol-related mortality is a first basic task inthis work. The next task is to see how changes in per capita alcohol con-sumption are related to changes in mortality.

5. Policy implications of the findings. What are the implications of thefindings for co-ordinated alcohol policies within the EU?

ORGANISATION OF THE RESEARCH

Researchers situated in Helsinki, Stockholm and Oslo have carried out theproject. In addition, the project had a support staff at the Swedish Instituteof Public Health, and collaborating partners from each of the study coun-tries. There was a certain division of labour, so that the Finnish researchersaddressed topics related to alcohol policies, drinking patterns, and demandanalyses. Issues related to consumption trends and alcohol-related harmwere treated by the Norwegian and Swedish researchers. Thor Norström wasProject Director, and Jussi Simpura deputy Project Director.

OUTLINE OF THE REPORT

The output from the project (as of June 2001) is summarised in the presentreport, following the structure outlined above. Four chapters thus focus oncountry differences and postwar trends in the following aspects: alcohol con-

thor norström 9

trol policies (Ch. 2), aggregate consumption (Ch. 3), drinking patterns (Ch.4), and alcohol-related mortality (Ch. 6). The topic of drinking patterns isalso treated in Chapter 5 that reports recent survey data. Chapter 7 address-es the link between mortality and population drinking, and Chapter 8 inves-tigates the role of alcohol in socioeconomic differences in mortality. Chapter9 includes the major conclusions of these chapters, while Chapter 10 spellsout the policy implications.

esa österberg & thomas karlsson 11

INTRODUCTION

In this chapter we are summarising our findings on the similarities and dif-ferences as well as on trends in alcohol policies in the second half of thetwentieth century in the current member states of the European Union (EU)and Norway with the exception of Luxembourg, hereafter called the ECAScountries.

According to the project plan of the European Comparative Alcohol Study(ECAS) the analysis of alcohol policies includes a systematic description ofdifferent methods used to prevent alcohol-related harm, including price andtax policy, physical availability, licensing policy, advertisement regulations,and education and information. Furthermore, the description of alcoholpolicies also includes regulations and enforcement practices of public drink-ing, including drunk driving, on-licence outlets and custody of drunk per-sons as well as a description of the administrative structure of alcohol poli-cies and treatment (Agreement SOC F (CVVF--)).

The definition and scope of alcohol policies and alcohol control policies

In the monograph Alcohol Control Policies in Public Health Perspective(Bruun et al., ) the term alcohol control policies referred ‘‘to the legal,economic and physical factors, which bear on the availability of alcohol to

Alcohol policies in the ECAScountries, 1950–2000by Esa Österberg & Thomas Karlsson

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the individual’’ (Bruun et al., , ; see also Lehto, , ). Consequently,alcohol control policies referred to all strategies and measures employed bygovernments or local administrative authorities to influence alcohol avail-ability no matter of the explicit or implicit motives for these activities.

The definition of alcohol control policies in Bruun et al. () is narrowinsofar that it makes no reference to informal social alcohol control. Strictlytaken, alcohol control policies do not even include alcohol information oreducation targeted to individuals or groups of individuals trying to affecttheir values and attitudes and, ultimately, the demand of alcoholic beverages.Logically then, advertisement or sponsorship of alcoholic beverages and thecontrol of these activities also fall outside alcohol control policies.

In the monograph Alcohol Policy and the Public Good (published in ),Edwards and his colleagues did not explicitly define the exact meaning of theterm alcohol policy. In this monograph, however, they considered alcoholpolicy as a public health response to the burden inflicted by alcohol to soci-ety. Alcohol control measures where then defined as public health responsesto alcohol-related problems dictated in part by national and historical cir-cumstances and beliefs of the fundamental nature of target issues and theefficacy of possible control strategies and measures (Edwards et al., , ).Consequently, alcohol policy included alcohol taxation, legislative controls ofalcohol availability, alcohol education and information, measures affectingdrinking within particular contexts and measures affecting directly certainalcohol-related problems like drunken driving.

The indirect definition of alcohol policy in Edwards et al. () is broad-er than the definition of alcohol control policies in Bruun et al. (). InEdwards et al., () alcohol policy still consisted only of authoritative deci-sions by governments through laws, rules and regulations, and actionsthrough legislators, judges and other public officials. Consequently, informalsocial alcohol control or decisions and actions by private alcohol industry,public interest groups or non-governmental organisations affecting alcohol-related problems fall outside alcohol policy even if also these activities clear-ly affect alcohol consumption and related problems. Furthermore, defined aspublic health response to alcohol-related problems, alcohol policy does orshould not include measures affecting alcohol production, trade or con-sumption with other aims than improving public health (see howeverEdwards et al., , -).

Alcohol issues, even if not always recognised or labelled as alcohol issues,are dealt with by all modern states, and there is a wide horizontal and verti-cal dispersion in handling them (Room, ). The state has also several dif-ferent tasks and interests with respect to alcoholic beverages as for instance


the fiscal interest, economic development interest, the interest of maintain-ing public order and safety and the interest in maintaining the reproductionand health of the population or working force (Mäkelä & Viikari, ).These interests with respect to alcohol are often split between different gov-ernment departments and levels. For instance, in the report Alcohol Policy inthe United Kingdom (), government departments were identified withsome interest in the production, distribution or sale of alcohol or the prob-lems resulting from alcohol consumption.

Alcohol is a causal factor, usually in association with other factors, in awide variety of social and health problems. This conditional nature of manyalcohol-related problems means that there is a wide scope both for labellingmany problems as alcohol-related problems, which Room calls probleminflation, or to ignore the association with alcohol and stress the causalitywith some other factor or factors leading to problem deflation from the alco-hol point of view (Room, ). As Room () shows, the term alcohol pol-icy or alcohol control only makes sense in cultural situations where peopleare noticing and emphasising the alcohol dimension in a broad range ofsocial and health problems. Consequently, in societies where the alcoholdimension is not noticed or emphasised the term alcohol policy or alcoholcontrol does not have any real meaning.

According to Room () the term alcohol policy came into English fairlyrecently, more or less as an import from the Nordic languages. In English theolder term for what now would be called alcohol policy or alcohol controlpolicy was the liquor question or the social liquor question, a term derivedfrom temperance-movement terminology. After the reaction against the ideaof prohibition in the s especially in the United States the alcohol-specif-ic state agencies or regulations have in the north America been known asalcoholic beverage control (ABC) systems (Room, ; Österberg, ).

When reading the alcohol literature it is quite easy to note that the prac-tice of using the terms alcohol policy and alcohol control policy is not veryconsistent or coherent overall, even within certain organisations or even incertain reports (see e.g. Harkin et al., ; Lehto, ; Rehn et al., ;Edwards et al., , Fahrenkrug, ; Vingilis et al., ). Also the ECASproject plan includes some instability as it uses these terms as synonyms foreach other. Despite these terminological problems, it is very clear that theECAS project plan is built on an inherent view on alcohol policy similar tothe study by Edwards et al. ().

When referring to government measures as responses to alcohol-relatedproblems we prefer in this chapter to use the term preventive alcohol policy,because, following Bruun et al. (), we will clearly include in the term

14

alcohol policy all government measures targeted to alcohol availability andto alcohol demand, no matter the motives behind these measures. Therefore,alcohol policy in this chapter includes also subsidising alcohol industries andtrade, as well as government’s efforts to decrease or increase the demand foralcoholic beverages or the licensing of alcohol production and trade, irre-spective of whether the licensing is motivated by social policy and publichealth aims or industrial and commercial interests of the state. In practice itis not very easy to follow this distinction, as it is quite often very difficult toprove the real motives behind certain alcohol policy moves.

In the following we are also using the term alcohol control policy as distinctfrom alcohol policy. As pointed out above, the definition of alcohol controlpolicies in Bruun et al. () included only those alcohol control measurestargeted to alcohol availability or supply, whereas alcohol policy also includesmeasures targeted to alcohol demand, as well as measures targeted directly tocertain alcohol-related problems like drunken driving. This distinction maysound purely academic, but it has practical importance, especially in situa-tions where different alcohol control measures are not developing in thesame direction, where for instance measures directed to alcohol supply arebecoming fewer or weaker at the same time as alcohol control measures tar-geted to alcohol demand or directly to alcohol-related problems are becom-ing more common or stronger.

THE COMPREHENSIVENESS AND STRICTNESS OF ALCOHOL

POLICIES IN 1950

In the early s alcohol policies and especially alcohol control policies werevery different in the ECAS countries (Figure .). In the Nordic countries thephysical availability of alcoholic beverages was strictly controlled. In thesecountries alcoholic beverages were also very heavily taxed. In some Medi-terranean countries there were hardly any alcohol policy measures in force,and also special taxes on alcoholic beverages were very low in comparison tothe Nordic countries. Furthermore, those alcohol policy measures that couldbe found in the Mediterranean countries were for the most motivated byindustrial and trade interests of the state (Österberg & Karlsson, ).

In earlier attempts to use quantitative scales to measure the strictness ofpreventive alcohol policies, the next step after summing up the scale pointshas usually been to classify the countries in high, medium or low alcoholcontrol countries (see e.g. Davies & Walsh, ). It is always somewhat arbi-trary to set the dividing lines between countries with high, medium or lowalcohol control. However, if we follow this kind of procedure we notice, notsurprisingly, that in the early s the Nordic countries, Denmark excluded,


would be classified as countries having a high alcohol control (see Karlsson& Österberg, ).

Defining the three Nordic countries in the ECAS project as high alcoholcontrol countries in the s certainly reflects the reality, as these countriesat that time had a comprehensive alcohol monopoly system including statemonopolies on the production, imports, exports, wholesale and off-premiseretail sales of alcoholic beverages (Österberg & Karlsson, ). Furthermore,these countries also controlled on-premise retail sales of alcoholic beveragesvery strictly by a licensing system, and practised very tight individual alcoholcontrol, too. In Sweden, for instance, the Bratt rationing system was still inforce, meaning that each individual wishing to buy alcoholic beverages offpremises needed a special rationing book in which purchases were recorded.Each person had the right to buy only a certain amount of distilled spirits permonth. The allocation for an unmarried woman was less than for an adultmale, and married women were not given any allocations at all, because theywere expected to share their husbands’ allocation, usually four litres of dis-tilled spirits per month (Holder et al., , ). In Finland females, were notallowed to enter restaurants either alone or as a female group, and males hadto wear suit and tie. Further, only a certain share of a restaurant’s turnovercould consist of alcohol sales, leading to the situation where patrons had toorder food after drinking a certain amount of alcoholic beverages in order tobe able to continue drinking. Also the age limits for purchasing alcoholicbeverages were higher in the Nordic countries than they are today.

Countries classified as having medium alcohol control in the s would

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Figure .. The comprehensiveness and strictness of alcohol policies in the ECAS coun-tries, 1 (maximum points).

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include the United Kingdom, Ireland, Italy, the Netherlands and Belgium,but also Germany, Denmark and Austria could be classified in this group(Figure .). If the level of special taxes on alcoholic beverages would beincluded in this comparison, Denmark would certainly be in parity with theUnited Kingdom and Ireland. The basic reason that these countries would beclassified as having a level of medium alcohol control is their licensing sys-tems and special restrictions on off- and on-premise sales of alcoholic bev-erages. Especially in the Anglo-Saxon countries, these kind of restrictions onon-premise retailing were very detailed, and they were effectively enforced.But also in Belgium and the Netherlands there were still remnants of formertight alcohol control measures in force, even if they were not enforced verystrictly (Österberg & Karlsson, ). In the s in Belgium, for instance,distilled spirits were not served in restaurants, and if one wished to buy dis-tilled spirits for consumption off premise the minimum volume was twolitres according to the law (Österberg & Karlsson, ).

The remaining four countries, Greece, Portugal, France and Spain, woulddefinitely be classified as having low alcohol policy control in the s. It isagain perhaps no surprise that all Mediterranean wine producing and wineconsuming ECAS countries with the exception of Italy fall within this lowalcohol control group.

THE COMPREHENSIVENESS AND STRICTNESS OF ALCOHOL

POLICIES IN 2000

In the s the classification of ECAS countries according to the compre-hensiveness and strictness of alcohol policies almost followed the classifica-tion of countries on the basis of beverage preferences (Bruun et al., , ).All high alcohol control countries were spirits countries. Most medium alco-hol control countries were beer countries. The two exceptions were Italy, awine country, and the Netherlands, which at that time was classified as a spir-its country. All low alcohol control countries were wine countries. Whenlooking at the situation in the year , the classification of the ECAS coun-tries according to the preferred beverage category and the comprehensive-ness and strictness of alcohol policies do not anymore coincide (Figure .).Also the classification of countries into beer, wine and spirits countries haslost much of its meaning, as all the former ECAS spirits countries hadalready by the s changed to beer countries (Leifman, ).

In the year the three Nordic alcohol monopoly countries still formedthe core of the high alcohol control group, despite the fact that in the mid-s then had abandoned all their former state alcohol monopolies exceptthe off-premise retail monopolies. Furthermore, nowadays it is even a little


difficult to call these state-owned retail networks monopolies, because inFinland, Norway and Sweden off-premise retail sale of beer – though in vary-ing degrees – is not any longer a state monopoly (see e.g. Holder et al., ).As a consequence, these off-premise retail alcohol monopolies do not sell allalcoholic beverages retailed off premise.

According to the scale points in the year , the ECAS countries areclearly much more similar with respect to their alcohol policies than theywere in the early s. Nowadays the United Kingdom, the Netherlands,Italy and Ireland could be classified as either high or medium alcohol controlcountries. Classifying especially the United Kingdom and Ireland as highrather than medium alcohol control countries could be justified by their levelof alcohol excise taxes, which in these countries are clearly higher than theEU average (Table .). These countries, as well as the Netherlands also havea quite strict licensing system for retail sales of alcoholic beverages, and inthese countries these controls are motivated by social and health considera-tions.

The dividing line between medium and low alcohol control countries isalso somewhat arbitrary. In Figure . one possibility would be to use ninepoints as the dividing line, meaning that Austria, Greece, Denmark, Germanyand Portugal would belong to countries with low alcohol control, and at leastSpain, Belgium and France would be classified as medium alcohol controlcountries. It is easy to note that low alcohol control countries - even if thedividing line would be put lower or higher than at nine points – is not a veryhomogenous group of countries. They are not Mediterranean countries or

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Figure .. The comprehensiveness and strictness of alcohol policies in the ECAS countri-es, (maximum points).

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wine countries, nor are they central European countries or beer countries.Furthermore, Denmark, belonging in the year according to the ECASscale to low alcohol control countries, has quite high excise taxes on alcoholicbeverages (Table .).

Table .. Excise taxes on alcoholic beverages in the ECAS countries according to beveragecategories in July , euro per litre pure alcohol.

Country Distilled spirits Intermediate products Wine Beer

Austria 10.03 4.04 0.00 5.21Belgium 16.61 5.51 4.28 4.28Denmark 36.99 7.88 8.62 9.30Finland 50.46 39.24 21.41 28.59France 14.50 11.86 0.30 2.59Germany 13.04 8.52 0.00 1.97Greece 9.45 2.60 0.00 2.92Ireland 27.62 22.01 24.82 19.87Italy 6.45 2.75 0.00 3.50Netherlands 15.04 4.71 4.43 4.26Norway 85.36 44.26 44.26 44.26Portugal 8.14 2.63 0.00 2.81Spain 6.85 2.55 0.00 1.68Sweden 57.35 28.70 28.28 16.81United Kingdom 30.10 17.59 21.59 18.30

Sources: European Confederation of Spirits Producers (CEPS). Calculations are based on the following alcoholcontents for beer, wine and intermediate products: beer 5% alcohol by volume, wine 11% alcohol by volume,intermediate products 18% alcohol by volume.

The first conclusion, therefore, is that according to the scale approachthere is nowadays less difference in alcohol policies among the ECAS coun-tries than there were in the early s. One could argue that alcohol policieshave converged among the ECAS countries during the last fifty years.However, this convergence is not only the outcome of diminishing differ-ences between the ECAS countries. As Figures and show some countrieshave changed their relative position quite much in terms of the comprehen-siveness and strictness of alcohol policies. For instance, Spain and Francehave moved upwards, and Austria and Germany have moved downwardsamong the ECAS countries (see also Appendix ).

THE RELEVANCE OF THE ECAS SCALE

Before continuing the analysis of the converging trend revealed by the ECASscale we should, however, take a critical look on the whole scale approach.After all, it is possible that the construction of the ECAS scale has weakness-es, which could have led to spurious results.


One problem with this kind of scale is that in practice it cannot include allalcohol policy measures linked to alcohol availability or to the demand foralcoholic beverages, not to mention measures that target various alcohol-related problems directly (Karlsson & Österberg, ). To cover all possiblealcohol control measure, one could try to devise a very detailed scale, includ-ing up to, say, or more different policy options. In principle, this kind ofscale could be useful in measuring the comprehensiveness of alcohol policies,but in practice it would be very laborious to collect the data for all items,with the risk of not obtaining all relevant data. And as Edwards et al. ()state, the list of potential alcohol control measures is extensive, and theirrange and inventiveness is continually expanding (Edwards et al., , ).

This brings us to another issue, namely how to weight different alcoholcontrol measures in order to measure the strictness of alcohol policies, or forthat matter, the strictness of preventive alcohol policies. In previous studies,all policy measures were usually given the same weight (Karlsson & Öster-berg, ). Another possibility would be to give different alcohol policymeasures different weights according to their relative importance. It is forinstance, clear that monopolising the off-premise retail sales of alcoholicbeverages is a much more powerful alcohol control measure than banningsales of alcoholic beverages in hamburger restaurants.

Another built-in flaw in all scales is that they do not take into considera-tion how effectively different laws and policy measures are enforced.Consequently, there may be a law banning the off-premise retail sales of alco-holic beverages to youngsters less than years of age. If this law is not effi-ciently enforced, it may have less effects on alcohol availability than an effec-tively enforced law banning alcohol sales to persons younger than years ofage. Anderson & Lehto () made an attempt to cover this aspect by addingto their scale two questions concerning the enforcement of alcohol control.These kinds of questions have, however, the drawback that without realresearch findings they are highly speculative and the scores given themdepend a lot on the subjective interpretation of the informant or theresearcher.

In constructing the scales and in interpreting the results, one also fre-quently runs into problems caused by identical or similar kinds of alcoholpolicy measures with totally different aims or motives hidden or open. Forinstance, in the Nordic countries there are many people who genuinely donot believe that the high alcohol taxes in these countries are there because oftheir preventive effects on alcohol-related problems. They rather believe thatalcoholic beverages are highly taxed only because the state has an interest tocollect more revenues through alcohol taxation. According this view, official-

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ly expressed social policy or public health motives for high alcohol taxes areonly trying to hide the true motives for high alcohol taxation.

Licensing is an issue where the motives are often more clearly and openlydeclared. Here the problem is whether we should give the same points for alicensing system officially motivated by public health or social policy consid-erations as we give to a licensing system officially motivated by industrial oreconomic development aims. In principal this distinction could be made, butwith respect to many alcohol policy measures we just do not know what thebasic motivation is because quite often there are many different motivesbehind one measure, and in many cases motives are not expressed at all.

One further problem with the scales is that they measure alcohol policiesonly on the national level. In some countries, like Belgium or Austria, thereare considerable variations in alcohol control measures between differentregions (cf. e.g., Österberg & Karlsson, ). What makes this problematic isthat when certain alcohol policy measures only exist in some parts of thecountry, one has to decide what is representative for the whole country. Thealcohol regulations and laws in a single “Land’’ (region) in Austria wouldhardly be representative for the country as a whole and vice versa.

In the ECAS project, we have tried to mitigate the problems connectedwith the scale approach by producing comprehensive country reports aboutalcohol policies in the ECAS countries during the period -, usingboth written sources and informants (Österberg & Karlsson, ). Whencomparing the scale points in Figure . and . to these country reports, oneusually gets the same impression of the relative comprehensiveness andstrictness of alcohol control in the various ECAS countries. Italy, however,ranks higher in Figure . (and also in Figure .) than one could expect onthe basis of the country report. The most immediate explanation of this isthe Italian licence requirements, special restrictions on off- and on-premiseretail sales, as well as age limits. These formal restrictions are importantenough to score relatively high on the ECAS scale even if these restrictionshave not been effectively enforced. On the other hand, however, when read-ing the Italian country report one cannot avoid the feeling that somethingvery special is and has been going on in Italy with respect to alcohol control(Allamani et al., ). A kind of semi-official informal social alcohol controlmay in fact partly explain the comparable low level of per capita alcohol con-sumption in Italy amongst the ECAS countries. But it is still definitely truethat despite the relatively high scoring on the ECAS scale, Italy does not havea strict formal alcohol control like the Nordic counties. In other words, theECAS scale seems to give too much weight to the formal alcohol controlmeasures found in Italy compared with other countries but – with all its


weaknesses – the whole scale approach may still capture some elements ofthe whole picture of alcohol control which it formally should not capture atall. In contrast, Denmark has a lower position both in Figure . and Figure. than it should have in reality, because the ECAS scale does not includeexcise taxes on alcoholic beverages. In Denmark alcohol excise taxes havebeen, and still are, clearly higher than in low alcohol control countries andalso in most medium alcohol-control countries, however defined. One rea-son for the inconsistency between the scale score and the country report isthat at the beginning of the twentieth century Denmark consciously chose apolicy of high alcohol taxes as an alternative to physical restrictions on alco-hol availability (Thorsen et al., ).

TRENDS IN DIFFERENT AREAS OF ALCOHOL POLICIES

Figure . shows the strictness of alcohol policies in the ECAS countries mea-sured by the ECAS scale according to the subgroups of alcohol policies bothin the year and . The two areas which get lower points in the year than fifty years earlier are the control of production and wholesale andthe control of distribution (Figure .).

In all other alcohol control areas, the scores are higher the year than. This leads to our second conclusion, namely that the changes in differ-ent areas of alcohol policy have been very different in the ECAS countriesduring the last fifty years. The convergence which could be found when look-ing at the developments of alcohol control in different ECAS countries seemsto be composed of at least two different trends. First, there has been adecrease in the strictness of alcohol control measures in areas which fallinside alcohol control policies. In other words, the control of alcohol avail-

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Figure .. The strictness of alcohol policies in the ECAS countries according to sub-groups of alcohol control, and .

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ability or the control of the supply side of the alcohol equation has decreased.On the other hand, alcohol control measures seem nowadays to be morecomprehensive and stricter with respect to measures aiming to affect thedemand for alcoholic beverages and trying to control certain alcohol-relatedproblems directly.

Control of production, wholesale and distribution

As table . shows that the control of the production and wholesale of alco-holic beverages has decreased especially in the s, in fact especially in theyears and , when Finland, Norway and Sweden, in connection withthe European Economic Area (EEA) Agreement and the Finnish and Swedishmemberships in the EU, were forced to give up their comprehensive alcoholmonopoly systems by abolishing state alcohol monopolies on alcohol pro-duction, imports, exports and wholesale (see Holder et al., ).

Table .. The strictness of alcohol policies in the ECAS countries according to subgroupsof alcohol control, to

Subgroup 1950 1960 1970 1980 1990 2000

Control of production and wholesale (3 p.)* 1.2 1.3 1.3 1.3 1.3 0.9Control of distribution (7 p.) 2.9 3.0 3.0 2.8 2.9 2.8Personal control (3 p.) 1.3 1.5 1.4 1.7 1.8 1.8Control of marketing (2 p.) 0.3 0.4 0.8 1.3 1.7 1.7Social and environmental control (3 p.) 0.6 0.9 1.2 2.0 2.3 2.7Public policy (2 p.) 0.5 0.7 1.0 1.1 1.4 1.5

* Maximum number of points for each subgroup in brackets

At present, only Norway has a production monopoly, and that is for dis-tilled spirits only (Table .). In addition to the three Nordic ECAS countries,Austria also had a monopoly regulating the spirits production until ,thereby effectively protecting domestic agrarian spirits production(Eisenbach-Stangl et al., ). Even today in Germany, raw alcohol pro-duced from potatoes or molasses has to be delivered to the FederalMonopoly Administration of Spirits, and spirits made from grain have to bedelivered to the German Utilisation Unit of Corn Spirit (Fahrenkrug, ;Kümmler et al., ).

Table . shows that in almost all ECAS countries producers or wholesalersfor beer, wine and distilled spirits need a licence. In many or even in mostECAS countries the licensing of alcohol production and wholesale has noth-ing to do with public health or social policy matters. Even in the Nordic


countries the granting of production and wholesale licenses is nowadaysdetermined only by legal considerations. In other words, every applicant ful-filling the legal requirements will get the license, without any special preven-tive alcohol policy considerations. The most important task of licensing is tokeep track of the actors in the alcohol field and to secure the payment ofalcohol excise taxes and value-added taxes (Österberg & Karlsson, ).

In some countries the cost of applying for or a getting production orwholesale licence may be seen as one way to collect tax money for the state,but in most cases the dues for licences, if any, are there only to cover the costsof the control functions. Also the fees for getting licenses have been decreasedin the Nordic countries since the (Holder et al., ). During themonopoly era there were no licensing fees in the Nordic countries.

Table .. Control of production and wholesale of alcoholic beverages in the ECAS coun-tries in the year

Country State Monopoly Licence No licence

Austria B, W, SBelgium B, W, SDenmark B, W, SFinland B, W, SFrance B, W, SGermany B, W, SGreece B, W, SIreland B, W, SItaly B, W, SNetherlands B, W, SNorway S B, W. SPortugal B, W, SSpain B, W, SSweden B, W, SUnited Kingdom B, W, S

(B = Beer, W = Wine, S = Spirits )

According to the ECAS scale, changes in control of the distribution ofalcoholic beverages are clearly smaller than in the control of production andwholesale (Figure .). This is partly stemming from the fact the three NordicECAS countries were able to keep their off-premise retail sales monopoliesfor most alcoholic beverages (Table .). As with the granting of the produc-tion and wholesale licenses also the granting of licenses, for off- and on-premise retailing is nowadays purely a legal matter, not an alcohol controlpolicy matter, with the exception of distilled spirits, intermediate products,wine and part of beer in the three Nordic ECAS countries.

24

In Finland, Norway and Sweden, state alcohol off-premise retail compa-nies still have a monopoly on all distilled spirits, all fortified wines and otherintermediate products, almost all wine and all strong beer. In Norway, beerswith an alcohol content over .% by volume are defined as strong beer, inFinland the limit is .%, and in Sweden all beers with an alcohol contentover .% fall into the category to be sold only in state monopoly’s liquorstores. In Finland, beers containing at most .% alcohol by volume and lightwines or wine-based drinks with an alcohol content at most .% are treat-ed equally, i.e., they both can be sold in ordinary grocery shops, which is notthe case for beverages of similar strength that contain distilled alcohol.

Table .. Control of off-premise retail sales of alcoholic beverages in the ECAS countriesin the year


Austria B, W, SBelgium B, W, SDenmark B, W, S Finland W, S BFrance B, W, SGermany B, W, SGreece B, W, SIreland B, W, SItaly B, W, SNetherlands B, W, SNorway W, S BPortugal B, W, SSpain B, W, SSweden W, S BUnited Kingdom B, W, S


State monopoly arrangements do not include on-premises sales of alco-holic beverages in any ECAS country (Table .). Also in the Nordic coun-tries for the last fifty years almost all restaurant have been privately owned.Until the mid-s, however, alcohol policy matters were crucial or at leastimportant in licensing policy (cf. e.g., Österberg, , -; Holder et al.,).

In addition to licensing arrangements, there are many other ways in whichgovernments seek to affect the retail sales of alcoholic beverages. Control ofdistribution includes many restrictions on off- and on-premise retailing, e.g.,special restrictions on days and hours and places for selling alcoholic bever-


ages; regulations concerning what types of shops, restaurants or surround-ings where alcoholic beverages are not allowed to be sold; upper limits for thenumber of shops or restaurants allowed to sell alcoholic beverages; rules forhow much or little a customer can purchase of alcoholic beverages; or regu-lations concerning in what kind of containers alcoholic beverages can be

Table .. Control of on-premise retail sales of alcoholic beverages in the ECAS countries in

the year


Austria B, W, SBelgium B, W, SDenmark B, W, SFinland B, W, SFrance B, W, SGermany B, W, SGreece B, W, SIreland B, W, SItaly B, W, SNetherlands B, W, SNorway B, W, SPortugal B, W, SSpain B, W, SSweden B, W, SUnited Kingdom B, W, S


sold. Many times these kinds of regulations are quite detailed. In Italy, forinstance, it is prohibited to sell alcoholic beverages containing more than% alcohol by volume from p.m. to a.m. on premises built along high-ways. In France, as in many other ECAS countries, it is forbidden to sell alco-hol from vending machines. In the s the minimum amount of distilledspirits one could buy was two litres. At the same time, in Finland a customercould buy at most two litres of distilled spirits. In the Netherlands, alcoholpolicy in the s was based on restrictions on the numbers of outlets perinhabitant. In Denmark, beer is not allowed to be sold in cans (Österberg &Karlsson, ).

As shown above, government restrictions on retail sales vary greatlyamong the ECAS countries, but generally speaking they have rather been los-ing than gaining ground during the last five decades. In many countries thenumber of opening days and hours of sales are greater nowadays than in theearly s. Especially in the Nordic countries, the number of opening days

26

and sales hours has grown immensely. In Finland, for instance, alcoholic bev-erages can nowadays be bought off-premise six days a week in the monopolyshops, and beverages containing at most .% alcohol by volume also onSundays (in grocery stores as well as in petrol stations and kiosks). Also thenumber of special days when the monopoly shops are closed has diminishedmarkedly. Similarly, the opening hours have increased greatly (Holder et al.,). It is nowadays also difficult to find rules regulating the volume of alco-hol purchases, or drinking behaviour in restaurants which used to be verycommon, especially in the Nordic countries. Also the system regulating on-premise sales in Ireland and the United Kingdom has been loosened throughthe years.

However, some countries have also restricted alcohol availability by ban-ning it from petrol stations or canteens at work places, as is the case in Italyand France. In the Netherlands, a ban on selling alcoholic beverages in non-food stores and petrol stations was introduced in autumn . Also footballhooliganism has contributed to some restrictions in alcohol availability insports stadiums and their surroundings. This is the case, for instance, inGermany, where serving of alcoholic beverages can be forbidden completelyor partly for certain time periods or places, if this is necessary to maintainpublic order. This regulation has been applied mostly at soccer games or con-certs. In the Netherlands an authorisation of the Ministry of Health to banalcohol sales at soccer stadiums, schools, swimming pools, hospitals etc. wasgiven in the year .

In this context it is also important to note that in some countries there areno special restrictions on alcohol retail sales as such, but the general rulesconcerning off- and on-premise sales regulate also the availability of alco-holic beverages. In fact, in some countries the closing hours for restaurantsmay in practice be stricter without any alcohol control measures than incountries where the drinking of alcohol in restaurants is controlled by stateregulations. This is difficult to show, as in countries without any restrictionson selling hours for alcoholic beverages, there most certainly exist placeswhere alcohol can be purchased for those off-premise around midnight. Butfor a traveller, for instance, with no special knowledge of the local customsand conditions, it may be quite difficult to obtain alcoholic beverages for useoff-premise even at p.m., or on-premise at p.m., in countries with no legalrestraints as compared, for instance with the three Nordic ECAS countries.

Personal control

In the year the average score for personal control in the ECAS countrieswas ., as compared with . in (Figure .). In the ECAS scale person-


al control was measured by the legal minimum age for buying alcoholic bev-erages off and on premise. In practice, this increase means that during thelast fifty years some ECAS countries with no age limits in the s havebegun to practise legal age limits for buying alcoholic beverages, and in someECAS countries these limits have been raised. During these years, forinstance, Denmark has given up the policy of no age limit at all in off-premise retail sales, by introducing the age limit of years in . Legal agelimits were also introduced in France gradually between and .Countries that practice stricter age limits in than in includeFrance, Germany, Portugal and Spain. The total change in this respect is evengreater than the ECAS scale average shows, as Finland and Sweden have infact lowered their age limits during the study period (Österberg & Karlsson,).

Table .. Age limits for off- and on- premise sales of alcoholic beverages in the ECAScountries in the year

Country Off-premise On-premiseBeer Wine Spirits Beer Wine Spirits

Austria 1 16 16 18 16 16 18Belgium 2 - - 18 16 16 18Denmark 15 15 15 18 18 18Finland 18 18 20 18 18 18France 3 16 16 16 16 16 16Germany 16 16 18 16 16 18Greece - - 18 - - 18Ireland 18 18 18 18 18 18Italy 3 16 16 16 16 16 16Netherlands 16 16 18 16 16 18Norway 18 18 20 18 18 20Portugal - - - 16 16 16Spain 4 16 16 16 16 16 16Sweden 18 20 20 18 18 18United Kingdom 5 18 18 18 16 16 18

1 The regulations regarding legal age limits differ considerably within the country (15 to 18 depending on theregion).

2 Anyone under the age of 16, unless married or accompanied by a parent or a guardian is prohibited from enter-ing a dance hall where fermented beverages are served, or any other licensed establishment when there isdancing.

3 No on-premise age limit if accompanied by a parent or a guardian.

4 There is no age limit for off- and on-premise sales of beer and wine if accompanied by a parent or a guardian.In some regions the legal age limit for distilled spirits is 18 years.

5 Persons aged 16 years and over may purchase beer, porter, cider or perry if consuming a meal (except inbars). In Scotland wine can also be bought.

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Table . summarises the situation with respect to age limits for off- andon-premise sales for alcoholic beverages in the year . At the moment,Belgium, Greece and Portugal seem to be the only ECAS countries not hav-ing any age limits at least some alcoholic beverages in off-premise retailing.All ECAS countries have an age limit at least for on-premise sales of distilledspirits. In the ECAS countries the age limits range from to years. As arule, age limits are higher for distilled spirits than for beer and wine. Usuallythey are the same for off- and on-premise sales. In Denmark age limits arelower for off-premise sales than for on-premise sales for all alcoholic bever-ages, whereas in Finland, Sweden and the United Kingdom we find lower agelimits for on-premise than for off-premise sales for some alcoholic beveragecategories.

In reality changes in the area of personal control have been even more dra-matic than the scale scores show. For instance, Sweden abolished the Brattrationing system in , and Finland has gradually given up a similar kindof system of personal control between the late s and the year . Thismeans that with respect to personal control there have been two divergenttrends in the ECAS countries; the Nordic monopoly countries have loosenedtheir control measures, whereas the control measures in other ECAS coun-tries have become stricter.

In many ECAS countries there are official rules for not selling alcoholicbeverages to drunken persons. In other countries this may be an unwrittenrule.

Control of marketing alcoholic beverages

According to the ECAS scale, the control of marketing gets on the average .

points in and . points in the year . As table . shows, the controlof marketing alcoholic beverages has been increasing throughout the studyperiod, and especially since the s. Table . summarises the situation inthe year .

On the EU-level, alcohol advertisement is regulated by Council Directive ⁄ ⁄ EEC on the coordination of certain provisions laid down by law, reg-ulation or administrative action in Member States concerning the pursuit oftelevision broadcasting activities (also called Television without Frontiers).The Directive, originally approved in October , was partially amended inJune by the Directive ⁄ ⁄ EC of the European Parliament and of theCouncil. The revised Directive lays down a firm legal framework allowingtelevision operators to develop their activities in the European Union. Themain objective is to create the necessary conditions for free movement of TVbroadcasts.


The Directive includes also some restrictions concerning alcohol adver-tisement in broadcast media. Article in the Directive states that advertisingfor alcoholic beverages shall comply with the following criteria:

(a) it may not be aimed specifically at minors or, in particular, depictminors consuming these beverages;

(b) it shall not link the consumption of alcohol to enhanced physical per-formance or to driving;

(c) it shall not create the impression that the consumption of alcohol con-tributes towards social or sexual success;

(d) it shall not claim that alcohol has therapeutic qualities or that it is astimulant, a sedative or a means of resolving personal conflicts;

(e) it shall not encourage immoderate consumption of alcohol or presentabstinence or moderation in a negative light;

(f) it shall not place emphasis on high alcoholic content as being a positivequality of the beverages.

At the beginning of the study period alcohol advertisement was quiteloosely regulated in Europe overall. In the s and s alcohol advertise-ment, especially in the broadcast media, became more strictly controlled.This undoubtedly had to do with the fact that the number of television setsand television broadcasts grew substantially during this period of time(Karlsson & Simpura, ). Restrictions on alcohol advertisements, mainlyin the form of voluntary codes, but also as legislation, began to emerge inseveral countries.

As one can see from Table ., the national regulations on alcohol adver-tisement differ substantially depending on the country in question. Forinstance, in Greece there are currently no restrictions concerning alcoholadvertisement, sales promotion and sponsorship. In Norway, on the otherhand, the situation is quite the opposite; virtually all alcohol advertisementsas well as sponsorship are forbidden. In most ECAS countries, advertise-ments are nowadays regulated by voluntary codes. In the Nordic countries,however, alcohol advertisements have always been regulated with statutorycontrol. An interesting feature is the development in Finland, where all formsof alcohol advertisement were banned in , and the advertisements ofmild beer, wine and intermediate beverages were allowed again in . Theattitude to alcohol advertisement, especially in sports arenas, has becomemore negative in the ECAS countries. During the last decade, several south-ern European countries, such as France, Spain and, since the beginning of, also Portugal, have banned alcohol advertisement in the sports arenas.

30

Table .. Primary form of regulation for alcohol advertisement and sponsorship in theECAS countries in the year .

Country Statutory control Voluntary control No regulation

Austria 1 XBelgium 2 XDenmark 3 XFinland 4 XFrance 5 XGermany 6 XGreece 7 XIreland 8 XItaly 9 XLuxembourg10 XNetherlands11 XNorway12 XPortugal13 XSpain14 XSweden15 XUnited Kingdom16 X

1 In Austria advertisement of alcoholic beverages is regulated by voluntary guidelines. In some settings mar-keting of alcoholic beverages is forbidden. National TV and radio broadcasts are partly regulated by statutorycontrols.

2 In Belgium advertisement of alcoholic beverages is mainly regulated by voluntary control. In some settings, forinstance in hospitals and working environments, marketing of alcoholic beverages is forbidden.

3 In Denmark advertisement of alcoholic beverages is regulated by a voluntary code. Advertisement of alcoholicbeverages is not allowed in national TV and radio broadcasts.

4 In Finland advertisement of alcoholic beverages up to 22 % alcohol by volume is allowed.

5 In France advertisement of alcoholic beverages is allowed, but very heavily controlled. For instance adver-tisement and sponsorship of alcoholic beverages in the sports arena is not allowed at all.

6 In Germany advertisement of alcoholic beverages is regulated by a voluntary code. There are some specialregulations concerning sponsorship in the sports arena.

7 In Greece advertisement of alcoholic beverages is hardly regulated at all. Advertisement of spirits is forbiddenin sports magazines and in television broadcasts. The control of this, however, is almost non-existent.

8 In Ireland there is no separate control for advertisement of alcoholic beverages. There is, however, a volun-tary code in force for advertisement of alcoholic beverages in national TV and radio broadcasts as well as inthe cinemas.

9 In Italy advertisement of alcoholic beverages is partly regulated by statutory control and partly by voluntaryguidelines.

10 In Luxembourg advertisement of alcoholic beverages is regulated by voluntary guidelines.

11 In the Netherlands advertisement of alcoholic beverages is regulated by a voluntary control system.

12 Norway has the strictest regulations for advertisement of alcoholic beverages in Europe. In practice thismeans a complete prohibition of advertisement of alcoholic beverages.

13 In Portugal advertisement of alcoholic beverages is only regulated in national TV and radio broadcasts.Otherwise there is no control.

14 In Spain advertisement of alcoholic beverages is primary regulated by statutory control. Advertisement of beeris not regulated at all in kiosks and other sales establishments. Advertisement of spirits is forbidden in nation-al TV and radio broadcasts. Sponsorship of alcoholic beverages in sports is forbidden.

15 In Sweden advertisement of alcoholic beverages is regulated by statutory control. Advertisement of alcoholicbeverages in TV and radio broadcasts is prohibited. This does not, however, include beverages below 2.25 %alcohol by volume.

16 In the United Kingdom advertisement of alcoholic beverages is partly regulated by statutory control and part-ly by voluntary guidelines.


Control of drunken driving

An area where the control of alcohol related problems has really increased isthe control of drunken driving. In , the average score for the ECAS coun-tries was .. In the year it was . out of . (Figure .). There werechanges especially in the s (Table .). As late as , there were sixECAS countries without any legal BAC limits for driving. In the year allECAS countries have legal limits of at most .%. Table . summarises thesituation in the year .

Table .. Blood alcohol concentration (BAC) limits in traffic in the ECAS countries inthe year , in per cent (%).

Country BAC-limit (%)

Austria 0.05Belgium 0.05Denmark 0.05Finland 0.05France 0.05Germany 0.05Greece 0.05Ireland 0.08Italy 0.08Netherlands 0.05Norway 0.05*Portugal 0.05Spain 0.05Sweden 0.02United Kingdom 0.08

*) In 2001, the limit changed to 0,02

A contributing factor in the development of BAC limits has been theincrease in the number of motor vehicles and in traffic on the roads. Traffic,especially in the s, grew to the extent that motor traffic had to be moreclosely regulated, and road safety issues, such as drunk driving, were givenmore attention (Karlsson & Österberg, ). The growing number of motorvehicles and people’s growing awareness of road safety issues undoubtedlycontributed to the introduction of BAC limits in most of the ECAS countriesin the s and s. Of course, also technical developments, especiallywith breathalysers becoming cheaper and more precise, have affected thisdevelopments. Therefore, no BAC limit in the s does not necessarilyindicate an absence of control on drunken driving. For instance, in Finlanddrunken driving has been criminalised since ; in the maximumterm of imprisonment was increased to four years; in blood alcohol testsand clinical examinations become mandatory; but not until were statu-tory blood alcohol limits introduced (Österberg, ).

32

The strictest legal BAC limits among the ECAS countries are nowadaysfound in the Nordic countries. Sweden, and (since January ) Norwayhave a BAC limit of .%. Also in Finland there have been discussions onlowering the limit to a level of .. The highest legal BAC limits, i.e., .%,are currently found in the United Kingdom, Ireland and Italy. The rest of theECAS countries have legal BAC limits of .%.

National alcohol prevention and education programmes

Nowadays most ECAS countries have national alcohol prevention and edu-cation programmes (Figure .; Table .). These programmes have beenmore prevalent since , especially since the s.

National alcohol prevention or education programmes are not alcoholcontrol measures as such. The most important reason to document theirexistence is that they are one indication of the place of alcohol control in thesociety. On the other hand, the existence of such programs or agencies alsoputs some pressure on the administration and the political structure for real-ising these plans and programs.

Table .. The existence of national alcohol prevention and education programmes in theECAS countries in the year .

Country National alcohol prevention National alcohol educationprogramme programme

AustriaBelgium X XDenmarkFinland X XFrance X XGermanyGreeceIreland X XItaly X XNetherlands X XNorway X XPortugal X XSpain X XSweden X XUnited Kingdom X X

Alcohol excise taxes

In Table . excise taxes on alcohol have been calculated on the basis of onelitre of pure alcohol in the beverage. The table shows that there is quite agreat variation in alcohol excise taxes among the ECAS countries. On the one


end we have the Mediterranean countries – Italy, Spain, Portugal and Greece– with very low alcohol taxes in each beverage category. On the other end,we have the Nordic countries – Norway, Finland and Sweden – with veryhigh alcohol excise taxes in each category. The United Kingdom, Ireland andDenmark also have quite high alcohol excise taxes. The Netherlands,Belgium, France, Austria and Germany fall in between these two extremes.However, if these countries are wine producers they have usually set an exciserate of zero euro for wine.

Table .. Excise taxes on alcoholic beverages in the ECAS countries according to bever-age categories in July , euros per litre pure alcohol

Country Distilled spirits Intermediate products Wine Beer

Austria 10.03 4.04 0.00 5.21Belgium 16.61 5.51 4.28 4.28Denmark 36.99 7.88 8.62 9.30Finland 50.46 39.24 21.41 28.59France 14.50 11.86 0.30 2.59Germany 13.04 8.52 0.00 1.97Greece 9.45 2.60 0.00 2.92Ireland 27.62 22.01 24.82 19.87Italy 6.45 2.75 0.00 3.50Netherlands 15.04 4.71 4.43 4.26Norway 85.36 44.26 44.26 44.26Portugal 8.14 2.63 0.00 2.81Spain 6.85 2.55 0.00 1.68Sweden 57.35 28.70 28.28 16.81United Kingdom 30.10 17.59 21.59 18.30

Sources: European Confederation of Spirits Producers (CEPS). Calculations are based on the following alcoholcontents for wine and intermediate products: wine 11% alcohol by volume, intermediate products 18% alcohol byvolume.

In every ECAS country, alcohol excise taxes are higher for distilled spiritsthan for any other alcoholic beverages. In three ECAS countries (Ireland, theUnited Kingdom and Sweden), the lowest tax rate is for beer. In Belgium andthe Netherlands the taxes are about the same for intermediate products, wineand beer. And finally, in most ECAS countries wine has the lowest rate ofalcohol excise taxes. In fact, in six ECAS countries the wine excise tax is zero.Furthermore, in some countries, e.g., Portugal, the value added tax is lowerfor wine than for other alcoholic beverages.

34

SIMILARITIES, DIFFERENCES AND TRENDS IN ALCOHOL POLICIES

IN THE ECAS COUNTRIES

In the early s, there were large differences in alcohol policies among theECAS countries. In all Nordic ECAS countries alcohol policies were based onhigh excise taxes on alcoholic beverages, and with the exception of Denmark,also on comprehensive state alcohol monopoly systems as well as strict con-trol on alcohol availability. In the Mediterranean wine drinking and wineproducing ECAS countries there were very few alcohol control measures inforce, and many of these were motivated by industrial or commercial inter-ests. One could argue that in the Mediterranean countries as well as in manyCentral European ECAS countries the terms alcohol policy or alcohol con-trol policy were not even known.

Compared to the Nordic countries, special taxes on alcoholic beveragesand especially on wine were very low in the Mediterranean countries in theearly s. As wine was the clearly preferred beverage in these countries,alcohol consumers hardly paid any alcohol taxes at all compared to theNordic drinkers, who, although they consumed much less alcohol concen-trated on drinking distilled spirits, the most heavily taxed form of alcohol inthese countries.

In those Central European ECAS countries where beer was the preferredbeverage, people also consumed distilled spirits, or at least had in earliertimes. Many of these countries also have a history of quite strong temperancemovement. Consequently, in the early s some of these countries, e.g.,Ireland and the United Kingdom, had a strict and functioning licensing sys-tem; others had at least relics of tight alcohol control measures (theNetherlands and Belgium). Usually the Central European beer countries alsocollected special taxes on alcoholic beverages. We must however admit that“Central European beer countries” is not a very good term as there are sys-tematic differences on the east-west dimension in alcohol policy in thesecountries. The above description for instance fits better to Ireland and theUnited Kingdom than to Germany and Austria.

When using the scale approach the second half of the twentieth centurylooks like a period of converging alcohol polices in the ECAS countries.However, it would be difficult to explain the converging tendency by refer-ring to similar trends in groups of countries either on the basis of the pre-ferred beverage or geographical location. The converging trend can be betterunderstood when looking at trends in different areas of alcohol policies. It is,however, interesting to note that in the year the level of alcohol excisetaxes still follows the old distinction made on the basis of the preferred bev-erage. Namely, alcohol excise taxes are clearly lowest in the Mediterranean


wine drinking and producing countries. Among the ECAS countries, in theformer spirits countries, alcohol excise taxes are highest followed by Irelandand the United Kingdom. The ECAS countries falling in between theseextremes are all located in continental central Europe. Even with respect tothe level of alcohol taxes, the Central European beer countries are not a veryhomogenous group, as can be seen by comparing the level of alcohol taxes inAustria and Germany to those in Ireland and the United Kingdom.

The data on the level of special taxes on alcoholic beverages are not com-plete for the - period. In the country reports we could usually fol-low the changes in special alcohol taxes from the beginning of the s tothe year (Österberg & Karlsson, ). Due to the changing exchangerates of the different currencies, and because of national variations in trendsin the cost of living index, it is hard to document accurately the changes inspecial alcohol taxes. The data available do not give any very clear picture ofcommon trends in special taxation on alcoholic beverages.

It is clear that especially the control of alcohol production and wholesale,but also the control of retail sales of alcoholic beverages has decreased. Inother words, alcohol control policies in the strict sense of targeting only alco-hol availability has lost ground. The most important explanations of thisdevelopment are on the one hand an increased market orientation, and onthe other the growth of consumerism. The increased market orientation isclearly seen in the development of the EU, with the creation of the singleEuropean market in , emphasising the free movements of capital, goods,services and labour, as well as the abolition of barriers to free enterprise andtrade. Especially this decision alone has led to the abolition of many alcoholcontrol measures, starting from production, import, export and wholesalemonopolies, and ending in the new regulations concerning licensing of retailsales outlets of alcoholic beverages. In most countries the licensing policy isnowadays a formal procedure where every applicant fulfilling some basicrequirements, for instanceof having no criminal record, will obtain thelicence. The free market principle seems not to leave too much room for spe-cial restrictions on alcohol availability motivated by social policy or publichealth considerations.

One could have expected that increases in alcohol consumption in theECAS countries from the early s to the mid-s could have led tostricter alcohol control measures. The growth of consumerism has, however,at the same time put pressure on alcohol control measures, as consumersnowadays are not anymore willing to be guided by the state (Sulkunen et al.,). Therefore, restrictions on the days and hours of sale, as well as otherobstacles to free consumer choice, have been increasingly criticised by alco-

36

hol consumers, and many restrictions have also loosened or been abolished.The legal age limits for buying alcohol have, however, been kept and evenbeen made stricter in the second half of the twentieth century. This reflectson the one hand changing drinking habits among adolescents and decreasesin informal social control of drinking. On the other hand, harms connectedto young people’s drinking are visible and therefore an easy target for strictercontrol measures.

Other areas that clearly have gained in importance among alcohol controlare social and environmental control, and control of marketing alcoholicbeverages. In practice, this means that there are nowadays definitely harsheralcohol control measures aimed at certain alcohol-related problems likedrunken driving, and also of public drinking either generally or in certainproblem-prone situations. Imposed or lower blood-alcohol limits in trafficmost certainly reflect the increases of alcohol-related problems in traffic asboth the traffic intensity and alcohol consumption have increased during thelast fifty years. In certain country reports it is even claimed that the controlof drunken driving by lower BAC limits has in fact reduced drinking in on-premise places, or at least the alcohol trade fears that (Hope et al., ).

There are also nowadays more measures aiming to affect the demand foralcoholic beverages by increasing alcohol information and education as wellas by new or stricter regulations on alcohol advertisements. With respect tothe control of alcohol advertisements as well as with the control of drunkendriving, the decisions and activities on the EU level have had an effect, asthere has been agreement on restrictions on alcohol advertising on television(Council Directive ⁄ ).

In most ECAS countries there is nowadays either a national alcohol pre-vention or education programme or a responsible agency. Even in countrieswhich are lacking these kinds of programmes, like Greece, there have beenserious discussions to introduce such programmes. Prevention and educa-tion programmes are not as such guarantees of efficient action. However,their existence means that the alcohol question has been included, in one wayor another, in the national political agenda, and that terms like alcohol poli-cy and alcohol control policy are nowadays understood, and this also affectsthe thinking and planning in alcohol issues. The fact that these kinds of pro-grammes have become more prevalent is partly related to the activities ofWHO, as its European office has developed alcohol action plans agreed on byits member states and has also encouraged its member states to put theseaction plans and recommendations into action.

We may conlude that alcohol policies are nowadays more similar than theyused to be in the early s. Behind the converging trends among the ECAS


countries there are two different basic developments. On the one hand, mea-sures affecting alcohol availability are nowadays applied to a much lesserextent than they used to be fifty years ago. In other words, countries whichin the s had strict alcohol control policies have dismantled them, whileand in countries that have begun to be interested in alcohol policy, have notfocussed on controlling the availability of alcohol. On the other hand, alco-hol control measures targeted to certain alcohol-related harms and aiming toaffect the demand for alcoholic beverages have become more common in theECAS countries, and alcohol policy questions are nowadays in some way oranother on the political agenda in most ECAS countries.

ALCOHOL POLICIES IN THE ECAS COUNTRIES

– PROJECTING THE FUTURE

In most ECAS countries, the level of alcohol consumption per capita washigher in the year than in (World Drink Trends, ). Especiallythe period from the end of the Second World War until the mid-s wascharacterised by a growth in total alcohol consumption. Since the mid-s,total alcohol consumption has been decreasing in the wine drinking ECAScountries, while it has been stable in most other ECAS countries, but hasincreased in some nations, e.g., Finland.

There is a positive relationship between total per capita alcohol consump-tion and alcohol-related problems, as has been documented in manyresearch reports and reviews before it was also confirmed in the ECAS pro-ject (see e.g. Bruun et al. ; Edwards et al. ). It has also been shownthat alcohol control measures which bear on the availability of alcoholic bev-erages generally affect total alcohol consumption (see e.g. Edwards et al.,). Especially changing alcohol prices havs been shown to affect alcoholconsumption (see e.g., Österberg, ). Many of the most convincing stud-ies of these relationships between changes in alcohol availability and totalalcohol consumption come from Anglo-Saxon or EU countries and especial-ly from the Nordic countries (see e.g., Österberg, ; Stockwell &Gruenewald, ). There is much less convincing evidence that measuresaffecting the demand for alcoholic beverages are effective (see e.g. Edwards etal., ).

Increases in total alcohol consumption combined with increases in alco-hol-related problems should, at least in principle, lead to higher needs formeasures preventing or alleviating alcohol-related problems. But, of course,the relation between increases in total alcohol consumption and increases inalcohol-related problems is not straightforward. It is possible that changingdrinking habits or other social changes affect this relationship. This may

38

mean that increases in total alcohol consumption have not led to increases inalcohol-related problems, and to increased needs for alcohol control mea-sures. This possibility seems not, however, to have been the outcome in theECAS countries during the last five decades. Therefore, one has to ask whythere is a general trend in the ECAS countries towards abolishing alcoholcontrol measures affecting alcohol availability and known to be effective.This question becomes even more important when the ECAS countries atthe same time are introducing control measures aiming to affect alcoholdemand even if they are known to be ineffective, at least in the short run.

From a social and public health policy point of view alcoholic beveragesare no ordinary commodities. They contain ethyl alcohol, and drinking alco-hol may cause much harm for the drinker him- or herself, his or her familymembers and friends, the local community or the society as a whole. Fromthe point of view of the alcohol industry and trade, alcoholic beverages aremore like ordinary commodities as they have, like wine, close ties to agricul-ture. It is therefore not infrequent to see contradictory governmental policiesrelated to alcoholic beverages and alcohol. Often the ministries of agricultureare trying to safeguard the interest of wine farmers, and perhaps even tryingto increase the markets for wine. The ministries of industry, on the otherhand, are acting for the interests of breweries and distilleries, while the min-istries of social affairs and health are trying to promote policies that woulddecrease the harms caused by alcohol, and perhaps also trying to curb totalalcohol consumption.

One explanation for the abolition of alcohol control measures affectingalcohol availability is that these measures are many times seen as obstacles tofree trade in alcoholic beverages. In analysing changes in alcohol controlmeasures in the ECAS countries we already mentioned that the EU singlemarket and the working of free market forces have gained in importancesince the Second World War. Guaranteeing free movement of capital, goods,services and labour has been the leading principle in organising the worldeconomy in recent decades, and this principle has overshadowed the publichealth and public order needs to control total alcohol consumption. It is dif-ficult to see that this trend being discontinued even if, for instance, in the EUsocial policy considerations have also gained some importance during thelast decade (see e.g., Sutton & Nylander, ). Therefore it seems likely thateven in the coming years measures restricting the availability of alcoholicbeverages will become fewer and weaker rather than more common andstronger. In any case, it is almost impossible that structures like the compre-hensive alcohol monopoly system, effective in the Nordic countries less thana decade ago could be rebuilt in any EU country in the future.


Despite the fact that alcohol consumption may lead to several kinds ofproblems, alcohol consumers mostly see alcoholic beverages as ordinarycommodities retailed in abundance in well-developed markets and satisfyingindividual consumers’ needs in many ways. Otherwise it could not be under-stood why individual consumers are willing to allocate a good share of theirmoney to buy alcoholic beverages. At the same time, based on well-distrib-uted information on alcohol, many alcohol consumers are fully aware of thepossible harmful effects of their drinking. This means that in developed soci-eties most alcohol consumers are by themselves controlling their drinkingeither generally or in certain situations, for instance, when they know theyhave to drive a car. As mentioned earlier, during the last decades members ofwestern industrialised societies have increasingly emphasised their role assovereign consumers rather than common citizens (see e.g. Sulkunen et al.,). As a consequence it is much more difficult to legitimate alcohol con-trol measures by referring to their effects on alcohol-related problems, assovereign alcohol consumers need no direct guidance from the state.Therefore, these developments are another reason for the abolition andunpopularity of control measures on alcohol availability.

The possible harms of drinking alcoholic beverages do not only affect thedrinker him- or herself. Many times third parties like the drinker’s familymember or friends or the local community are affected. Therefore, it is quitecommon that the drinker’s environment is trying to control the drinking byinformal social control, which can take the form of direct personal control orthe form of more or less developed social and cultural norms about where,when and how drinking should or should not be practised. In some coun-tries, this traditional way to cope with alcohol-related problems is not any-more working as it used to work. For instance, one explanation of theincreased interests in controlling youthful drinking by legal and formal alco-hol control measures rather than by informal alcohol control is that in adeveloping, globalised world the need for controlling youth is still there butthe old informal control methods do not work. As informal control is losingground we may possibly also see other new forms of alcohol control, likerestrictions on alcohol consumption in workplaces, educational or publiccare buildings, government offices, public transport, sporting or other leisureevents as well as in parks and streets.

In summary, it can be projected that alcohol control measures aiming toaffect alcohol availability and targeted at the supply side of the alcohol equa-tion will continue in the future to become less prevalent and weaker.However, in certain areas the control of alcohol availability may increase.This tendency may be seen in measures aiming to affect certain groups of

40

alcohol consumers, for instance increased age limits for controlling adoles-cent drinking or trying to block the purchase possibilities of known drunk-ards. This tendency may also be seen in trying to affect alcohol consumptionin certain problem-prone situations, for instance prohibiting alcohol salesduring a football game or increasing the legal responsibility of on-premiseplaces for behaviour of the patrons. It is, however, quite certain that theseexceptions to the overall decreasing trend in the control of alcohol availabil-ity will not include measures affecting the total population. For instance, itwould be a surprise if the exceptions to the general trend would includelegally imposed earlier closing hours for restaurants, bars, and the like.

As these kind of measures will not affect the level of total alcohol con-sumption, and as alcohol-related problems are common in the ECAS coun-tries, we will probably see more activities trying to affect the demand side ofthe alcohol equation, as well as the relationship between alcohol consump-tion and related problems. In other words, the trend in these areas of alcoholcontrol will most certainly continue. Legal BAC limits will continue todecrease; in the future the limits may be diversified between different drivercategories, for instance lower limits for young drivers or professional drivers.Alcohol advertisements and sponsorship will be increasingly controlled inthe future, and also here some diversification may be noticed, for instance,sponsoring of sport events by alcohol industry and trade may become muchmore difficult than it is nowadays

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General V, Employment, Industrial Relations and Social Affairs.Allamani, A., Cipriani, F., Voller, F., Rossi, D., Anav, S., Karlsson, T. & Österberg, E. ()

Italy, in: Österberg, E. & Karlsson, T. (Eds.) Alcohol Policies in EU Member States andNorway (Helsinki, Stakes).

Anderson, P. & Lehto, J. () Evaluation and Monitoring of Action on Alcohol, WHORegional Publications, European Series No. (Copenhagen, WHO Regional Office forEurope).

Bruun, K., Edwards, G., Lumio, M., Mäkelä, K., Pan, L., Popham, R. E., Room, R., Schmidt,W., Skog, O.-J., Sulkunen, P. & Österberg, E. () Alcohol control policies in publichealth perspective. A collaborative project of the Finnish Foundation for AlcoholStudies, the World Health Organization Regional Office for Europe & The AddictionResearch Foundation of Ontario (Helsinki, Finnish Foundation for Alcohol Studies).

Davies P. & Walsh B. () Alcohol Problems and Alcohol Control in Europe (London &Canberra, Croom Helm).

Edwards, G., Anderson, P., Babor, T. F., Casswell, S., Ferrence, R., Giesbrecht, N., Godfrey,C., Holder, H., Lemmens, D. P., Mäkelä, K., Midanik, L., Norström, T., Österberg, E.,Romelsjö, A., Room, R., Simpura, J. & Skog, O.-J. () Alcohol Policy and the PublicGood (Oxford, Oxford University Press).


Eisenbach-Stangl, I., Uhl, A., Karlsson, T. & Österberg, E. () Austria, in: Österberg, E.& Karlsson, T. (Eds.) Alcohol Policies in EU Member States and Norway (Helsinki,Stakes).

Fahrenkrug, H. () The role of "Das Branntweinmonopol" in the alcohol beverageindustry of the Federal Republic of Germany, in: Kortteinen, T. (Ed.) State Monopoliesand Alcohol Prevention. Report and Working Papers of a Collaborative InternationalStudy, Report No. , pp. - (Helsinki, The Social Research Institute of AlcoholStudies).

Fahrenkrug, H. () Alcohol control policy in the EC member states, ContemporaryDrug Problems, , -.

Harkin, A. M., Anderson, P. & Lehto, J. () Alcohol in Europe - a Health Perspective(Copenhagen, WHO Regional Office for Europe) (document EUR/ICP/ALDT

/CN/Alcohol in Europe).Holder, H. D., Kühlhorn, E., Nordlund, S., Österberg, E., Romelsjö, A. & Ugland, T. ()

European Integration and Nordic Alcohol Policies. Changes in alcohol control policies andconsequences in Finland, Norway and Sweden, - (Aldershot, Ashgate Publishing Ltd).

Hope, A., Byrne, S., Karlsson, T. & Österberg, E. () Ireland, in: Österberg, E. &Karlsson, T. (Eds.) Alcohol Policies in EU Member States and Norway (Helsinki, Stakes).

Karlsson, T. & Österberg, E. () A scale of formal alcohol control policy in EuropeanCountries, Nordisk alkohol- & narkotikatidskrift, Nordic Studies on Alcohol and Drugs,

(English Supplement), -.Karlsson, T. & Simpura, J. () Changes in living conditions and their links to alcohol

consumption and drinking patterns in European countries, to , Nordiskalkohol- & narkotikatidskrift, Nordic Studies on Alcohol and Drugs, (EnglishSupplement), -.

Kümmler, P., Jünger, S., Kraus, L., Karlsson, T. & Österberg, E. () Germany, in: Öster-berg, E. & Karlsson, T. (Eds.) Alcohol Policies in EU Member States and Norway(Helsinki, Stakes).

Lehto, J. () Approaches to Alcohol Control Policy, WHO Regional Publications,European Series No. (Copenhagen, WHO Regional Office for Europe).

Leifman, H. () Homogenisation in alcohol consumption in the European Union,Nordisk alkohol- & narkotikatidskrift, Nordic Studies on Alcohol and Drugs, (EnglishSupplement), -.

Mäkelä, K. & Viikari, M. () Notes on alcohol and the state, Acta Sociologica, , -.Österberg, E. () Alcohol and traffic in Finland, Accident Analysis and Prevention, ,

-.Österberg, E. () Country Profiles: Finland, in: Kortteinen, T. (Ed.) State Monopolies

and Alcohol Prevention, Report and Working Papers of a Collaborative InternationalStudy, Report No. , pp. - (Helsinki, Social Research Institute of AlcoholStudies).

Österberg E. () Current approaches to limit alcohol abuse and the negative consequencesof use: A comparative overview of available options and an assessment of proven effective-ness, pp. -, Expert meeting on the Negative Social Consequences of Alcohol Use,Oslo, - August (Oslo, Norwegian Ministry of Health and Social Affairs)

Österberg, E. (Ed.) () International Seminar on Alcohol Retail Monopolies: Exchange ofInformation and Experience. Proceedings of a seminar held in Saariselkä, Ivalo, Finland,September - , , Themes / (Helsinki, Stakes).

Österberg, E. () Effects of price and taxation, in: Heather, N., Peters, T. J. & Stockwell,T. (Eds.) International Handbook of Alcohol Dependence and Problems, pp. -

(Chichester, U.K., John Wiley & Sons, Ltd).

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Österberg, E. & Karlsson, T. () (Eds.) Alcohol Policies in EU Member States and Norway(Helsinki, Stakes).

Rehn, N., Room, R. & Edwards, G. () Alcohol in the European Region - consumption,harm and policies (Copenhagen, WHO Regional Office for Europe).

Room, R. () The idea of alcohol policy, Nordisk alkohol- & narkotikatidskrift, NordicStudies on Alcohol and Drugs, (English Supplement), -.

Stockwell, T. & Gruenewald , P. () Controls on the physical availability of alcohol, in:Heather, N., Peters, T. J. & Stockwell, T. (Eds.) International Handbook of AlcoholDependence and Problems, pp. - (Chichester, U.K., John Wiley & Sons, Ltd).

Sulkunen, P., Sutton, C., Tigerstedt, C. & Warpenius, K. (Eds.) () Broken Spirits. Powerand Ideas in Nordic Alcohol Control. NAD Publication No. (Helsinki, Hakapaino Oy).

Sutton, C. & Nylander, J. () Alcohol policy strategies and public health policy at anEU-level. The case of alcopops, Nordisk alkohol- & narkotikatidskrift, Nordic Studies onAlcohol and Drugs, (English Supplement), -.

Thorsen, T., Karlsson, T. & Österberg, E. () Denmark, in: Österberg, E. & Karlsson, T.(Eds.) Alcohol Policies in EU Member States and Norway (Helsinki, Stakes).

Vingilis, E., Lote, R. & Seeley, J. () Are trade agreements and economic co-operativescompatible with alcohol control policies and injury prevention? Contemporary DrugProblems, , -.

World Drink Trends () International Beverage Consumption and Production Trends.Productschap voor Gedistilleerde Dranken (Oxfordshire, United Kingdom, NTCPublications Ltd).


Appendix . The ECAS scale for measuring the comprehensiveness and strictness of alco-hol policies

CONTROL OF PRODUCTION AND WHOLESALE (max. 3 points)

1. State monopoly for the production or wholesale of Spirits (1 p.), Wine (1 p.), Beer (1 p.)

2. No production or wholesale monopolies but a licence is required for the production or wholesale of alcoholic beverages (1 p.)(no points if the score for question 1 is 3 points)

CONTROL OF DISTRIBUTION (max. 7 points)

3. State monopoly for off- or on-premise retail sales of Spirits (1 p.), Wine (1 p.), Beer (1 p.)

4. No monopoly for off- or on-premise retail sales of alcoholic beverages but an alcohol specificlicence is needed for off- or on-premise retail sales of alcoholic beverages (1 p.) (no points if the score for question 3 is 3 points)

5. Special restrictions on sales days and hours in off-premise retail sales of alcoholic beverages (1 p.)(the sale of alcoholic beverages is differently regulated than the sales of other commodities)

6. Other special restrictions on off-premise sales of alcoholic beverages (1 p.)(alcoholic beverages cannot be sold for instance in kiosks, gasoline stations, near churches or kinder-gartens etc. or there is an upper limit on the number of stores able to sell alcoholic beverages)

7. Special restrictions on sales days and hours in on-premise retail sales of alcoholic beverages (1 p.)(alcohol sales has to be stopped earlier than other sales; special restrictions concerning alcohol sales on-premise)

8. Other special restrictions on on-premise sales of alcoholic beverages (1 p.)(special kinds of premises are not allowed to serve alcoholic beverages – canteens at work, in hospitalsetc.; alcohol cannot be sold in certain places - for instance near churches, kindergartens; there is an upperlimit on the number of restaurants able to sell alcoholic beverages)

PERSONAL CONTROL (max. 3 points)

9. Legal age limit for off-premise sales at least 20 for some alcoholic beverages (1,5 p.)18 for some alcoholic beverages (1 p.)16 for some alcoholic beverages (0,5 p.)

10. Legal age limit for on-premise sales at least 20 for some alcoholic beverages (1,5 p.)18 for some alcoholic beverages (1 p.)16 for some alcoholic beverages (0,5 p.)

CONTROL OF MARKETING (max. 2 points)

11. Restrictions on alcohol advertising: Statutory control (2 p.)Voluntary code (1 p.)

SOCIAL AND ENVIRONMENTAL CONTROLS (max. 3 p.)

12. Drunk driving: BAC 0.05% or less (3 p.)BAC 0.08% or less (2 p.)BAC more than 0.08 % (1 p.)

PUBLIC POLICY (max. 2 points)

13. National alcohol prevention programme or agency (1 p.)

14. National alcohol education programme or agency (1 p.)

44

Appendix . The comprehensiveness and strictness of alcohol policies in the ECAS coun-tries, –

Country 1950 1960 1970 1980 1990 2000

Austria 4 7 7 6 7 7Belgium 6 7 8 8.5 10.5 11.5Denmark 4 4 6 7 7 8.5Finland 17 17 15.5 18.5 18.5 14.5France 1 6.5 9.5 9.5 10.5 12.5Germany 4 4 5 6 7 8Greece 2 2 2 2 6 7Ireland 8 8 12 12 12 12Italy 7 7 8 12 12 13Netherlands 6 6 6 11 13 13Norway 17 17 17 19 19 17Portugal 1 2 2 4 6 8Spain 0 0 0 4.5 10 10Sweden 17.5 18.5 18.5 18.5 18.5 16.5UK 8 9 14 14 14 13

Average score 6.8 7.7 8.7 10.2 11.4 11.4

håkan leifman 45

INTRODUCTION

This chapter summarizes the major findings from the ECAS studies that per-tain to consumption trends during the postwar period. Since sales data areused as aproxy for consumption, the issue of unrecorded alcohol consump-tion has been addressed as well, both by assessing trends in unrecorded con-sumption and by giving point estimates in as many of the study countries aspossible.

Explanations of changes in consumption trends, drinking patterns andalcohol-related problems is one major issue in the whole ECAS project. Thischapter will discuss different explanations of consumption trends. Chapter also discusses explanations for changes in drinking, above all drinking pat-terns. As to the impact of economic factors, results from econometric analy-ses of the effects of real price and real income (measured as expenditure forprivate consumption) on alcohol consumption will be presented there.

The long study period (–) encompasses several dramatic transfor-mations, both socially and economically. Drinking habits, too, have changedsubstantially over the years. One of the terms most frequently used to denotethe trends in alcohol consumption in the industrialised world is that ofhomogenisation. What this usually refers to is that national differences in

Trends in population drinkingby Håkan Leifman

3.

46

consumption levels are shrinking and/or that each countrys’ traditionallydominant beverage type is losing ground in relative terms (e.g., Sulkunen,; Simpura, ).

Previous studies have addressed only parts of the time period between– and have not fully discussed the importance of homogenisationand globalisation for national policies. A new appraisal of the evidence istherefore in order. It is not quite clear whether we can detect a process ofhomogenisation for the whole study period, in particular in consumptionlevels (in litres of % alcohol per capita). Furthermore, it is not clear if allstudy countries are approaching the mean EU-level from both sides of themean or if it is a few countries that are approaching the rest.

These questions are important, especially from an alcohol policy point ofview. If there is evidence of long-term reduced differences between most ofthe countries in levels of alcohol consumption, this means that nationalcharacteristics in culture, economy, and politics do not affect the develop-ment of alcohol consumption to the extent they used to. The question couldthen be raised whether there is any scope for and any reason to maintainnational alcohol policies. Alternatively, the impact of these global factors maydiffer across countries and may be offset by specific national characteristics.In that case, the study countries could follow the same long-term trends inconsumption but still not show any clear trends towards homogenisation inabsolute levels of consumption.

Also the nature of changes in aggregate alcohol consumption over timehave been discussed in several studies (without necessarily focusing onhomogenisation between countries) (e.g., Room, ; Skog, ). Severalstudies have pointed out that the trends in alcohol consumption in mostcountries in the industrialised world take the shape of long lasting repeatedcycles of downward and upward trends. Mäkelä et al. () discern threelong waves from the mid-th century to the mid- or late s. The last ofthese long waves was the upward postwar trend in consumption in mostWestern countries that continued until the mid-or late s. As will be evi-dent below, the consumption data for the last – years do not show anyuniform picture, and it is possible, but still too early to definitely establish,that these kind of common changes have come to an end (see also Smart,).

This chapter is divided into three interrelated parts. The first part exam-ines trends in beverage preferences, and especially in aggregate alcohol con-sumption (in litres of % alcohol), with special focus on the differences, ordispersion, between all study countries over time. This will give an overviewof all the study countries as but will not yet highlight the individual coun-

håkan leifman 47

tries, nor specific trends. Therefore, trends for different groups of countriesas well as for individual countries will be presented. The results will be dis-cussed in the light of the alleged homogenisation processes. The second partaddresses the issue of unrecorded alcohol consumption. Both trends and lev-els of unrecorded consumption will be assessed. The third part concerns dif-ferent explanations of the consumption trends.

DATA AND METHOD

The analyses of consumption trends in this chapter are based on aggregaterecorded alcohol consumption at the country level and focus on aggregatechanges in alcohol consumption and in beverage preferences. The data arepublished by the Brewers’ Association of Canada. The statistics cover both thetotal per capita consumption of alcohol and the per capita consumption ofbeer, spirits and wine, expressed in litres of % alcohol. For a few countrieslacking complete data, additional data sources have been used. For Ireland,the data from the Brewers’ Association of Canada have been supplemented bynational sales data collected by the ECAS-collaborating partner in Ireland,Dr Ann Hope. The differences between the two sources are smallest for spir-its and biggest for beer. In addition, cider and perry are not included in thedata from the Brewers’ Association of Canada but have been compiled by DrHope. According to her figures, the annual sales of cider/perry amounted toapproximately . litres of % alcohol (per capita, aged +) in the s,’s and s. After that, the sales increased from . litres in to . litresin and . litres in . For Germany, the data refer to former WestGermany for the period to and the unified Germany for –.The German data for – are published by Produchschap voorGedistilleerde Dranken (World Drink Trends), and for – and –

by the Brewers’ Association of Canada.To facilitate comparisons between different regions, the countries will be

grouped into three categories: low, medium, and high consumption countries.The low consumption countries are the three countries in Northern Europe,namely Finland, Norway and Sweden. The intermediate group includesAustria, Belgium, Denmark, Germany, Ireland, the Netherlands, Ireland andthe UK. Finally the high consumption group comprises the five Mediterraneancountries: France, Greece, Italy, Portugal and Spain. The countries within eachgroup are not only similar in term of consumption levels, but are also reason-ably homogeneous with regard to alcohol policy regimes and drinking pat-terns, including choice of beverage (see below).

In the calculations of the total of unrecorded and recorded consumptionfor each country, the recorded consumption will be based on the mean annu-

48

al consumption for the three-year period –. Statistics for this periodhave been published by Produchschap voor Gedistilleerde Dranken (WorldDrink Trends). All consumption data have been recalculated to per capitaconsumption per inhabitant aged or older (per capita, +).

Measures of dispersion and mean (for regions or all study countries) arebased on unweighted data, i.e., each country counts as one unit, regardless ofthe population size. For most countries, the study period is to .

Two dispersion measures are used in order to calculate the dispersionbetween the study countries over time in alcohol consumption and beveragepreferences. One is the coefficient of variation (CV), a relative dispersionmeasure expressing the standard deviation in relation to the mean. Since theCV tends to decrease when the mean value increases and the absolute varia-tion is relatively constant, the standard deviation (SD) will also be presented,referring to the absolute dispersion measure. For instance, if the countriesshow upward trends in per capita consumption but the absolute differencesremain intact, the CV will decrease but the SD will remain the same. If theupward trend is combined with less absolute differences, the SD is alsoreduced.

All data suffer from validity problems, recorded consumption data includ-ed (see e.g., Simpura, ). One is that the recorded consumption is notequivalent to the total consumption and that the proportion recorded oftotal consumption varies between countries. In this chapter point estimatesof and trends in unrecorded alcohol consumption are presented for most ofthe study countries.

This chapter will present point estimates reported from earlier surveystudies but also from some other data sources. It will also present resultsfrom a recent alcohol survey that was initiated by the ECAS project, withquestions about private imports of alcohol, home-distilled spirits and home-produced wine, cider or beer. The ECAS survey data were collected in thespring of from random samples of the general population aged –

in six EU member states: France, Italy, Germany, the UK, Finland andSweden. In each of the countries approximately , interviews were con-ducted by means of telephone interviews (see also Leifman, a). All in all,point estimates will be presented for all countries involved, but it should bestressed that most of them are very approximate.

Norström (, ) has presented an indirect method of estimating thedevelopment of unrecorded consumption over time. Rather than beingbased on survey data, this method relies on national time-series data onrecorded alcohol consumption and alcohol-related mortality, and couldtherefore be of special value in Central and Southern Europe, where infor-

håkan leifman 49

mation on the development in unrecorded consumption is lacking. Themethod will be applied to all the study countries to estimate trends inunrecorded consumption for the period to .

The indirect method aims at estimating the discrepancy between theobserved development of alcohol-related mortality and the developmentthat should be expected from changes in recorded consumption only. Thetrend in this discrepancy thus expresses the impact of factors other than therecorded consumption on alcohol-related mortality. One such factor isunrecorded consumption. The method will be applied in two steps. To beginwith, each of the study countries involved will be subjected to time-seriesanalyses on the effect of recorded alcohol consumption on alcohol-relatedmortality, applying the ARIMA-modelling technique. Since a ten-year laggedalcohol series is used in each country, the actual time period on which thetrends of unrecorded consumption can be estimated for most of these coun-tries, is from to . In the second step, the estimated alcohol effectparameters will be used to estimate the noise term, which reflects the trendin alcohol-related mortality net of the effects of recorded consumption. Thetrend in the noise term can be seen as an indicator of the trend in unrecord-ed alcohol consumption (see also Norström, , ; Leifman, b).

The indicator of alcohol-related mortality is a composite measure, includ-ing liver cirrhosis () (the single largest cause of alcohol-related death forall countries), alcohol psychosis (), alcoholism (alcohol dependency inICD-) (), alcohol poisoning (E), pancreatitis (), and starting withthe introduction of ICD-, alcoholic polyneuropathy (.), alcohol abuse(.), alcoholic cardiomyopathy (.) and alcoholic gastritis (.).Alcohol-related mortality is expressed as the rate per , inhabitantsaged years and above. The effects of the introduction of the new ICD-ver-sions are controlled for by dummy variables for each country. (For a moredetailed description, see Leifman, b.)

LONG WAVES OF ALCOHOL CONSUMPTION AND HOMOGENISATION:

THE EMPIRICAL EVIDENCE

Similar long waves of consumption trends in several countries do not neces-sarily imply that the differences in consumption are diminishing. Theincrease in consumption in the Western world during the three postwardecades, however, were accompanied by reduced dispersion in consumptionlevels. Figure . shows the trends in total alcohol consumption for the studycountries, including all alcoholic beverages combined according to ethanolcontent, the relative (CV) and absolute dispersion (SD). Consumptionincreased during the first three postwar decades, until the mid-s. At the

50

same time, according to both measures of dispersion, the differences in con-sumption levels between the countries were reduced. From the beginning ofthe s, however, per capita consumption tended to decrease slightly until, particularly for wine and somewhat for beer (data not shown). In thes, both the absolute and the relative variation indices have remained onthe same level which indicates that there has not been any further homogeni-sation in per capita consumption in the first half of the s.

Also when it comes to beverage preferences, measured as the proportion ofeach alcoholic beverage in the total consumption, between country differ-ences have been reduced over time. Figure . illustrates this for wine. Theproportion of wine consumption to total consumption has been rather sta-ble over time, contributing to % of the study countries’ overall consump-tion. The differences between the countries, however, have diminished from to . In , the CV for the proportion of wine wa approximately%, in , about % and in , roughly %. The same trend can beobserved also for beer and spirits. The national differences in beverage pref-erences hence show a clear trend towards homogenisation and, in contrast tothe trends in consumption levels, this has proceeded at the same pace duringthe whole study period.

Figure .. Total alcohol consumption in litres: mean values and measures of dispersion(CV, SD), (alcohol 100% per capita, +).

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håkan leifman 51

Figure .. Proportion % of wine consumption: mean values and measures of dispersion(CV, SD) in the study countries –, per capita, +.

The data presented in this section are based on recorded sales figures. Itshould therefore be made clear already at this stage that the consumptiontrends and homogenisation would look much the same even if the estimat-ed unrecorded alcohol consumption was added to the recorded alcohol con-sumption (see below in the section on unrecorded alcohol consumption).

The homogenisation described above across all study countries does notreveal the trends for groups of countries and for separate countries. Thistime starting with the beverage preferences, Table . shows the percentage ofbeer, spirits and wine consumption to total consumption for all the countriesfor different years from the s until the mid-s. In terms of the domi-nating beverage (marked in bold), the pattern has been quite stable. In allcountries where beer was the dominating beverage in the first or second peri-od, it has continued to dominate for all following periods as well. The tradi-tionally beer-drinking countries are Austria, Belgium, Denmark, Germany,Ireland, the Netherlands and the UK.

The traditionally wine-drinking countries have included the same fivecountries for the whole study period, i.e., France, Italy, Portugal, Spain andGreece. Even though the wine consumption has increased in proportion inmany of the countries in Northern Europe, it has not been enough to makewine the dominating beverage.

All the remaining countries have shifted from spirits to beer as the domi-nating beverage in the s or later. These former spirits-drinking countries

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are Finland, Norway and Sweden. As shown in Table ., beer is the dominantbeverage for the majority of the study countries (ten countries) in –. Inthe remaining countries, wine dominates. Seen from this perspective, there isno spirits-drinking country left among the countries studied.

Table . also shows the proportion of the remaining (non-dominant) bev-erages. In most countries, the proportion of spirits increased slightly or wasrather stable until the s and has since declined, except for the wine-drinking countries where the proportion of spirits is rather stable over timeor has increased. The beer proportion, too, has increased in the wine-drink-ing and former spirits-drinking countries. Only the traditional beer-drink-ing countries show a trend towards a reduced proportion of beer. Theincreased proportion of spirits and beer to total consumption in the wine-drinking countries is mainly the result of a substantial decrease in wine con-sumption, rather than increases in beer and spirits consumption.

That there has been a homogenisation also between these three group of coun-tries is shown in Table . which shows the development of the CV and SD of bev-erage preferences for the three groups of countries. First, it clearly shows that thetraditional beverage has lost in popularity within each of the three groups. In thewine-drinking countries, for instance, the proportion of wine has been reducedfrom more than % in to less than % in . The table also shows thatthere has been an increasing equalisation in the relative share of each alcoholicbeverage within the group of beer-drinking countries and within the former spir-its-drinking countries. Except for the proportion of beer consumption, no con-vergence trends could be detected in the wine-drinking countries.

Aggregate consumption

Figure . shows the trends in the total recorded consumption for the threegroups of countries from to . The most marked change during thelast years is the decline in consumption in the wine-drinking countries:per capita consumption has been reduced by approximately litres of %alcohol per capita, from a peak in the mid-s of roughly litres to lessthan litres in the mid-s. The consumption in the beer-drinking coun-tries and the former spirits-drinking countries increased in the s anduntil the mid-s. Since then, the consumption has been rather stable inboth groups. Due to the large consumption decline in the wine-drinkingcountries, the differences between this group and the two others have beenreduced. In the mid-s, there is no real difference in consumptionbetween the wine and the beer-drinking countries.Wine-drinking countries. From the mid-s all wine-drinking countries,except Greece, have recorded a declining trend (Figure .). For France the

håkan leifman 53

decline started already in the mid-s. The largest decline for the last twodecades has occurred in Italy where total consumption has dropped fromalmost litres in the first half of the s to less than litres in the s.Except for Italy, the traditionally wine-drinking countries show the highestconsumption for all periods, but the differences between them and the otherten countries have narrowed substantially in the last decades.

It is the reduction in consumption of wine that accounts for the large dropin total alcohol consumption in the Mediterranean countries. In France,wine consumption decreased by litres of pure alcohol, from litres in– to litres in –, and in Italy by litres, from litres in –

( litres ) to less than litres in –. As has been noticed elsewhere(Pyörälä, ; Simpura, ), beer consumption has on a long-term basisincreased in Greece, Italy, Portugal and Spain, but has decreased slightly inFrance from onwards. Spirits consumption has remained stable inFrance for the whole study period; for the last twenty years in Greece,Portugal and Spain; and decreased in Italy from the mid-s.

Beer-drinking countries. As shown in Figure ., the consumption in thegroup of traditionally beer-drinking countries increased until the mid- or lates and has since then been rather stable. Figure . shows that this increaseduring the first half of the study period occurred in all seven of the countrieswhereas the trends in the second half look somewhat different for differentcountries. In Austria, the consumption level decreased from the peak in themid-s until the beginning of the s and has since been rather stable,except for an increase in the late s. Belgium, Germany and the Netherlandsshow declining trends in consumption in the s and rather stable levels inthe s, although German consumption goes up for a few years in the lates and early s (the data refer to the unified Germany from ). ForDenmark and the UK, the consumption levels are roughly on the same level inthe s as in the late s. Denmark’s alcohol consumption does, however,rise slightly in the s. Ireland shows an upward trend since the mid-s.

Austria is in the s the leading beer-drinking country as measured bytotal alcohol consumption, followed by Denmark, the two recording thethird and fourth highest total consumption of all study countries.

The beer-drinking countries have thus approached the wine-drinkingcountries in total consumption levels. Compared to the wine-drinking coun-tries, the beer-drinking countries thus show smaller changes in total con-sumption during the last decades. The differences between the seven beercountries in their total consumption increased from the start of the study period until , then decreased until the late s and has since then beenon more or less the same level in terms of CV and SD.

54 Table .. Percentage of beer, spirits and wine consumption of the total alcohol consumption in the study countries. Bold figures indicate the dominant beverage

1953–55 1963–65 1973–75 1983–85 1993–95Country Beer Spirits Wine Beer Spirits Wine Beer Spirits Wine Beer Spirits Wine Beer Spirits Wine

Austria 45 25 30 45 23 33 45 17 38 47 14 39 51 13 36Belgium 75 11 14 71 14 15 61 19 20 55 19 25 55 13 32Denmark 78 12 11 71 17 11 64 19 17 62 15 23 59 11 31Finland 37 50 12 33 53 14 41 44 15 43 43 14 56 27 17France 5 13 82 9 13 78 12 14 74 14 16 69 15 21 64Germany1 56 26 18 55 28 17 56 27 18 57 22 22 57 24 20Greece2 – – – 10 – 90 18 – 82 19 30 51 25 31 44Netherlands 36 58 6 46 43 11 47 36 17 49 28 23 53 22 25Ireland 73 22 3 69 25 4 63 30 5 67 24 6 65 20 9Italy 1 9 90 3 12 86 5 15 81 8 10 82 15 7 78Norway 42 49 9 45 48 7 47 43 10 52 33 14 58 21 21Portugal3 – – 100 2 3 96 10 7 83 13 6 81 31 7 62Spain4 3 – 97 9 20 71 15 19 66 23 25 52 30 25 45Sweden 29 64 7 29 58 13 37 47 17 32 41 27 46 27 27UK 77 15 6 71 18 10 63 22 14 57 23 18 55 19 22

1 From 1991 the data refer to Germany, before that to the former West Germany.2 No data for wine until 1961, beer until 1961 and spirits until 1976, but wine is the dominant beverage.3 No data for beer before 1960 and spirits 1964, but wine is the dominant beverage.4 No data for spirits before 1962, but wine is the dominant beverage.

håkan leifman 55

Table .. Proportion of beer, spirits and wine consumption: mean values and measures ofdispersion (CV, SD)

Wine-drinking Beer-drinking Former spirits-countries1 countries drinking countries

Year Mean CV SD Mean CV SD Mean CV SD(% of total) (% of total) (% of total)

Wine1950 93 9 9 12 94 11 5 33 21955 92 8 8 13 74 10 9 27 219602 90 8 7 14 63 9 9 29 31965 83 13 11 15 65 10 12 33 41970 80 12 10 16 71 12 12 21 31975 77 10 8 19 55 10 14 24 31980 67 19 13 20 49 10 16 29 51985 66 24 16 23 42 9 19 40 71990 58 26 15 23 39 9 20 36 71995 59 23 14 25 36 9 22 21 5

Beer1950 3 56 1 59 35 21 34 14 51955 4 61 2 63 27 17 37 19 719603 6 62 4 62 23 15 36 19 71965 7 60 4 60 21 12 36 23 81970 10 50 5 61 16 10 45 9 41975 12 41 5 56 14 8 41 13 51980 14 34 5 55 12 7 40 21 81985 16 39 6 56 11 6 43 20 91990 24 42 10 58 10 6 50 15 81995 23 32 7 56 8 4 53 12 7

Spirits1950 - - - 29 71 20 61 9 51955 - - - 25 60 15 54 14 81960 - - - 24 45 11 55 8 51965 13 59 8 25 40 10 52 10 51970 13 48 6 23 38 9 43 8 319754 18 57 10 25 33 8 45 4 21980 20 51 10 24 29 7 44 8 31985 18 58 10 22 25 5 38 11 41990 19 55 10 19 31 6 31 18 61995 18 59 11 18 33 6 25 14 4

1 Beer and wine: Greece is included 1961 and Portugal for beer 1960. Spirits: Greece included 1976, Portugal1964 and Spain 1962. The results do not deviate substantially if Greece is excluded during the whole timeperiod.

2 For the wine-drinking countries the year is 1961. Thereby all five countries are included. 1950 and 1955 onlyFrance, Italy and Spain.

3 For the wine-drinking countries the year is 1961. Thereby all five wine countries are included.4 For the wine-drinking countries the year is 1976. Thereby all five wine countries are included.

56

As for the different alcoholic beverages, the overall trend for the last twen-ty years is a reduction in spirits consumption, especially from the mid-sto the end of the s. For the UK though, the level has remained rather sta-ble but with a peak in . Wine consumption has over time become morepopular (see e.g., Pyörälä, and Hupkens et al., ). During the lasttwenty years Belgium, Denmark and the UK in particular, show continuousupward trends in wine consumption. Austrian wine consumption hasdeclined since the s, while in Germany and the Netherlands, the con-sumption increased until the early s and has since declined to the samelevel as in the first half of the s.

None of the beer-drinking countries show a substantial increase in the con-sumption of beer. In four of them, beer consumption was lower in the sthan in the s (Belgium, Germany, Ireland and the UK) and in the remain-ing three (Austria, Denmark, the Netherlands) the level stayed approximatelythe same between the two periods. In –, Ireland had the highest beerconsumption of all the study countries, followed by Denmark.

Former spirits-drinking, now beer-drinking countries. The rate of increase for theformer spirits-drinking countries was especially high during a ten-year periodfrom the mid-s to the mid-s, with a doubling of consumption (Figure.). Figure . shows that this increase was the sharpest in Finland. In Norwayand Sweden, consumption peaked in the second half of the s or early .Finnish consumption increased until , remained stable for ten years andthen continued to increase until , the peak consumption year. In Norway,consumption has been rather stable since the drop between –. Swedenshowed a decrease from the middle of the s until . From then on, con-sumption has been rather stable. In Finland consumption decreased by rough-ly . litres from to .

The differences between the three countries are not less at the end of thestudy period than in the beginning; the SD has actually increased. Both theabsolute and relative differences were first reduced between and ,

and then increased until . Both measures have since been on roughly thesame level. Spirits consumption shows a long-term declining trend accord-ing to recorded sales and survey data. However, the decrease during the lastten years or so in Finland, and especially in Norway and Sweden, is not asmarked as the recorded consumption indicates. In both Norway and Sweden,the proportion of unrecorded spirits to total spirits consumption hasincreased, and contributed in the mid-s to approximately half of thetotal spirits consumption (Holder et al., ; Kühlhorn et al., ; NOU,). Since spirits accounts for the highest degree of unrecorded consump-

håkan leifman 57

tion in Norway and Sweden, both countries move up in the spirits league. InFinland, the proportion of unrecorded spirits is less (see also the sectionbelow on unrecorded alcohol consumption).

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Figure .. Consumption trends for three group of countries, (litres alcohol % percapita, +).

Figure .. Trends in the consumption of alcohol – for the traditionally wine-drinking countries, (litres alcohol % per capita, +).

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Figure .. Trends in the consumption of alcohol – for the traditionally beer-drin-king countries, (litres alcohol % per capita, +).

Figure .. Trends in the consumption of alcohol – for the former spirits-drinkingnow beer-drinking countries, (litres alcohol % per capita, +).

håkan leifman 59

The results so far indicate that the increased homogenisation in aggregatealcohol consumption between the study countries in the first half of thestudy period was the result of strong consumption growth in the mediumconsumption countries (central European countries, Ireland, the UK) andNorthern Europe (Finland, Norway, Sweden), whereas the levels in the highconsumption Mediterranean countries remained more stable or, as forFrance, declined from the mid-s. During the second half of the studyperiod, the homogenisation is in substantial part due to a convergencebetween the consumption in the wine-drinking countries and the remainingten countries. The wine-drinking countries’ consumption has thus droppedapproaching the other countries’ per capita consumption. The average diffe-rence between the beer and wine-drinking countries in total consumption inthe mid-s amounts to no more than a few decilitres of pure alcohol (percapita, +).

It should be mentioned that the decreasing differences in alcohol con-sumption, especially between the wine and beer-drinking countries, is alsoreflected in alcohol-related mortality (see Ch. ), such as liver cirrhosisdeaths. This suggests reduction over time that not only in the differences inper capita alcohol consumption between the wine-drinking countries andthe remaining countries (especially the beer-drinking countries), but also inthe differences in the prevalence of chronic heavy drinking.

The description of each country’s total recorded consumption over timealso reveals that the trends look somewhat different for different countries,not only between the three groups of countries, but also between countriesbelonging to the same group. This is also true for the trends in cirrhosis rates(see Ch. ). It is possible that the more or less uniform changes in consump-tion evident during the first half of the study period have come to an end.The different trends for different countries also mean that, in the search forexplanations of the overall homogenisation, different explanations may berelevant for different countries.

UNRECORDED ALCOHOL CONSUMPTION

Unrecorded alcohol consumption includes three main categories. The first islegal or illegal home-made production of alcoholic beverages. Another cate-gory is private import including small-scale and large-scale smuggling andlegally imported alcohol for personal use. The third category pertains to allthe alcohol that is consumed by foreign visitors.

The results section will begin with presenting results on the country-spe-cific point estimates, before applying the indirect method to estimate trendsin unrecorded consumption for each country.

60

It should be mentioned that even though all home-production of alco-holic beverages is unrecorded in Northern Europe, this is not necessarily thecase in all other EU countries. It is possible, for example, that parts of thehome-production in Southern Europe is reported to the authorities and thusrecorded. More investigations are needed here in order to improve ourknowledge of what is actually counted in the recorded statistics and what isnot and also how large a part of home-produced alcohol for exampleremains as unrecorded for the alcoholic beverages.

Point estimates of unrecorded alcohol consumption

The ECAS-survey included questions on personal imports of alcohol and onthe use and home production of different alcoholic beverages. Table .shows the results pertaining to privately imported alcohol during the past months. The French and Italians report the lowest quantities of importedalcohol. The high-price countries – represented by Finland, Sweden and theUK – show the highest quantities of privately imported alcohol (duty-freealcohol and/or alcohol bought in other shops abroad). The results imply thatthe private imports alone contribute to an underestimation of the real alco-hol consumption in these countries by about –. litres pure alcohol. InSouthern Europe (here France and Italy), the volumes are negligible.

A study addressing the consumption of alcohol during journeys abroad,and of duty-free purchases, points in the same direction (Trolldal, ). Thestudy adjusted each country’s recorded consumption by considering thealcohol consumed during stays abroad and duty-free purchases. The effectsof the adjustments were that the recorded consumption in all theMediterranean countries should be lowered due to a tourist surplus (foreigntourists spend more nights within the Mediterranean countries than touristsfrom those countries do abroad). The duty-free purchases in those countrieswere also low, especially in comparison to the high-price countries. The lat-ter countries thus showed considerably higher purchases of duty-free alcoholand most of them have a tourist deficit. The recorded consumption in thesecountries should therefore be adjusted upwards.

Taken together, the import habits and the tourist flows imply that the onlyunrecorded part that could be of any substantial quantity in theMediterranean countries is the domestic (home) production of alcoholicbeverages.

Table . shows the prevalence of drinkers of home-distilled spirits andhow common it is to make, produce and buy alcoholic beverages directlyfrom a producer. The Swedish proportion of % of the drinkers who haveconsumed home-distilled spirits is in agreement with other recent studies.

håkan leifman 61

The Finnish percentage (.%) is a few percentage points lower than thatfound in – (Leifman et al., ; Österberg, ). The highest per-centage of users, however, is found in Italy: % have tried home-distilledspirits at least once or twice during the past months. France shows thethird highest percentage, %, while only % of the UK and German respon-dents report drinking home-distilled spirits in the previous months.

It should be noticed that the meaning and kind of home-distilled spiritsprobably differ among countries. In the Nordic countries home destillat isprimarily of cheap vodka-like spirits consumed in order to get drunk, and isparticularly common among heavy drinkers (Kühlhorn et al., ). This isnot necessarily the case in Italy, for example, where home-made Grappacould be associated with entirely different values.

Buying directly from the producer seems to be a rather common practicein the wine-producing countries. As regards home production, all countriesbut Finland and Italy show low proportions. In Finland, it is especially beerthat is home-produced. The Italians not only reported the highest numbersof home-producing (%) but also of buyers of wine or cider directly fromthe producer (%). In Germany and France, % and % respectively hadbought alcohol directly from the producers.

Table .. Volume of privately imported alcohol. In alcohol % per respondent -

years of age

Finland France Germany Italy Sweden UKn=1003 n=1000 n=1000 n=1000 n=998 n=984

Beer 0.3 0.0 0.0 0.0 0.2 0.1

Spirits 0.4 0.1 0.1 0.0 0.3 0.4

Wine 0.2 0.0 0.3 0.0 0.2 0.6

Total 0.9 0.1 0.4 0.03 0.7 1.1Total per importer 2.0 1.2 2.5 0.7 1.9 4.1

Adjusted upward by a factor of 1.252

Total 1.1 0.1 0.5 0.04 0.9 1.4Total per importer 2.5 1.4 2.9 0.8 2.3 5.0

1 The limit for privately imported alcohol is set at 10 litres for spirits, 90 litres for wine and 100 litres of beer.For respondents reporting higher volumes than these, only the volumes up to these limits are counted.

2 The adjustment factor of 1.25 is based on Swedish findings that suggest an underreporting of the number oftrips by roughly 20% (Kühlhorn et al., 1999).

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Table .. Proportion (%) of respondents aged - that have had home-distilled spirits,that have made own beer, wine or cider, and proportion who got someone to producecider and wine for them during the past months

Finland Sweden Germany UK France Italyn=1003 n=992 n=974 n=983 n=999 n=1000

Have had home-distilled spirits: 7.5 17.9 5.0 4.6 12.7 25.7

Made own beer, wine or cider: 10.1 4.3 1.1 3.5 0.9 16.3

Someone produced wine or cider for you: 1.9 .. 2.7 2.8 1.5 ..

Bought beer or wine directly from a producer: .. .. 18.1 .. 14.3 32.5

.. = not included in the questionnaire: In some countries these habits are very rare, and because we had a strict-ly limited number of questions, not all of these questions were included for all countries (for more information,see Leifman, 2001b).

The results from this ECAS survey, the study of tourist flows and duty-freepurchases (Trolldal, ), and other available sources (e.g., published surveydata), are the basis of the estimates of unrecorded consumption shown inTable .. The right column of the table presents a crude subjective assess-ment of the reliability of the national estimates based on the type and quan-tity of data. Norway, Finland and Sweden have received three stars, indicat-ing the highest reliability: these countries have conducted several surveystudies over time measuring different forms of unrecorded alcohol. Togetherwith the UK and Denmark, they are placed in the group with the highestunrecorded quantities (approx. litres per capita +).

As to the Mediterranean countries, it was shown above that the effects ofimported quantities and tourist flows are small. The net effect could actual-ly be that the recorded consumption should be somewhat reduced. Thequantities of home-produced unrecorded alcohol are not known. However,the ECAS survey showed that buying from producers is not an uncommonpractice.

According to the WHO global profiles (), declared home productionof wine in France was million litres of % ethanol in – and to

million litres in – (WHO, ). If the figures are fairly correct, thiscould mean that roughly . litres pure alcohol per capita was home pro-duced in . Nothing indicates that this volume has increased since, prob-ably the opposite (see below). An unrecorded alcohol consumption of litrepure alcohol per capita + in France in the s seems to be a plausible, butcertainly very approximate, estimate.

håkan leifman 63

Italy showed consistently higher proportions than France in the ECAS sur-vey: including, for example, twice as many consumers of home-distilled spir-its and more than twice as many buyers of wine or cider directly from theproducer. The quantity of unrecorded level is thus most likely higher in Italythan France: probably more than litre but still less than litres (see Table.).

No recent information is available for Portugal and Spain. The so-calledISAB study (International Statistics on Alcoholic Beverages, ) madeinquiries in several countries, including Spain. According to this, the quanti-ty of unrecorded alcohol was less than litre per capita in the s. An edu-cated guess would be that Spain and Portugal, too, have levels of about litreof unrecorded alcohol, or possibly less than that. The crudeness of these esti-mates should be noted.

Once again it must be stressed that whether all home produced alcoholand all the alcoholic beverages bought directly from the producer inSouthern Europe is unrecorded, or if some parts are recorded, is not reallyknown. However, that a substantial part of this alcohol goes unrecorded ismost likely.

Trends in unrecorded alcohol consumption

This indirect method of assessing the trends in unrecorded consumptionrelies on time-series analyses of national data on recorded alcohol consump-tion and alcohol-related mortality. The method will be applied on all the study countries and will yield estimated trends in unrecorded consumptionfor the period to . The rationale of the method is to estimate the dis-crepancy between the observed trends in alcohol-related mortality and thetrends that would be expected from changes in recorded consumption only.The trend in this discrepancy (the noise-term) expresses the impact of otherfactors than the recorded consumption on alcohol-related mortality. Onesuch factor is unrecorded consumption (see Data and method).

The first step was thus to analyse the relationship between recorded alco-hol sales and alcohol-related mortality over time. These time-series analysesshowed positive and significant effect estimates in all countries. Thestrongest effect estimate was found for Sweden, followed by Norway andFinland. The UK and Portugal displayed the strongest alcohol effects of thenon-Nordic countries (see Leifman, b). In the second step, these esti-mated alcohol effect parameters were used to estimate the noise-term foreach country, i.e., the estimate of the trend in unrecorded consumption.

For Denmark, Finland, Norway and Sweden, point estimates from surveysindicate increases in unrecorded consumption for the past – years from

64 Table .. Estimates on unrecorded alcohol consumption in EU member states in the s

Group of countries sorted by approx. Comments (all litres in alcohol 100% per capita, 15+) Reliability ranklevel of unrecorded consumption of the estimates(litres alcohol 100% per capita, 15+)

Approx. 2 litres (±0.5 litres)Norway Survey estimates: 1973: 1 litre, 1979: 1.5 litre, 1991: 1.5 litres, 1994: 1.8 litres and in

1999 1.85 litres (Horverak et al., 2000; Norström, 1998). ***

Finland Survey estimate: 1984: 1.4 litres, 1992: 1.6 litres, 1994: 2 litres, 1995 2.5 litres; 1996-9: 2.1-2.3 litres (Österberg, 2000). ***

Sweden Survey estimates: 1989: 1.2 litres, 1995: 1.6, 1996: 2.1; 1998. 2.2, 2000: 2.0-2.2 litres (Leifman et al., 2000). ***

Denmark According to Thorsen (1990): 1977: 1 litres, 1986: 2 litres. NAT 1994: 2.4 litres 1993 (probably an overestimation). Almost all surveys concern the cross-border shopping between Denmark and Germany. Cross-border shopping in 1991= 10% of total consumption (Österberg, 1993). 1999: 20% of beer consumption is made up of imported beer (Wrede, 1999). **

UK A sum of personal import quantities (ECAS survey: 1.1-1.4 litres), cross-border smuggling (several independent sources: approx. 0.3 litres), and home-production (ECAS survey: probably a few decilitres) gives a total of roughly to 2 litres or possibly some decilitres less, thus: 1.5-2 litres. **

More than 1 but probably less than 2 litres:Italy High levels of home-production and buying from other producers in the ECAS survey

but a tourist deficit and low quantities of imported alcohol: about 1.5 litres (see also text). *

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Approx. 1 litre:Austria The effect of tourist surplus and duty-free purchases is a slight reduction of the recorded

consumption. This together with results from a large survey 1993 (Uhl & Springer, 1994) could indicate a level of roughly 1 litre unrecorded. *

Germany ECAS-survey: 0.5 litres imported per adult aged 18-64. The prevalence of home-producers indicate at least additional 0.5 litres. *

France Low levels of privately imported and a tourist deficit but rather high prevalence of purchasers of beer or wine directly from a producer and almost 13% had tried home-distilled spirits during the past 12 months: roughly 1 litre unrecorded (see also text). *

Ireland The sum of a tourist surplus and duty-free purchases is an addition to the recorded consumption. Illicit spirits production occurs. Number of seizures plants of illicit distillation 1980-85 varied between 108 and 147 yearly. The assumed 1 litre is only a cautious guessand more uncertain than for most of the countries. (*)

Portugal The tourist flows and duty-free (and most likely the imported quantities) are small. In analyses below it will be assumed that they have approx. the same level of unrecorded alcohol as France. (*)

Spain See Portugal and also text. (*)

Approx. 0.5 litres:Netherlands Lemmens (1999) reviews three sources of unrecorded consumption (no surveys are used)

and presents an educated guess at 3-5% unrecorded consumption of the total consumptionas a maximum, i.e., 0.3-0.5 litres. According to Trolldal (2000), the tourist surplus and

duty-free purchases amounts to circa 0.5 litres in the mid-1990s. *

Belgium Belgium shows a rather similar tax burden on alcoholic beverages as the Netherlands and a similar tourist surplus and duty-free purchases. It also appears from Lemmens study (1999) that the two countries share partly the same past experiences as regards illegal spirits production. It is possible that the unrecorded consumption is on the same level as in the Netherlands. (*)

*** repeatedly conducted surveys with several questions (scales) on the consumption of different kinds of unrecorded alcohol.** at least one survey that covers the most important sources of unrecorded alcohol consumption .* only crude estimates, not based on survey data or only based on the ECAS-survey.(*) no information on unrecorded alcohol consumption available.

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about litre in the early or mid-s to about litres of pure alcohol (percapita, +) in the mid-s (see Table .). Except for Sweden, the trends inthe noise series also point towards an increase. This is shown in Figure .(Denmark, Finland) and Figure . (Norway, Sweden). The point estimates,however, indicate larger increases.

The situation is more complex for Sweden, where the most accurate andcomprehensive survey of unrecorded alcohol was conducted in . Sincethe available Swedish mortality statistics also covered , the time-seriesanalyses for Sweden were extended to cover the period from to . Inaddition, the trends in alcohol-related mortality for the last – years willdiffer if one studies only the underlying diagnoses compared to both under-lying and contributory diagnoses. Since the mortality data in Sweden permita division into underlying and contributory causes of death, two noise serieswere calculated, one based on the underlying diagnoses, the other on bothunderlying and contributory diagnoses.

According to the noise series for the underlying cause of deaths, theunrecorded consumption level has been rather stable in Sweden; it increasedslightly from the s until the mid-s, but has since decreased.According to the series based on the underlying and contributory diagnoses,unrecorded consumption increased between and , after which itwas fairly stable.

Figure .. Estimated trend in unrecorded consumption in Denmark and Finland based onadjusted alcohol-related mortality indicator.

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Figure .. Estimated trend in unrecorded consumption in Norway and Sweden based onadjusted alcohol-related mortality indicator.

Figure .. Estimated trend in unrecorded consumption in Germany, Ireland and the UKbased on adjusted alcohol-related mortality indicator.

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Figure .. Estimated trend in unrecorded consumption in Austria, Belgium and theNetherlands based on adjusted alcohol-related mortality indicator.

Figure .. Estimated trend in unrecorded consumption in France, Italy, Spain andPortugal based on adjusted alcohol-related mortality indicator.

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håkan leifman 69

In both Sweden and Finland, it is especially the large increases in un-recorded alcohol according to the point estimates between and

(Finland) and – (Sweden) (see Table .) that are not matched bysimilar increases in the noise series. Finland also shows a large increase in thenoise series in the late s, with a peak in . To some extent, this can beexplained by a dramatic increase in alcohol poisoning deaths in –,which was the result of increased use of unrecorded industrial spirits(‘Taloussprii T’) among heavy drinkers (see Pöysä & Mäkelä, , ).

Figure . illustrates the noise series for Germany, Ireland and the UK.Germany shows a fairly stable level for the whole period, Ireland a reductionby % from . There has been a % increase in alcohol-related mortal-ity in the UK from to (see Ch. ). Since data for and

became available during the course of this study, and there are other indica-tors showing both high consumption levels in the UK in (Leifman,a), and a continuing increase in unrecorded consumption, the analyseswere extended until . As can be seen, the UK noise series shows a slightdownward trend until , and from then on a % increase, with thesharpest rise taking place as from . Alcohol-related mortality has contin-ued to increase by as much as % from to and by % from .During the same period (–), the recorded alcohol consumptionincreased by only %.

The increase in the UK noise series accords with other signs of increasedunrecorded consumption, and is to some extent the result of increased cross-border trade between France and the UK (see also Leifman, b). Thiscross-channel shopping and smuggling has grown since the opening of thesingle market in and was in – estimated at a good . litre purealcohol per capita per year (see e.g., HM Customs and Excise, ; WSA,; IAS, ).

Figure . shows the trends for three central European countries: Austria,Belgium and the Netherlands. The Netherlands remains at a stable level forthe whole period, while unrecorded alcohol consumption possibly has slight-ly dropped in Austria and Belgium from the mid-s.

The trends for the Mediterranean countries are shown in Figure .. Thenoise series suggest that there have been no major changes in the level ofunrecorded consumption in the Mediterranean countries. The weak down-ward trend in the noise series from at least the s in France, Italy andSpain may actually indicate a slight reduction in unrecorded consumptionover time.

70

COUNTRY DIFFERENCES IN TOTAL CONSUMPTION

Table . shows the level of consumption in the study countries in –

(mean of the three years) with and without adjustment for the unrecordedalcohol consumption (as estimated). The highest recorded consumption isfound in Portugal (and not in France, which was previously the case for thewhole postwar period). The annual mean recorded consumption for all thestudy countries is . litres of pure alcohol per capita aged or more(counting each country as one unit). The figure increases to . litres whenestimated unrecorded consumption is added. The overall differencesbetween the countries are measured by the standard deviation (SD) and thecoefficient of variation (CV). As shown, both the absolute and relative dif-ferences are somewhat reduced when unrecorded alcohol consumption isadded to the recorded consumption.

The reduced differences are fairly modest, but they clearly imply thatcountries with the lowest recorded alcohol consumption begin to approachthe consumption levels of the remaining countries when the ‘total’ con-sumption is taken into account.

Some countries also shift in rank when the unrecorded consumption isadded, but to a large extent the overall differences between the low-con-sumption and high-consumption countries remain the same. For example,Norway and Sweden register both the lowest recorded and total consump-tion, whereas Portugal and France top the tables in both. Finland, however,moves up two positions and shows a higher total consumption than eitherItaly or the Netherlands.

The indirect estimate of the trend in unrecorded alcohol consumptionindicated small changes over the past years in Mediterranean and mostcentral European countries. Total consumption trends would therefore bealmost identical to the trends in recorded consumption but on somewhathigher levels. In the Nordic countries and the UK, however, the developmentwould look more different, since their unrecorded consumption seems tohave increased. All in all, this means that the homogenisation process inWestern European consumption levels, with diminishing national differ-ences in drinking (see e.g., Simpura, ; Leifman, c), appears strongerif the analyses are based on total consumption instead of only recorded alco-hol consumption.

However, the changes in unrecorded consumption that have occurred arenot large enough to alter the pace of the homogenisation process. This wasalso tested by assuming an increase in unrecorded consumption in the UKand the Nordic countries from to litres from the mid-s to mid-s,but with the same levels of unrecorded consumption in the remaining coun-

håkan leifman 71

tries during both periods. The relative positions between the countries thusremain more or less intact for both periods, both with and without adjust-ment for unrecorded alcohol.

Table .. Recorded alcohol consumption per year - and recorded plus unrecordedalcohol %, per capita, +.

Recorded consumption Recorded + unrecorded consumption

Portugal 13.7 Portugal 14.7France 13.6 France 14.6Ireland 12.7 Denmark 13.9Germany 11.9 Ireland 13.7Denmark 11.9 Germany 12.9Spain 11.8 Spain 12.8Austria 11.5 Austria 12.4Belgium 10.9 UK 11.4Netherlands 10.0 Belgium 11.4UK 9.4 Finland 11.1Italy 9.2 Italy 10.7Finland 8.6 Netherlands 10.5Sweden 6.1 Sweden 8.1Norway 5.3 Norway 7.1

Mean 10.5 11.8

CV 24 19SD 2.6 2.3Range 8.4 7.6

For estimates of unrecorded consumption, see Table 3.5.1 Source: Produchschap voor Gedistilleerde Dranken (World Drink Trends), 1999.

To sum up, this study finds evidence of homogenisation in beverage prefer-ences for the whole study period, which is in line with other studies. In quan-titative terms, however, the homogenisation in aggregate alcohol consump-tion was stronger in the first half of the study period. For the last – yearsthe homogenisation has been less distinct and can be explained mainly by adrastic reduction in wine consumption in the Mediterranean wine-drinkingcountries. In the beer and former spirits-drinking countries, there has notbeen any quantitative convergence since the mid-s. The absolute varia-tion between these beer-drinking countries has actually increased duringthe study period.

One important result from the assessments of unrecorded alcohol con-sumption is that the downward trend in recorded consumption in theMediterranean countries for the past – years is most likely a factualdecrease. The method used in this study of estimating the trend in con-

72

sumption of unrecorded alcohol gives no indication of an increasedunrecorded alcohol consumption in those countries. On the contrary, theindirect measure, i.e., the noise series, in France, Italy and Spain, would indi-cate a slight decrease. In the countries in Northern Europe, however,unrecorded alcohol consumption seems to have increased, from about litrein the s to litres per capita + in the second half of the s. There aresigns of increased unrecorded alcohol consumption in the UK, too, startingfrom the mid-s. In the remaining countries in Central Europe, thechanges in unrecorded alcohol appear to have been more modest over time.The levels seem to be especially stable in Germany and the Netherlands.

After adjusting for differences in estimated unrecorded consumption wecan conclude that the differences between the countries become somewhatreduced when the total consumption is taken into account. However, despitedifferences in unrecorded alcohol, the relative position of the countriesremains to a large extent unaffected, both in the s and in the s. Thus,the explanation as to why consumption has declined in Southern Europe andwhy Norway and Sweden, in particular, show a lower per capita consumptionthan the other countries must be sought elsewhere than by referring to coun-try differences in the volume of unrecorded alcohol.

EXPLANATIONS OF CHANGES IN CONSUMPTION TRENDS

Figures .–. showed that the estimated trends in alcohol-related mortali-ty not caused by recorded alcohol consumption are quite stable for mostcountries in Central and Southern Europe. This implies that the trends inalcohol-related mortality can be explained by the trends in recorded overallalcohol consumption.

The question then is how to explain consumption trends, and the reduc-tion in consumption in the traditionally wine-drinking countries in particu-lar. This will be discussed within three broad and highly interrelated areas inwhich the forces of globalisation and homogenisation make themselves felt:economy, culture (including modernisation, living conditions), and politics.

Economic factors

Different explanations have been given of the appearance of the long wavesof alcohol consumption, the last of these being the upward postwar trend inmost Westerns countries that continued until the mid- or late s. Severalscholars have pointed out that the explanatory variables normally referred toin relation to changes in alcohol consumption cannot explain these con-sumption trends. For instance, Mäkelä et al. () argue that such factors aspurchasing power and availability cannot explain these waves, despite the

håkan leifman 73

fact that the Western world witnessed a large increase in prosperity and inpurchasing power during the decades following the Second World War (e.g.,Sulkunen, ).

An econometric analysis (Leppänen et al., ), based on EU-countrydata for the period –, shows that alcohol prices as well as real incomeaffect overall consumption (alcohol sales). The estimated income elasticitieswere rather similar across all study countries, whereas the estimated priceelasticities were stronger in Northern Europe and weakest in SouthernEurope, but still statistically significant in the three groups of countries: wineproducing countries in Southern Europe, former spirits countries inNorthern Europe, and the traditionally beer drinking countries in CentralEurope, Ireland and the UK. Within these three groups of countries, the priceelasticities were equal.

The analyses also show that real incomes have increased in theMediterranean countries (as well as in the other study countries during thislong time period) and that the real prices have been rather stable for the past years or even decreased somewhat in Southern Europe.

Taken together, all this would trigger an increase in alcohol consumptionin all countries, including the Mediterranean countries. Since the consump-tion actually has gone down in Southern Europe, it means that the sum ofthe other factors influencing the consumption downwards has a strongerexplanatory power than real alcohol prices and real incomes. This conclusionis supported by the econometric time series analyses, which also estimatedthe effects of non-economic factors, after having taken the economic factorsinto account. The analyses showed that country-specific level parameters(excluding price and income) seem to account for the major part of theexplanation of the differences in alcohol consumption between the countries(Leppänen, ).

Culture, modernisation and living conditions

Several studies have pointed out different aspect of culture as the main orone important explanatory factor behind the consumption decline inSouthern Europe (see e.g., Simpura, ). One cultural process is the mod-ernisation process, which leads to a progressive homogenisation of life-styles(e.g., Sulkunen, ; Gual & Colom, ; Karlsson & Simpura, ). Thisstudy, however, has shown that at least for the last – years the differencesin consumption levels, in contrast to beverage preferences, point towardsonly a modest homogenisation and practically none if the Mediterraneancountries are excluded from the analyses.

Changes in living conditions – which can be seen as a part of modernisa-

74

tion process – and their links to alcohol consumption and drinking patternswere analysed by Karlsson & Simpura (). They concluded that rathersimilar trends in the development of living conditions in the EU memberstates (urbanisation, occupational structure, labour force participation,changes in transport and communication technologies, changing familystructure, spread of mass entertainment and mass tourism) have contributedto almost opposite results in terms of alcohol consumption in differentcountries and at different times. Urbanisation, industrialisation, the rapidgrowth of the service sector, high female labour force participation, thediminishing agricultural sector the emergence of new means of communica-tion and changes in the patterns of time use are common features of all stud-ied countries (see Karlsson & Simpura, ). However, the effect of thesechanges on alcohol consumption, differ between countries. In theMediterranean wine drinking countries, these changes have contributed to adecrease in consumption whereas almost the same process seem to have ledto an increase in the level of alcohol consumption in the former spiritsdrinking countries and some of the beer drinking countries. Thus, there is nodirect link between changes in living conditions and drinking. The process isindirect, mediated by each country’s historical and cultural background.

Two other mechanisms mentioned by Gual & Colom () which couldbe understood as cultural, economic and/or political processes are marketingand the entrance of new alcohol-free beverages. Marketing has grown duringthe last years but mostly for beer and spirits, which dominate the alcoholadvertising. Wine advertising appears only sporadically. Alcohol-free bever-ages give people the option to choose from several beverages, not only wine,and not only alcoholic beverages.

Political factors

Awareness of the negative consequences of alcohol has grown in SouthernEurope during the last years, and as result, new policies have been imple-mented which limit the availability, including a minimum drinking age andbanning of alcoholic beverages in the work-place (Gual & Colom, ;Simpura, ). Another ECAS study showed that homogenisation has alsoaffected the numbers of alcohol policy measures implemented in the studycountries (Österberg & Karlsson, ). The beer-drinking countries, andalso especially the wine-drinking countries, have an increasing number ofmeasures coming into force between and . In the former spirits-drinking countries, the number of measures was rather stable between– (although with a slight decrease in –), increased between–, stable again between –, was and decreased between

håkan leifman 75

–. The growing number of alcohol policy measures in theMediterranean countries is compatible with the observed pattern of thedownward trend in alcohol consumption. This, however, does not imply thatthe decline in consumption is the direct result of an increasing number ofalcohol measures, even though it is likely that they have contributed to theoverall consumption decline.

Common factors, such as fluctuations in the world economy, may con-tribute to similar trends in consumption. It is important to note, however,that all these global factors have not been strong enough to maintain thehomogenisation process at the same rapid speed for the last – years. Thismay indicate that the instruments of control or the drinking cultures still dif-fer markedly between countries and remain important enough to explainnational differences in the levels of consumption.

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Leifman, H. & Romelsjö, A. () The effect on changes in alcohol consumption on mor-tality and admissions with alcohol-related diagnoses in Stockholm Country - a timeseries analyses, Addiction, , -.

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jussi simpura, thomas karlsson & kalervo leppänen 79

Drinking patterns are at the same time a simple and self-evident phenome-non of everyday life, and a complicated issue located at the crossing of con-cerns of preventive alcohol policies, alcohol consumption and alcohol-relat-ed harm. Therefore, views on the role of drinking patterns with respect toother alcohol-related issues may differ radically. For laymen in the field ofalcohol prevention, drinking patterns are the most visible part of everydaylife experience with alcohol. Worries about problem drinking, and theunderlying changes in alcohol consumption, are of secondary importancefor them. For experts in the prevention field, the consequences of drinkingcome as the most visible part and fluctuations in alcohol consumption there-after, while drinking patterns have a secondary or tertiary role. Both for lay-men and experts, such issues as cultural change, or changes in living condi-tions and in economic factors, are background issues, not easily connectedwith their immediate concerns about alcohol. Still, from the viewpoint of thestudy of drinking patterns, understanding the role of the socioeconomicbackground is of crucial importance. This chapter brings together the find-ings that are available on long-term trends in drinking patterns in the ECAScountries, and tries to catch the main features of the dynamics of changestherein.

European trends in drinkingpatterns and their socio-economic backgroundby Jussi Simpura, Thomas Karlsson & Kalervo Leppänen

4.

80

THE ROLE OF DRINKING PATTERNS AND THEIR SOCIO-

ECONOMIC BACKGROUND IN THE EUROPEAN COMPARATIVE

ALCOHOL STUDY

Drinking patterns reflect centuries-old cultural traditions, are influenced bychanging living conditions and economic factors, and are the arena wherechanges in alcohol consumption (see Chapter ) are realised in everyday life.Thus, they are a multifaceted phenomenon not easily caught by comparativeresearch (see Chapter for an example). Drinking patterns also appear as apotential factor explaining a small part of the variation in the link betweenalcohol consumption and alcohol-related harm (see Chapters and ).Finally, drinking patterns can be taken as a target for preventive policies, inthe hope that patterns that are considered less detrimental could be promot-ed (see examples in Chapter ). Putting the ECAS project into a schematicformat, the role of drinking patterns can be viewed as in Figure . below, asan intervening factor between alcohol consumption and alcohol-relatedharm.

Each element in this scheme, indicated by small letters from a to g, pertainsto a certain part of the ECAS project as follows:

a. Alcohol policyb. Changes in alcohol consumption, registered and unregisteredc. Changes in drinking patternsd. Changes in living conditionse. Econometric analyses of changes in alcohol consumptionf. Changes in the prevalence of various consequences of drinkingg. Summary: the role of alcohol policy in influencing alcohol-related harm

This chapter is about three interrelated issues shown at the left-hand side ofthe scheme above: drinking patterns, living conditions and economic condi-tions. The question of cultural change is discussed only in passing. The focusis on drinking patterns (see Simpura & Karlsson a for a summary andb for more detailed country reports; also, see Chapter for an exampleof comparative research) and their socioeconomic background (see Karlsson& Simpura a for a summary and Karlsson & Simpura b for moredetails). It is important, however, to notice that economic conditions alsohave an important bearing on changes in alcohol consumption, as has beenshown in a demand analysis conducted as a part of the ECAS study (seeLeppänen et al., a for a summary and b for more details).

The concept of drinking pattern

A central problem of analyses of drinking patterns is that the concept of pat-terns is in itself vague. Some aspects of patterns are relatively unproblematic


(e.g., prevalence and frequencies of drinking, gender and age distributions),whereas some others pose difficulties. One conceptual difficulty lies in sepa-rating indicators of drinking patterns from those of alcohol consumption.The most frequently mentioned feature in international comparisons ofdrinking patterns is beverage preferences, probably because information onpreferences is easily available (see Chapter ). Stereotypically it is believedthat each beverage type (beer, wine, spirits) would have a characteristic pat-tern of use, which is more harmful with some beverages than others. Someeven go so far as to believe that the substances (beer, wine, spirits) in them-selves can be either harmful or beneficial. The issue is, however, complicatedand contradictory. For instance, thinking about context-specific drinkingpatterns, wine is the drink at meals mostly in the Mediterranean countries,but in Northern Europe, wine is used effectively as a beverage of leisure,sociability and intoxication, too. For many, distilled spirits are first and fore-

BACK- ALCOHOL- ALCOHOL ALCOHOLGROUND SPECIFIC POLICY RELATED

PROCESSES HARM

a

ECONOMIC ALCOHOLDEVELOPMENT POLICY

e b

ALCOHOL g CONSEQUENCES CONSUMPTION OF DRINKING

(REGISTERED AND

UNREGISTERED) f

CHANGES INLIVINGCONDITIONS

d

DRINKING PATTERNS

c

CULTURALCHANGES

Figure 4.1. The relationships between the various components of the ECAS project.

82

most intoxicants, but it goes unnoticed that vodka is a popular beverage atmeals in many places in Eastern Europe. Also in Spain, for instance, distilledspirits have an important role in sociability, to the extent that there the con-sumption of distilled spirits has been higher than in many “former spiritscountries’’ (this expression refers to the Northern European countries wherewhite spirits used to be the dominant beverage, in some countries as late asthe s). Evidently, beverage preferences are far too crude an indicator ofdifferences in drinking patterns for international comparisons.

A number of other features of drinking patterns are also problematic asanalytic and descriptive tools. From the viewpoint of the ECAS project, themost important is binge drinking. Intuitively, it is evident that the prevalenceof certain alcohol-related harms may be different depending on whether agiven amount of alcohol is consumed in a manner where consumption isconcentrated on a few occasions of high intake, say, during the week, com-pared with a more evenly distributed pattern. Therefore, information on thefrequency of occasions of high intake would be relevant. In internationalcomparisons, another problem arises from the fact that the idea of what is anoccasion may vary from one country to another.

Policy-relevant aspects of drinking patterns

Besides binge drinking, a number of features of drinking patterns may haverelevance from the point of view of preventive health policies (see Rehm etal., ). The first one is abstinence. Several studies have suggested thatabstainers may have a higher CHD mortality than moderate drinkers (seee.g., Poikolainen, ). The second important feature is the age and genderdistributions of alcohol consumption. There is much concern about drinkingby women and adolescents, and studies of the drinking patterns of women(e.g., Bloomfield et al., , Ahlström et al., ) and the ESPAD reportsabout adolescents (Hibell et al., , ) are central sources of informa-tion. Thirdly, the population distribution (i.e., how the population is distrib-uted between different levels of the volume of alcohol consumption) is ofcrucial importance, as several studies have suggested that the shape of theconsumption distribution is fairly similar in different countries (e.g., Skog). Such findings suggest a link between the per capita consumption andthe proportion of heavy drinkers in the population (see Edwards et al.,

for more details). Again, studies of drinking patterns are the only source ofinformation on population distributions. Finally, different risks of harm maybe related to different drinking contexts, like home vs. public drinkingpremises (bars, pubs etc.), sports and leisure events, traffic, etc. Here, too, theinformation on these aspects of drinking patterns can be collected only by


surveys of drinking patterns. So far, the issue of drinking contexts is aneglected topic in international alcohol research.

COMPETING EXPLANATIONS FOR CHANGES IN DRINKING

PATTERNS: CULTURE, ECONOMY, LIVING CONDITIONS

AND ALCOHOL POLICIES

What makes drinking patterns change and how do the changes become actu-alised? A number of competing explanations are available. We shall brieflyintroduce four competing models and then discuss the long-term dynamicsof changes in drinking patterns.

The cultural explanation

Cultural explanations refer to dynamics in local cultures that produce newvariations of old themes and adopt new elements from other cultures. Thecrucial question concerns the persistence of local traditional patterns underthe pressure from other cultures. Some of the rare long-term follow-up stud-ies suggest that traditional cultural patterns are surprisingly persistent in theface of changes in economy, living conditions and alcohol policies. So, thetradition of binge drinking did not weaken in Finland from the s tos, despite the quite dramatic changes in other conditions (Simpura &Partanen, ). Similarly, traditional patterns of wine drinking are far fromdisappearing from the Mediterranean countries despite decades of decliningalcohol consumption (see e.g. Gli Italiani e l’alcool, , about recent trendsin Italy).

The economic explanation

Economic factors, such as prices and purchasing power, should be consid-ered not only as aspects of overall social change, but also as factors withstrong and specific effects on alcohol consumption and beverage preferences.Economic considerations related to production and trade of alcoholic bever-ages often limit the scope of preventive alcohol policies, and even the burdenof alcohol-related diseases and other harms can be assessed in economicterms. Therefore, the economics of alcohol deserve more attention than isusually the case in studies on alcohol consumption, alcohol policies and alco-hol-related harm.

The econometric analyses of the ECAS study (Leppänen et al., a,b)show that economic factors have had a significant effect on alcohol con-sumption in the countries that could be included in the demand analysis(EU member countries (excluding Luxembourg and Germany), andNorway). However, dummy variables that account for the country mean val-

84

ues alone explained over percent of the variation in alcohol consumptionin an analysis of variance (see Table ..). Introducing country-specific priceand expenditure variables added about per cent to the explanation. Theremaining percent were accounted for by trend components. Thus, whenthe analysis was conducted by introducing the economic variables aftercountry mean values, the results suggested that the specific role of the eco-nomic factors was quite small, although certainly significant. In contrast,introducing only the price and expenditure variables (the latter reflectingchanges in purchasing power) with common parameters explained slightlyover half of the total variation. Thus, the role of economic factors in explain-ing variation in alcohol consumption appears more significant in the latterapproach. There are no self-evident scientific grounds for preferring oneapproach to another, and therefore the question about the exact role of eco-nomic factors remains open.

Table 4.1. The role of economic factors in explaining the variation in consumption ofabsolute alcohol in 14 European countries: a variance decomposition table

Model Share explained Increase Number of parameters Increase

Country dummies 0.826 0.826 13Adding economics 0.935 0.109 51 28Adding trends 0.981 0.045 73 22

Price and expenditure 0.559 2

Source: Leppänen et al., 2001b, 43

Following the first approach and introducing non-economic factors firstinto the models, the non-economic factors (i.e., factors other than alcoholprices and purchasing power) have a major role in explaining differencesbetween countries in alcohol consumption. The non-economic factors arerelated to culture and living conditions, and even to alcohol policies.Drinking patterns are one aspect of everyday life patterns that are largely cul-turally determined, although certainly not immune to change. Changes inliving conditions shape the context where drinking takes place, where drink-ing patterns are put in use and continuously reformulated, and where alco-hol-related harms occur differently in different times, places and even coun-tries. However, as Leppänen et al. (b, ) conclude, it may not be an easytask to find objective characteristics and measurable variables that lie behindthe non-economic factors.

The results from the econometric demand analysis have also been used to


assess how economic factors are related to the harmonisation of absolutealcohol consumption among the countries. It would appear that harmon-isation could be more easily achieved by equal prices than by equal realexpenditure levels across the countries (Leppänen et al., b, ).

Economic explanations of changes in drinking patterns operate by pricesand purchasing power. Price changes have an effect on the overall level ofalcohol consumption, and thereby also on drinking frequencies and intakeper occasion. Price changes can also influence beverage preferences, if sometype of alcoholic beverages were favoured at the expense of others in taxationof alcohol. Changes that relate to drinking contexts may occur, e.g., drinkingon public premises may become less expensive in relative terms. Price elas-ticities, i.e., the intensity by which changes in prices are felt in the consump-tion of alcohol, vary between countries and over time in Europe. Also,changes in incomes generally affect drinking. In the countries, increasingincomes have tended to lead to increasing alcohol consumption. The esti-mated price and expenditure elasticities are shown in Table .. Importantly,the analysis produced a common expenditure elasticity estimate for allgroups of countries, showing similar income effects everywhere.

Table 4.2. Estimated price and expenditure elasticities from the demand analysis for alco-holic beverages.

Countries Price elasticities Expenditure elasticities

Monopoly countries -0.782 (10.6) 0.752 (14.4)Wine producers -0.216 (4.6) 0.752 (14.4)Others -0.495 (5.5) 0.752 (14.4)Netherlands -1.466 (5.8) 0.752 (14.4)

(T values in parentheses)

Source: Leppänen et al., 2001b, 33Monopoly countries: Finland, Sweden, NorwayWine producers: Austria, France, Greece, Italy, Portugal and SpainOther countries: Belgium, Denmark, Ireland, United KingdomThe Netherlands comprised a category of its own

The explanations by changes in living condition

In a broad sense, changes in culture and economy are two important aspectsof changes in living conditions. More specifically, it can be assumed that sev-eral processes of changing living conditions could extend their influence ondrinking patterns. In the analyses conducted for the ECAS study (Karlsson &Simpura, a,b), general issues like modernisation, urbanisation and inter-nationalisation were considered. If cultural traditions are, as seems to be the

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Figure 4.2.b. Urban population as percentage of total population vs. level of totalalcohol consumption, 15 EU countries (+Norway), 1950-1995.

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Figure 4.2.c. Urban population as percentage of total population vs. level of totalalcohol consumption, 15 EU countries (+Norway), 1950 - 1995.

Former spirits countries

Sources: Miettinen, 1997; United Nations Demographic Yearbook 1970; 1963; 1952; 1997; UnitedNations Statistical Yearbook 1990/91; Hurst et al., 1997.

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case, an important element in drinking patterns, modernisation would be amajor challenge. When it comes to drinking patterns, it is not self-evident,however, that modernisation works in the same direction in different coun-tries. For instance, rapid urbanisation in the low-consumption countries inNorthern Europe since the s led to increasing alcohol consumption(although not to qualitatively very different patterns; see Figure .), whilemodernisation in the Mediterranean countries has contributed to the declineof alcohol consumption, and of wine drinking in particular (but again withrelatively small changes in the qualitative features of drinking).

Urbanisation, changes in transport and communication technologies,changing family structures and the spread of international mass entertain-ment and tourism (see Trolldal, ) all may have an effect on drinking pat-terns. Such effects are not easily extractable from existing studies.

Alcohol policies and drinking patterns

Alcohol policies are often targeted at harmful drinking patterns, eitherdirectly or indirectly (see Chapter ). An example of indirect measures, andactually the largest single alcohol policy measure in the EU member statessince World War II, is the Finnish reform of . One purpose of the reformwas to get the Finns to abandon their beloved distilled spirits, available at thestate monopoly stores only, by introducing a milder ‘’medium’’ beer that wasmade available at all grocery stores and cafés. It was believed that easy accessto a mild alcoholic beverage would lead to a reduction in binge drinking ofspirits that was considered particularly harmful. Unfortunately, none of theexpectations of the reformers were fulfilled: the Finns did not substitute beerfor vodka, they did not turn away from binge drinking, and the aggregatealcohol consumption was more than doubled in one year, with concomitantincrease in alcohol-related harm (see Mäkelä et al., for details).

Today, many voices declare that it must be possible to take measures thatare focused on harmful drinking patterns rather than on aggregate alcoholconsumption (see e.g. the ‘’harm reduction’’ approach, Rehm, ; alsoRehm et al., , and the remarks by Simpura, ). Focusing on harmfulpatterns is also echoed in the second European Alcohol Action Plan ()by the WHO Regional Office for Europe. So far, little is known about theeffectiveness of the measures targeted at specific aspects of drinking patterns,but undoubtedly such studies will increase in number in the coming years.

Long waves and slow homogenisation?

Finally, earlier research suggests that changes in drinking patterns may re-semble changes in overall alcohol consumption (see Chapter for more

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detail on European countries) in two respects. First, in addition to short-term fluctuations, alcohol consumption may show very long waves, withwavelengths of to years or even more. There was thus a peak in alcoholconsumption in many countries around the middle or end of the th cen-tury, followed by a trough in the s and s, and then a new peakaround the s (see Room, for discussion; also Skog, ). It isunclear how changes in qualitative features of drinking patterns are relatedto these long waves. Secondly, it is well known that per capita alcohol con-sumption and beverage preferences have shown a slow homogenisation inWestern Europe since World War II (see Chapter ), although there still aremajor differences between the countries. Intuitively, but not obviously, thishomogenisation would suggest a homogenisation of more qualitative fea-tures of drinking patterns as well.

LACK OF COMPARATIVE LONG-TERM DATA ON DRINKING PATTERNS

The ECAS research group compiled information on drinking habit surveysin all of the ECAS countries in order to collect material for a comparativestudy in trends of drinking patterns since . However, four major obsta-cles arose that made the task almost impossible:

Lack of studies that are comparable over a longer period of time. Only a fewcountries can provide long series of studies that are comparable over severaldecades (see Simpura & Karlsson, a,b for detail and references). TheNetherlands is the only country with nation-wide representative and com-parable data since the s. Finland, Norway, Sweden and, to some extent,the United Kingdom can provide series that begin in the late s or in thes. In other countries, the series begin in the s (Denmark, Austria), inthe s (Germany, Italy, France), or there are only scattered studies(Ireland, Spain, Portugal, Greece), or no nation-wide studies at all(Belgium). Experience from countries with longer series of studies showsthat a period of to years or less may be too short for significant changesin drinking habits to occur. Therefore, trends in drinking patterns can bedescribed and analysed for a few countries only.

Incomparable measures of drinking pattern. There is no widely acceptedstandard for how drinking patterns should be measured in surveys in orderto ensure comparability, although there are a few ongoing efforts towardsthis end. In practice, studies from different countries may differ greatly in theaspects of drinking patterns they cover and by what kind of questions. Thereis seldom any possibility to adjust the data afterwards in order to make themmore comparable. This leads to a situation where it would be worthwhile toanalyse the trends in each country separately, as far as possible; only there-


after should a comparison of trends be completed. This would require accessto national data sets and labour input by national experts on a scale thatcould not be achieved within the ECAS study.

Limited coverage of different aspects of drinking patterns. Even in specificdrinking habits surveys, only a limited number of aspects of drinking pat-terns can be covered. Usually, some measures of abstinence (drinkers vs.nondrinkers) and drinking frequencies (often by type of beverage) are avail-able. Information on typical volumes per occasion or per day or week is alsocommon. More seldom, one can find data on actual intake per occasion, oron binge drinking. Data on drinking contexts are very scarce. Fortunately,however, most studies contain the standard socioeconomic variables (ageand gender) in a comparable fashion. The lack of data on binge drinking wasperhaps the most serious drawback for the general goals of the ECAS study.

The variable degree of underreporting. In surveys where some type of esti-mate of daily, weekly, monthly or annual alcohol consumption by therespondents can be provided, it is possible to compare the survey estimate ofper-capita alcohol consumption with sales data (see Chapter for an exam-ple). Usually, the comparisons between survey estimates and sales data indi-cate major underreporting. Typically, -% of actual alcohol consumptionis covered by surveys. What makes the problem even more difficult in a com-parative study is that the underreporting seems to vary over time as well asacross countries. This problem does not only concern studies that aim atmeasuring alcohol consumption, but it is present (although undetectable) instudies with more modest purposes (e.g., the ESPAD study (Hibell et al.,, ) on drinking patterns among --year-olds). Users of any surveydata on drinking patterns should be seriously warned against the use of com-parative survey findings at face value. In addition to these problems, there arethe normal difficulties that arise in comparative work because of differencesin sampling, fieldwork procedures, response rates and the wording of ques-tions (and even their interpretation, see e.g., Chapter ).

TRENDS IN DRINKING PATTERNS IN 1950 TO 1995:

SLOW HOMOGENISATION BUT STILL MAJOR DIFFERENCES

The following sections sum up the main features of trends in drinking pat-terns that could be distilled from the unexpectedly scarce data that finallywere available. Below we first show examples of trends in such countrieswhere trend data are available from several decades. In the next section, weshall show additional, more comparative examples. The results below comefrom country reports on drinking patterns compiled for the ECAS study(Simpura and Karlsson, b).

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Beverage-specific drinking frequencies

Official consumption statistics show large changes in beverage preferencesover decades (see Chapter ), to the extent that countries may have movedfrom one group to another. So, the Nordic countries are today “former spir-its countries’’, as beer and wine have become increasingly popular. Behindthe consumption statistics, the changes in drinking patterns may be muchslower. The example from the long series of surveys in Norway is illustrative(Table .):

Table 4.3.Trends in beverage-specific drinking frequencies in Norway: average number ofannual occasions of drinking beer, wine and spirits, among the users of each beveragetype, in six nation-wide surveys (number of occasions per year, in population aged 18years or more)

Year 1962 1966 1968 1973 1979 1985

Beer 32 38 39 45 42 34Wine 14 16 17 16 20 20Spirits 19 24 23 26 26 23

Sources: Nordlund 1985, 54; Nordlund 1987

Abstinence

In the traditionally temperance-minded Nordic countries (the “former spir-its countries’’ Finland, Norway, and Sweden) abstinence rates started todecline in the s and s. At the same time, the differences in abstinencerates between men and women diminished, but did not disappear. In theCentral European beer countries, the data do not allow for any long-termanalyses, but the figures that are somehow comparable with the Nordic onesindicate a lower prevalence of abstinence than in the Nordic countries. InBritain, however, comparable data covering more than two decades is avail-able, showing very little fluctuation in abstinence rates (Table .):

Table 4.4.Trends in abstinence rates in the United Kingdom: respondents who reportedno drinking in the last 12 months in General Health Surveys, 1978 to 1996 (percent ofmale/female respondents aged 18 years or more)

Year 1978 1980 1982 1982 1986 1988 1990 1992 1994 1996

Men 5 5 6 7 6 7 6 6 7 7Women 11 12 12 13 11 12 12 12 14 13

Sources: Data compiled from General Health Surveys for the ECAS country report on drinking patterns in the UK,see Simpura and Karlsson 2001c.


The few results from the Mediterranean wine-drinking countries containsome surprising findings (see Figure . below). In some studies, abstinencerates among women are very high, as high as or higher than in the Nordiccountries. Here, as always, a reservation must be made for the comparabilityof the data. It is not certain whether the expression “I have not drunk alco-holic beverages during the last month/ months” is understood similarly indifferent cultures.

Gender and age distributions

A detailed study of drinking patterns of women in nine countries in thes, as compared with men (Bloomfield et al., ; see also Ahlström et al.,), showed that women’s share of aggregate alcohol consumption variedroughly between and %. Similar proportions have been reported by sev-eral earlier studies. Except for the Nordic countries, the Netherlands and theUK, there is fairly little information on possible trends in women’s share. Thedecline of temperance among women in the former spirits countries of thenorth led to a significant increase of women’s share in the s and s. Inthe Netherlands, a similar turn occurred somewhat earlier. Otherwise, it iseven difficult to say whether an increase in women’s drinking may have beenan all-European phenomenon in the postwar years. Actually, given thedecline in alcohol consumption in the wine-drinking countries, even anincrease in the women’s share of alcohol consumption could have accompa-nied a decrease in the actual annual per-capita consumption among women.It is impossible to say anything certain about present trends in the genderdistribution of alcohol consumption.

Our review did not try to cover systematically drinking among adoles-cents, as this issue has been broadly dealt with in the reports related to theESPAD studies from and (Hibell et al., and ). Even theESPAD studies cover too short a period for saying anything about trends.When it comes to the question of which age groups drink most in differenttimes and different countries, neither systematic patterns nor any commontrends can be detected. Only one thing seems certain: contrary to stereotyp-ical prejudices, in no country do young people under the age of drinkmore than their elders. Otherwise, the heaviest drinking group may havebeen young adults in some countries and at some time, or middle-aged peo-ple in other countries and other times, or even the elderly at their sixties inyet other countries. Most typically, however, the heaviest-drinking groups aremales in their thirties and forties. As an example, we show the compiled find-ings from various Italian studies from the s to the s (Table .):

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Table 4.5. Differences in per capita alcohol consumption between age groups in Italy fromthe 1950s to the 1990s (index numbers; each year, the average consumption formen/women is set by 100)

Decade Average 15-24 25-34 35-44 45-54 Over 54years years years years years

Men:1950s 100 63 74 110 131 1181960s 100 60 70 115 129 1111970s 100 55 68 110 134 1121980s 100 56 71 114 126 1161990s 100 42 63 121 133 115

Women:1950s 100 52 63 101 105 1031960s 100 51 62 103 108 1021970s 100 50 59 102 115 1071980s 100 51 64 109 107 1111990s 100 40 59 118 102 109

Source: Data compiled and calculated by the ECAS contact persons from various studies in Italy; see the coun-try report in Simpura and Karlsson, 2001b, for references.

The population distribution of alcohol consumption

Although many studies contain information on the volume of daily, weekly,monthly or annual alcohol consumption, this information is seldom report-ed in a fashion that would allow a study of the shape of the consumption dis-tribution. More detailed studies of the shape of the consumption distribu-tion would require access to original national data sets. The few existinglonger series of national studies do not suggest that any radical changes inthe basic shape of the population distribution have taken place during thestudy period.

Binge drinking

Unfortunately, no comparative European data are available on trends in theprevalence of binge drinking. As mentioned above, this information wouldhave been of crucial importance when considering the links between alcoholconsumption, drinking patterns and alcohol-related harm. There is not evenvery much comparable information on differences between countries today.Even if it did exist, the situation would be problematic, as it is quite possiblethat the prevalence of binge drinking and its share of all alcohol consump-tion could have changed over a longer period of time. The few existingnational studies that provide some basis for such considerations suggest,however, that qualitative features, such as binge drinking, are not prone tochange quickly. The experience from Finland since the s (Table .)shows, first, that the prevalence of binge drinking increased after the liberal-


isation of alcohol policies in . Secondly, there are no signs of weakeningof this traditional pattern in the s. On the contrary, binge drinking hasbecome more prevalent among women in particular, at the same time whenwomen’s drinking increased in the country. A stabilisation of the trend hasoccurred in the s.

Table 4.6 Trends in the prevalence of binge drinking in Finland: proportion of drinkerswho report having drunk at least once a week “enough to feel it a little” (percent ofmale/female respondents between 15 and 69 yers of age each year)

Year 1968 (1976) 1984 1992 2000

Men 14 .. 25 29 30Women 2 .. 5 11 13

Sources: Mustonen et al., 1999, original data from the Finnish drinking habits survey 2000 (see Mustonen et al.,2001)

Note: The question on binge drinking was not included in the 1976 study. The column of 1976 is shown here forthe sake of illustration of equal intervals between the studies.

One of the few existing international comparisons (Mäkelä et al., ,) on binge drinking in Europe (Denmark, Finland, Norway and Sweden,with data from ) shows that there may be differences between countries,although they were not dramatically large between these four somewhat sim-ilar countries. But that study also showed how the wording of questions canchange the order of the countries with respect to the prevalence of bingedrinking.

Specific drinking contexts

The scarce existing data on drinking in different contexts cannot be used tosupport or to disprove the numerous popular beliefs about differencesbetween drinking occasions taking place in different contexts. Thus, we can-not ascertain whether drinking at home and with family is associated withlower consumption and a lower blood alcohol concentration than drinkingin other contexts, e.g., bars. Even less can be said about whether this wouldhave been true everywhere and in all times, or whether the countries wouldhave become increasingly similar with respect to such context-specific fea-tures. However, more and more data are being collected in different coun-tries on drinking contexts, and in a few years it may become possible to saysomething more specific about these questions.

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COMPARATIVE EXAMPLES OF THE SLOW

MOTION OF DRINKING PATTERNS

Many of the findings on changes in drinking patterns suggest that thechanges are typically slow and take decades and even generations to becomeclearly visible. Much of the evidence to support this view is, however, frag-mentary and descriptive only (Simpura & Karlsson (a,c) present sum-maries of the available findings). A proper analysis of the dynamics of slowchanges would require long series of technically comparative studies, prefer-ably with regular intervals, and ideally, with a repeated data collection fromthe same respondents from one year to another. Then, an age-period-cohortanalysis could distinguish between three types of time-related changes: age-ing, effects that relate to specific events at specific times (e.g., major reformsin alcohol policy), and the effects of shared life experience of a birth cohort.As is evident from the review presented in this chapter, these requirementscannot be met in any European country.

In some countries, however, attempts have been made to proceed in thisdirection. The most ambitious effort is the Dutch cohort analysis conductedby Neve et al. (), using survey data from the years , , and. They discussed changes in abstinence rates, levels of alcohol consump-tion, prevalence of heavy drinking, and gender differences in changes. Theyconcluded (Neve et al., , ) that (a) “abstinence appears to be associat-ed with age of respondents, while no evidence was found for cohort or peri-od effects”; (b) “no cohort effects were found in the analysis of developmentsin levels of alcohol consumption”, so that “the Dutch population as a wholeto a large extent behaves collectively with respect to drinking behavior”; ( c)“developments in heavy drinking appeared to be related strongly to those inmean consumption”; and (d) “while large differences in drinking behaviourpersist throughout the period covered, results for women show more regu-larity than those of men”.

Another example, although more descriptive in nature, is provided fromthe long series of Finnish surveys on drinking patterns. Sulkunen (; seealso Sulkunen ) suggested that a “wet generation” (those born in thes) could be found, and that this generation had largely abandoned thetemperance culture of their parents, the “dry generation”. The differencebetween the two generations was most visible in the steep decline of absti-nence rates in the s and s. Simpura and Partanen () analysed thesuggested rise of a “modern” drinking pattern (more regular intake of small-er amounts per occasion) and the respective decline of “traditional” drinking(irregular occasions with high alcohol intake as the dominant pattern). It wasexpected that the “modern” pattern should have been more popular among

the younger age cohorts, and the “traditional” pattern among the older.However, the results showed that the “traditional” pattern had not weakenedat all, but had strengthened all through the population. The “modern” pat-tern had got some foothold among well-educated groups in their s ands, but not among the younger. It was difficult to distinguish between ageand cohort effects in this analysis.

On the European level, two issues would be most interesting for an age-period-cohort analysis of drinking patterns. The first one is the decline inabstinence rates that has been experienced in Northern Europe. An interpre-tation of this decline would be a cultural shift away from the temperance-minded ideas of the older generations. A decline in traditionally high absti-nence rates could be expected among women in the Mediterranean countriesas well, where the changes could be related to the changing position ofwomen in general. In Figure ., we present a compilation of findings onabstinence rates in the ECAS countries.

Only one wine country (Italy; trend data not available for men and womenseparately) and one beer country (the Netherlands) provide long series offindings on abstinence rates among the adult population. Equally long seriesare available for all three former spirits countries (Finland, Sweden,Norway). The findings presented in Figure . show that the development ofabstinence rates has been smooth in Italy and the Netherlands, whereas asteep decline was experienced among women in Finland, Norway andSweden in the s and s. Among men, the decline of abstinence rateshas been less dramatic but still significant in the former spirits countries.

The second issue of interest for an age-period-cohort analysis are changesin the regularity of drinking. Regular daily drinking, often at meals, could betaken as a sign of a higher level of integration of drinking into everyday life,as against irregular, non-integrated drinking. In policy debates, integrateddrinking is often presented as less harmful than non-integrated drinking.The prevalence of daily drinking and drinking at meals would then serve asindicators of regularity and integration, and the prevalence of binge drink-ing as an indicator of risky, irregular drinking. The underlying idea would bethat regularity and routines create good ground for informal control ofdrinking. On the other hand, irregular drinking would not promote the riseand use of informal control but would call for more formal and externalmeasures.

Evidently, the concepts of regularity and integration are more vague thanthe concept of abstinence, and there are more problems on the level ofempirical indicators, too. Anyway, it would be of interest to find out to whatextent “integrated” drinking develops in countries with traditionally more

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Figure 4.3.b. Abstainers as percentage of adult population. Males and females separa-tely. 1950 to 1995.

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Figure 4.3.c. Abstainers as percentage of adult population. Males and females separa-tely. 1950 to 1995.

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“non-integrated” patterns. These countries are typically located in NorthernEurope. Similarly, it is of interest to know to what extent the decline in alco-hol consumption in the Mediterranean countries could be related to adecline of the traditional “integrated” drinking. Again, lack of longer seriesof studies makes it impossible to say anything very specific about thesechanges. In the Mediterranean countries, the Italian series of studies is thebest available source (see the country report on Italy in Simpura & Karlsson,b). So far, there are no signs of any dramatic weakening of the pattern of“integrated” drinking in Italy. At the other end of the scale, the long series ofFinnish studies (see the country report on Finland in Simpura & Karlsson,b) shows that the drift to an “integrated” drinking pattern has proceed-ed slowly, if at all.

CONCLUDING REMARKS

Because of lack of comparable data, hardly any systematic all-European trendsin drinking patterns could be ascertained on the basis of the existing compara-ble data from 15 countries since 1950. Not even the simplest things, such asrates of abstinence, or the gender distribution of alcohol consumption couldbe described in such detail as to reveal clear-cut tendencies. Still, manyEuropeans today drink more than ever (in the Nordic countries), and evenmore Europeans today drink less than ever (in the Mediterranean countries).Something may well have happened to drinking patterns, too, but we areunable to know exactly what. Still it is worthwhile to make a few remarksabout the dynamics of change in drinking patterns. Homogenisation and theassumed slow trends and long waves were the most important overalldescriptive models for the change.

The homogenisation between the European countries that is visible inper capita alcohol consumption and beverage preferences can have takenmany different routes in drinking patterns. It may have happened throughhomogenisation of frequencies of drinking, or of intake per occasion. It mayhave led to diminishing relative differences in the share of binge drinking. Itis, however, important to note that, today there is still a wide variationbetween countries in most aspects of drinking patterns, perhaps with the excep-tion of women’s share of aggregate alcohol consumption.

But evidently there has been much homogenisation in living conditions,although the countries have experienced urbanisation, internationalisationand the spread of the automobile revolution, mass tourism and global enter-tainment at different times (see Karlsson & Simpura, a,b). There remain,of course, differences between countries in these aspects of living conditions,too. It is impossible to say whether the homogenisation of living conditions

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has proceeded further than the homogenisation of drinking patterns. Ourhypothesis of the persistence of qualitative features of drinking patternswould suggest that differences in drinking patterns could prevail even inspite of quite homogeneous living conditions. The countries show also aremarkable homogenisation in economic conditions. There may even besigns of homogenisation in the manner of how economic factors affect alco-hol consumption (see Leppänen et al., a,b).

Our findings suggest that typically the qualitative features of drinking pat-terns change slowly, in decades and generations rather than in a few years. Suchfeatures have survived in spite of radical changes of alcohol control policies,economy and living conditions. This makes it difficult to imagine how pre-ventive policy measures could successfully influence qualitative features,such as binge drinking or preferences for different drinking contexts. This isnot to say that drinking patterns are unchangeable. They change all the time,but the processes of change are mostly beyond the reach of public policymeasures. Only in some very specific instances are the measures targeted atliving conditions likely to be successful.

But at the moment there is very little evidence one way or the other of thepotential of measures targeted at drinking patterns in the prevention of alcoholrelated harm. Evidently, much of the political debate around these issues isbased on sheer imagination, stereotypical images and prejudice. Again, thisdoes not mean that drinking patterns and specific harms related to specificpatterns would be immune to preventive interventions. But much moreresearch, and, unfortunately, quite many years, will be needed until we canknow exactly how drinking patterns are associated with different alcohol-related harms and how policies can be developed to influence this link. A firststep to improve the international knowledge base on drinking patternswould be an internationally co-ordinated and supported effort to preparesystematic national trend reports. The ECAS experience shows that sucheffort will become possible in many countries in the first years of the s,with the increasing number of studies on drinking patterns

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Leifman, H. (2001) Homogenisation in alcohol consumption in the European Union,Nordic Studies on Alcohol and Drugs, 18, English Supplement, 15-30.

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håkan leifman, örjan hemström& mats ramstedt 105

INTRODUCTION

Most comparative studies on national differences in alcohol consumptionare based on analyses of recorded alcohol consumption, i.e., alcohol sales.These aggregate data, however, do not permit any detailed analyses ofnational differences in drinking patterns, nor is it possible to break downthese consumption data in sub-populations defined, for example, by genderand age. For these purposes individual-level data are needed. Given thescarcity of such data (see Ch. ), the ECAS project conducted a special sur-vey in six Member States in spring . The survey was conducted in coun-tries representing groups with different drinking cultures. The traditionalwine-drinking countries were represented by France and Italy, the beer-drinking countries by Germany (excluding former East Germany) and theUK, and the former spirits-drinking countries, but now beer-drinking coun-tries, by Finland and Sweden. In each country, about , respondents, aged to years, were randomly selected. Five reports have been written on thebasis of these data: one dealing with methodological issues (Leifman, a),one on drinking habits (Leifman, b), one on alcohol-related conse-quences (Ramstedt, ), one on informal control (Hemström, a), andone on attitudes (Hemström, b). The present chapter summarises thesereports.

The ECAS-survey on drinking patterns and alcohol-related problemsby Håkan Leifman, Örjan Hemström & Mats Ramstedt

5.

106

DATA

The data derive from general population surveys conducted in each of the sixcountries. Different fieldwork agencies for the different countries collectedthe data by telephone interviews. The Swedish field agency was commis-sioned to co-ordinate the work of the other five agencies. The work was donein co-operation with ECAS researchers.

The sampling procedure (Random Digit Dialing) differed somewhatbetween the countries, but should in each be representative of the adult pop-ulation aged - years. The ‘birthday method’ was used, meaning that theperson in the household next in line to have a birthday should be inter-viewed. A maximum of seven calls were made to each household.

In all study countries, the questions were made as similar as possible. TheQuantity-Frequency scale (QF-scale) was used for estimating volume ofdrinking. Each country included the QF-scale for beer, spirits and wine (andcider in all countries except Sweden and Italy). For each of the alcoholic bev-erages, the respondents were asked how often they drink, and when they dodrink how much is usually consumed.

Binge drinking was defined as an occasion when the respondent had con-sumed at least one bottle of wine, centilitres of spirits or cans of beer.The prevalence of current drinking problems was measured by the followingeight items: Have you ever during the past months:

(1) Got into a fight when you had been drinking? (2) Been in an accident of any kind when you had been drinking? (3) Ever felt that you should cut down on your drinking? (4) Regretted something you said or did after drinking? (5) Felt that your drinking harmed your home life or marriage? (6) Felt that your drinking harmed your work or studies? (7) Felt that your drinking harmed your friendships or social life? (8) Felt that your drinking harmed your health?

Various dimensions of negative experiences of one’s own drinking are sub-sequently included e.g., reckless behaviour, dependency symptoms and socialharm.

There were also questions on context of drinking, consumption and pro-duction of home-made alcoholic beverages, private import of alcoholic bev-erages from abroad, informal control (if one has tried to influence other peo-ple to drink less), attitudes towards alcohol control, and alcohol and vio-lence, in particular the excuse value of drinking for violence.

A crucial issue concerns the comparability of the six samples. This issuewas raised at the beginning of the analyses since we found large country dif-


ferences in response rates and coverage rates (i.e., the self-reported surveyestimate of per capita consumption in relation to the recorded per capitaconsumption, see Leifman (a) for a more detailed discussion). However,it should be noted that these differences limit the comparability across studycountries. As a consequence, direct comparisons of drinking across the coun-tries will be largely avoided. Instead, most of the comparative analyses will bebased on ratios calculated for each country, such as age and gender ratios indrinking and the number of heavy drinking occasions per drinking occasion.The rationale for this is that it may be assumed that both dimensions (e.g.,heavy drinking occasions and frequency of drinking) and both groups (e.g.,men and women, young and old) show approximately the same degree ofunderestimation.

DRINKING PATTERNS

Frequency of drinking

Table . shows the frequency of drinking days by gender, based on the mostfrequently consumed beverage for each respondent (including the abstain-ers). The results should be seen as minimum levels, since different beveragesmay be consumed on different occasions and days. However, it should give arather good picture of the general trends. The frequencies differ substantial-ly between the six countries, with the highest frequency of regular drinking

Table .. Frequency (%) of drinking. Based on the beverage that has the highest frequen-cy for the respondent

Daily 4-5 days 2-3 days Once 2-3 days Once One or a Nevera week a week a week a month a month few days

a year

Men:Finland 4 4 20 32 19 7 8 6France 21 5 19 23 7 5 8 13Germany 12 6 24 18 11 11 7 12Italy 42 3 17 14 4 4 6 11Sweden 3 4 16 24 23 12 12 7UK 9 16 31 18 8 4 4 11

Women:Finland 2 2 7 22 22 14 24 8France 9 3 10 16 9 12 14 27Germany 5 2 13 20 15 10 17 18Italy 26 4 10 12 8 4 14 22Sweden 1 1 5 17 24 17 23 13UK 5 6 18 22 12 10 11 14

108

(- times a week or more often) for both men and women in Italy, followedby the UK, France and Germany. The lowest frequencies are found in the twoNordic countries. Also the proportion of daily drinkers is by far highest inItaly, with France in second place. Forty-two percent of Italian men and %of women drink daily. In France, % of men and % of women drink daily.Germany and the UK show about the same proportions for daily drinking:approximately % of men and % of women. In Sweden and Finland, thepercentage of daily drinkers is much lower: among women -% and amongmen -%.

Age-specific analyses showed that the frequency of drinking increases withage in all study countries, except for the UK, where results suggest that theyoungest drink as often as their elders.

Volume per drinking occasion

The results suggest that the volume of alcohol consumed per drinking occa-sion differs across the study countries. However, here the highest quantitiesare generally found in Northern Europe and the lowest in Southern Europe(Table .). For both men and women, at all ages, the highest consumptionper drinking occasion is found in the UK, Sweden and Finland.

Shifting the focus to age differences, the table shows that, in all countries,the youngest show the highest quantity of spirits consumption per drinkingoccasion and, in all countries but Germany, the highest beer consumptionper drinking occasion. Wine consumption is more evenly distributed acrossage groups, but generally somewhat higher in the middle age group. Thelargest percentage difference between the youngest (-) and their elders isfound in Finland, Sweden and the UK.

Binge drinking

In line with the findings regarding average quantity per drinking occasion,also the number of heavy drinking occasions (binge drinking defined asdrinking one bottle of wine or equivalent on the occasion), and especially theproportion of heavy drinking occasions to all drinking occasions, show anorth-south gradient, with the highest frequency in north and the lowest insouth (Table .). This north-south gradient is visible both for men andwomen. It may be noted that men report approximately to times morebinge drinking occasions than women in all six countries (data not shown).In addition, analyses showed that in all countries, except Italy, the youngestreported the highest frequency of binge drinking.


Table .. Volume (cl. alcohol %) per drinking occasion for each alcoholic beverage

Finland France Germany Italy Sweden UK

Men:Beer:18-29 9.0 3.1 3.0 2.0 9.7 8.930-49 4.8 2.4 3.3 1.9 6.4 6.150-64 3.7 1.5 2.8 1.2 2.5 5.4Total 5.9 2.4 3.1 1.7 6.3 6.7

Wine:18-29 2.9 2.4 3.0 2.1 3.3 3.730-49 3.6 3.1 3.2 2.4 3.5 3.950-64 3.6 2.9 2.5 2.5 2.9 3.6Total 3.4 2.8 3.0 2.3 3.3 3.8

Spirits:18-29 7.4 3.4 3.3 1.9 6.9 4.030-49 7.0 2.2 2.5 1.1 4.1 2.450-64 6.7 1.3 1.7 1.0 3.1 2.6Total 7.1 2.4 2.5 1.3 4.7 2.9

Women:Beer:18-29 4.5 1.2 1.9 1.2 4.5 3.430-49 2.2 0.6 1.6 1.2 2.2 1.950-64 1.5 0.5 1.1 0.8 1.1 1.1Total 2.0 0.8 1.5 1.1 2.5 2.0

Wine:18-29 3.4 1.5 2.8 1.5 3.9 3.830-49 3.3 1.8 2.5 1.9 3.2 3.850-64 2.8 1.5 2.2 1.6 3.0 3.0Total 3.2 1.6 2.5 1.7 3.3 3.6

Spirits:18-29 2.7 1.1 2.0 1.1 2.4 3.830-49 2.4 0.9 1.2 1.3 1.8 2.250-64 2.5 0.4 1.1 0.9 1.4 1.4Total 2.5 0.8 1.4 1.1 1.9 2.3

Total alcohol consumption

Table . shows the gender-specific total alcohol consumption in three agegroups: -, - and - years. (Total consumption is calculated as theproduct of the frequency of drinking occasions and the volume per occasion,summed across all alcoholic beverages.) In Finland, Sweden and the UK,both for men and women, the youngest group reports the highest consump-tion, while in the three other countries consumption peaks in the middle oroldest age group (except for German females). The table also shows that, inall age groups, men consume - times more alcohol than do women. In the

110

Table .. Proportion (%) of binge drinking to total number of drinking occasions

Country Percentage binge drinking occasions of all drinking occasions (occasions past 12 months)

Men:Finland 29France 9Germany 14Italy 13Sweden 33UK 40

Women:Finland 17France 5Germany 7Italy 11Sweden 18UK 22

UK, it appears as if gender differences are most pronounced among the old-est group, whereas the opposite seems to be the case for Sweden. In Finlandand France, the ratios are very similar between all three age groups. InGermany, the youngest group stands out with a lower gender ratio.

Gender-specific age distributions for each of the three main alcoholic bev-erages are shown in Figures . and .. Not surprisingly, beer is the domi-nating male beverage in the central and northern European countries,whereas wine dominates among men in France and Italy. The age pattern ofalcohol consumption within each country, however, differs for the differentbeverages. Beer consumption is highest among the youngest men – exceptfor France, with a similar level among the youngest and the middle aged –and lowest in the oldest age group in all six countries.

In France and Italy, spirits consumption decreases with age, in Finland – aformer spirits-drinking country – the age pattern is the opposite: spirits con-sumption increases with age. In both Sweden and the UK, both the youngestand the oldest show a higher spirits consumption than the middle age group,whereas the opposite is true for Germany.

Wine consumption among men shows almost the opposite age patternfrom that of beer. In all countries, wine consumption increases with age,especially in France and Italy, the two traditionally wine-drinking countries.In France, for instance, those - years old report a wine consumptionmore than times higher than that of the youngest, whereas the youngestreport a spirits consumption times higher than that of the oldest.

Also for women, beer is the typical beverage for young people. OnlyFinland shows rather similar levels for all three age groups. In all other coun-


tries, beer consumption is lowest in the oldest age group. Spirits show a sim-ilar age distribution: highest among the youngest in all six countries, lowestamong the oldest in all but Finland and Germany.

As with men, women’s wine consumption shows the opposite age distrib-ution from beer and spirits for most countries; this is most clearly seen inFrance and Italy. In both countries, wine consumption is twice as highamong the - to -year-olds as among those - years old. The UK, how-ever, does not follow this pattern, but displays a decreasing consumptionwith age even for wine.

Table 5.4. Total alcohol consumption (litres 100% /year) by gender and age

Men WomenStudy Total con- Index Total con- Index Ratiocountries Age-groups sumption Total=100 sumption Total=100 men/women

Finland 18-29 8.2 117 2.9 121 2.830-49 6.2 89 2.2 92 2.850-64 6.8 97 2.4 100 2.8Total 7.0 100 2.4 100 2.9

France 18-29 6.1 81 1.8 82 3.430-49 8.0 107 2.4 109 3.350-64 8.6 115 2.4 109 3.6Total 7.5 100 2.2 100 3.4

Germany 18-29 4.3 81 3.2 133 1.330-49 6.1 115 2.2 92 2.850-64 5.2 98 2.1 88 2.5Total 5.3 100 2.4 100 2.2

Italy 18-29 6.4 90 2.5 71 2.630-49 7.0 99 3.8 109 1.850-64 7.7 108 3.8 109 2.0Total 7.1 100 3.5 100 2.0

Sweden 18-29 7.5 142 1.9 112 3.930-49 4.7 89 1.6 94 2.950-64 3.8 72 1.6 94 2.4Total 5.3 100 1.7 100 3.1

UK 18-29 16.0 122 7.9 155 2.030-49 11.1 85 5.0 98 2.250-64 13.2 101 3.1 61 4.3Total 13.1 100 5.1 100 2.6

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Figure .. Annual mean alcohol consumption for the three main alcoholic beverages.Men in three age groups.

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Context of drinking

Figure . shows how common it is to drink in different contexts: at lunch-time, at dinner (afternoon/evening meal), at a bar/restaurant and at homebut not in connection with any meal. Drinking alcoholic beverages at lunchis most common in France and Italy, and least common in Finland andSweden. Drinking at restaurants/bars and at home but not in connectionwith meals is most common in the UK. Drinking at restaurants/bars is leastcommon in Finland and Sweden, whereas drinking at home, but not in con-nection with meals, is least common in Southern Europe.

Table . shows the relative distribution among these four types of drink-ing contexts within each country. The results show a marked differencebetween the two southern European countries and the remaining four. InFrance and Italy, the drinking occasions in connection with lunch and din-ner comprise about % of all drinking occasions; the corresponding figurefor Germany, Sweden and the UK is %, and for Finland %. Finlandshows by far the highest proportion of drinking occasions at home but notin connection with a meal. These country differences hold true for both menand women.

As can be seen in Figure ., drinking in connection with meals (lunch anddinner) is more common at higher ages in most of the six countries, where-as the reverse age pattern is true for drinking in restaurants/bars. Drinking at

Table .. Distribution of context of drinking (%)

Countries Lunch Dinner Restaurant / bar At home but not inconnection with meals

France: Men 31 40 17 13Women 37 46 11 5

Italy: Men 40 44 12 5Women 46 44 7 3

Germany: Men 12 40 18 29Women 7 44 22 26

UK: Men 10 36 27 28Women 5 45 22 28

Finland: Men 14 15 26 46Women 15 23 20 42

Sweden: Men 9 41 20 31Women 5 60 16 18


home but not in connection with meals has different age profiles in the var-ious countries. By and large, men report higher frequencies than do womenin all six countries in all four contexts. The distribution among the fourdrinking contexts, however, showed some differences between men andwomen (Table .). It appears as if lunch and especially dinner drinking occa-sions contribute to a larger proportion of all drinking occasions for womenthan for men in most countries, whereas the opposite may hold true fordrinking occasions at restaurant/bars and/or at home but not in connectionwith meals. These differences, however, are not very dramatic.

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Figure 5.3. Number of drinking occasions in different contexts during last days in sixcountries by age.

THE EXPERIENCE OF ADVERSE CONSEQUENCES

The findings to be presented in Ch. suggest that changes in per capita alco-hol consumption have a stronger impact on various kinds of alcohol-relatedmortality in Northern Europe. Many alcohol-related problems, however,extend beyond the area of mortality and concern, e.g., harmful social andpsychological consequences associated with alcohol use. Can a similar cross-cultural pattern be observed with respect to this kind of harm? The presentsurvey data provide an opportunity to compare the population-level results

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for alcohol-related mortality with individual-level data on drinking andalcohol-related social harm.

As can be seen in Table ., the overall prevalence of alcohol-related harm(according to a combined measure based on questions) was highest inFinland and the UK and lowest in Italy. Only minor differences wereobserved among the other countries with the exception of French womenhaving nearly as low rates as Italian women. With regards to individual alco-hol-related problems, regretting things said or done after drinking was theonly experience that differed substantially across countries. Both men andwomen reported this outcome to a much higher extent in Finland, Swedenand the UK compared to those in Southern Europe and Germany.

The risk curves in Figure . indicate a positive association between alco-hol consumption and negative consequences of alcohol. Some country dif-ferences can be observed. Thus, the risk curves for Italy and France tend tobe less steep than those for other countries. This pattern is particularly clearwhen we look at the risk curves of regrettable conduct after drinking (Figure.), where also Germany adheres to the flat curvature of Southern Europe.The risk-curve analysis also revealed that problems occurred at fairly lowdrinking levels, i.e., that no threshold effect could be established in any coun-try, either for men or for women.

Overall drinking remained a statistically significant predictor of mostproblems also when controlling for age and binge drinking in multivariatelogistic regression analyses (estimates not shown). A consistent result wasthat the likelihood of harm per litre alcohol was larger for women. Withregard to country differences, a higher likelihood of experiencing alcohol-related harm was observed in Sweden and Finland compared to the othercountries. For each litre of pure alcohol consumed during the past months,the probability of reporting at least one harm increased % in Finland andSweden compared to between % and % in the other countries.

INFORMAL ALCOHOL CONTROL

There has been little interest in informal social control of alcohol drinking,or how the social network of friends, family members, co-workers or anyother close person might influence an individual to drink less alcohol. Cross-country studies in the area are rare. We found only one study presenting acomparison between U.S. and Canadian data (Room et al., ). Thosecountries are relatively similar as regards drinking culture. In this section, weanalyse the social pattern of informal control of alcohol drinking in the sixstudy countries, representing a greater diversity in drinking cultures than theprevious North American study.

118 Table .. Proportion (%) reporting adverse consequences of own alcohol use during the past months (abstainers excluded)

Overall rates Chronic harm Behavioural concomitants Social reactions

At least Average Ever Alcohol Regretted Got Got into Alcohol Alcohol Alcohol N one number considered harmed things said into a an harmed harmed harmed

harm of harms cutting health or done fight accident work/ homelife/ friendshipsdown studies marriage

MENFinland 463 46.8 0.93 33.0 17.3 25.1 4.2 2.6 4.5 6.8 5.2Sweden 508 35.5 0.54 11.0 8.0 25.8 1.3 3.5 3.0 1.9 0.6Germany 451 33.5 0.51 17.8 17.3 7.2 5.5 0.5 3.3 3.0 1.6UK 434 45.0 0.95 24.5 18.6 27.9 7.5 3.6 9.1 6.5 5.1France 431 27.1 0.58 15.2 18.0 12.7 2.0 3.5 2.6 3.3 3.6Italy 441 18.3 0.43 10.7 9.8 4.9 1.2 1.6 5.7 4.3 6.0Average 34.5 0.66 18.7 14.8 17.3 3.6 2.6 4.7 4.3 3.7

WOMENFinland 444 28.6 0.50 18.5 6.6 17.0 1.4 0.8 2.1 2.5 2.6Sweden 417 18.6 0.28 6.0 5.7 13.0 0.6 1.3 0.8 0.5 0.7Germany 393 20.2 0.33 12.1 9.8 5.9 1.8 0.7 1.6 2.0 1.2UK 406 32.7 0.61 19.6 8.8 21.5 3.6 3.4 4.1 4.5 5.1France 363 12.1 0.20 4.7 8.0 4.4 0.0 0.4 0.4 0.2 1.3Italy 389 8.5 0.17 3.5 4.3 3.6 0.2 0.2 1.7 1.3 2.3Average 20.5 0.35 10.7 7.2 10.9 1.3 1.1 1.8 1.8 2.2


Figure .. Gender specific risk curves for the likelihood of experiencing at least one harm-ful consequence.

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Figure .. Gender specific risk curves for the likelihood of regretting things said or donewhile drinking.

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GE

FR

FI

Yearly consumption of pure alcohol (%)

Women

876543210

Reg

rett

ed t

hin

gs

said

or

do

ne

afte

r d

rin

kin

g (

%)

40

30

20

10

0

UK

SW

IT

GE

FR

FI


problematic drinking, such as drinking to intoxication, in a country increas-es the probability of someone influencing anyone to drink less. The latterhypothesis would suggest that people in the north (Finns, Swedes) should bemore inclined to exert informal control as compared to those in the south(people in France, Italy).

The dependent variable, influencing anyone to drink less alcohol, consistsof yes- or no-answers to eight questions regarding the respondent’s mother,father, spouse, child, other family member, friends, workmates/colleagues orneighbour. An index was constructed for the purpose of performing logisticregression analyses on a binary summary measure of informal alcohol con-trol.

In all countries, it was most common to have influenced a friend to drinkless (Table .). A number of country differences appeared, both regardingthe proportion that reported this (% of the respondents in Italy, but onlyabout % in Finland and the UK) and regarding which persons had beeninfluenced to drink less. In Finland and the UK, it was nearly as common tomention the spouse (% and % respectively) as a friend, but only % men-tioned the spouse in France. Overall, findings on individual items display avaried picture. There were low proportions reporting having influencedmother, father, child, workmate or neighbour to drink less (on average lessthan %). Between % and % in France, Germany, Italy and the UK men-tioned having influenced another family member to drink less. In Italy,Sweden and the UK, it was relatively common that the respondent had influ-enced a workmate to drink less (-%) compared to the other three countries(-%).

Table .. Proportion (%) of respondents reporting that they had influenced any of thefollowing persons to drink less in the past months. N= .

Finland France Germany Italy Sweden UK Wholesample

Mother 2 1 2 2 2 4 2Father 4 2 3 6 2 5 4Spouse 11 3 8 6 7 9 7Child 4 1 3 3 4 7 4Other family member 3 6 6 7 3 6 5Friends 11 16 16 24 13 10 15Workmates/colleagues 3 2 4 6 7 7 5Neighbour n.i. 1 3 2 2 1 2Any of above 31 28 33 38 30 32 32

n.i. = not included

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Having influenced any of the eight persons to drink less was most com-mon in Italy (%). This was the case among % in Germany, % in theUK, % in Finland, % in Sweden and % in France.

Analyses for each country showed that young age (- years) appeared tobe the most important determinant of influencing anyone to drink less,although this was not the case in Finland. There was a relatively commoneffect of gender across countries (women more often exerted informal con-trol), but this was not the case in the French and Italian samples. Self-report-ed alcohol consumption was of importance for informal alcohol control insome of the countries, but the patterns obtained were not uniform acrosscountries. In Finland and the UK, people in the middle/low consumptiongroup were more likely than the average to exert informal control, whereasin Italy and Germany this was observed among high consumers (Table .).In all countries but Sweden, influencing anyone to drink less was least com-mon among non-drinkers.

Table .. Country-specific odds-ratios for various alcohol drinking categories to influ-ence anyone to drink less. Relative deviation from the average (=.) estimated by logisticregression models when age, gender, education, household status and occupational statuswere controlled for.

Finland France Germany Italy Sweden UK

Alcohol consumptionNone 0.72 0.79 0.60** 0.71* 1.25 0.67*Low 0.87 1.10 1.15 1.18 0.97 1.02Middle-low 1.42** 0.97 0.90 1.07 0.93 1.48**Middle-high 1.03 1.03 1.18 0.87 0.97 1.12High 1.08 1.14 1.37* 1.28 0.92 0.90

* p <= 0.05 ** p <= 0.01

When age, gender, alcohol consumption, household status and occupationalstatus were controlled for, the Italians were significantly more likely and theFrench and the Swedes significantly less likely to influence anyone to drinkless compared to the six-country average (data not shown).

Gender-specific analyses revealed that there were small country differencesamong women. The only significant finding was that French women wereless likely to influence anyone to drink less. Among men, on the other hand,country differences were clearly greater than among women. Men in Italywere . times more likely to report influencing anyone to drink less com-pared with the all-country average. Significantly low proportions of menreported this in Finland and Sweden.


ATTITUDES TOWARDS ALCOHOL POLICY

There has been a growing interest in attitudes towards different alcohol pol-icy issues, such as opinions on increasing the price of alcoholic beverages(Goodstadt et al., ) or warning labels on beverage containers (Hilton &Kaskutas, ). However, comparative studies of attitudes towards alcoholpolicy are rare. We could only find comparisons between the attitudes ofCanadians and Americans (Room et al., ; Giesbrecht & Greenfield, ),and for three Nordic countries regarding wine sales in food stores (Holder etal., ).

Here, we describe differences between the six European countries regard-ing attitudes towards alcohol policy in a global sense. The attitude towardsalcohol control policy was measured by the statement: ‘‘The government hasa responsibility to minimise how much people drink.’’ There were fiveresponse alternatives, ranging from “Strongly agree” to “Strongly disagree”and “don’t know”.

Nearly half of the respondents in Italy strongly agreed with the abovestatement, whereas more than % of Germans and Finns strongly disagreed(Table .). When the sample was categorised by those who agreed and thosewho disagreed (“don’t know”-answers excluded), it is observed that a largemajority of people in Italy and Sweden (about %) supported governmen-tal responsibility for alcohol control. This was the case for % in France,% in the UK, % in Finland and % in Germany.

Table .. Answers to the alcohol attitude statement: “The government has a responsibilityto minimise how much people drink”, and a division between those who agreed and dis-agreed. Percent. N= .

Finland France Germany Italy Sweden UK Wholesample

Strongly agree 13 36 12 48 38 20 28Somewhat agree 24 21 16 29 36 26 25Somewhat disagree 20 12 27 11 7 26 17Strongly disagree 42 26 42 11 18 24 28Don’t know 1 4 2 1 1 3 2

Agree 38 60 29 77 75 48 54Disagree 62 40 71 23 25 52 46

This pattern remained after a number of social factors were controlled for.In all countries, the attitude was strongly related to alcohol consumption:non-drinkers and low consumers were most and high consumers least sup-portive.

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A positive association was found between public attitudes and the strict-ness of prevailing alcohol policy. The country with the most liberal alcoholpolicy also had the most liberal attitudes (Germany) and the country withthe strictest policy had a high proportion with positive attitudes (Sweden).These results are expected from the (democratic) support model describedby Saglie (), although not all countries conformed to this pattern.

A number of limitations should be observed. Among them that the atti-tude question might have been interpreted differently by respondents acrosscountries, and that there was only one global question in the survey. The atti-tudinal differences by social factors in each country indicated that the glob-al attitude measure is probably valid in a relative sense within countries – forinstance as evidenced by the stable finding on personal alcohol consumptionacross countries – but this is more uncertain when comparing the absolutelevel of support across countries. Additional questions on specific alcoholpolicy items are needed in order to better understand why there are attitudi-nal differences towards alcohol policy across countries, whether these reflectprocesses of individual preference, support for prevailing policy or discon-tent with such policy (Saglie, ). Within countries there was clear supportfor the individual preference model; in all six countries, high consumers pre-fer a liberal alcohol policy.

DISCUSSION

One lesson we learned from carrying out this study is that there are indeedmany circumstances that make it difficult to obtain comparable survey data:• each country has its own tradition of sampling procedures and fieldwork,

and it seems to be difficult to achieve a uniform approach;• the willingness of the population to participate seems to vary considerably

across countries, resulting in a great variation in response rate;• there may well be cultural differences in the degree to which people give

honest responses, as judged from the great variation in coverage rate ofalcohol consumption (-%).This study has thus tried to find a delicate balance between not pushing

the data too far and over-interpreting findings, on the one hand, and notbeing so cautious as to neglect interesting findings, on the other. In any case,the approach taken in this study has been to be cautious in making compar-isons of absolute figures, especially mean consumption levels. Instead, moreattention has been paid to cross-country comparisons of different ratios andof age and gender distributions.

Bearing the limitations in mind, the study has focused on several dimen-sions of drinking. The following are some of the main results:


Drinking habits

• Whereas regular drinking is most common in Southern Europe and leastcommon in Northern Europe, the quantity consumed when drinking, thatis per drinking occasion, was highest in Northern Europe and the UK, andlowest in Southern Europe and Germany.

• There are systematic country differences in the age profile in drinking: inFinland, Sweden and the UK, the youngest (the - year-olds) drink themost, not only per occasion but also on an annual basis. In none of theother three countries (except women in Germany) do the young adultsreport the highest alcohol consumption. It is difficult to say whether thisis due to a generation effect, an age effect, or both. If it is a generationeffect, this implies that the homogenisation process evident in analyses onrecorded alcohol consumption in the postwar period is stronger amongyoung people.

• The frequency of heavy drinking occasions, in absolute terms as well as inrelation to all drinking occasions, is highest in young people (-) in allthe countries but Italy. Lacking data over time, it is not possible to ascer-tain whether this pattern is a continuation of traditional cultural patternsor the result of new drinking patterns among the youngest.

Self-reported alcohol-related problems

• The prevalence of social alcohol-related harm was lowest in SouthernEurope and highest in Finland and the UK.

• The level of drinking and the number of heavy drinking episodes areimportant determinants of the experience of alcohol-related problems inall six countries.

• The association between alcohol consumption and having experienced analcohol-related problem was stronger in Sweden and Finland than in theother countries. This pattern is consistent with the population-level stud-ies of the link between alcohol and mortality (Ch. ).

Informal alcohol control and attitudes towards alcohol policy

• Country differences in the exertion of informal alcohol control were fair-ly small, although differences were greater among men than amongwomen. Men were significantly more likely in Italy, and significantly lesslikely in Finland and Sweden, to influence anyone to drink less.

• In all countries, high consumers have the most liberal attitudes towardsalcohol policy.

126

REFERENCES

Giesbrecht, N. & Greenfield, T. () Public opinions on alcohol policy issues: A compa-rison of American and Canadian surveys, Addiction, , 1-1.

Goodstadt, M., Smart, R. G. & Gillies, M. (). Public attitudes toward increasing theprice of alcoholic beverages, Journal of Studies on Alcohol, , -.

Hemström, Ö. (a) Informal alcohol control in six EU countries. Stockholm University& Karolinska Institutet, CHESS. Submitted to Contemporary Drug Problems.

Hemström, Ö. (b) Attitudes towards alcohol policy in six EU countries. Stockholm:Stockholm University & Karolinska Institutet, Centre for Health Equity Studies(CHESS). Submitted to Contemporary Drug Problems.

Hilton, M. E. & Kaskutas, L. (). Public support for warning labels on alcoholic bevera-ge containers. British Journal of Addiction, , -.

Holder, H. D., Kühlhorn, E., Nordlund, S., Österberg, E., Romelsjö, A. & Ugland, T. ()European Integration and Nordic Alcohol Policies (Aldershot, England and Brookfield,USA, Ashgate).

Leifman, H. (a) Validity problems in alcohol surveys with special emphasis on thecomparative six country ECAS survey. Stockholm University, SoRAD. Submitted toContemporary Drug Problems.

Leifman, H. (b) A comparative analysis of drinking habits in six EU countries in theyear . Stockholm University, SoRAD. Submitted to Contemporary Drug Problems.

Ramstedt, M. () Alcohol consumption and the experience of adverse consequences –A comparison of six European countries. Stockholm University, SoRAD. Submitted toContemporary Drug Problems.

Room, R., Bondy, S. & Ferris, J. () Determinants of suggestions for alcohol treatment,Addiction, , -.

Room, R., Graves, K., Giesbrecht, N. & Greenfield, T. () Trends in public opinionabout alcohol policy initiatives in Ontario and The US -, Drug and AlcoholReview, , -.

Saglie, J. () Attitude change and policy decisions: The case of Norwegian alcohol poli-cy, Scandinavian Journal of Political Studies, , -.

mats ramstedt 127

INTRODUCTION

In previous chapters, we could observe considerable national variations inpostwar Western Europe with regard to alcohol policies and populationdrinking. The focus is now shifted to national differences in the prevalenceof alcohol-related harm. More specifically, the aim of this chapter is to assessdifferences and trends in alcohol-related mortality and how these matchvariations in overall consumption of alcohol.

Liver cirrhosis mortality is a classical indicator of harmful drinking in apopulation and this measure is still the main marker in comparative studies(see e.g., Munoz-Perez & Nizard, ; Ramstedt, ; Edwards et al., ;Davies & Walsh, ; Bruun et al., ). The rationale for using deaths fromliver cirrhosis for this purpose is based on two chief circumstances: ()chronic excessive drinking is a well-established risk factor for cirrhosis, and() the number of deaths is generally large enough to allow for meaningfulcomparisons between countries.

It is yet surprising that no comparative study has considered deaths explic-itly caused by alcohol, e.g., alcoholism, alcohol psychosis and alcohol poi-soning. Besides that it may seem to be a matter of course to include suchcauses in analyses of alcohol-related mortality, a broader indicator is gener-ally regarded as more reliable than a narrower one. Let’s assume that nation-

Alcohol-related mortality in 15 European countries in the postwar periodby Mats Ramstedt

6.

128

al differences in cirrhosis mortality are partly explained by a preference forcompeting codes (e.g., alcoholism) in some countries. If this were the case,the comparability of data would be improved if these competing codes werebrought into the analysis. Liver cirrhosis and alcoholism are indeed diag-noses that may be confused since an indication of alcohol induced liver dis-ease is one criterion for using the diagnosis alcoholism (Romelsjö et al.,). Similarly, practical difficulties have been noticed in the choice betweenalcoholism, alcohol poisoning, alcohol psychosis and alcoholic cardiomy-opathy (see e.g., Poikolainen, ; Sundby, ).

On the other hand, it is well known that diagnoses with a mention of alco-hol are strongly underreported in many countries (Savolainen et al., ;Haberman et al., ; Ågren et al., , Maxwell & Knappman, ). Littleis known about national differences in this respect, but it may be noted thata substantial variation in certification and coding practices across Europeancountries have been found for other less controversial causes of death, suchas diabetes (Jougla et al., ). It can thus not be taken for granted thatadding explicitly alcohol-related deaths to cirrhosis mortality improves onthe comparability of the resultant composite measure. The results below willshed some light on this issue.

It should be stated from the outset that the purpose of the chapter is notto estimate the total load of mortality caused by alcohol (for an example ofsuch efforts, see e.g., Single et al., ) but only to give a description of mor-tality where alcohol is the major risk factor.

DATA

Annual population and mortality data (gender-specific in -year age groups)were compiled for the study countries from various sources. Data on livercirrhosis mortality were obtained from WHO (Geneva office), whereas datafor explicitly alcohol-related deaths were gathered from national statisticalagencies, often through helpful project collaborators within each country.Liver cirrhosis includes also other chronic liver diseases but is hereafterreferred to as only liver cirrhosis. The category referred to as “explicitly alco-hol-related deaths” comprises deaths from alcoholism, alcohol psychosis andalcohol poisoning up to the ninth revision of the International Classificationof Diseases (ICD-), which mostly came into practice around -, exceptfor the Nordic countries where it was applied in -. The introduction ofICD- included the following alterations: the previous category “alcoholism”was renamed to “alcohol dependence”, and four new mortality categoriesexplicitly attributable to alcohol were introduced: alcohol abuse (non-dependent abuse of alcohol), alcoholic gastritis, alcoholic cardiomyopathy

mats ramstedt 129

and alcoholic polyneuropathy (World Health Organisation, ). Moreover,we obtained data on liver cirrhosis deaths with explicit mention of alcohol(alcoholic cirrhosis) for - from WHO (Geneva office). Table . liststhe causes of death (and ICD-codes) that are included in the composite mea-sure of AAA-mortality

Data on per capita alcohol consumption (litres % alcohol per inhabi-tant +) were derived from the Brewers Association of Canada ().

Table .. Causes of death included in the study.

Causes of death ICD 6-7 ICD-8 ICD-9

Liver cirrhosis* 581 571 571Alcoholic diseases of the liver - - 571.0-571.3Alcoholism /Alcohol dependence syndrome 307 303 303Alcoholic Psychosis 322 291 291Alcohol Poisoning E880 E860 E860 Alcohol Abuse - - 305.0Alcoholic Cardiomyopathy - - 425.5Alcoholic Gastritis - - 535.3Alcoholic Polyneuropathy - - 357.5

*) Chronic liver diseases since ICD-9

The approximate study period is -, but for many countries someyears are missing. For instance, data on explicitly alcohol-related mortality inPortugal and Greece were not available before (see Table .).

Table .. Observation period and years for missing data.

Country Observation period Notes

Austria 1955-1995 AAA missing 1969Belgium 1954-1994Denmark 1951-1995Finland 1952-1995France 1950-1995Greece 1961-1995 AAA missing prior to 1980 The Netherlands 1950-1995Norway 1951-1995Ireland 1950-1995 Alcohol poisoning missing prior to 1979Italy 1951-1993Portugal 1955-1995 AAA missing prior to 1980Spain 1951-1995 Alcohol poisoning missing prior to 1981Sweden 1951-1995United Kingdom 1950-1995West Germany 1952-1995 Alcohol psychosis missing prior to 1968


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RESULTS

Variations in mortality from liver cirrhosis and explicitly alcohol-related causes

Table . presents age adjusted liver cirrhosis mortality rates among men andwomen in the study countries at time periods during the postwar period.The average mortality rates are also presented for three groups of countries:Northern Europe (Finland, Norway and Sweden), Central Europe (Austria,Belgium, Denmark, Ireland, the Netherlands, UK and West Germany (WholeGermany after )), and Southern Europe (France, Greece, Italy, Portugaland Spain). The countries within the three groups are fairly similar withrespect to consumption levels and beverage preferences (see Ch. ) as well asto alcohol policy regimes (see Ch. ).

Table .. Age adjusted liver cirrhosis mortality rates (per , +) for men andwomen in European countries in the postwar period.

1950-65 1966-80 1981-1995 1995Country Men Women Men Women Men Women Men Women

Northern EuropeFinland 8.4 4.5 11.1 3.9 16.9 5.8 19.7 5.8Norway 5.9 4.1 7.6 3.9 9.5 4.2 7.6 3.6Sweden 7.7 4.1 17.1 6.8 11.7 4.9 9.3 4.9Average 7.3 4.2 11.9 4.9 12.7 5.0 12.2 4.8

Central EuropeAustria 44.1 12.2 65.8 17.0 54.3 16.2 47.1 15.1Belgium 15.9 7.4 21.7 10.4 19.6 9.9 18.6 9.5Denmark 9.8 11.0 15.3 9.3 22.2 9.7 27.7 13.3Ireland 4.7 2.5 6.8 4.1 5.8 3.7 4.3 4.0Netherlands 7.3 4.8 9.0 4.7 8.9 4.4 7.7 4.4UK 4.4 2.8 5.6 3.8 8.2 5.4 11.1 6.4West-Germany 31.6 12.8 49.8 38.5 14.8 3.2 36.8 14.5Average 16.8 7.6 24.9 12.5 19.1 7.5 21.9 9.6

Southern EuropeFrance 57.4 23.5 69.7 24.7 38.8 14.3 28.0 11.0Italy 40.8 13.5 67.2 21.1 49.4 18.6 35.0 15.8Spain 34.9 17.1 53.3 19.4 40.2 12.8 29.3 9.4Portugal 67.1 27.6 82.2 29.2 58.5 18.2 42.5 12.1Greece 36.7 13.3 31.0 11.0 16.6 5.5 9.5 3.3Average 47.4 20.4 68.1 23.6 46.7 16.0 33.7 12.1Total average 25.1 10.7 34.2 13.9 25.0 9.1 22.3 8.9

The regional differences follow a north-south gradient; the lowest cirrho-sis rates are consistently found in Northern Europe and the highest ratesappear in Southern Europe. The differences are most marked during the firsttwo time periods (- and -) with men in Southern Europe hav-ing about - times higher cirrhosis mortality than men in Northern Europe,and - times the rates of Central Europe. The same regional pattern is dis-

mats ramstedt 131

closed for women, although the differences are somewhat smaller. Themale/female ratio in mortality is typically in the range between and , re-flecting men’s higher consumption.

However, the regional differences decrease over time, and the north-southgradient during - is weaker than at the beginning of the study peri-od for both men and women. Thus, in , Southern European men andwomen have cirrhosis rates barely times higher than those observed inNorthern Europe, and only about . times the cirrhosis rates found inCentral Europe.

The experience for individual countries indicates a fairly stable rank-orderthroughout the postwar period. Most countries with high cirrhosis ratesduring the s and s have high rates during the s as well, e.g.,Austria, West Germany and the Southern European countries. Likewise,most countries with low cirrhosis rates in the s (Ireland, the Nether-lands, UK and the Northern European countries) keep that position duringthe s. However, there are some countries that have changed positionsquite notably. A previously high rate country “Greece” is among the lowest inthe most recent period (-), whereas a previously low-rate country“Denmark” is approaching the death rates of Southern European countriesduring the s.

Looking at the situation in , Southern and Central European countriesstill are found among the five countries with the highest cirrhosis rates. Formen, cirrhosis deaths are most common in (from highest to lowest) Austria,Portugal, Germany, Italy, and Spain and the corresponding high rate coun-tries for women are Italy, Austria, Germany, Denmark and Portugal. How-ever, the lowest cirrhosis rates are found among a mix of countries from allregions. For men the lowest rates are found in (starting with the lowest)Ireland, Norway, the Netherlands, Sweden and Greece, and for women inGreece, Norway, Ireland, the Netherlands and Sweden.

Although all liver cirrhosis deaths are not alcohol-related, it is generallyagreed upon that cirrhosis deaths classified as “alcoholic cirrhosis” (.-. in ICD-) are less reliable for cross-cultural comparisons (see e.g.,Hyman, ). However, variation in the use of this code across countriesmay shed some light on cultural differences in diagnostic practises concern-ing alcohol-related deaths.

Table . shows the rates of alcoholic cirrhosis as well as the fraction of thetotal of deaths from liver cirrhosis that are diagnosed as alcoholic during theperiod -. The comparison reveals a quite different result: the highestmale mortality rate is found in Northern Europe, whereas Southern Europeis somewhat higher than Central Europe. Regarding females, the average

132

rates are about the same in the different regions. However, the higher con-sumption among men is reflected in a male/female ratio that approximatesthe one for total cirrhosis.

Table .. Mortality from alcoholic liver disease (.-. in ICD-) and its share of thetotal number of deaths from liver cirrhosis (). Average for the period -.

Country MEN WOMENAlcoholic Share of all liver Alcoholic Share of all livercirrhosis cirrhosis (%) cirrhosis cirrhosis (%)

Northern EuropeFinland 16.9 90 4.2 56Norway 7.9 79 2.5 50Sweden 4.9 42 1.5 25Average 9.9 70 2.7 44

Central EuropeAustria 4.9 10 1.7 6Belgium 6.8 32 3.6 31Denmark 15.2 65 5.8 55Ireland 1.7 33 0.6 20The Netherlands 4.5 61 1.9 40UK 4.2 45 2.4 38West Germany 11.6 31 4.4 28Average 7.0 40 2.9 31

Southern EuropeFrance 19.2 56 7.3 54Greece 1.3 9 0.2 3Italy 3.5 8 0.9 4Portugal 13.9 22 4.2 23Spain 4.2 10 0.9 5Average 8.4 21 2.7 18


The cross-national pattern is the result of major national variations in theshare of all cirrhosis deaths that mentions alcohol. The fraction of alcoholiccirrhosis among men is highest in Northern Europe (%), lower in CentralEurope (%) and lowest in Southern Europe (%). Substantial differencesare observed among individual countries with the largest differences for menrevealed between Finland (%) and Italy (%). The corresponding regionalfractions for women are % in Northern Europe, % in Central Europeand 18% in Southern Europe. Also in this case Finland shows the highestproportion (%), whereas Greece has the lowest (%).

Some exceptions from this general pattern are worth noting. Sweden hassubstantially lower rates and shares than Finland and Norway; Austriabelongs rather to the typical Southern European pattern. France deviatesclearly from the other Southern European countries and has substantiallyhigher death rates than particularly Greece, Italy and Spain. In fact, France is

mats ramstedt 133

more similar to Central and Northern Europe in this respect. However, thetendency to use the explicitly alcohol-related cirrhosis diagnoses seems to besubject to substantial cultural variations which follows a north-south gradi-ent opposite to the one observed for the total number of cirrhosis deaths.

We now turn to the explicitly alcohol-related causes of deaths (AAA). Therelative proportion of the various causes of death included in the AAA mea-sure is presented for each country in Table ..

Table .. The fraction (%) of the causes of death included in AAA-mortality. The causesof death are: alcohol dependence (), alcohol psychosis (), alcohol poisoning (E)and other explicitly alcohol-related causes of death (alcohol abuse, alcoholic cardiomyopa-thy, alcoholic gastritis and alcoholic polyneuropathy). Average for the period -.

Country MEN WOMEN303 291 E860 Other 303 291 E860 Other

Northern EuropeFinland 13 6 61 20 12 4 70 14Norway 72 3 21 4 63 2 32 3Sweden 64 3 27 6 58 2 35 5Average 50 4 36 10 44 3 46 7

Central EuropeAustria 85 2 0 13 87 1 0 12Belgium 80 8 2 10 78 6 2 14Denmark 84 1 14 1 74 1 24 1Ireland 68 4 28 0 62 1 37 10The Netherlands 51 9 3 37 54 11 2 33UK 37 3 17 43 40 1 20 39West Germany 60 5 1 34 66 3 1 30Average 66 5 9 20 66 3 13 20

Southern EuropeFrance 82 9 0 9 87 6 1 6Greece 87 8 1 4 63 20 0 17Italy 83 8 2 7 81 8 3 8Portugal 66 24 9 1 82 15 3 0Spain 72 15 1 12 68 12 7 13Average 78 13 3 7 76 12 3 9

All countries 67 7 12 13 65 6 16 14

The new codes introduced in ICD- are lumped together, whereas the frac-tions of alcohol dependence, alcohol poisoning and alcohol psychoses arepresented separately. The results are based on data for - where datafor all countries are complete, and the same ICD-version is applied. The out-come is fairly consistent across countries, in the sense that alcohol depen-dence mortality typically dominates and other categories are of rather minorimportance. The only exceptions are Finland, where alcohol poisoning is themost frequently used diagnosis, and the Netherlands, UK and West Germany

134

where the new ICD- codes play a larger than average role in the mortalitypattern. The most common cause of death within this category is alcoholiccardiomyopathy.

Table . shows age-adjusted mortality rates for a composite measure of allexplicitly alcohol-related mortality at the same time points as previouslypresented for liver cirrhosis. Compared to liver cirrhosis, the gender-ratio ismuch larger for AAA-mortality. The male/female ratio in mortality is about in the beginning, and in the end of the study period.

Table .. Age adjusted mortality rates from explicitly alcohol-related causes (AAA) formen and women (per , +) in European countries in the postwar period.

1950-65 1966-80 1981-1995 1995Country Men Women Men Women Men Women Men Women

Northern EuropeFinland 9.5 0.4 18.3 1.4 23.6 3.2 28.6 4.0Norway 1.7 0.2 7.6 1.0 14.3 2.7 14.0 3.3Sweden 2.6 0.2 11.7 1.8 15.1 2.8 10.6 2.1Average 4.6 0.3 12.5 1.4 17.7 2.9 17.7 3.1

Central EuropeAustria 6.8 1.1 5.9 1.3 5.7 1.2 7.6 1.5Belgium 3.4 0.8 5.2 1.5 4.8 1.5 5.6 2.1Denmark 0.8 0.1 2.6 0.6 8.5 2.5 9.6 3.0Ireland 0.4 0.1 0.9 0.3 2.0 0.8 2.8 2.0The Netherlands 1.4 0.1 1.9 0.3 2.8 0.6 3.1 0.8UK 0.3 0.1 1.2 0.5 2.2 0.8 2.8 1.1West Germany 1.5 0.3 7.5 1.8 13.3 3.2 16.8 4.0Average 2.1 0.4 4.0 1.0 5.6 1.5 6.9 2.1

Southern EuropeFrance 20.8 4.9 18.8 4.1 12.7 2.6 9.2 2.0Italy 3.4 0.4 2.0 0.2 1.4 0.2 1.3 0.2Spain 3.1 0.7 3.2 0.4 2.3 0.4 1.9 0.3Portugal 9.6 1.8 5.5 0.7 2.9 0.2 1.4 0.2Greece N.A N.A 2.1 0.1 0.9 0.0 1.1 0.0Average 9.2 2.0 6.3 1.1 4.0 0.7 3.0 0.5Total average 4.7 0.8 6.5 1.1 7.5 1.5 7.8 1.8

The stable north-south gradient revealed for cirrhosis mortality is notfound for explicit alcohol-related mortality even though the highest rates ofAAA-deaths are found in Southern Europe during -. However,Northern Europe has the highest rates already during the next period (-), and this position is maintained throughout the study period. From thes on the lowest rates are instead found in Southern Europe. In fact, thecross-national pattern observed for AAA-mortality during - is verysimilar to that revealed for alcoholic cirrhosis during -. Severalmatching results are also observed for AAA and alcoholic cirrhosis in indi-

mats ramstedt 135

vidual countries. For instance, the rank order within Northern Europe isidentical, with Finland on top and Sweden with the lowest rate. Further,Denmark and Germany have the highest rates in Central Europe, and thehighest rates in Southern Europe are found in France.

So far, we must conclude that the pattern of alcohol-related mortalityacross the study countries varies depending on which mortality category thatis in focus. In fact, the patterns for total liver cirrhosis and AAA mortality arereversed, while the pattern for alcoholic cirrhosis is similar to that of AAA.The analyses below will shed more light on this paradox.

Postwar trends in liver cirrhosis and explicitly alcohol-related mortality

In this section the focus is shifted from the geographical to the temporal vari-ation in cirrhosis and AAA-mortality. Figure . shows how death rates fromliver cirrhosis and AAA have developed among men and women in eachcountry between approximately -. Generally, we can observeincreasing trends until the mid-s in both cirrhosis and AAA for men,with AAA-mortality in Austria as the only clear exception. It can be notedthat AAA-mortality peaked somewhat earlier in Southern European coun-tries; this is also the case for cirrhosis in France and Greece. This outcomeholds true also for female mortality rates with exceptions for cirrhosis trendsin Finland, Norway, the Netherlands and Denmark and AAA-trends inAustria and Southern Europe. Thus, although deviations exist, particularlyamong women, the general rule is a fairly close correspondence between thetwo indicators in most countries during the first postwar decades.

From the mid-s on, diverse trends appear in various groups of coun-tries not necessarily coinciding with geographic location or similarities indrinking cultures. Thus, a more or less permanent mortality drop is foundfor men and women in all Southern European countries, in Belgium and inSweden according to both indicators. In another group of countries, Finland,Denmark and UK, alcohol-related mortality increases for men and womenaccording to both indicators like in .

However, in Austria, West Germany, the Netherlands, Ireland and Norway,AAA and cirrhosis trends started to diverge, generally so that AAA-mortali-ty increased while cirrhosis decreased. We do not know what factors mayhave caused this discrepancy. Skog () suggested that discrepancies be-tween alcoholism mortality and liver cirrhosis mortality in Norway were re-lated to changing diagnostic practices. However, on the whole we can concludethat when looking at the time trends, AAA and cirrhosis mortality display areasonably consistent picture, in stark contrast to the geographical pattern.

136

Finland

95908580757065605550

40

30

20

10

0

Cirrhosis, men

Cirrhosis, women

AAA, men

AAA, women

Norway

95908580757065605550

20

10

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mats ramstedt 137

Austria

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Sweden

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Belgium

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Denmark

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mats ramstedt 139

Ireland

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The Netherlands

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UK

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mats ramstedt 141

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Portugal

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Figure .. Gender-specific trends in liver cirrhosis (per , +) and AAA-mortalitybetween - in 15 European countries.

Greece

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mats ramstedt 143

The geographical association between per capita consumption and mortality

Both theoretical considerations and empirical findings suggest that the high-er the level of alcohol consumption in a population, the higher the rate ofalcohol-related mortality (Edwards et al., ). This expectation is borneout in the data shown in Figure .; countries with a high consumption leveltend to have more male deaths by cirrhosis than countries with low con-sumption. (The consumption measure is weighted to take present and pastconsumption into consideration, see Ch. for details of the lag-scheme.)However, there are certainly countries that deviate from the expected rate.For instance, Ireland, the UK and the Netherlands score lower than expectedwhereas Finland and Italy score higher.

Could it be the case that a country scoring below the expected rate in cir-rhosis compensates for this by scoring higher than expected in other alcohol-related diagnoses? If this is so, the inclusion of AAA mortality would providea composite measure that would display a better match with per capita con-sumption than cirrhosis.

To illuminate this question, we look at the corresponding figure whereexplicitly alcohol-related deaths (AAA-mortality) have been added to cirr-hosis mortality. However, the result does not support this conjecture; as amatter of fact the fit is worsened (as indicated by a reduction in R2 from .

to .), and the deviating countries remain the same, only with bigger disc-

Italy

95908580757065605550

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Per capita alcohol consumption (weighted)

1816141210864

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Figure 6.2. Relationship between per capita alcohol consumption (litres alcohol 100%)and male liver cirrhosis mortality. Average for the period 1987-1995.

1816141210864

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Figure .. Relationship between per capita alcohol consumption (litres alcohol 100%)and male liver cirrhosis mortality + AAA-mortality. Average for the period -.

mats ramstedt 145

1816141210864

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A-m

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(L

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Figure .. Relationship between per capita alcohol consumption and AAA-mortality.Average for the period -.

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Figure .. Relationship between per capita alcohol consumption and male AAA-mortalityin Northern, Central and Southern Europe. Average for the period -.

146

repancies (Fig. .). Finland has now even more alcohol-related deaths thanis expected from the drinking level, while Ireland and the Netherlands havefewer deaths than expected. The explanation of the weakened relationshipbecomes obvious when only AAA-mortality is used as the outcome, seeFigure .. In fact, the geographical correlation between consumption andmale AAA-mortality is negative, as indicated by the slope of the solid line.

However, within each of the three groups of countries that represent dif-ferent drinking cultures the relationship is positive, (see Figure ..) Thissuggests that the recording of alcohol-related deaths is affected by culturalfactors, and that one should analyse the link between alcohol and mortalityin a way that minimises their impact. One solution is to avoid the cross-national variation and instead look at the temporal co-variation betweenalcohol and mortality within countries, proceeding from the plausibleassumption that culture is more stable across time than space. This is thetopic of the next chapter.

REFERENCES

Blake, JE., Compton, KV., Schmidt, W. & Orrego, H. () Accuracy of death certificatesin the diagnosis of alcoholic liver cirrhosis, Alcoholism: Clinical and ExperimentalResearch, , -.

Brewers Association of Canada () Alcoholic Beverage Taxation and Control policies(Ottawa. Ninth Edition).

Bruun, K., Edwards, G., Lumio, M., Mäkleä, K., Pan, L., Popham, R.E., Room, R., Schmidt,W., Skog, O.J., Sulkunen, P. & Österberg, E. () Alcohol Control Policies in PublicHealth Perspective (Helsinki, Finnish Foundation for Alcohol Studies).

Davies, P. & Walsh, D. () Alcohol Problems and Alcohol Control in Europe (New York,Gardner Press).

Edwards, G., Anderson, P., Babor, T.F., Casswell, S., Ferrence, R., Giesbrecht, N., Godfrey,C., Holder, H.D., Lemmens, P., Mäkelä, K., Midanik, L.T., Norström, T., Österberg, E.,Romelsjö, A., Room, R., Simpura, J., and Skog, O.-J. (4) Alcohol Policy and the PublicGood. (Oxford, Oxford University Press).

Haberman, P.W. & Weinbaum, D.F. () Liver cirrhosis with and without mention ofalcohol as cause of death, British Journal of Addiction, , -.

Hyman, M. M. () “Alcoholic”, “unspecified” and “other specified” cirrhosis mortality: Astudy in validity, Journal of Studies on Alcohol, , -.

Jougla, E., Balkau, B., Papoz, L. & the Eurodiab Subarea C study group. () Death certi-ficate coding practises related to diabetes in European countries - the Eurodiab study,International Journal of Epidemiolgy, , -.

Maxwell J.D. & Knappman, P. () Effects of coroners’ rules on death certification foralcoholic liver disease, British Medical Journal, , .

Munoz-Perez, F. & Nizard, A. () Alcohol Consumption and Cirrhosis Mortality in theIndustrial countries Since , European Journal of Population, , -.

mats ramstedt 147

Norström, T. () The impact of per capita consumption on Swedish cirrhosis mortality,British Journal of Addiction, , -.

Poikolainen, K. () Alcohol Poisoning Mortality in Four Nordic Countries (Helsinki,Finnish foundation for alcohol studies).

Ramstedt, M. () Liver cirrhosis mortality in European countries. Trends and diffe-rences during the post war era, Nordic Studies on Alcohol and Drugs, EnglishSupplement, , -.

Romelsjö, A., Karlsson, G., Henningsohn, J. & Jakobsson, S.W. () The prevalence ofalcohol-involved mortality in both sexes: variation between indicators, Stockholm, ,American Journal of Public Health, , -.

Savolainen, V.T., Pentillä, A., & Karhunen P.J. () Delayed increases in liver cirrhosismortality and frequency of alcoholic liver cirrhosis following an increment and redis-tribution of alcohol consumption in Finland: Evidence from mortality statistics andautopsy survey covering cases in -, Alcoholism: Clinical and ExperimentalResearch, , -.

Single, E., Robson, L., Rehm, J. & Xie, X. () Morbidity and mortality attributable toalcohol, tobacco and illicit drug use in Canada, American Journal of Public Health, ,-.

Skog, O.-J. () The risk function for liver cirrhosis from lifetime alcohol consumption,Journal of Studies on Alcohol, , -.

Skog, O.-J. () The wetness of drinking cultures: A key variable in epidemiology ofalcoholic liver cirrhosis, Acta Medica Scandinavica, Suppl. , S-S.

Sundby, P. () Alcohol and Mortality. (Oslo, Universitetsförlaget).World Health Organisation. () The International Classification of Diseases.

Revision. Vol . (Geneva, World Health Organisation).Ågren, G. & Jakobsson S.W. () Validation of diagnoses on death certificates for male

alcoholics in Stockholm, Forensic Science, , -.

norström, hemström, ramstedt, rossow & skog 149

Most of the literature on alcohol and mortality is concerned with the indi-vidual level relationship. However, in this chapter we address instead theaggregate level relationship. Rather than asking, “to what extent does alcoholaffect the individual’s mortality risk?” we pose the question “to what extentdo changes in overall alcohol consumption in society have an effect on mor-tality rates?” We argue that this kind of analysis, i.e., based on aggregate timeseries data, is the most feasible approach for addressing questions that con-cern the overall public health consequences of changes in population drink-ing (Norström & Skog, ).

In this chapter we will thus focus on the relationship between per capitaconsumption of alcohol and mortality in the study countries during thepostwar period. More specifically, the following forms of mortality are con-sidered (ECAS-studies in parentheses):

• liver cirrhosis mortality (Ramstedt, a);• explicitly alcohol-related mortality (Ramstedt, b);• accident mortality (Skog, a; Skog, b);• suicide (Ramstedt, c);• homicide (Rossow, );• ischemic heart disease (IHD) mortality (Hemström, );• all-cause mortality (Norström, ).

Mortality and populationdrinkingby Thor Norström, Örjan Hemström, Mats Ramstedt, Ingeborg Rossow & Ole-Jørgen Skog

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The rationale of selecting a broad range of mortality indicators is to obtain acomprehensive assessment of the impact of population drinking on mortal-ity. Although cirrhosis mortality is the classical indicator of harmful effectsof chronic heavy consumption, the category “explicitly alcohol-related mor-tality” should be seen in the same way. Accident mortality is more likely to belinked to episodic intoxication drinking, thus reflecting acute consequencesof consumption. Suicide and homicide “...can be regarded as extreme expres-sions of, respectively, self-destructive and aggressive behaviours which areeither unrecorded or poorly recorded, and thus not amenable to statisticalanalyses, but which are nevertheless likely to be influenced by drinking.”(Edwards et al., , p. .) The cardioprotective effect of alcohol that is sug-gested by numerous individual level studies warrants analyses of how IHD-mortality responds to changes in per capita consumption to see if any posi-tive health effects can be discerned at the population level. Considering thatalcohol may have positive health consequences in addition to the negativeones, it is of interest to assess the net effect of drinking. A feasible way ofdoing that is to focus on a global outcome, i.e., all-cause mortality.

Although the overall purpose of our studies is to estimate the relationshipbetween mortality and per capita consumption, we are also interested inwhether the magnitude of this relationship varies across regions of countriesthat differ with respect to alcohol culture and consumption level. The ratio-nale for such a variation in alcohol effect is not always the same for all kindsof harm and is therefore treated separately for each of the mortality indica-tors discussed below.

LIVER CIRRHOSIS MORTALITY

According to clinical evidence, alcohol is harmful for the functioning of theliver (Rhodes et al., ), particularly heavy users of alcohol have a muchelevated risk to die of liver cirrhosis and other chronic liver diseases(Andersson, ; Rhodes et al., ; Parrish et al., ). The mortality riskis found to be an approximately exponential function of alcohol intake, i.e.,the effect on the risk of a given change in consumption is dependent on thelevel of drinking (Corrao et al., ; Skog, ; Pequignot et al., ).Hence, the impact on the risk from a change in alcohol intake is small atlower drinking levels whereas it is substantially larger if it occurs amongheavy drinkers.

Although the relationship at issue is strong at the individual level, its exis-tence at the population level is not evident. For alcohol-related damages withan exponential risk function like liver cirrhosis, an aggregate link is expectedonly if per capita consumption reflects the intake of the risk group, i.e., heavy


drinkers. (It is worth noting that such a condition would not be required ifthe risk function instead were linear). Thus, if variations in per capita con-sumption only mirror changes in alcohol intake among consumers who runa low cirrhosis risk, a population level association is not to be expected, inspite of the strong micro-level link. The corresponding condition is, ofcourse, required if a relationship between cirrhosis mortality in variousdemographic groups and per capita consumption is to be expected.

According to a wide range of studies, overall consumption seems to bepositively associated with cirrhosis mortality, both according to cross-coun-try comparisons and temporal analyses for separate countries (Bruun et al.,; Edwards et al., ). However, most existing studies are confined to alimited number of countries and mostly to drinking cultures in NorthernEurope. Further, these studies are often restricted to the male adult popula-tion, while there are hardly any studies pertaining to women or different agegroups. An important task is therefore to broaden the empirical basis of therelationship between per capita consumption and cirrhosis mortality byincluding a larger set of countries, and by considering various demographicgroups in the analyses.

Although interesting in itself, the relationship at issue is also of relevenceas a supplementary test of the collectivity theory of drinking cultures (Skog,a). On the basis of comparative studies of the distribution of alcoholconsumption in various countries, this theory suggests that different con-sumption categories, including heavy drinkers, tend to change their alcoholintake in concert. Since survey measurements of alcohol consumption, par-ticularly excessive consumption, suffer from many methodological prob-lems, aggregate level findings provide important supplementary evidence ofthis theory (Skog, 1985a). More specifically, the theory implies that per capi-ta consumption should be positively correlated with indicators of heavydrinking - such as cirrhosis mortality - in various demographic groups.

EXPLICITLY ALCOHOL-RELATED MORTALITY

Explicitly alcohol-related mortality comprises causes of death where the con-tribution of alcohol is definitional. The individual level link between alcoholand these causes of death is thus obvious. However, no previous study hasassessed the relationship at the population level.

The composite measure that will be used includes mortality from alco-holism, alcohol psychosis, alcohol poisoning and the four new alcohol-relat-ed diagnoses that were introduced in ICD ; viz., alcohol misuse, alcoholicgastritis, alcoholic cardiomyopathy and alcoholic polyneuropathy (see Table.). The new codes consist mainly of cases previously classified as alco-

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holism. ICD was implemented around - in most countries, exceptfor the Nordic countries where it was introduced in 1986-87, althoughDenmark switched directly from ICD to ICD in . No other countryapplied ICD during the study period.

Table .. Classification codes for alcohol-related deaths during different revisions of ICD

Cause of death ICD 6-7 ICD 8 ICD 9

Alcohol Dependence (Alcoholism in ICD 6-8) 307 303 303Alcoholic Psychosis 322 291 291Alcoholic Poisoning E880 E860 E860 Alcohol Misuse - - 305.0Alcoholic Cardiomyopathy, - - 425.5Alcoholic Gastritis - - 535.3Alcoholic Polyneuropathy - - 357.5

ACCIDENT MORTALITY

It is a well-established fact that alcohol intoxication is associated with anincreased risk for different types of accidents - see for instance Brismar &Bergman () for a recent review of the literature. Specifically, severalemergency room studies from recent years (e.g. Cherpitel, ) havedemonstrated that alcohol intoxication is more common among injuredpatients than among the uninjured. Furthermore, Andreasson et al. ()demonstrated a large excess accident mortality among heavy consumers ofalcoholic beverages in a prospective study. An Australian case control studyuncovered a substantially elevated risk for sustaining an injury after con-suming more than 60 g of alcohol in a -hour period (McLeod et al., ).

Traffic accidents are clearly the most heavily researched area, and alcoholseems to be a causal factor of considerable importance (e.g., British MedicalAssociation, ; National Highway Traffic Safety Administration, ).Furthermore, in many countries, alcohol also plays a significant role in acci-dental falls (Hingson & Howland, ), accidents caused by fire – probablydue to correlation with smoking (Glucksman, ; Leth, Gregersen &Sabroe, ), and accidental drowning (Lunetta, Penttila & Sarna, ).Some studies also suggest that the presence of alcohol may be associated withgreater severity of injury (Holt et al., ; Evans & Frick, ), but this find-ing remains controversial (Li et al., ).

The causal role of alcohol in accidents probably varies a lot across drink-ing cultures and historical periods, depending on consumption levels anddrinking patterns. In countries where high levels of intoxication are an inte-


gral part of the drinking culture, the etiological significance of alcohol oughtto be larger. For instance, in a comparative study of emergency departmentsin Spain and the US, Cherpitel et al. () found a significant difference withregard to alcohol between injured and non-injured in the US, but not inSpain. Furthermore, when comparing coroner’s cases in two North Americanstates, Cherpitel () found a higher prevalence of alcohol in cases in thestate with the lower per capita consumption of alcoholic beverages.

One would also expect that within cultures, the etiological significance ofalcohol tend to change over time, particularly when the overall level of alco-hol consumption changes. This hypothesis is based on the assumption thatthe correlation between alcohol and accidents at the individual level is in factthe result of a causal relationship. In periods when per capita consumptionincreases, the number of drinking occasions would, ceteris paribus, alsoincrease, and hence the number of occasions where the risk of accidents iselevated. This temporal co-variation between per capita alcohol consump-tion and accident mortality rates ought to be present in cultures with bothhigher and lower prevalence of high levels of intoxication. A study ofNorwegian data has reported a significant temporal co-variation (Skog,).

SUICIDE

The link between suicide and alcohol is substantiated by a large number ofstudies. According to a review of individual level studies from several differ-ent countries, a history of alcohol abuse and heavy drinking was present in-% of suicides. Moreover, follow-up studies of alcoholics reveal a markedexcess suicide mortality (Rossow, ).

Whereas alcohol-related diseases such as liver cirrhosis result from thetoxic effects of alcohol, the connection between alcohol and suicide is morecomplex. Two main ways in which alcohol might imply an elevated suiciderisk have been suggested. One concerns the destructive social consequencesof chronic abuse, and the other that intoxication may trigger suicidalimpulses. Considering the great cultural variation in the pattern of alcoholuse, it seems likely that the link between alcohol and suicide is not uniformacross countries. One hypothesis is that the association would be stronger indry drinking cultures than in wet (Norström, ). The rationale of thishypothesis is that dry countries would be characterised by: () a more sui-cide-inclined composition of heavy drinkers because of a stronger selectionof persons with social and psychiatric problems into alcohol abuse, () ahigher prevalence of intoxication occasions, and () a lower acceptance ofheavy drinking and alcohol abusers.

154

During the last - years, several studies employing ARIMA time-seriesanalyses have examined the link between alcohol and suicide in many differ-ent countries. However, only two studies explicitly addressed the question ofcultural differences: an intra-Nordic comparison (Norström, ) and acomparison between Sweden and France (Norström, ). Since the alcoholeffect turned out to be stronger in Norway and Sweden than in Denmark,and also stronger in Sweden than in France, both studies gave support for thehypothesis of a stronger link in dry societies. However, a case that did notcorrespond to this conclusion was Finland, a supposed dry country, whereno significant effect could be found in the Nordic comparison. In a morerecent Finnish study, however, alcohol turned out to be positively related tothe suicide rate in certain age groups (Mäkelä, ).

Moreover, comparing results from previous studies employing theARIMA-technique without taking an explicit cross-national approach con-firms on the whole that the suicide rates tends to be more responsive tochanges in per capita alcohol consumption in dry countries. Consideringstudies where a significant alcohol effect was revealed, a stronger effect wasfound for Sweden (Norström, ), Norway (Norström, ; Norström &Rossow, ), Finland (Mäkelä, ) and the U.S. (Coase, ) than in wet-ter countries like France (Norström, ), Portugal (Skog et al., ) andHungary (Skog & Elekes, ). Moreover, no significant positive effect wasfound in fairly wet countries like Denmark (Norström, ) and Switzer-land (Gmel et al., ).

HOMICIDE

The role of alcohol in violent behaviour has been assessed in a number ofstudies applying various designs and methods (see Lenke, ; Pernanen,; Gustafsson, for reviews). To a large extent a positive associationbetween alcohol and violence has been demonstrated. Hence, a large pro-portion of offenders of violent crimes, as well as the victims, have beenreported to have been under the influence of alcohol at the time of the vio-lent behaviour (see Room, ; Pernanen, for reviews). However, it maywell be argued that many of these violent crimes might have taken place evenin the absence of alcohol because of a common factor behind excessivedrinking and inclination to violent behaviour. To avoid this problem of selec-tion, analyses of aggregate data is a feasible alternative. Under the assump-tion that an increase in total consumption implies an increase in the amountof drinking occasions and thereby in the number of events of acute intoxi-cation in which violent behaviour may be triggered, it can be hypothesizedthat an increase in total consumption be followed by an increase in the level


of violent behaviour. This hypothesis is supported by a large number of stud-ies (Skog & Bjørk, ; Lenke, ; Norström, ; Parker, ; Parker &Cartmill, ; Norström, ). Furthermore, it may be hypothesized thatthe magnitude of such an aggregate relationship would vary across drinkingcultures that differ in drinking patterns and drunken comportment. In otherwords, a one litre increase in per capita consumption would imply a largerincrease in violence in a drinking culture where drinking often leads tointoxication as opposed to drinking cultures with a less explosive drinkingpattern. There is some scattered empirical support for such a hypothesis(e.g., Lenke, ) but it remains to explore whether such a cross-culturalvariation can be established on a broader empirical basis.

ISCHEMIC HEART DISEASE (IHD) MORTALITY

Over the last two decades, there have been many reports suggesting a reducedrisk of ischaemic heart disease (IHD) with a moderate level of alcohol con-sumption (for reviews, see Beaglehole & Jackson, ; Ferrence et al., ;Marmot, ; Marmot & Brunner, ; Rimm et al., ; Shaper, ).Alcohol abstainers tend to have higher mortality from IHD than do light andmoderate drinkers. However, studies do show a considerable variationregarding the shape of the risk function. A large number of studies reportsmall changes with increased consumption, approximating an L-shaped riskcurve (Doll et al., ; Gordon & Doyle, ; Keil et al., ; Scragg et al.,; Thun et al., ; Wannamethee & Shaper, ), whereas one studyfinds the lowest IHD mortality in the group with the highest alcohol con-sumption (Miller et al., ). One of the largest studies demonstrated a pat-tern in between an L- and a U-shaped relationship (Boffetta & Garfinkel,). There are also some few studies finding no significant differencesbetween non-drinkers and groups of alcohol drinkers (e.g., Camacho et al.,; Hart et al., ).

A number of plausible biochemical mechanisms have been suggested forthe alleged cardioprotective effect of alcohol, such as increased HDL choles-terol, decreased LDL cholesterol levels, reduced clotting activity of the bloodas well as healthier fibrinogen concentrations (e.g., Criqui et al., ; Criqui,). On the other hand, blood pressure tends to increase with increasedalcohol consumption, which could be one mechanism underlying a non-lin-ear risk function. The biochemical effect of alcohol is assumed to be fairlyinstantaneous (Maclure, , p. ).

An issue that has caused considerable debate is to what extent non-drinkers are selected regarding psychosocial factors related to poor health ingeneral, and to what extent the apparent cardioprotective effect of alcohol

156

could be an artefact (Wannamethee & Shaper; ; Andréasson, ).Further, assuming that alcohol consumption does have a protective effect forcertain categories of people, little is known about its potential impact at thepopulation level. These issues are addressed by analysing aggregate data; suchdata are expected to be less problematic with respect to the selection prob-lem, and they can also elucidate the question of whether changes in overallconsumption have any impact on IHD mortality.

What aggregate level relationship should be expected if an inverse riskfunction is indeed true? According to Skog’s () calculations the decreasein mortality following a one-litre increase in consumption will be muchgreater if per capita consumption is low. On the basis of the risk reductiontypically observed (one quarter to halved risk when going from abstention tog alcohol/day), a one-litre increase in a low-consumption country (

litres/year) is expected to decrease IHD-mortality by about %; the corre-sponding figure for a high-consumption country ( litres/year) is -%.

ALL-CAUSE MORTALITY

In the sections above we have mostly discussed the adverse impact of alco-hol, but also a possible beneficial cardioprotective effect. If alcohol con-sumption has negative as well as positive health consequences, it is of inter-est to know what the balance is. One way of assessing this is to estimate theimpact of alcohol on a global outcome, such as mortality risk. Variousmethodological approaches have been applied to this end. There is, thus, alarge number of longitudinal or case-control studies based on observationaldata. These studies generally find a U- or J-shaped curve relating intake tomortality risk, with an elevated risk for abstainers and heavy drinkers (forreviews, see Edwards et al., ; Poikolainen, ). The U-shape is inter-preted as the amalgam of two risk curves: the risk for coronary heart diseasemortality decreases as a function of intake, at least up to the level of moder-ate consumption, while the risk for accidents and certain chronic outcomes,such as liver cirrhosis, increases with increasing consumption. However,there is still some controversy regarding the causal interpretation of the U-shaped risk curve. Although many researchers seem to be convinced thatthere is a causal relationship underlying the curve, some are more sceptical,and point out that abstainers are a selective category in ways that may biasthe results (Shaper, ; Skog, ; Andréasson, ). It is therefore ofinterest to estimate the relationship between alcohol and mortality at theaggregate level where selection effects of this kind are not expected.

What population-level relationship should we expect? In an analyticallyoriented paper, Skog () predicts an aggregate risk curve that is based on


a J-shaped individual-level risk function where the benefit is % (RR=.)at a consumption level of l alcohol (%) per year. The resultant aggre-gate risk function is shown in Figure .. As can be seen, the optimum con-sumption level for the population is located at l/year, this would yield a %benefit compared with a population with no consumption. Increases in percapita consumption up to l would thus be associated with decreased mor-tality, whereas consumption increases above this level would give rise tomore deaths. In populations below the horizontal reference line, alcoholobviously has a net protective effect, and we can make the more substantiveobservation that in the region that is to the right of the optimum and belowthe horizontal reference line (i.e., on the interval - l), increased consump-tion is associated with increased mortality, while there is still a net protectiveeffect of alcohol. Not too much attention should be paid to the exact num-bers in the predicted curve since they depend critically on the underlyingassumptions. However, within reasonable alterations of the underlyingassumptions the main feature of the predicted curve remains intact, that is,its quadratic form and the fact the optimum consumption level for the pop-ulation and the associated beneficial effect both are appreciably lower thanfor the individual. Further, in low-consumption countries a larger propor-tion of a given increase in total consumption would occur among people atlow consumption levels, compared to what would be the case in high-con-sumption countries. The ratio between protective and harmful effects thatfollows from increases in total consumption should thus be more favourablein low- than in high-consumption countries, and we should therefore expecta gradient in the alcohol effect on total mortality as we move upwards on thescale of overall consumption. The existing aggregate-level studies (Bandel,

Per capitaconsumption (litres/year)

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Figure .. Expected aggregate risk curve between mortality and per capita consumption(adapted from Skog, ).

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; Skog, ; Norström, ; Norström, ; Her and Rehm, ) aretoo scattered to assess the validity of this prediction; a more systematic andcomprehensive analysis is needed that covers a spectrum from low- to high-consumption countries.

DRINKING PATTERNS

There appear to be large differences between drinking cultures with respectto levels of intoxication, and this may well imply the relationship betweenalcohol and harm is not invariant across countries. Comparative data ondrinking patterns are scarce (see Ch. ). Yet, based on published reports fromthe Nordic countries (Mäkelä et al., ) and Italy (OsservatorioPermanente sui Giovani e l’Alcool, ), Rossow () calculated a mea-sure regarding the importance of drinking to intoxication in the Nordiccountries compared to Italy. This indicated a north-south gradient, with ahigher importance of drinking to intoxication in Finland and Norway, alower in Denmark and the least reported by Italians. Thus, it seems that adrinking occasion in the Nordic countries (i.e., Finland, Sweden andNorway) more often leads to intoxication as compared to the SouthernEuropean countries, with the central European countries somewhere inbetween. The findings from the ECAS-survey (Ch. ) are also consistent withsuch a pattern. One could thus expect a north-south gradient in the magni-tude of the relationship between alcohol and those types of mortality whereintoxication is an important antecedent, that is violent deaths.

DATA AND METHODS

The analyses comprise all member states of the European Union as of ,with the exception of Luxembourg (due to its small and less well-definedpopulation) and Greece (due to the limited availability of data on alcoholconsumption). In addition, Norway has been added to the set of study coun-tries to broaden the representation of Northern Europe, making a total of

countries. The longest observation period is -, though it is apprecia-bly shorter for some countries. As a proxy for consumption, we used sales ofalcohol expressed in litres at % for per capita years and above (source:Brewers Association of Canada, ). Age-specific mortality data for menand women were obtained from the WHO Mortality Database (Geneva), andfrom various agencies in the individual countries. For most outcomes, age-standardised mortality rates (number of deaths per population) formen and women were constructed for the categories years and above, andthree age-groups, typically - years, - years, - years (the presentreport is confined to the category years and above).


The study countries are grouped into three categories: low-, medium- andhigh-consumption countries. The low-consumption group includes threeNorth European countries: Finland, Norway and Sweden. The intermediategroup comprises Central Europe and the British Isles, i.e., Austria, Belgium,Denmark, Ireland, the Netherlands, United Kingdom, and West Germany.Finally, the high-consumption group comprises four South European coun-tries: France, Italy, Portugal, and Spain. Thus, the countries within the threegroups are not only similar in terms of consumption levels, but are also rea-sonably homogenous with regard to alcohol policy regimes and drinkingpatterns, including beverage preferences.

In the estimation of the relationships between alcohol and mortality weuse the technique for time series analysis that has been suggested by Box andJenkins () often referred to as ARIMA models. The method requires sta-tionarity and possible time trends are removed by filtering; in most cases asimple differencing of the series is sufficient to eliminate non-stationarity.This procedure reduces greatly the risk of obtaining spurious correlationssince an omitted variable is more likely to be correlated with the explanato-ry variable as a result of common trends than as a result of synchronisationin the yearly changes. Further, the noise term, which includes explanatoryvariables not considered in the model, is allowed to have a temporal struc-ture that is modelled and estimated in terms of autoregressive or movingaverage parameters.

However, if an omitted variable tends to change in concert with the input,that is, alcohol consumption, the differencing procedure is of little avail.Instead, the potential confounder should be explicitly incorporated into themodel. In the analysis of IHD-mortality, tobacco consumption was thusincluded as a control, and in the analysis of male all-cause mortality, femalemortality was used as a control (regarded as a proxy for other etiological fac-tors affecting mortality in both sexes).

Another methodological complication is the time-lag in the mortalityresponse to changes in consumption. This is, of course, not expected in thecontext of acute consequences, such as fatal accidents, but rather for chron-ic outcomes. It is particularly in analyses of trends in cirrhosis mortality thatthe time-lag phenomenon has been addressed, and not considering it cangive rise to quite erroneous conclusions (Skog, ). One way of taking thetime-lag into account is to use a weighted alcohol series as input, where thelag weights are fixed a priori on the basis of external information and priorexperience (Norström, ; Skog, ). This has been applied in the analy-ses of cirrhosis mortality, explicitly alcohol-related mortality, and all-causemortality.

160

Semi-log models have been estimated for all outcomes, except for acci-dents where a linear model was deemed more appropriate.

To facilitate comparisons between low-, medium-, and high-consumptioncountries, the estimated alcohol effects are pooled within the three groups ofcountries. The pooling is a simple unweighted averaging, and does not re-quire homogeneity of estimates. The procedure shrinks the estimated stan-dard error substantially (proportionally to the square root of the number ofcountries).

RESULTS

Table . shows the estimated percentage changes for the various outcomesassociated with a one-litre increase in per capita consumption. It is seen thatin every country a consumption increase leads to a significant increase inmale mortality from either cirrhosis or explicitly alcohol-related mortality,but in no country is there a significant decrease in IHD-mortality. We notethat for accidents, about half of the country-specific alcohol effects and allpooled estimates for the three country-groups are positive and significant(this holds true for males as well as for females). More detailed analyses(Skog, b) suggest that in Central and Southern Europe, the role of alco-hol is most important in relation to traffic accidents. In Northern Europe onthe other hand, it is a substantial risk factor in relation to accidental falls andother accidents, but of somewhat less importance in relation to traffic acci-dents. As to homicide, the pooled estimates, and about half of the country-specific estimates, are significant and positive for men, while the female esti-mates are by and large insignificant. With respect to suicide, strong and sig-nificant alcohol effects (positive) are found in all low-consumption countriesof Northern Europe (including age-specific estimates not reported here),while the effects are generally weak and insignificant in other countries. Theestimated effect on all-cause mortality is positive and significant in half ofthe countries. Confining the analyses to mortality from diseases (i.e., exclud-ing violent deaths) had only a marginal effect on the outcome (results notshown).

Comparisons between countries as well as between males and femalesmust be done with great care. It should be cautioned that big differences inrelative effects may primarily be the result of a marked difference in mortal-ity rates. However, there is a general tendency that all forms of mortalityanalysed (except IHD) respond more strongly – whether measured in rela-tive or absolute terms – to changes in overall consumption in NorthernEurope than in the other country groups. (For cirrhosis mortality the elevat-ed effect is noted only for Sweden).

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161

Table .. Percentage change in various forms of mortality for men (M) and women (F) associated with a one-litre increase in per capita consump-tion of alcohol. All figures (except for accidents) are based on estimates from semi-logarithmic models estimated on differenced data for the approxi-mate period -. Figures for accidents are calculated on the basis of estimates from linear models combined with accident rates

Cirrhosis Explicitly alc.- Accidents Suicide Homicide IHD Totalrelated mor- mor-

tality tality

Low-consn. M F M F M F M F M F M F McountriesFinland 15.6* 6.5 8.9 27.9 4.8 8.9* 3.7 4.3 11.2* 3.9 0.6 -1.5 1.7Norway 22.1 4.7 45.1* 116.0* 11.3* 5.0* 12.9 24.6* 25.5* 6.4 -1.2 2.7 4.1*Sweden 57.3* 39.5* 52.2 81.9* 11.0* 14.9 10.6* 8.2* 16.3* 14.1* -2.4 0.3 3.1*Pooled est. 31.7* 16.9* 35.4* 75.3* 9.0* 9.6* 9.1* 12.4* 17.7* 8.1 -1.0 0.5 3.0*

Medium-consn.countriesAustria 9.9* 8.2* 1.9 29.8 6.6* 5.2* -1.5 0.9 .2 3.8 0.9 2.3 1.1*Belgium 8.8* 8.0* 7.7 15.9 2.4 6.3* 4.6 9.9* 14.2 10.9 1.5 2.0 0.8Denmark 10.2* -5.4 29.8* 13.2 2.9 -3.8 -1.8 -0.2 17.4 4.5 0.5 2.3 1.5Ireland 6.7* 4.8 13.7 14.8 7.5* 7.6* 3.3 1.1 20.6* 4.8 -1.5 1.7 -0.1Netherlands 7.8* 2.1 11.2 27.4* -2.0 0.0 -1.6 6.7* 9.1 4.8 0.7 1.1 2.4*U.K. 11.6 13.8* 48.0* 62.4* 2.0 -0.8 -1.1 2.7 8.4 11.9 0.4 2.7 0.2W.Germany 8.7* 4.7* 12.4* 27.1* 4.5* 4.8* 0.6 2.9 3.5 5.9 1.5 0.2 1.6*Pooled est. 9.1* 5.2* 17.8* 27.2* 3.4* 2.8* 0.4 3.4* 10.5* 6.7* 0.6 1.8* 1.1*

High-consn. countriesFrance 11.6* 18.3* 8.9* 8.9* 4.0* 3.4* 0.2 0.1 1.7 -1.3 0.2 -0.8 1.2*Italy 11.6* 8.4* -3.7 -6.9 2.2* 3.2* -1.3 0.3 3.9 1.4 -0.9 -1.4 1.0Portugal 10.6* 12.9* - - 1.0 -0.2 1.6* 1.4 6.7* -0.4 0.9 1.0 1.7*Spain 5.2* 2.8* 4.8 1.0 2.0* 1.2 -2.8 0.1 16.0* 7.3 3.4* 2.3* 0.2Pooled est. 9.8* 10.6* 3.3 1.0 2.3* 1.9* -0.6 0.5 7.1* 1.8 0.9 0.3 1.0*

*p<.05

162

DISCUSSION

The relationship between harm rates and overall consumption has certainlybeen addressed in previous research, but differences in scope and methodol-ogy limit the comparability across extant studies. By applying a commonmethodological protocol on a broad range of outcomes, and using data froma large set of countries representing different drinking cultures, it has beenpossible to get a more comprehensive and multifaceted assessment of howchanges in consumption impact on population health. The findings rein-force but also modulate the cornerstone of the public health perspective(Bruun et al., ); although per capita consumption stands out as a crucialdeterminant of alcohol-related harm, its impact appears to be amplified ormitigated depending on the drinking culture and its drinking patterns. Asuccinct expression of this is the aggregate link between alcohol and suicide;it is quite marked in Northern Europe, but weak or non-existent in Southand Central Europe. One interpretation of this pattern is that the more theuse of alcohol is integrated into everyday life, the less does excessive intakegive rise to social marginalisation and disintegration (which suicide is amarker of). The north-south gradient in the alcohol effect on accidents andhomicide accords with the expectation based on national differences inintoxication drinking. However, this does not readily explain the tendencytowards an elevated alcohol effect in Northern Europe also on mortalityfrom diseases, where chronic abuse should be the main alcohol mechanism.This brings us to another possible mechanism, differences in the distributionof consumption. If the top %, say, of the consumers drink a larger share oftotal consumption in low-consumption countries than in countries withhigh consumption, per capita consumption in the former country groupwould also be a more sensitive marker of the risk group for chronic alcohol-related harm. There is indeed some evidence that indicates such differencesin the consumption distribution, viz., the inverse relationship that has beenobserved between consumption level and the relative dispersion of the dis-tribution (Bruun et al., ; Skog, a). The findings indeed reveal otherintriguing variations across country groups in the relationship between alco-hol and harm that might be related to differences in drinking patterns.However, to make any progress along that line of inquiry requires morecomparable data on the cultural dimension of drinking.

For several outcomes, but in particular for cirrhosis mortality, significantalcohol effects were found also for various age-groups. This outcome wouldnot obtain unless there was a fairly high degree of synchronisation in howconsumption changes in the population, and can thus be seen as a supple-mentary support for the theory of the collectivity of drinking.


The one relationship that is invariant across countries as well as differentage groups of men and women is the zero-correlation between alcohol andischemic heart disease mortality. This suggests that an increase in per capitaconsumption does not provide any cardioprotective effect at the populationlevel. This accords with the outcome for all-cause mortality; here the hypoth-esis based on a U-shaped risk function predicted a stronger alcohol effect thehigher the per capita consumption. Instead, the strongest effect was foundfor the low-consumption countries.

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örjan hemström 169

INTRODUCTION

Alcohol is one of the factors known to contribute to socioeconomic differ-entials in total mortality. Studies from Britain (Harrison & Gardiner, ),Finland (Mäkelä et al., ), France (Behm & Vallin, ) as well as Sweden(Leifman, ; Lundberg & Östberg, ), show that manual workers havemarkedly higher alcohol-related mortality compared with upper nonmanu-als. A Finnish study (pertaining to the period -) estimated that nearlyone-quarter of the difference in life expectancy (from age ) between malemanual workers and upper nonmanuals was due to alcohol-related deaths(Mäkelä et al., ). The contribution was percent for female manualworkers. A smaller contribution was found for Sweden for the period -

(Lundberg & Östberg, ), probably in part because another definition ofalcohol-related deaths was applied, and the economically inactive wereexcluded.

The limitations of earlier Swedish studies make it warranted to again esti-mate the contribution of alcohol-related deaths to socioeconomic differ-ences in all-cause mortality. This analysis also serves as an empirical exampleof the role alcohol might have in social differences in premature mortality ina country included in the ECAS-study, although it is not possible to gener-alise findings to other countries.

The contribution of alcohol to socioeconomic differentials in mortality: the case of Swedenby Örjan Hemström

8.

170

DATA AND METHODS

Data from a Swedish Census-Linked Death Registry were analysed. AllSwedes who participated in the and censuses are included. Deathswere linked from the Cause of Death Registry for the period November , to December , using each person’s identification number. Those- years old in were selected for the analysis. In the mortality follow-up (-), the study population was - years old. Persons who emi-grated during the follow-up period were excluded.

Alcohol-related deaths were defined from those causes of death wherealcohol is a major causative agent, and when such a cause was given as eitheran underlying or a contributory cause of death (see Table .). Similar defin-itions have previously been applied (Mäkelä et al., ), although it was notpossible in the present data to distinguish accidents related to alcohol fromnon-alcohol-related accidents, something that is possible in Finland.

A total of , alcohol-related deaths were found, of which % were fromcontributory causes of death (Table .). Alcohol dependence syndrome(ADS) dominated strongly among the alcohol-related contributory causes(% of all cases), and also make up a considerable share of underlying caus-es (% of all cases). There is a relatively high rate of reporting causes suchas ADS and alcohol poisoning in Sweden, Finland and Norway comparedwith many other European countries. There is also great variation in the pro-portion of cirrhosis deaths attributed to alcohol – from % in Italy to %in Finland (see Chapter ).

Socioeconomic position was measured from the Census, or from the Census if the individual did not have gainful employment in . TheSwedish socioeconomic classification was used (Statistics Sweden, ). Thefollowing groups were distinguished for the analysis: manual workers, lowernonmanuals, upper nonmanuals (intermediate to higher level and profes-sionals), entrepreneurs, farmers and four categories with inadequate occu-pational details (unclassifiable occupation, early retired, unpaid homework-ers and ‘others’, such as unemployed and students). In some presentationsbelow, unclassifiable, early retired, homeworkers and others are merged into‘unclassifiable & others’.

Socioeconomic differences for alcohol-related mortality, all-cause mortal-ity and non-alcohol related mortality were estimated in a similar way as wasdone in earlier studies (Lundberg & Östberg, ; Mäkelä et al., ). Resultsfrom this analysis show relative mortality rate differences between socioeco-nomic groups as compared to the level of mortality of upper nonmanuals(reference group). An estimate of means that the mortality rate (controlledfor age differences in one-year age groups) is twice that of upper nonmanuals.


When estimating the contribution of alcohol to total mortality differences– as compared to the mortality of upper nonmanuals – only absolute mor-tality rate differences are used (for all-causes and for alcohol-related mortal-ity). This is done for specific five-year age groups and in total. The latter esti-mation requires age standardisation. Therefore, rates for the whole age stra-ta (-) are weighted by the age distribution (five-year age groups) in thetotal population selected for the study. The estimation procedure can bedescribed by the following fictitious example (in rates per , person-years): () the age standardised (- to - year-olds) all-cause mortality is for upper nonmanuals and , for manual workers; () the corre-sponding alcohol-related mortality rates are and respectively; () weobserve a total differential of (,-) and an alcohol-related differ-ential of (-); () the contribution of alcohol to the total number ofexcess deaths among manual workers is thus % (/).

Table 8.1 Alcohol-related deaths by diagnosis (ICD-9). Sweden 1990-95, ages 30-79years

Cause of death ICD-codes Number of deaths %

Alcohol psychosis* 291.0-291.9 79 0.8Alcohol dependence syndrome* 303 1,598 16.7Alcohol abuse* 305.0 10 0.1Alcohol-related epilepsy 345+303 100 1.0Alcoholic cardiomyopathy* 425.5 145 1.5Alcoholic liver cirrhosis* 571.0-571.3 1,219 12.8Alcoholic diseases of pancreas* 577.0-577.1 447 4.7Alcoholic polyneuropathy or alcoholic gastritis* 357.5 or 535.3 22 0.2Poisoning by alcohol* E860 or N980 690 7.2Underlying cause not due to alcohol, but at least one of the ICD-codes indicated by * 5,237 54.9above given as a contributory cause on the death certificate

Alcohol psychosis 117 1.2Alcohol dependence syndrome 3,888 40.7Alcohol abuse 731 7.7Alcoholic cardiomyopathy 32 0.3Alcoholic liver cirrhosis 364 3.8Alcoholic diseases of pancreas 438 4.6Alc. polyneurop. or alcoholic gastritis 21 0.2Poisoning by alcohol 253 2.7

All alcohol-related deaths 9,547 99.9

RESULTS

Some descriptive data and a summary of general findings are given in Table.. Male manual workers had . times higher alcohol-related mortality thanupper nonmanuals, and the corresponding figure for female manual workerswas .. For both sexes, lower nonmanuals and entrepreneurs also had sig-nificantly elevated alcohol-related mortality, and male farmers had signifi-cantly lower such mortality. All four unclassifiable and other groups hadclearly elevated alcohol-related mortality for both sexes.

Among men, the contribution of alcohol to the all-cause excess mortalityamong those who had an unclassifiable occupation or belonged to the cate-gory ‘others’ was estimated at about one-fourth. The corresponding estimatewas about % for manual workers, % for early retired, % for lowernonmanuals and -% for entrepreneurs and unpaid homeworkers (Table.). The contribution among women was lower and exceeded % onlyamong ‘others’. It was in the range -% for manual workers, lower non-manuals and unpaid homeworkers and less than % for entrepreneurs andearly retired.

Table 8.2. Distribution of person-years, number of alcohol-related deaths, age standardised rate ratios (SRR) for alcohol-related mortality with 95% confidence intervalsand the proportion of the absolute all-cause mortality difference (as compared with uppernonmanuals) that was due to alcohol. Sweden 1990-95, ages 30-79 years

Distri- Number of SRR Proportionbution of alcohol- alcohol-related of mortalityperson- related mortality difference due

Socioeconomic group years (%) deaths (95% CI) to alcohol (%)

Men (11,327,243 person-years) 7,766Upper nonmanuals 29.3 758 1 (ref.group) -Manual workers 39.7 3,304 3.18 (2.94-3.45) 15.9Lower nonmanuals 9.5 494 1.90 (1.70-2.13) 9.6Entrepreneurs 6.9 318 1.69 (1.48-1.93) 7.3Farmers 3.0 59 0.63 (0.48-0.82) -17.2Unclassifiable 4.2 474 4.51 (4.02-5.06) 28.5Early retired 3.7 1,191 8.37 (7.61-9.21) 14.2Homeworkers 0.1 11 3.87 (2.13-7.02) 8.0Others 3.6 1,157 11.94 (10.89-13.09) 23.9

Women (11,613,530 person-years) 1,781Upper nonmanuals 21.0 137 1 (ref.group) -Manual workers 36.3 593 2.36 (1.96-2.85) 6.3Lower nonmanuals 18.2 245 1.97 (1.60-2.43) 5.6Entrepreneurs 3.0 38 1.79 (1.25-2.57) 3.4Farmers 1.5 11 0.96 (0.52-1.77) -0.7Unclassifiable 3.4 84 3.79 (2.89-4.98) 9.6Early retired 5.7 308 5.98 (4.81-7.43) 4.1Homeworkers 6.5 143 2.64 (2.07-3.36) 5.9Others 4.3 222 7.04 (5.67-8.73) 10.6

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Women

Men

Figure 8.1. Contribution of the absolute excess in alcohol-related mortality to all-causemortality differentials between socioeconomic groups (upper nonmanuals constitute thereference mortality rate) in 10 age groups for women and men, Sweden 1990-95.

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Age-specific analyses revealed a great variation in the contribution ofalcohol across age groups (Fig. .). In the age span - years, -% of thetotal mortality differential between male manual versus upper nonmanualworkers was due to an excess number of alcohol-related deaths in the formergroup - results that are much the same for men in the ‘unclassifiable & other’group. The contribution is about the same for lower nonmanuals and entre-preneurs as for manuals and ‘unclassifiable & others’ in the age group -

years (%), but somewhat lower (and more irregular) in the age-range - years (-%). Among men years and older, the contribution of alco-hol is smaller; less than % among - to -year-olds. Farmers were exclud-ed here due to very few deaths in some age groups.

There is also a variation with age among women. In the age span -

years, -% of the excess mortality among manual workers, lower non-manuals and ‘unclassifiable & others’, compared to upper nonmanuals, couldbe ascribed to alcohol-related deaths. The highest contribution was estimat-ed for female manual workers in the age group - (.%).

DISCUSSION

It is difficult to strictly compare studies that have estimated socioeconomicdifferences in alcohol-related mortality and its contribution to such differ-ences in all-cause mortality. Studies define alcohol-related deaths differently,cultures differ in their willingness to mention alcohol at the time of death,classifications of socioeconomic position and age groups included also varyacross studies. All these factors have an impact on results and conclusions. Inan earlier Swedish study (Lundberg & Östberg, ), the contribution ofalcohol was smaller than here, mainly because previous occupational datawere not available and contributory causes not considered. More than half ofall alcohol-related deaths were distinguished from the contributory causes inthe present study (Table .).

Results suggest that the contribution of alcohol reaches a peak among themiddle-aged in Sweden (- to -year olds). If a lower upper age limit than years had been chosen, the total contribution of alcohol would have beengreater. Exclusion of - to -year-olds () has little impact: there are fewdeaths with an alcohol diagnosis and there is considerable social mobility(e.g., students becoming upper nonmanuals) in this age group that couldintroduce a bias.

How to define an alcohol-related death is debatable. Individual level fol-low-up studies show that heavy alcohol consumption increases the risk ofmortality for many, if not most, causes of death (Doll et al., ). For manydiseases, the contribution of alcohol is uncertain. In Finland, the largest


share of alcohol-related deaths was attributed to violent deaths (Mäkeläet al., ). This suggests that the % of the total mortality differentialbetween male manual workers and upper nonmanuals that could be attrib-uted to alcohol in the present study, should be seen as a ‘low’ or a ‘minimumestimate’.

A number of social factors might influence the degree of socioeconomicdifferentials in alcohol-related mortality, not least differences in drinkinghabits. Although there are no substantial differences in total consumptionbetween manual and nonmanual groups, a larger share of manual workersmay become heavy drinkers in Sweden (Norström & Romelsjö, ). Bingedrinking (a high intake in a drinking occasion) has long been more commonamong manual than nonmanual groups in Sweden (Leifman, ). Suchdrinking is relatively widespread in Sweden, and might influence the possi-ble risk of developing alcohol dependence syndrome. Socioeconomic differ-entials are particularly pronounced for alcohol dependence syndrome, butsmaller for liver cirrhosis mortality (Leifman, ; Lundberg & Östberg,). Studies on persons treated for alcohol abuse tend to show that manu-al workers are over-represented compared to nonmanual groups (Romelsjö& Lundberg, ), but it might also be that manual groups more easilyreceive a diagnosis of alcohol dependence or alcoholism (Hemmingsson,). Social factors specific to manual workers’ environment and life histo-ry might also contribute to their high alcohol-related mortality, such as lowdecision latitude in the job and risk factors for alcoholism established alreadyin late teenage (Hemmingsson & Lundberg, ). Thus, problem drinkerstend to move into certain occupations, and such mobility probably enlargessocioeconomic differences in alcohol-related mortality in Sweden. Earlyproblem drinking or drug use during school ages could increase the risk oflifetime non-employment. It is also known that alcohol problems are reasonsfor disability pensioning in Sweden (Upmark, ).

CONCLUSION

Alcohol seems to play a significant role for socioeconomic mortality differ-entials in Sweden. The contribution varies strongly with age. Among men inthe age group - about one-third of the total excess mortality for manu-al workers, lower nonmanuals, entrepreneurs as well as ‘unclassifiable & oth-ers’, in relation to upper nonmanuals, could be attributed to alcohol. Amongthose years and older the contribution of alcohol is fairly small. Althoughthe age pattern showed a similar shape among women as among men, thecontribution of alcohol to socioeconomic mortality differences was smallerthan for men. In Sweden, relative all-cause mortality differentials between

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manual and nonmanual workers tend to peak in the age-span - (Vågerö,). This corresponds with the finding here that alcohol-related deathscontribute the largest number of excessive deaths in this age-span.

REFERENCES

Behm, H. & Vallin, J. () Mortality differentials among human groups. in: Preston, S.H. (Ed.) Biological and Social Aspects of Mortality and the Length of Life (pp. -)(Liege, Belgium, Ordina Editions).

Doll, R., Peto, R., Hall, E., Wheatley, K., Gray, R. & Sutherland, I. () Mortality in rela-tion to consumption of alcohol: 3 years’ observations on male British doctors, BritishMedical Journal, , -8.

Harrison, L. & Gardiner, E. () Do the rich really die young? Alcohol-related mortalityand social class in Great Britain, 88-, Addiction, , 8-88.

Hemmingsson, T. () Explanations of differences in alcoholism between social classes andoccupations among Swedish men: a register based follow up study (Stockholm, KarolinskaInstitute, Department of Public Health Sciences, Division of Occupational Health,Thesis).

Hemmingsson, T. & Lundberg, I. (8) Work control, work demands, and social supportin relation to alcoholism among young men, Alcoholism: Clinical and ExperimentalResearch, , -.

Leifman, H. (8) Socialklass och alkoholvanor (Stockholm, Swedish Institute for PublicHealth).

Lundberg, O. & Östberg, V. () Bidrar klasskillnader i alkoholrelaterad dödlighet tilldödlighetsskillnaderna i Sverige (Class and alcohol: do differences in alcohol-relatedmortality contribute to the overall mortality gradient)? Alkoholpolitik – Tidskrift förNordisk alkoholforskning, , -.

Mäkelä, P., Valkonen, T. & Martelin, T. () Contribution of deaths related to alcohol useto socioeconomic variation in mortality: register based follow up study, British MedicalJournal, 3, -.

Norström, T. & Romelsjö, A. () Social class, drinking and alcohol-related mortality,Journal of Substance Abuse, , 38-3.

Romelsjö, A. & Lundberg, M. () The changes in social class distribution of moderateand high alcohol consumption and alcohol-related disabilities over time in StockholmCounty and Sweden, Addiction, , 1307-1323.

Statistics Sweden (8) Socioekonomisk indelning (SEI) [Swedish socioeconomic classifica-tion] (Stockholm, Statistics Sweden).

Upmark, M. () Alcohol, Sickness Absence, and Disability Pension: a Study in the Field ofDisease, Ill Health, Psychosocial Factors, and Medicalisation (Stockholm, KarolinskaInstitute, Department of Public Health Sciences, Division of Social Medicine, Thesis).

Vågerö, D. () Health inequalities from the cradle to the grave? Hypotheses on healthpolicy, International Journal of Health Sciences, , -8.

conclusions 177

In this chapter we present the major conclusions from the various parts ofthe ECAS study.

TRENDS IN ALCOHOL CONTROL POLICIES

Based on the experience from earlier studies, we have created a scale to mea-sure the strictness of alcohol control policies and have applied it to the coun-tries included in the ECAS project.

If we take a closer look at the classification of the countries at the begin-ning of the period we notice that the Nordic countries, Denmark excluded,were classified as countries having a high alcohol control. Countries classi-fied as having an average alcohol control in the s were the UnitedKingdom and Ireland, accompanied by Italy. In the s these countrieswere joined by Austria and Belgium. The reason why these countries wereclassified as having at least medium-level alcohol control is mainly in theirlicensing systems and sales restrictions for on- and off-premise sales of alco-hol, which have long traditions in the Anglo-Saxon countries in particular.The remaining nine countries were classified as having low alcohol control.

From the s onwards we can notice a subtle, but gradual shift towardsa stricter alcohol policy in almost all the studied countries. The UnitedKingdom could be regarded as having a high alcohol control as early as the

Conclusions

9.

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s, and the number of countries classified as having medium alcohol con-trol grew slightly from five countries in to six in .

A more distinct move towards a stricter and more extensive alcohol con-trol policy could be detected between and . In , five countrieswere regarded as having a high alcohol control and eight countries as havingan average alcohol control. The “low alcohol control” category was by far thesmallest, containing only Portugal and Greece. A contributing factor in thisdevelopment was that the number of motor vehicles had grown to the extentthat motor traffic had to be more closely regulated, and road safety issues,such as drunk driving, were given more attention. This led to the introduc-tion of BAC limits in traffic in most of the countries in the s and s.Age limits for sales of alcoholic beverages were also introduced and/or sharp-ened in several countries during this period. The number of television setsand television broadcasts grew substantially during this time, and restric-tions on alcohol advertisements (mainly voluntary codes), as well as otherrestrictions, began to emerge in several countries.

In the year none of the countries can be classified as having low alco-hol control. Portugal and Greece have also joined the category of mediumalcohol control countries. At the same time, however, we notice that the scorehas dropped substantially for the strictest alcohol policy countries in Europe,namely Norway, Sweden, and Finland. The reason can mainly be found inEuropean integration: all three joined the European Economic Area (EEA)on January , Finland and Sweden becoming full EU members on 1January .

However, comparing scores across countries or over time is problematic,because changes in these numbers reflect two different trends. On the onehand there has been a decrease in the control of production and sales of alco-holic beverages or the regulation of alcohol availability. On the other hand,alcohol control measures targeted at demand or alcohol-related problemshave become more prevalent. This is not to deny that alcohol control policieshave become more similar in the second half of the twentieth century, but itdoes mean that the convergence is not a process leading towards a certainkind of alcohol control policy that was already in place in the s. Instead,the countries are adopting similar measures or approaches for alcohol con-trol and giving up control measures or strategies of another kind. The con-vergence or homogenisation is a real phenomenon, but we should not mea-sure its progress or differences in the strictness of alcohol control betweencountries by counting changes in average points or the relative number ofpoints given to different countries.

conclusions 179

TRENDS IN ALCOHOL CONSUMPTION

We found evidence for increased homogenisation (equalisation) in beveragepreferences for the whole study period (-). In terms of consumptionlevels (litres % alcohol per capita aged and above), the homogenisationbetween the study countries in the first half of the study period was the resultof strong consumption growth in the low- and medium-consumption coun-tries in Northern and Central Europe, whereas the levels in the high-con-sumption Mediterranean countries remained more stable or, as for France,declined from the mid s. During the second half of the study period, thehomogenisation is mainly due to a rapprochement between the consump-tion in the wine-drinking countries and the remaining ten countries, withthe wine-drinking countries’ consumption approaching the other countries’per capita consumption. The average difference between the beer and wine-drinking countries in total consumption in the mid s amounts to nomore than a few decilitres pure alcohol per capita.

The estimations of unrecorded alcohol consumption give no indicationthat this would have increased in the Mediterranean countries. On the con-trary, the results indicate a slight decrease in unrecorded alcohol consump-tion. In the countries in Northern Europe, however, unrecorded alcohol con-sumption seems to have increased, from about litre in the s to litresper capita in the second half of the s. There are signs of increasedunrecorded alcohol consumption in the UK, too, starting from the mids. In the remaining countries in Central Europe, the changes in un-recorded alcohol consumption appear to have been more modest.

After adjusting for differences in estimated unrecorded consumption thedifferences between the countries become somewhat reduced, although therank order of the countries remains by and large unaffected, both in thes and in the s.

Econometric analyses suggested that economic conditions have a bearingon the changes in alcohol consumption. The estimated income elasticitieswere fairly similar across all study countries, whereas the estimated priceelasticities were stronger in Northern Europe and weakest in SouthernEurope. Since real incomes have increased and real prices have been ratherstable, or even decreased for the past years, economic factors cannotexplain the decreased consumption in Southern Europe.

It is concluded that common factors, such as fluctuations in the worldeconomy, may contribute to similar trends in consumption levels over time.It is important to note, however, that these global factors have not beenstrong enough to maintain the homogenisation process at the same rapidspeed for the last - years. The description of each country’s total record-

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ed consumption over time also reveals that the trends look somewhat differ-ent for different countries, not only between countries in southern, centraland northern Europe, but also between countries within the same group. Itis possible that the more or less uniform changes in consumption evidentduring the first half of the study period, have come to an end.

This may indicate that the instruments of control or the drinking culturesstill differ markedly between countries and remain important enough toexplain national differences in the levels of consumption. The explanationsof the consumption trends may thus be different for different countries,despite global influences in culture, economy and perhaps politics.

TRENDS IN DRINKING PATTERNS

Trends in drinking patterns were studied in order to discuss three majorissues. First, it was expected that variation in drinking patterns could explainsome of the differences between countries in the link between alcohol con-sumption and alcohol-related harm. Secondly, if drinking patterns wouldhave importance as an intervening variable between consumption and harm,then preventive policies targeted to specific features of drinking patternscould be an important contribution to the arsenal of preventive measures.Thirdly, it is of interest to know whether a homogenisation of drinking pat-terns would has taken place, parallel to the partial and slow homogenisationof per capita alcohol consumption and socio-economic living conditions.The last issue also concerns the natural time-scale of changes in drinkingpatterns.

None of the three issues could be illustrated with sufficient, reliable andcomparable data on trends in drinking patterns over longer periods of time.Indeed, only a few countries provide any information on drinking patternsuntil the s or s. Moreover, the information rarely covers issues thatare proposed to be most relevant when considering the role of drinking pat-terns in the link between consumption and harm. The lack of data on bingedrinking and drinking at specific drinking contexts is the most striking prob-lem here. Also, it turned out that there are good reasons to believe that eventechnically identical data on drinking patterns cannot be used in compar-isons at face value, as there may be large variation in the cultural patterns ofanswering questions on drinking. As a consequence of the problems metwith the first issue, the second issue of preventive policies targeted on specif-ic features of drinking patterns cannot be satisfactorily studied in a compar-ative European setting. The third issue of homogenisation also remainsmostly unanswered, as any longer time series of comparative data cover onlya few countries and only a few very basic aspects of drinking patterns, like

conclusions 181

abstinence rates and overall drinking frequencies. There is some indication,however, that a very slow homogenisation may be going on. The changesoccur slowly indeed, in generations rather than in decades or years. Today,when somewhat more comparable data are already available, the differencesbetween countries in drinking patterns seem still to be large even in the basicissues of abstinence rates and drinking frequencies.

The main conclusion from the drinking patterns part of the ECAS study isthat so far, there is not sufficient evidence to support nor to refute thehypothesis that differences in drinking patterns between countries would bea major issue when considering their prospects for preventing alcohol prob-lems. More research, both comparative and national, will be needed with dif-ferent designs targeted to the role of drinking patterns as a link between alco-hol consumption and alcohol-related harm. An international system ofmonitoring changes in drinking patterns together with changes in consump-tion and harm would be an ideal solution. There are several ongoing effortsto improve the methodological basis required for such a monitoring.Hopefully, their results will be put into use in the near future. Even then, itwill last long until any better basis for considering trends in drinking pat-terns will become available.

THE IMPACT OF CHANGING LIVING CONDITIONS ON DRINKING

Analysis of the development of living conditions in post-World War IIEurope shows that the same trends have emerged in all the current EU mem-ber states. Some of the most important changes we recognise are increasingurbanisation and the emergence of the service sector. The growing impor-tance of wage labour has had a fundamental effect on life styles and con-sumption. It has widened the gap between production and consumption,and modified our use of time, as well as affected human relationships in general.

While we can distinguish similar patterns in the development of livingconditions in the EU member states, this is not the case in the developmentof alcohol consumption. Overall alcohol consumption in the wine countrieshas been decreasing, while the consumption levels have been on the rise inthe beer and former spirits countries. We can only speculate if this develop-ment is going to continue or stabilise in the future and lead to a homogeni-sation of the consumption levels. As the decrease in alcohol consumption inthe wine countries is primarily due to a decline in wine consumption, espe-cially in the rural areas, the changes in living conditions such as urbanisationhave undoubtedly contributed to the decreased consumption levels. It alsoseems that modernisation processes such as de-agrarianisation, the emer-

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gence of new means of communication and changes in the patterns of timeuse have decreased the consumption levels in the wine countries. In contrast,in the former spirits countries and to some extent in the beer countries, too,the same processes seem to have led to an increase in the level of alcohol con-sumption.

Also, we can distinguish a qualitative homogenisation of drinking patternsin the EU member states: the general trends as to the preferred beverages arevery similar. Beer has increased its popularity in the traditional wine, and,spirits drinking countries and although its popularity has decreased slightlyin some of the traditional beer-drinking countries, it is still the mostfavoured beverage by far.

There is no direct “functional” link between the living conditions anddrinking habits, at least not at individual level. The links are collective, andthe process through which alcohol gets its new use values is a cultural one,even though it is the living conditions that determine the character of thenew use values. Therefore, the effects that changes in living conditions haveon people’s drinking habits have varied considerably from country to coun-try depending on the countries’ historical and, more importantly, culturalbackgrounds.

Finally, we can conclude that the modernisation process in the EU mem-ber states shows clear similarities, and that modernisation in fact emerges asa broad common denominator across Europe. It seems, however, that themodernisation of drinking habits has different features in different coun-tries. In the former spirits countries, for instance, modernisation has beenused to explain increasing alcohol consumption, whereas the situation in thewine countries has been the opposite. The changes in living conditions –which we can see as part of the modernisation processes – have producedalmost opposite results in different countries and at different times. This alsoapplies to the development of drinking habits and alcohol consumption inthe EU member states during the latter part of the th century.

THE ECAS SURVEY ON DRINKING PATTERNS

AND ALCOHOL-RELATED PROBLEMS

Given the scarcity of individual-level data on drinking patterns, the ECASproject conducted a special survey in six EU member states in the spring. The traditional wine-drinking countries were represented by Franceand Italy, the beer-drinking countries by Germany (excluding former EastGermany) and the UK, and the former spirits-drinking countries, but nowbeer-drinking countries, by Finland and Sweden. In each country, about, respondents, aged to years, were randomly selected.

conclusions 183

One lesson we learned from carrying out this study is that there are indeedmany circumstances that make it difficult to obtain comparable survey data.Firstly, each country has its own tradition of sampling procedures and field-work, and it seems to be hard to achieve a uniform approach. Secondly, thewillingness of the population to participate seems to vary considerablyacross countries, resulting in a great variation in response rate. Thirdly, theremay well be cultural differences in the degree to which people give honestresponses, as judged from the great variation in the coverage rate of alcoholconsumption (-%).

As a consequence, this study has stressed caution in using comparativesurvey findings at face value without considering the validity problems thatlimit the degree of comparability. Instead, the approach taken in this studyhas been to pay more attention to cross-country comparisons of variousratios and of age and gender distributions than to comparisons of absolutefigures. Bearing the limitations in mind, the study has focused on severaldimensions of drinking with the following main results:

Drinking habits

• Whereas regular drinking is most common in Southern Europe and leastcommon in Northern Europe, the quantity consumed when drinking ishighest in Northern Europe and the UK, and lowest in Southern Europeand Germany.

• There are systematic country differences in the age profile in drinking: inFinland, Sweden and the UK, the youngest (the - year-olds) drink themost, not only per occasion but also on an annual basis. In none of theother three countries (except women in Germany) do the young adultsreport the highest alcohol consumption. It is difficult to say whether thisis due to a generation effect, an age effect, or both.

• The frequency of heavy drinking occasions is highest in young people (-) in all the countries but Italy. Lacking data over time, it is not possibleto ascertain whether this pattern is a continuation of traditional culturalpatterns or the result of new drinking patterns among the youngest.

Self-reported alcohol-related problems

• The prevalence of social alcohol-related harm was lowest in SouthernEurope and highest in Finland and the UK.

• The level of drinking and the number of heavy drinking episodes are im-portant determinants of the experience of alcohol-related problems in allsix countries.

• The association between alcohol consumption and having experienced an

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alcohol-related problem was stronger in Sweden and Finland than in theother countries.

Informal alcohol control and attitudes towards alcohol policy

• Country differences in the exertion of informal alcohol control were fair-ly small, although differences were greater among men than amongwomen. Men were significantly more likely in Italy, and significantly lesslikely in Finland and Sweden, to influence anyone to drink less.

• In all countries, high consumers have the most liberal attitudes towardsalcohol policy.

ALCOHOL-RELATED MORTALITY

The aim of the descriptive part was to look at country differences and trendsin two indicators of alcohol-related mortality; (i) liver cirrhosis mortality,and (ii) a composite measure of explicitly alcohol-related causes of death(AAA), where the most important diagnoses are alcoholism, alcohol psy-chosis, and alcohol poisoning. We also addressed the cross-country compa-rability of the two mortality indicators.

For cirrhosis mortality, a marked north-south gradient was found, withthe highest rates in the south and the lowest in the north; this pattern appliedthroughout the study period for both men and women. However, this gradi-ent weakened with the passage of time, and the initially quite substantialregional differences declined during the study period. As to the developmentover time, cirrhosis mortality increased in all countries during the period-, while a more diverse development occurred thereafter. A markedreduction was observed during the last decades in Southern Europe whereasa less favourable development was observed in the UK, Denmark andFinland.

Turning to AAA-mortality, we found a geographical pattern opposite tothat of cirrhosis, i.e., the highest rates in North, and the lowest in South. Onthe basis of these observations, one may wonder whether one of the indica-tors is more reliable than the other as a measure of the total load of alcohol-related mortality, or whether they supplement each other by reflecting dif-ferent forms of mortality. To shed some light on this issue we first inspectedthe geographical relationship between per capita consumption and cirrhosismortality. A fairly close positive relationship appeared, but the fit was notimproved by combining cirrhosis and AAA-mortality into a single outcomemeasure. As a matter of fact, the geographical correlation between alcoholconsumption and AAA-mortality was negative. However, within threegroups of countries that represent different drinking cultures, the relation-

conclusions 185

ship between per capita consumption and AAA-mortality turned out to bepositive. Further, when looking at the development over time, trends in AAAand cirrhosis mortality display a reasonably consistent picture, in stark con-trast to the geographical pattern. The outcome thus suggests that the nation-al variation in mortality from AAA is strongly influenced by cultural differ-ences with regard to recording practices, whereas this problem seems to besmaller when the temporal development within a drinking culture is studied.

This is the approach taken in Chapter , which addresses the relationshipbetween overall consumption and a broad range of mortality outcomeswithin each of the study countries. By and large, the results from these analy-ses confirm the importance of per capita consumption; in each country alco-hol-related mortality (cirrhosis or AAA-mortality) responds to changes intotal consumption. However, for most outcomes there is a geographical gra-dient in the alcohol effect, so that it is stronger in Northern and weakest inSouthern Europe, suggesting a modifying impact of drinking culture and itsdrinking patterns. A clear expression of this is the aggregate link betweenalcohol and suicide; it is quite marked in Northern Europe, but weak or non-existent in South and Central Europe. One interpretation of this pattern isthat the more the use of alcohol is integrated into everyday life, the less exces-sive intake gives rise to social problems and disintegration. The one relation-ship that was invariant across countries as well as different age groups of menand women was the zero-correlation between alcohol and ischemic heartdisease mortality. This suggests that an increase in per capita consumptiondoes not provide any heart benefit at the population level. In this context itmay also be noted that the relationship between alcohol and total mortalitywas significantly positive in the majority of the study countries; in no coun-try were increases in consumption significantly associated with decreases inmortality.

Socioeconomic differentials in alcohol-related mortality

We know that manual workers generally have a higher mortality risk thannonmanuals. To what degree can this excess mortality be explained by an ele-vated alcohol-related mortality?

The analyses of Swedish data that were performed to address this issuesuggest that alcohol has a significant role for socioeconomic mortality dif-ferentials. The contribution of alcohol was found to be particularly largeamong the middle-aged. Among men in the age group - about one-thirdof the all-cause excess mortality for manual workers, lower nonmanuals,entrepreneurs as well as ‘unclassifiable & others’, in relation to upper non-manuals, could be attributed to alcohol-related mortality. Among the elder-

186

ly (+ years) the contribution of alcohol was found to be of minor impor-tance. A similar pattern was detected among women, although the relativecontribution of alcohol was clearly lower among women than men.

allamani, hope, byrne, room and the ecas research team 187

This final chapter is devoted to the policy implications of the study. To pro-vide the reader with insights from alternative perspectives, we begin by pre-senting invited comments and suggested policy implications from three dif-ferent points of view1: a Southern European perspective (Allaman Allamani),a central European view influenced by various considerations within the EU(Ann Hope and Sean Byrne), and a summary combining research and poli-cy experiences from different parts of the world (Robin Room). At the endof the chapter, the ECAS research team presents its own set of nine policyimplications. Hopefully, they will serve as building blocks for those wishingto consider the prospects for coordinated European alcohol policies.

Lessons from the ECASstudy: comments and policyimplicationsby Allaman Allamani, Ann Hope, Sean Byrne, Robin Roomand the ECAS research team

10.

1 The three sections by Allamani, Hope and Byrne, and Room, were originally presented at the ECAS semi-nar, 17-18 February, 2001, in Stockholm, Sweden.

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POLICY IMPLICATIONS OF THE ECAS-STUDY RESULTS: A SOUTHERN

EUROPEAN PERSPECTIVE

by Allaman Allamani2

The European Comparative Alcohol Study (ECAS) constitutes a remarkableeffort to collect large amounts of information concerning Northern, Centraland Southern Europe. For the first time, sufficient data are presented andcommented upon to allow certain comparisons among different regions ofEurope. Also, in our view, these data highlight the importance of pursuing aspecific Southern European prevention policy.

In this discussion, we shall focus on Southern European (orMediterranean EU) countries, that is Greece, Portugal, Spain, and Italy.France is sometimes considered, since although it is a wine and a Latinnation, i.e., sharing features of three of the above-mentioned countries, it isalso characterised by a central position in the geography of Europe.

Although the notion that all Mediterranean EU wine countries constitutean entity has been questioned (Simpura, ), for most of them their Latinroots, rural tradition, time-honoured strength of family ties and relativelyrecent process of industrialisation should nevertheless be considered com-mon denominators.

Finally, cultures where drinking alcohol is part of the routine of daily lifehave a quite different perception of alcohol problems compared to thosewhere drinking is episodic, as is common in Northern Europe. Also, as wewill discuss later on, variables relevant to our study, i.e., trends in consump-tion and alcohol-related mortality, as well as changes in the pattern of drink-ing, behave in a way that seems to be specific to the southern countries anddivergent from the northern countries as a whole.

Such a generalisation is indeed questionable, since examples can be foundindicating that Mediterranean countries do differ from one another.Nevertheless it has an explanatory power that allows us to explore possiblepolicy implications. Moreover, our source of information is limited to theECAS materials and some other papers. Even if studies on the issue of alco-hol in Southern Europe do not abound, they certainly outnumber our refer-ences. Our provisional conclusions should, therefore, be challenged withdeeper and more informed arguments.

2 Centro Alcologico Integrato, Florence, Italy. The author wishes to thank Francesco Cipriani, and FabioVoller, Florence, and Daniele Rossi and Enrico Tempesta, Rome, for their valuable suggestions and com-ments.


Consumption patterns and values attributed to alcoholic beverages

A broad cultural division of the European territory has been used to definetwo large European regions (Cottino, ; Heath, ; Allamani, Voller etal., ): (a) the northern dry area – typically Sweden, finland, and Norway,where spirits and beer are the leading beverages, consumed on weekends andoutside mealtimes; (b) the southern, or Mediterranean wet area – typicallyItaly, Spain, Portugal, Greece and France, where wine is the main beverage,usually consumed at meals. Such a drinking distinction parallels the above-mentioned cultural and economic differences between Northern andSouthern Europe.

In the northern countries, alcohol is described as a psychotropic agent. Ithelps one to perform, maintains a Bacchic and heroic approach, and elatesthe Self. It is used as an instrument to overcome obstacles, or to prove one’smanliness. It has to do with the issue of control and with its opposite – “dis-control” or transgression.

In the southern countries, alcoholic beverages – mainly wine – are drunkfor their taste and smell, and are perceived as intimately related to food, thusas an integral part of meals and family life. Actually, wine tends to be con-sidered as a food item. The idea of a good wine is close to that of a good oliveoil or a good food item. It is traditionally consumed daily, at meals, in thefamily and other social contexts. It is perceived as a social vehicle though itssocialising property per se is not pursued. People do not drink because theywish to be more sociable through the chemical effects of alcohol; on the con-trary, wine is a symbol of sociability per se. Typically, wine is not connectedto the topic of control and does not elicit any image of either achievement orperformance. Southern Europeans tend to equate alcohol with spirits andbeer perhaps with soft drinks, but certainly not alcohol with wine.

In the past, the strong extended families and the intense community ties inthe mainly rural southern societies largely served as an informal control ofexcessive drinking as well as a consistent model of a traditional drinking pat-tern to be transmitted across the generations. Traditional family and societalties, however, have weakened since the s, at different rates in each coun-try, corresponding to increased urbanisation, industrialisation, migrationand tourism. Together with new attitudes, new alcohol beverages also camefrom the North, especially beer and spirits (for Greece, see Madianos,Madianou & Stefanis, ).

As mentioned before, in the Mediterranean countries wine drinking isusually restricted to meals, contrary to practices in the northern countries.Men typically drink everyday and consumption is higher in rural areas andpossibly among the less educated (for Greece, see Yfantopoulos, ; for

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Italy Osservatorio Permanente sui Giovani e l’alcool, ). In these contexts,alcohol-related problems are rarely socially visible because consumption isregulated and established by local customs (Anderson, ).

According to the Catholic perspective, wine becomes the Divine Blood inthe Holy Mass. Following an anthropologic viewpoint, wine connects with amystery related to the limitation of the ego, which owes its salvation to theHoly Spirit or Grace of God. In many wine-producing communities, sym-bolic relationships among both religious and human life cycles wereobserved to parallel the seasonal cycles both of vine cultivation and of winefermentation (Alcohol and the Community, n. d., -).

Among Southern Europeans, another aspect connecting wine and natureis the common awareness that wine is part of the vegetal realm and producedfrom the vineyard visible in the countryside, and sometimes cultivated inone’s own garden. Even today, the fashionable household wine productionand the private purchase of wine direct from the winery recall the values ofnature and creation. The land and the alcoholic beverage made and con-sumed within the community tend to define the community identity(Alcohol and the Community, n. d.).

Implications of Southern European perceptions of drinking for studies and preventive action

A practical implication of the above discussion concerns the wording ofquestions in alcohol surveys and of educational ideas in preventive pro-grams. While as a rule questionnaires are translated into Southern Europeanlanguages from Anglo-American or Scandinavian projects owing to the valu-able studies done in those countries, local alcohologists should be quite cau-tious, tailoring questions and concepts to their own cultures. When imple-menting prevention programmes, they should be careful while introducingnew ideas about alcoholic beverages, since such ideas could be rejected, use-less or even disruptive of traditional behaviours. The expert’s biology-biasedattitude prioritising universal truth must come to terms with the local pop-ulation’s perception of its own alcohol practices and problems.

As an example, questions such as “Do you drink?” or “How much do youdrink?” may well be misunderstood in the Mediterranean countries wherethey would commonly be perceived as exploring deviant (excessive drinking)as opposed to normal social drinking. Since, in this case, “drinking “ is attrib-uted to abusers or alcoholics, a common answer to such questions is “I donot drink”. The influence of alcohol on comportment and health is moreinsidious and less evident than in northern countries, where the hazard ofalcohol consumption is more easily seen because of its behavioural effects.


Thus, alcohol experts should take time and engage in careful communicationwith the local population (Alcohol and the Community, n. d.).

Changes in the amount of consumption and in the drinking pattern

In the second WHO European Alcohol Action Plan (), Italy and Spainare cited as being among the three countries that achieved the European tar-get under the Health-for-all Policy of a % reduction in alcohol consumptioncompared with consumption in , when the first WHO European AlcoholAction Plan () was published. Also France and Portugal, and to a lesserextent Greece, decreased their alcohol intake during the s.

In fact several data sources (see Leifman, ) demonstrate that alcoholconsumption declined remarkably in the Southern European countries,mainly because of a drastic reduction in wine intake – by more than % in years in both Italy and France. In the same period, beer consumption hadincreased in Portugal, Spain, Greece and Italy, but not sufficiently to balancethe decrease in wine, which still stands as the main alcoholic beverage. Onthe other hand, during the same period, consumption in the northern coun-tries as well as in Central Europe has generally increased, especially from thes to the early s. Such a development takes the shape of a convergenceof alcohol intake among the European nations, even if there are still largecultural differences across countries.

How can such changes be understood? As to the decrease in alcohol con-sumption – in accordance with the collectivity theory of Skog () – ahypothesis was proposed for the case of France that “the pioneers of the con-sumption decline were led by the middle classes who were already drinkingless than the others” and this model was followed by the population at large(Simpura, ). Research in Italy gives a more variable picture: according totwo national surveys in and in , there was a decrease in the numberof heavy and excessive young upper-middle-class male drinkers, and anincrease in young well-educated urban beer lovers and in lower-middle-classlight drinkers (Osservatorio Permanente sui Giovani e l’alcool, , ).

As to changes in the choice of beverage type, presently in Southern Europethe mainly wine-drinking groups seem to include old-fashioned and tradi-tional people, while the more educated and urbanised belong to the groupsthat drink less wine (light drinkers). The opposite behaviour, i.e., drinkingwine more frequently, occurs in the northern countries (Knibbe, Drop &Hupkens, ). All in all, as for the new types of alcoholic beverages, womenand men differ less in frequency of consumption of beverages novel to theirculture than in frequency of consumption of traditional beverages(Hupkens, Knibbe & Drop, ).

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Drinking patterns, i.e., drinking contexts and context-specific drinkingbehaviours (Simpura, ), are also changing and showing signs of conver-gence, but at a much slower pace than alcohol consumption. Typically,Mediterranean people’s drinking is still characterised by relatively evenweekly consumption, while in northern cultures drinking is concentrated torare occasions with high intake per session (Simpura & Karlsson, ). Inthe South, the changing agents are young people, who prefer beer to wine,and tend to drink outside mealtime – even if their behaviour expresses anambivalence towards the distinction between tradition and innovation(Forni, ) – so that the new beverage can also be absorbed into the pre-existing pattern of drinking alcohol while eating. This may explain the argu-ment by Knibbe, Drop and Hupkens that most beer drinking occasions werereported to occur both with meals (particularly in Greece, Italy, and Spain)and outside mealtime (particularly in Portugal and France) (Knibbe, Drop &Hupkens, ).

Mortality and alcohol-related harm

The cultural dimension of drinking affects alcohol mortality. In fact it hasbeen claimed that the more the use of alcohol is culturally integrated, the lessexcessive consumption gives rise to social problems and disintegration(Norström & Skog, ).

Typically, liver cirrhosis is an indicator of biological damage due to con-tinued alcohol drinking, and its gradient is North-South. On the whole, cir-rhosis death rates began to decline during the s in the southern coun-tries, while they increased in the northern countries, in keeping with changesin alcohol consumption. Bear in mind that death rates are still higher in theSouth than in the North (Ramstedt, ). However, if we use the explicitlyalcohol-related cirrhosis diagnoses there is a reverse gradient, i.e., South-North (Ramstedt, ; see also Chapter in this volume). Assuming that thediagnoses are accurate (which might not be the case due to cultural factorsinfluencing the process of diagnosis), we can see that the negative effects ofalcohol in Southern Europe are smaller than what is commonly believed.

As to mortality rates due to accidents associated with alcohol consump-tion, death in Southern (and Central) Europe tends to be related to trafficaccidents, while death due to falls and other accidents tends to dominate inNorthern Europe (Skog, ).


What prevention policy and programs have been carried out in Southern Europe?

Among Southern European health professionals, administrators and thegeneral population there has traditionally been little worry about the issue ofalcohol-related problems. Two papers presenting the alcohol problem to GPsor non-specialised physicians appeared in France at the beginning of thes (Lereboullet, ), and in Italy at the end of the same decade (Iandolo& Capuano, )

In the post-war period and until the s, just a few cases of alcoholism –perceived as societal problems – were placed in mental hospitals. Later on,gastroenterology hospitals began to admit people affected by liver cirrhosisand pancreatic disease, both of which were then acknowledged as being alco-hol-related.

In the s, the U.S. -step programme Alcoholics Anonymous had itsbirth in both Spain and Italy and slowly spread, followed some years later byAlAnon, an association for relatives of alcoholics. The non-governmentalClubs of Treated Alcoholics (CAT) was transferred to Italy from Yugoslaviain the s; like AA they flourished especially during the s, their ideol-ogy being that the community should support the alcoholic family eventhrough a stance against social attitudes towards drinking.

During the s, the European Office of the World Health Organisationbegan to foster initiatives concerning alcohol-related harm through an inter-national collaborative study on community response to alcohol-relatedproblems (-) (Alcohol and the Community, n. d.). Three Medi-terranean nations were involved. In Portugal, three new regional services forprevention and treatment were established in , which were able to createprojects to educate primary health care and school professionals – projectsthat promoted sensible drinking together with nutritional guidelines. In tworegions of Spain – Andalucia and Cantabria – courses for health and socialworkers were developed, and the mass media were involved. The Greek pro-ject explored the role of culture in the response to alcohol in one rural andone urban community around and within Athens, and found a basis forintroducing preventive strategies, while taking into consideration the rele-vance of extant local coping strategies.

According to ECAS, a few formal measures to control alcohol intake wereadopted in Southern Europe between the s and s (Karlsson & Öster-berg, ). During the s, the European Office of the World HealthOrganisation made an effort to establish common European guidelines toprevent alcohol-related problems by reducing alcohol consumption. TheWHO European Alcohol Action Plan of recommended: (a) an approach

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directed at the general population, and (b) an approach directed at groups atrisk due to alcohol consumption, such as people with liver disease or otherphysical illness, automobile drivers, and pregnant women. WHO also pro-moted projects at the local level, e.g., the Demonstration Project in Lahti,Finland (Holmila, ) and the WHO Collaborative Project on Alcohol andPrimary Health Care, implementing country-wide early identification andbrief intervention (EIBI) strategies in primary health care, especiallyaddressed to GPs, where Catalonia, Spain (Colom & Gual, ) and Italy(Bardazzi, Boscherini & Voller, ; Struzzo & Peressini, ) were called in.

In , a project directed at youngsters was planned in the PortugueseCity of Matosinhos, close to Porto. This project involves the whole schoolsystem and includes different kinds of both preventive and promotionalinterventions (Duarte & Barrias, ). In Italy, at least two AlcoholCommunity Projects were implemented in the s: () one in the quarterof Rifredi, Florence (Allamani, Basetti Sani et al., ), () the other, nation-wide, involved four towns, namely Padua, Rimini, Bari and Biella(Osservatorio Permanente sui Giovani e l’Alcool, ), while a () thirdstarted at the beginning of in the south-west belt of Florence and willend in . The three projects share the ideas that: (a) the community hasthe means to respond to the harm caused by alcoholic beverages, (b) localactivists are needed to implement local preventive actions, and (c) many sec-tors, such as health, police, and school, should be involved so that the actionsmay be successful. The aims and targets differ since the two Florentine pro-jects focus on responsible drinking among the general population, and thefour city projects aim at promoting risk perception among - to -year-olds. Results were a fair mobilisation of citizens and their increased aware-ness of the risk induced by alcohol. There was also evidence that a local pre-vention project can affect both the opinion and attitude of local people.If a community changes its own perception of an alcohol problem, shiftingfrom the exclusive idea of “alcoholism” to the inclusive concept of “riskydrinking”, it has become active and more autonomous in taking preventiveinitiatives.

In summary, the decline of alcohol consumption in the s-s can-not be reasonably explained in terms of the impact on the population of thefew and late preventive or treatment initiatives, ministry moves to controladvertising or establishment of BAC limits when driving. It seems more sen-sible to interpret this as part of a larger changing attitude in SouthernEuropean populations, whereby people have become more concerned aboutdrinking alcohol and its possible harmful effects. This concept may alsoexplain another Mediterranean paradox: in Portugal, Catalonia and Italy, the


number of alcohol services and self-help groups grew while the level of con-sumption was already declining.

How to explain the changes in consumption and drinking patterns?

According to Jussi Simpura’s observation, the decline of alcohol consump-tion in wine-producing countries during the last years is one of theMediterranean mysteries. The author asked whether such an experiencecould be used as a guide for discovering natural processes that should beencouraged in order to prevent alcohol problems in other European regionswhere alcohol consumption has increased (Simpura, ). However, onemay consider such a development in light of a broader change, encompass-ing the entry of new beverages onto the market, the modernisation of drink-ing patterns, the growth of alcohol services and of the -step associations,the start of prevention initiatives, changes in society at large, etc.

Different explanations were found (Gual & Colom, ; Leifman, ),none of which appears conclusive. Although economic factors obviouslyaffect prices and purchases, they are nevertheless endowed with a lowexplanatory power, because in Southern Europe during the last twenty yearsreal incomes have increased and real prices of alcohol beverages have beenstable or even decreased. However, the growing role of wage labour did havesome effect, since too much wine or alcohol consumption is thought toreduce the capacity to meet the more and more exacting demands of dailywork.

Following the Second World War, and for many decades thereafter, theMediterranean belt was less industrialised and much more rural than mostof the other Western European regions. During the last thirty years, howev-er, rural workers – the heaviest drinkers among the population – greatlydecreased in number and a large shift of the workforce occurred towards theindustrial and service markets.

Considering marketing factors, the wine market consists of small produc-ers, while beer and spirits – and also new alcohol-free or soft drinks nowentering the competition – are controlled by a few multi-national companiesable to effectively advertise and distribute their products to many nations.The advertising companies are well aware of the changing alcoholic beveragepreferences of young adults and women, who therefore became special tar-gets (for Italy, see Beccaria ).

As to political factors, EU agricultural policies have curbed and cut downthe number of vineyards and wine production. At the same time, extensiveas opposed to intensive cultivation was favoured, and the production ofquality wine was supported.

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Also, in the last years, an awareness of the harm done by alcoholic bev-erages grew among Southern Europeans, as was shown by mass media. Thisphenomenon is not due to any formal governmental measure, but is part ofan informal “healthy lifestyle wave” (Allamani, Cipriani, Gordon et al., ),through which people became more aware of their own bodily and psycho-logical needs and their self-control.

Since in the Southern European culture wine is perceived and described asa food item, it might be disregarded by customers who feel free to chooseamong other food items, which during some periods may become moreattractive (Allamani, Cipriani, Cottino et al., ).

By and large, beyond the aforementioned explanations, Mediterraneansocieties, during the s-s, seem to have been able to reverse theincrease in their own alcohol consumption and, as a consequence, the relat-ed peak in alcohol mortality. In terms of drinking patterns, the principles ofsuch informal control may rely on the regularity of daily drinking, its con-nection with meals and its “elasticity” due to its pervasive integration intoeveryday life. This phenomenon cannot simply be attributed to the massiveadvent of relatively novel beverages like beer and of northern drinking pat-terns, which may explain just a minor fraction of the changes in terms ofamount and pattern. In any case, new studies are necessary to better under-stand changes in the alcohol practices of the Mediterranean populations,which will be an important task in the years to come.

Policy implications from a Southern European perspective

Many European policies have been based on the brilliant and extensive stud-ies carried out in Northern Europe and in North America. They put greatemphasis on control and restriction measures. On the other hand, only rela-tively little energy and scarce efforts have been devoted to this issue by theLatin countries. As a consequence, alcohol studies and experiences arestrongly influenced by both the Nordic and English-speaking countries.International agencies, and WHO itself, have possibly been influenced by thissituation.

Nevertheless, remarkable differences in values, patterns, and consequencesare found among the “dry” and the “wet” countries, demanding re-thinkingof some ideas on alcohol prevention.

If the southern drinking pattern and its informal control property are aflexible means to adapt to the health needs of reducing both alcohol con-sumption and alcohol-related harm, this pattern should be appreciated as apotential preventative tool for Southern Europe itself. Hazardously, someauthors set their hopes even to “the spread of wine culture, with its heavy


load of immaterial loads of self-regulation” to Nordic contexts (Simpura,). However, it would seem doubtful that a culture-specific drinking pat-tern could be exported into another culture from the top down. On theother hand, novel beverages – beer and spirits – and new drinking patterns –drinking occasionally outside mealtimes – were introduced, especiallyamong youngsters, who are consequently subject to relatively new types ofalcohol-related harm such as traffic accidents and violent behaviour.

Therefore, from the southern perspective, alcohol policy should be con-sidered Mediterranean-specific and namely, based on a mixture of the totalconsumption model and the harm reduction model. It would seem that astrategy is useful when it takes tradition into account and also looks at pre-sent and future challenges.

On the one hand, “a focus on drinking pattern in prevention seems toimply that local intervention and community action should have a moreimportant role in prevention” (Simpura, ). At the community level, theconcept of responsible drinking seems appropriate. Here the message shouldbe “to drink between tradition and risk”, where the traditional practice ofinformal control and new scientific information on risk could be dynamical-ly mobilised among the community actors. Programs acting locally should:() approach the whole local population, () support the extant drinking tra-dition, focusing the issue of “drink less and better is better”, () link winedrinking to the fashionable rediscovery of traditional peasant food, () pro-mote the role model of parents and old people as informal controllers of thewine pattern, and () highlight the possible harm of alcohol and find promptsolutions if problems arise. In the interaction with local stakeholders andgroups, the alcohol experts should adjust to community beliefs about wineand other beverages, making negotiations and alliances and trying to tailortheir scientific – biologically-biased and behavioural – knowledge to thecapacities of the population.

On the other hand, as to the specific groups at risk, which are behavingaccording to the new northern pattern of drinking outside mealtimes andwhich seek the psychotropic effects of beer and spirits, i.e., the youngergroups, a set of policy measures could be effective. As an example: () prohi-bition of alcoholic beverages sales near soccer or music events, () promot-ing better control of drinking and driving through extensive, random use ofthe breathalyzer by the police, and () tackling the problem of alcohol-relat-ed workplace accidents through local intervention involving both tradeunions and employers.

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ECAS FINDINGS: POLICY IMPLICATIONS FROM AN EU PERSPECTIVE

by Ann Hope3 and Sean Byrne4

The European Comparative Alcohol Study (ECAS) is a welcome and invalu-able piece of research. It expands previous work and provides for the firsttime a comprehensive examination of key alcohol issues relating to a set ofcountries linked by an international framework, the European Union. It isessential that the EU utilises and maximises the findings to develop andensure that alcohol as a determinant of health is comprehensively addressedfrom a public health perspective.

Alcohol consumption

The ECAS analysis on alcohol consumption contains relevant findings onoverall consumption, beverage preference, unrecorded estimates and drink-ing patterns.

Firstly, an increase in consumption among Central and NorthernEuropean countries during the first half of the study period provided thebases for homogenisation of alcohol consumption. During the second halfof the study period, homogenisation occurred due to a decline in total con-sumption among the Mediterranean countries. This decline was as a result ofa substantial decrease in wine consumption. By the s, the homogenisa-tion process appears to have stabilised, which the researchers suggest couldmean the current end to a uniformity of change. Secondly, beverage prefer-ences also showed a trend towards homogenisation for the entire study peri-od. Former spirits-drinking countries shifted to beer as the dominant bever-age and, along with the traditionally beer-drinking countries, now representthe majority (ten) as beer-drinking countries. Wine continues to dominatethe traditionally wine-drinking countries.

Unrecorded consumption is a vital ingredient when policy decisions areformulated, therefore shedding some light on this area is a major step for-ward. The finding that estimated unrecorded consumption has increased inNorthern Europe to litres by the s, with a similar increase in the UK, isof particular importance given the implications for national policy decisionssuch as pricing and excise duty. Indeed the increased cross border trade andsmuggling from France into the UK since the introduction of the single mar-ket in is also reflected in increased alcohol-related mortality.

3 Health Promotion Unit, Department of Health and Children, Dublin, Ireland. Views expressed are perso-nal and do not represent those of the Department of Health and Children.

4 Dublin Institute of Technology, Dublin, Ireland


An important finding from an EU policy perspective was that trends intotal consumption looked different for different countries at different times.This was true in terms of the difference between the north, central and southas well as between countries within each group. The researchers also notedthat drinking cultures still continue to provide a key explanation for nation-al differences in the level of consumption despite global influences.

The study suggested that the significant reduction in alcohol consumptionamong the Mediterranean countries was more likely a result of changes inliving conditions that impacted on wage labour rather than a result of alco-hol policy measures. Although the introduction of alcohol policy measuresalso occurred during this period, there is little evidence to suggest they con-tributed to the overall decline. The new policies included greater awarenessof the negative consequences of alcohol, limiting availability primarilythrough a minimum drinking age and banning alcohol in the workplace. Theimpact of a minimum age measure is perhaps of little significance for over-all alcohol consumption, given that sixteen was the age limit set in theMediterranean countries. Raising awareness, although valuable as part of abroad set of measures, has not been demonstrated to be an effective mecha-nism for change (Edwards et al., ).

The importance of drinking patterns as a mediating factor in explainingchange in alcohol consumption and its inter-dependence on culture, econo-my and living conditions was well argued. However, the paucity of informa-tion in this area, especially regarding binge drinking and specific drinkingcontexts, must clearly constitute a top priority for action at the EU level.From the limited available data, Simpura & Karlsson (; see also Chapter in this volume) concluded that the qualitative features of drinking patternschange slowly over generations rather than years. The policy implication istherefore that the development of policy measures to affect drinking patternsin the short term may be questionable public policy level as a means ofreducing alcohol-related harm. This viewpoint reflects only the drinking pat-terns embedded in cultures that are slow to change. However, there are alsoparallel market-driven drinking patterns, particularly attractive to youngpeople, which operate within a shorter time frame and are more open tochange. The alcopop saga and the ‘new’ designer drinks are prime exampleswhere drinking patterns are negatively influenced (Hughes et al., ).These market-driven promotions were the catalyst for EU involvement andthe forth coming EU Council Recommendation on the drinking of alcoholby children and adolescents.

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Mortality

During the last two decades, alcohol-related mortality showed a markedreduction in Southern Europe, which has also been paralleled by a decreasein total alcohol consumption. The study suggests that cultural factors doaffect the recording of alcohol-related deaths, therefore it is recommendedthat selecting a measure (cirrhosis or AAA) appropriate to the individualcountry will be more informative.

The findings of this study reaffirm the importance of per capita consump-tion as a determinant of alcohol-related harm. In each country, alcohol-related mortality responds to changes in total consumption. However, thestrength of the risk varies for different harm indicators, which theresearchers suggest most likely reflects the drinking culture and drinking pat-terns. Alcohol as a risk factor for traffic accidents is stronger in Central andSouthern Europe (Skog, ), while accidental falls and other accidents rep-resent a more substantial risk factor in Northern Europe. Alcohol is asignificant risk factor for suicide in all low consuming countries (Fnland,Sweden and Norway) and the relation to homicide is positive for men inabout half of the countries. Therefore, selecting country-relevant harm indi-cators and developing policies must take into account drinking culture anddrinking patterns. The findings also validate the continued monitoring ofboth overall consumption and mortality figures as meaningful outcomeindicators for policy effectiveness.

The argument that an increase in alcohol consumption could provide acardio-protective effect at the population level is not supported. The evi-dence also demonstrates that in no country was an increase in consumptionsignificantly associated with decreased mortality.

Alcohol policy

One of the most significant changes in policies has been the shift away frommeasures controlling the supply of alcohol. This has resulted in greater avail-ability of alcohol in the market place. The change has been most dramatic inNorthern Europe where the monopoly system has been weakened or dis-banded. In other countries, longer opening hours and more outlets for thesale of alcohol have increased availability over the years, although availabili-ty of alcohol continues to be regulated through licensing, opening hours andoutlet density. While most countries in Southern Europe had few, if any, con-trol policies in the s, in more recent years some measures to regulateavailability have been evident. The nature and type of the measures now usedin many countries would suggest the overall purpose is primarily to reduceharm rather than reduce overall consumption. This changing focus among


Member States is also evident in the European Alcohol Action Plan ().However, as argued by Skog (), measures to address overall alcohol con-sumption and targeted measures for specific situations are not mutuallyexclusive, and in fact combining them would optimise prevention measures.

The current set of alcohol policy measures that have gained support arebased on restrictions regarding drinking and driving, curtailing alcohol incertain environments such as sports stadiums, gasoline stations or work-places, and having a set age limit for alcohol sales. Although many of thesemeasures are valuable in limiting harm in certain situations and reducingacute alcohol-related harm, they do not necessarily influence overall con-sumption or the drinking patterns that contribute to chronic alcohol-relatedharm.

Another cluster of policy measures attempts to influence the demand sideof alcohol use, with the rationale that such efforts help to shape the culturaland social context in which alcohol is perceived and promote individualresponsibility. Among these measures are restrictions on the marketing ofalcohol, alcohol information and education. However, the evidence base fortheir effectiveness in reducing alcohol-related harm is weak (Edwards et al.,).

From an alcohol policy perspective, the most salient finding of the ECASreports is that cultural background, with its enduring value base, continuesto be the key factor in explaining regional and in many cases individualcountry differences, in terms of consumption, mortality and policy mea-sures.

Implications for the European Union

The major instruments of alcohol control policy are physical controls onproduction, distribution and taxation. The most extreme form of physicalcontrol is a state monopoly on control and distribution. Such extreme con-trols are used in Sweden, Finland and Norway still today, although with anumber of modifications. These controls are no longer acceptable because ofchanging cultural values and because, in the case of Sweden and Finland,integration into the EU and participation in the Single European Market hasmade such state monopolies unacceptable. It is important to note that whilea return to state control of production and distribution is not feasible, suchpolicies did succeed in maintaining overall per capita consumption at a rel-atively low level, if often at the price of extremely excessive drinking by aminority of drinkers.

The Nordic experience of having to modify alcohol control policies inorder to comply with the EU Single Market and the World Trade

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Organisation (WTO) agreements is a reminder that the relentless movetowards global free trade takes no account of the quality of life of citizensacross countries with different behavioural and social patterns. Global tradeagreements are now a major constraint on many areas of national policymaking, one of which is alcohol control policies. The WTO, an agreementbetween governments and corporations, seems to regard any attempt bynational governments to restrain the activities of private corporations inorder to protect the health of its citizens as a restriction on free trade.Corporations who consider that governments restraining their activities arein breach of the WTO agreement can take a case against such a governmentto the WTO (Grieshaber-Otto, et al., ). However, a government that isconcerned about the public health consequences of a corporation’s actionshas no recourse to the WTO to seek to restrain the activities of that corpora-tion. It is all the more necessary, therefore, for governments to use what pow-ers that remain to them effectively. Article of the Treaty of European Unionraised health protection to the status of a community objective and Article of the EU Treaty provides for the EU to take public health initiatives;moreover, the present Commissioner seems disposed to take whateveractions are within his power to protect public health.

It must be kept in mind that the global alcohol industry is becoming moreconcentrated and the world alcohol market is now dominated by a few firms.There is a considerable danger to public health in this concentration, as thegiant corporations that now control the alcohol industry have considerablepolitical influence and may use this influence to counteract the alcohol con-trol policies of individual governments while encouraging consumption bymeans of huge marketing budgets. Developing a policy framework to regu-late and monitor alcohol markets is an important public health challenge.Only international organisations such as the EU can effectively resist thepower of the global drinks industry by having an effective common policy onalcohol control.

The drinks industry attempts to portray all restrictions on the availabilityof alcohol as an intolerable infringement of personal liberty and sees thosewho make arguments for control as anti-alcohol and anti-free markets. TheWorld Bank, which is generally hostile to excessive regulation in the eco-nomic sphere, accepts that decisions about the control of alcohol, tobaccoand other drugs are among the most important health-related choices thatsocieties can make collectively. The World Bank acknowledges that restric-tions on the promotion of and access to alcohol, high taxation and publiceducation are effective ways of reducing alcohol-related harm (World Bank,). While cultural differences between countries are important in deter-


mining the impact of alcohol control policies, there is ample evidence thatlevels of tax and price can reduce alcohol-related harm. High prices not onlyprovide an incentive for heavy drinkers to drink less, but also an incentive formoderate drinkers to remain moderate.

A major constraint on the use of alcohol taxation as part of a control pol-icy is the drive to harmonise taxes as part of the integrated EU market.Ireland and Denmark resisted lowering their relatively high excise duties onalcohol to the EU average largely because excise duties are an importantsource of revenue in both countries. In Ireland’s case, the alarming increasein alcohol consumption per capita is a compelling reason for not reducingthe price of alcohol by reducing excise duty. Maintaining control of exciseduty levels as part of an alcohol control policy is a good reason for resistingthe use of qualified majority voting on taxation policy in the EU Council ofMinisters. Harmonisation of excise duties will mean reduction for countriessuch as Ireland and Denmark and a possible increase in consumption percapita. Therefore, an increase in excises duties for countries with low rates,rather than a lowering of high rates, would provide an effective EU alcoholpolicy strategy.

The difficult problem facing the EU is that while taxation policy and reg-ulation of physical access to alcohol have been important means of restrain-ing consumption in the Northern EU countries, they face increasing resis-tance from the advocates of the free market. It is necessary therefore to con-sider what effective alternatives are available for reducing consumption orpreventing it from rising. The evidence from Spain and France shows thattighter controls and a possible ban on advertising can be effective in settinga social and cultural context for drinking. France also uses warning labels onalcoholic drinks, similar to those required on cigarette packages. However,the effectiveness of such policy measures need to be researched across cul-tures. Stricter enforcement of the legal drinking age is also effective, as is areduction in the numbers of outlets at which alcoholic drink is available.

The Council Directive on Alcohol Advertising (/) provides one of thefew opportunities to strengthen an extant EU regulation. There will bestrong resistance from the drinks industry to controls on advertising andavailability, and such controls will no doubt be challenged under the Treatyof Rome or the Treaty of Maastricht. The European Court has, however,found that restrictions on advertising are acceptable under Article of theTreaty of Rome, which accepts restraints in the interests of public health(European Court Decision / ).

Perhaps the most significant aspect of the evidence on consumption pat-terns cited in the ECAS study is the influence of culture on the pattern of

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alcohol consumption. The same level of consumption can have very differ-ent social and economic effects depending on the cultural context withinwhich the drinking takes place. In the Southern European countries, alcoholleads to less social harm than in Northern Europe, with drunken driving theexception, because the act of drinking is seen as normal and there is little orno social pressure to drink. In the southern societies, education about drink-ing starts early and in the home. Young people are taught under their parents’supervision and through their parents’ example that drinking should bedone moderately. The experience of the southern countries suggests that it isimportant to avoid both demonising alcohol and promoting abstinence askey elements of alcohol control.

In order to emulate the success of the alcohol control policies of the south-ern countries, the EU should consider a strategy that includes the followingelements:• Encourage moderate drinking among those who choose to drink with

moderate drinking and abstinence being presented as equally acceptablechoices.

• Clarify and promote the distinction between acceptable and unacceptabledrinking.

• Firmly penalise unacceptable drinking, both legally and socially.Intoxication must never be humoured or accepted as an excuse for badbehaviour. Avoid stigmatising alcohol as inherently harmful, as such stig-matisation can create emotionalism and ambivalence.

Although it is not possible to reproduce the cultural norms of one society inanother, the attitude towards alcohol in the Southern European societies canhelp inform the process. A greater understanding of drinking patterns andspecific drinking contexts would greatly assist in formulating relevant policymeasures and reducing alcohol-related harm. While controls and legislationwill continue to have an important place in alcohol policy, they will need tobe supplemented by policies that influence attitudes as well as behaviour.


A HAZARDOUS COMMODITY WITH CULTURE-BOUND EFFECTS:

POLICY IMPLICATIONS OF ECAS

by Robin Room5

Twenty years from now, researchers and policymakers will look back at theEuropean Comparative Alcohol Study as a landmark in the alcohol field.ECAS will be seen as having established a benchmark on which work thatfollowed was built, and perhaps also still as a standard against which it willbe judged. In the course of the study, its researchers have diligently soughtout what could be found in the way of alcohol-related data for the half cen-tury after , and have also collected and assembled new data. Building onthis, they have given us an exemplary range of analyses, which advance thefield in several directions, and at the same time illuminate how muchremains to be done.

Interpreting the findings of ECAS

The difficulties ECAS faced in its investigations turn out to be part of thefindings. In a global perspective, the countries it examined are all part ofthe developed and relatively affluent world. As part of this world, each ofthem collected national statistics on a variety of topics throughout the peri-od of the study. Thus Karlsson & Simpura () are able to draw on datathroughout the period, with relatively few missing values, for such basicdemographics as the proportion of urban dwellers and the average size ofhouseholds, and for rates of motor vehicles, televisions and telephones perinhabitant. With some losses along the way, Norström (; see alsoChapter of this volume) and his colleagues are able to draw on data onmortality by cause for the entire period. Data on production and trade inalcoholic beverages were also available, if not otherwise as part of generalcommercial commodity statistics.

But beyond this, the availability of alcohol-specific data is tremendouslyimbalanced. Even within the mortality statistics, Ramstedt finds evidencethat “cultural factors affect the recording of alcohol-related deaths”(Norström, :; see also Chapter of this volume), with alcohol-specificcauses less likely to be recorded in Southern than in Northern Europe. Forother data sources, the imbalances are more obvious. Simpura et al.’sdescription (Norström, :; see also Chapter of this volume) of theavailability of drinking surveys in the different ECAS countries gives a com-

5 Centre for Social Research on Alcohol and Drugs (SoRAD), Stockholm University, Stockholm, Sweden

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parative picture of this. By the s, there had been surveys in theNetherlands, Finland, Norway, Sweden and the United Kingdom. Series ofsurveys begin in the s in Denmark, Austria, Germany, Italy and France.Only scattered or single surveys were found for Ireland, Spain, Portugal andGreece, while none at all were found for Belgium. The five countries withtraditions already in the s are precisely those with the strongest tradi-tions as “temperance societies” (Levine, ), that is, with strong traditionsof popular anti-alcohol movements, and four of them (not the Netherlands)form the list with scores of or above in Karlsson & Österberg’s () scaleof formal alcohol control policies as of the year . The imbalances ECASfound in the available data, in other words, still reflect the historical situationof the very different cultural framing of alcohol in the different countries inECAS at the beginning of the study period.

Another quantitative indicator of the persistence of great differences with-in the Europe Union, and more broadly within Europe, is the persistence oflarge differences in excise taxation of alcohol. The chart by Karlsson &Österberg () of excise taxes on alcohol in July in European coun-tries, including Norway, shows -fold differences in spirits taxes, and -folddifferences in beer taxes. Since wine is taxed at in six EU countries, no ratiocan be computed, but the differences are large. While there is no questionthat governments appreciate the revenue from alcohol taxes, it is clear thatthe differences do not arise from different needs for revenue. In fact, asLeppänen et al. () remark, nowhere in Europe is the alcohol taxationlevel as high as it would need to be to optimise government revenue. Rather,the differences arise from different principles of taxation. In a considerablepart of Europe, alcohol taxes have been viewed as an instrument of publichealth and order, a way of holding down the social and health harms associ-ated with drinking.

Although in formal terms the European Union adopted an alcohol exciseharmonisation directive in , in practical terms the directives amountedto an agreement to continue to disagree. The issue of alcohol taxation in theEU has been used analytically, in fact, as a case study in the cultural limits onprocesses of European integration (Lubkin, ).

The imbalances in the available data and in the tax levels are symptomaticof a wider set of divergences on alcohol issues in the countries of theEuropean Union, and more generally of Europe. The findings of ECAS sug-gest that there have been some important convergences in the last years,for instance on levels of alcohol consumption and in terms of formal alcoholcontrol policies. But it should be noted that great differences also remain.


We may characterise the situation for alcohol in the European Union, asrevealed by the ECAS reports, as follows:

() Western European countries appear to have converged somewhat interms of total alcohol consumption levels, and also of choice of beverages.However, the convergence is only partial, and may have slowed down inrecent years. In a global perspective, the convergence is at a level of con-sumption that is quite high (WHO, ) – along with Eastern Europe, by farthe highest level for any world region.

() At the range of current levels of consumption of EU countries, it doesnot appear that increases in alcohol consumption at the population levelhave any net beneficial effects on heart disease. Hemström’s (b) analysisfor ECAS appears to confirm the theoretical prediction on this made by Skog(). In terms of policies for the population as a whole, then, there doesnot appear to be any counterbalancing loss that would neutralise part of thegains from holding down alcohol consumption levels.

() In terms of long-term physical harm from drinking, using liver cirrho-sis mortality as a main indicator, increases in alcohol consumption levelwould be harmful, and decreases in consumption beneficial, throughoutWestern Europe. The adverse effects of increased drinking on cirrhosis seemto be particularly strong north of the Baltic Sea.

() In terms of problems associated with particular drinking occasions,such as accidents and homicide, detrimental effects also appear to be associ-ated with increased alcohol consumption throughout Western Europe. Here,however, there is a very clear gradient, with considerably stronger effectsnorth of the Baltic, and weaker effects south of Benelux and the Alps, than inthe middle range of countries.

() Since levels of per-capita alcohol consumption remain higher in coun-tries where alcohol appears to do less harm for each extra litre per capita, thedifferences between Northern and Southern Europe in aggregate damagedone by alcohol in a population will be much less.

() Broadly speaking, there appears to be some match between the degreeto which an extra litre of alcohol per capita brings extra harm in a society,and the two measures of intensity of alcohol control policies: the index ofscope and strictness of alcohol controls, and the level of alcohol taxation. Inother words, the differences in national control and taxation policies can beseen as societal responses proportional to the potential for harm from anextra quantum of drinking.

On the other hand, the intensity of alcohol control policies does notappear to be well matched to the aggregate damage done by alcohol in the

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population. Southern Europe’s policies are still not proportionate to theoverall level of harm from drinking.

These findings, primarily from aggregate levels, fit together quite well.Their implications are to point to the potential importance of patterns ofdrinking and of social reactions to problematic drinking as potential expla-nations of the differences that were found. The ECAS research accordinglyundertook comparable sample surveys in each of countries: two from thenorth (Finland and Sweden), two from the middle band of countries(Germany and UK), and two from the south (France and Italy) (see Chapter of this volume).

() An exploration of differences in drinking patterns in the ECAS survey(Leifman, b; see also Chapter of this volume) did find that heavy drink-ing occasions accounted for a higher proportion of all drinking occasions inSweden, Finland and Britain than in France, Germany and Italy, providingsome limited support for the hypothesis of differences in drinking patternsbetween Northern and Southern Europe. However, on several indicators ofalcohol-related problems, the differences between national samples did notfall into a clear north vs. south pattern (Ramstedt, ; see also Chapter ofthis volume). In terms of the average number of experienced interpersonalor casualty problems, patterns of relation between volume of drinking andfrequency of heavy drinking showed some broad similarities across coun-tries, though among those drinking high volumes, German and Italian menand French and Italian women appeared less likely to report problems. Theidea that informal social controls on drinking are stronger in Southern thanin Northern Europe also received only limited support (Hemström, a;see also Chapter of this volume): Italians were more likely than others tohave tried to influence friends to drink less, but rates of this did not differmuch in the other countries studied.

It must be said that these very interesting results create as many puzzles asthey solve. The tasks of reaching a more complete understanding of the roleof drinking patterns, and more generally of what lies behind the differencesfound at the aggregate level, remain for future work.

Policy implications of the findings

On the basis of these results, what are the policy implications? It seems thatthe implications lie in three directions: in terms of needs for research andmonitoring, in terms of national policies, and in terms of policies in theEuropean Union and the European Economic Area.

Needs for research and monitoring. ECAS has created a substantial set ofdatabases, which are already being used more broadly for further analyses.


For instance, the ECAS mortality data have been used for new estimates onthe burden of disease attributable to alcohol (Rehm & Gmel ). And thework of ECAS points to areas in which a continuing program of research andmonitoring work is needed, on a pan-European basis. Let us identify someelements of that program.

() Further work is needed on improving measurement of alcohol con-sumption levels across Europe, to take into account unrecorded consump-tion. A particularly helpful step, also, would be to develop comparable meth-ods for measuring alcohol consumption within such subdivisions of nation-al states as regions and counties (see () below).

() In its last months, ECAS has pursued some first steps in assessing com-parability and differences in national recording practices for alcohol-relatedcauses of illness and death. These first steps will need to be followed up witha program to improve the recording of alcohol-related illness and mortality.

() At least in some European countries, there is the potential to carry outtime-series analyses like those conducted by ECAS at the level of the regionor county. The place of alcohol in daily life and in the culture varies a gooddeal among regions in many European states, and regional-level analyses willcontribute new insights on the range and causes of variation, as well as help-ing to identify priority areas for policy action.

() There is a need to develop cross-European data sets that allow for com-parative analysis and monitoring of alcohol’s role in disability and in illness.This may include such techniques as regular sampling of cases in emergencyhospital wards, and in police custody, measuring potential alcohol involve-ment in each particular case.

() Periodic alcohol surveys in the general population carried out cross-nationally on a comparable basis would provide an invaluable resource formonitoring developments in drinking patterns and problems across Europe.They also provide a means for testing hypotheses about factors underlyingthe national differences found in population-level studies.

() There is a need to move towards an experimental approach to alcoholpolicy changes, where such changes are regularly evaluated. As feasible, well-designed experiments measuring the effects of policy changes should be car-ried out before new policies are applied. Where policy changes occur as “nat-ural experiments”, their effects should be evaluated.

() Methods should be developed and applied for tracking in a compara-ble fashion societal responses to alcohol problems, including not only treat-ment and other handling by social agencies, but also informal responses toproblematic drinking.

() Such a program of research and monitoring needs to take a settled

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institutional form, with a regular international funding stream. The institu-tional form needs to encourage a cumulative research tradition that tran-scends and reaches across national boundaries, including all regions ofEurope.

Policy implications at the national and local level

() Alcohol is a substantial contributor to disability and death in everyEuropean country. Attention to the effects of national and local policies onrates of alcohol-related problems is thus a public health imperative. Publichealth and public order interests should be taken into account in settingnational policies on alcohol availability and promotion and in influencingthe time, place and manner of drinking.

() Policymakers should seek the co-operation of researchers in develop-ing trials and demonstrations of alcohol policy initiatives. The crucial crite-ria for evaluating such trials are the effects on rates of alcohol-related prob-lems.

Policy implications at the European Union and international levels

() The familiarity of alcoholic beverages in our daily lives should not beallowed to blind us to the fact that alcohol is not an ordinary commodity, butone which carries with it extraordinary rates of social and health harm. Interms of the global burden of disability and disease in lost life-years, theadverse effects of alcohol outrank those of tobacco and of illicit drugs. Thereis a need for a broad recognition by European Union commissioners andstaff that these facts mean that substantial interference with free market con-ditions in the interests of public health and order is a positive duty ofEuropean governments.

() The ECAS findings of differential effects of alcohol in different parts ofEurope lend weight to the argument that it is appropriate for national alco-hol policies to differ within the EU, and that EU mechanisms and rulesshould support rather than undercut public-health-oriented national alco-hol policies.

() In particular, there is a need for action at the EU level to support theexisting high-tax regimes where they are a settled part of national alcoholpolicy, and to encourage raising of taxes where they are not. High-taxregimes are particularly threatened at this time by the setting of unrealisti-cally high travellers’ allowances for personal consumption. A good standardfor such allowances would be four bottles of wine or equivalent, i.e., aboutwhat someone drinking two drinks a day might consume in two weeks.Besides their adverse effect on public health, high travellers’ allowances pro-


vide an unfair price bonus to the relatively affluent, who more frequentlytravel across borders, just as tax-free shops did.

() More broadly, there is a need to develop mechanisms for comity with-in the EU, by which other member nations support the tax and regulatorypolicies of members. In particular, co-operation agreements between policeand customs authorities are needed to discourage smuggling and other eva-sions of national and local control regimes.

() In the s, the health experience was particularly adverse in much ofEastern Europe. Alcohol appears to have played a particularly strong role inthis, due to a combination of particularly harmful drinking patterns and thefailure of public-health-oriented control of alcohol markets. Countries thatare candidates for admission to the European Union should be included inthe research and monitoring arrangements noted above. International comi-ty with respect to alcohol control arrangements should be extended inadvance of membership. Technical assistance in policymaking and evalua-tion, where required, should be supported.

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CONCLUDING POLICY IMPLICATIONS

by the ECAS research team

The final task of the ECAS project was to spell out the implications of itsfindings for coordinated and cost effective alcohol policies within the EU.The nine theses below condense the policy implications of our findings. Thereaders may find it useful and interesting to compare this list with other listsaiming at general conclusions from the policy perspective. Such lists havebeen proposed by various camps around the alcohol policy issues, such as theWHO Regional Office for Europe with its second European Alcohol ActionPlan (), or the beverage industry with recommendations by theAmsterdam Group (), or research groups such as the internationalresearch team behind the book Alcohol Policy and the Public Good (Edwardset al., ). The comments presented above by Allamani, Hope and Byrne,and Room also contain a number of policy implications. Also importantly,the Council Recommendation () of the EU, “On the Drinking ofAlcohol by Young People, in particular Children and Adolescents”, acceptedin June , lists a number of policy implications on health promotion, edu-cation and information, as well as on codes of conduct, accompanying mea-sures and follow-up at the community level. We have been aware of all thesesummaries, but have striven to base our implications on the ECAS projectonly. It should be remembered that the focus of the ECAS project is on thepopulation at large, and not on special groups, such as young people.

A number of general questions are connected with any effort of preparingpolicy implications on alcohol issues. The most important ones would be thefollowing: Does total per capita alcohol consumption matter? Do drinkingpatterns modify the link between consumption and alcohol-related harm?How much weight should be put on measures controlling per capita alcoholconsumption? How should such measures be implemented, and what impactcan be expected from such an approach? Corresponding questions can beasked with regard to measures targeted at specific harmful patterns of drink-ing. An important issue concerns the role of public bodies and official alco-hol control measures, as compared to the capacity of informal control andself-mobilization of communities to prevent alcohol-related problems. Andfinally, on what administrative level should alcohol control measures beimplemented? Thus, the ultimate question would be: What should and canthe EU and its member states properly do to prevent alcohol-related harm?An initial discussion within the project of these issues has been published ina collection of articles (see Rehm, ; Room, ; Simpura, ; and Skog, ).


Our list is certainly not exhaustive. The nine points below do, in any case,belong to the core set of issues concerning the prospects for alcohol policyinitiatives within the EU. These initiatives, if gaining political support, maybe implemented on the EU-level, or they may be implemented jointly butnationally in the EU-member countries, or in certain member states only.

Policy implication 1:TOTAL CONSUMPTION MATTERS

One of the controversies in alcohol control issues is the importance given tothe relationship between total alcohol consumption and alcohol-relatedproblems. The proponents of the control-of-consumption view maintainthat regulating per capita alcohol consumption is an effective way of con-trolling consequences of drinking. Their critics point out the unclear evi-dence to support the control-of-consumption view and instead emphasisemeasures that target harmful drinking patterns, not per capita consumption.According to the findings presented in this report, it is evident that per capi-ta alcohol consumption matters in all ECAS countries: in every country, aconsumption increase leads to a significant increase in mortality from eithercirrhosis or explicitly alcohol-related mortality. For fatal accidents, homi-cide, and all-cause mortality about half of the country-specific alcohol effectsare positive and significant. In no country is an increase in consumptionassociated with a decrease in any of these mortality indicators.

Policy implication 2:DRINKING PATTERNS MODIFY THE LINK BETWEEN CONSUMPTION

AND HARM – BINGE DRINKING IS A MATTER OF PARTICULAR

CONCERN

The relationship between changes in overall consumption and changes inalcohol-related harm varies across countries, being stronger in Northernthan in Southern Europe. This difference may be related to differences indrinking patterns, particularly binge drinking, or high intake of alcoholicbeverages at one occasion, which is a more salient feature of the drinkingpattern in the north than in the south. The Northern European drinkingstyle thus seems to reinforce the detrimental effect of a given volume ofintake.

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Policy implication 3:THERE IS A GROWING CONCERN ABOUT ADOLESCENT DRINKING IN

MANY COUNTRIES, EVEN THOUGH CONSUMPTION LEVELS ARE

EQUALLY HIGH AMONG ADULTS

Much of the public debate around alcohol problems in the ECAS countriesconcerns adolescent drinking. Basically this is probably an eternal issue, asthe new generation with its new patterns of life is always a bit suspect in theeyes of the older. In practice, this concern is quite new in someMediterranean countries, meaning that concern about drinking among ado-lescents is currently the largest common alcohol issue among the ECAScountries. From the point of view of the EU Commission, drinking amongadolescents can be identified as a common European problem, and conse-quently an EU-level action on this issue would reinforce national policiesrather than intervene in them. On the member states level concern aboutadolescent drinking has led to lower legal age limits for buying alcoholicdrinks. However, it should be remembered that in most ECAS countries,adults of all ages, except the elderly, drink as much as, or more than do ado-lescents, and suffer more alcohol-related harm. Therefore, it is importantthat the political interest in adolescent drinking should not overshadow thehigh harm rates among the adults.

Policy implication 4:DRUNKEN DRIVING AND DRINKING IN PUBLIC PLACES HAVE

EMERGED AS SPECIAL PROBLEMS IN MANY COUNTRIES

Urbanisation, extended car use (“automobilization”) and new internationallifestyles are also creating common ground for alcohol policies within the EUmember states. As a consequence of increasing numbers of motor vehicles,and the heavy load of alcohol-related road accidents, an increasing numberof EU member states have raised drunken driving on their political agenda.An expression of this is that the legal BAC limits have been lowered in manycountries. Similarly, alcohol-related disorder and violence in connectionwith sport and leisure events have created more concern about alcohol poli-cies everywhere. Drunken driving and drinking in public places are the twoissues that would most likely serve as additional common factors, after ado-lescent drinking, in creating joint European alcohol policies.


Policy implication 5:THERE ARE STILL MAJOR DIFFERENCES AMONG THE ECAS

COUNTRIES, BUT ALSO SLOW HOMOGENISATION IN ALCOHOL

CONSUMPTION, BEVERAGE PREFERENCES AND DRINKING HABITS.

BOTH DIFFERENCES AND HOMOGENISATION SHOULD BE

ACCOUNTED FOR IN POLICY PROGRAMS

The differences in overall alcohol consumption have decreased among theECAS countries during the last decades, but they are still appreciable; therange in per capita consumption is between and litres of pure alcohol.Similarly, the differences in beverage preferences have diminished so that thetraditionally dominating beverage (wine in the Mediterranean countries,beer in the Central Western Europe and spirits in the Nordic countries) haslost ground in all ECAS countries. Yet, there still exist marked differenceswith respect to beverage preferences and drinking patterns among variousregions of EU member states. It is likely that the slow homogenisation willcontinue, but that differences will prevail for many decades to come. For pol-icy considerations, this means that some countries may expect increasingconsumption levels and higher harm rates, and others diminishing con-sumption and lower harm rates. These different future prospects should beaccounted for in shaping joint EU alcohol policies.

Policy implication 6:A MULTITUDE OF POLICY MEASURES IS AVAILABLE

Our results show that during the last two decades in particular, the numberof alcohol policy measures in use has increased in most ECAS countries. Anexception is the Nordic countries, which have been forced to abolish some oftheir earlier extensive alcohol control measures, such as the comprehensivealcohol monopoly system. Taxation, age limits for purchasing alcoholic bev-erages, regulations of advertising, and licensing of alcohol production andtrade are the most widely used approaches after direct controls, e.g., ofdrunken driving. There is no single optimal set of measures that would workin any country, but to some extent, any of these measures can be applied inany country. The final mix of measures must be determined in each countryseparately, taking into account the technical and political feasibility of vari-ous approaches in the existing national conditions.

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Policy implication 7:ALCOHOL PRICES IMPACT ON CONSUMPTION AND THUS ON

ALCOHOL-RELATED HARM

Many studies have shown that changes in alcohol prices clearly affect alcoholconsumption. In some reports alcohol price policy has been assessed as themost effective alcohol control measure. The econometric demand analysis ofalcoholic beverages, conducted in the ECAS project, also shows that prices ofalcoholic beverages have an effect on alcohol consumption and thereby onalcohol-related harm in all countries. This effect is smaller in wine-drinkingMediterranean countries than in other ECAS countries. Effects of changes inpurchasing power on alcohol consumption do not differ markedly betweencountries. The econometric analysis points out, however, that the overalleffect of economic factors is, although significant, still smaller than that ofnon-economic factors, such as culture, living conditions and preventivemeasures.

Policy implication 8:THERE IS A NEED AND POTENTIAL FOR CONTINUED COORDINATED

REGULATION AND HARMONISATION OF ALCOHOL TAXATION ON THE

EU LEVEL

In spite of the extant coordinated regulation of alcohol taxation in the EUmember states, there still remain substantial differences across memberstates as well as among beverage categories. Therefore, there seems to be bothscope and need for harmonisation of these regulations within the singleEuropean market. Although tax levels are still mostly low, there is a tenden-cy for increasing interest in higher taxation in many countries. The econo-metric demand analysis of the ECAS project suggests that in all countries, thelevel of alcohol taxes is presently below the revenue-maximising levels.

Policy implication 9:BECAUSE THE USE OF ALCOHOLIC BEVERAGES CARRIES SPECIAL

RISKS EVERYWHERE, THEY SHOULD BE TREATED AS SPECIAL

COMMODITIES, BUT REFLECTING LOCAL AND NATIONAL CULTURAL

TRADITIONS

Despite all cultural variation in alcohol consumption and drinking patterns,alcoholic beverages are commodities that contain special risks everywhere.The research evidence on the positive and negative health effects of drinkingwill probably always remain controversial. However, our conclusion for theECAS countries is that the alcohol-related health risks that follow fromincreased population drinking are not balanced by any possible positive


health effects. As a matter of fact, our analyses of the link between changes inper capita alcohol consumption and cardiovascular mortality show no heartbenefits from increasing drinking on the population level. But even thoughchanges in per capita consumption matter in all countries, the treatment ofalcoholic beverages as special commodities cannot be uniform. This isbecause drinking patterns, consumption levels and harm-risk profiles varyacross countries. In some countries, problems of binge drinking are empha-sised, whereas in others, long-term excessive drinking plays a more promi-nent role in the profile of alcohol-related harm.

* * *

A very important issue, outside the scope of the ECAS study, is the powerfuleconomic interests surrounding production and sales of alcoholic beverages.These interests are also on the move, speeded up by the European integra-tion. As these background processes of the mobilisation of interests are actu-ally among the core elements of the European economic and political inte-gration, our analysis serves to make visible the links between the changingalcohol field and the general integration processes. Because of such links,there is scope and potential for joint preventive alcohol policies on the EUlevel. However, given the large differences between the countries and the veryslow pace of homogenisation, the possible joint policies cannot be intro-duced in a top-down fashion only, but sufficient space must be left fornational initiatives and specifications

The ECAS study provides rich background materials for evidence-basedpolicy making on alcohol issues. The evidence is clear about the link betweenconsumption and consequences. There is evidence on various effective poli-cy measures, too. Changes in economy, culture and living conditions, andtheir effects on drinking patterns and alcohol consumption can also beaccounted for. The use of this evidence is a matter of political will, both onthe national level and on the EU level.

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Grieshaber-Otto, J., Sinclair, S. & Schacter, N. () Impact of international trade, servicesand investment treaties on alcohol regulation, Addiction, , Supplement , S-S.


Gual, A. & Colom, J. () Why has alcohol consumption declined in countries ofSouthern Europe? Addiction, , Supplement , S-S.

Heath, D. ed. () International Handbook on Alcohol and Culture (Westport,Connecticut, Greenwood Press).

Hemström, Ö. (a) Informal alcohol control in six EU countries (Stockholm, StockholmUniversity, Centre for Health Equity Studies).

Hemström, Ö. (b) Per capita alcohol consumption and ischaemic heart disease mor-tality, Addiction, , Supplement , S-S.

Holmila, M. (Ed.) () Community Prevention of Alcohol Problems (Basingstoke,McMillan).

Hughes K., Mckintosh, A., Hastings, G., Wheeler, C., Watson, J & Inglis. Young people,alcohol and designer drinks: quantitative and qualitative study, British Medical Journal,, -.

Hupkens, C., Knibbe, R. & Drop, M. () Alcohol consumption in the EuropeanCommunity: uniformity and diversity in drinking patterns, Addiction, , -.

Iandolo, G. & Capuano, P. () Il piccolo e il grande alcoolismo, Il Policlinico, , -.

Karlsson, T. & Simpura, J. () Changes in living conditions and their links to alcoholconsumption and drinking patterns in European countries, to , NordicStudies in Alcohol and Drugs, , (English Supplement), -.

Karlsson, T. &. Österberg, E. () A scale of formal alcohol control policy in Europeancountries, Nordic Studies on Alcohol and Drug, , (English supplement), -.

Knibbe, R., Drop M. J. & Hupkens C. (1996) Modernization and geographical diffusion asexplanation for regional differences in the consumption of wine and beer in theEuropean Community, Substance Use and Misuse, , -.

Leifman, H. (a) Homogenisation in alcohol consumption in the European Union,Nordic Studies on Alcohol and Drug, , (English Supplement), -.

Leifman, H. (b) A comparative analysis of drinking habits in six EU countries in theyear 2000 (Stockholm, Stockholm University, Centre for Social Research on Alcoholand Drugs. Mimeo).

Leppänen, K., Sullström. R. & Suoniemi, I. (2001) Effects of economic factors on alcoholconsumption in European countries, Nordic Studies in Alcohol and Drugs, ,(English Supplement), -.

Lereboullet, J. () Qu’est-ce que l’alcoolisme? La Revue du Praticien, XIV, -.Levine, H. () Temperance cultures: concern about alcohol problems in Nordic and

English-speaking cultures, pp. -, in: Lader, M., Edwards G. & Drummond, D.C.(Eds.) The Nature of Alcohol and Drug Related Problems (Oxford, Oxford UniversityPress).

Lubkin, G.P. () Is Europe’s Glass Half-Full or Half-Empty? The Taxation of Alcoholand the Development of a European identity. Jean Monnet Working Papers No. /,(Cambridge, MA: Harvard Law School), URL:<

http://www.jeanmonnetprogram.org/papers//ind.html>.Madianos, M.G., Gefou-Madianou D., & Stefanis, C. () Patterns of alcohol consump-

tion and related problems in general population in Greece, Addiction, , -.Norström, T. (Ed.) () Alcohol and Mortality: the Post-War Experience in the EU

countries, Addiction, , Supplement .Norström, T., (compiler) () Alcohol in Post-War Europe: Consumption, Drinking

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February (Copenhagen, World Health Organisation, Regional Office for Europe).

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Norström, T. & Skog, O.-J. () Alcohol and mortality: methodological and analyticalissues in aggregate analyses, Addiction, , Supplement , S-S.

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Osservatorio Permanente sui Giovani l’alcool () Young People and Alcohol betweenSchool and Work, A Community Action, Roma, Logica.

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Ramstedt, M. () Alcohol consumption and the experience of adverse consequences acomparison of six European countries (Stockholm, Stockholm University, Centre forSocial Research on Alcohol and Drugs. Mimeo.).

Ramstedt, M. () Alcohol-related mortality in European countries in the post-warperiod, in: Norström, T. (compiler): Alcohol in Post-war Europe: Consumption, DrinkingPatterns, Consequences and Policy Responses in 15 European Countries. Report at theWHO European Ministerial Conference on Young People and Alcohol, Stockholm -

February (Copenhagen, World Health Organisation, Regional Office for Europe).Ramstedt, M. () Liver cirrhosis mortality in European countries. Differences and

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Simpura, J. & Karlsson, T. () Trends in drinking patterns among adult population in European countries, to : a review, Nordic Studies on Alcohol and Drugs, ,(English supplement), -.

Skog, O.-J. () Alcohol consumption and mortality rates from traffic accidents, acci-dental falls and other accidents in European countries, Addiction, , Supplement ,S-S.

Skog, O.-J. () Alcohol policy, Why and roughly how? Nordic Studies on Alcohol andDrug, , (English supplement), -.

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221

ARTICLESHemström, Ö. () Per capita alcohol consumption and ischaemic heart disease mortal-

ity, Addiction, , Supplement , S-S.Karlsson, T. & Österberg, E. () A scale of formal alcohol control policy in European

Countries, Nordic Studies on Alcohol and Drugs, (English Supplement), -.Karlsson, T. & Simpura, J. () Changes in living conditions and their links to alcohol

consumption and drinking patterns in European countries, to , NordicStudies on Alcohol and Drugs, (English Supplement), -.

Leifman, H. (a) Estimations of unrecorded alcohol consumption levels and trends in European countries, Nordic Studies on Alcohol and Drugs, (English Supplement),-.

Leifman, H. (b) Homogenisation in alcohol consumption in the European Union,Nordic Studies on Alcohol and Drugs, (English Supplement), -.

Leppänen, K., Sullström, R. & Suoniemi, I. () Effects of economic factors on alcoholconsumption in fourteen European countries, Nordic Studies on Alcohol and Drugs,

(English Supplement), -.Norström, T. () European Comparative Alcohol Study – ECAS. Project presentation,

Nordic Studies on Alcohol and Drugs, (English Supplement), -.Norström, T. () Per capita alcohol consumption and all-cause mortality in

European countries, Addiction, , Supplement , S-S.Norström, T. & Skog, O.-J. () Alcohol and mortality: Methodological and analytical

issues in aggregate analyses, Addiction, , Supplement , S-S.Ramstedt, M. () Liver cirrhosis mortality in European countries, Nordic Studies on

Alcohol and Drugs, (English Supplement), -.

Publications from ECAS

Appendix 1

222

Ramstedt, M. (a) Per capita alcohol consumption and liver cirrhosis mortality in European countries, Addiction, , Supplement , -.

Ramstedt, M. (b) Alcohol and suicide in European countries, Addiction, ,Supplement , S-S.

Rehm, J. () Draining the ocean to prevent shark attacks? Nordic Studies on Alcohol andDrugs, (English Supplement), -.

Room, R. () The idea of alcohol policy, Nordic Studies on Alcohol and Drugs,

(English Supplement), -.Rossow, I. () Alcohol and homicide – a cross-cultural comparison of the relationship

in European countries, Addiction, , Supplement , S-S.Simpura, J. () Drinking patterns and alcohol policy, Nordic Studies on Alcohol and

Drugs, (English Supplement), -.Simpura, J. () Trends in drinking patterns and alcohol consumption: sociological and

economic explanations and alcohol policy, Nordic Studies on Alcohol and Drugs,

(English Supplement), -.Simpura, J. & Karlsson, T. () Trends in drinking patterns among adult population in

European countries, to : a review, Nordic Studies on Alcohol and Drugs,

(English Supplement), -.Skog, O.-J. () Alcohol policy: Why and roughly how? Nordic Studies on Alcohol and

Drugs, (English Supplement), -.Skog, O.-J. (a) Alcohol consumption and overall accident mortality in European

countries, Addiction, , Supplement , S-S.Skog, O.-J. (b) Alcohol consumption and mortality rates from traffic accidents, acci-

dental falls, and other accidents in European countries, Addiction, , Supplement ,S-S.

Trolldal, B. () Sales of alcoholic beverages and the inhabitants’ consumption in European countries. A correction based on consumption during journeys abroad andtax-free purchases, Nordic Studies on Alcohol and Drugs, , (English Supplement), -.

REPORTSAllamani, A., Cipriani, F., Voller, F., Rossi, D., Anav, S., Karlsson, T. & Österberg, E. ()

Italy, in: Österberg, E. & Karlsson, T. (Eds.) Alcohol Policies in EU Member States andNorway (Helsinki, Stakes).

Britton, A., Karlsson, T. & Österberg, E. () The United Kingdom, in: Österberg, E. &Karlsson, T. (Eds.) Alcohol Policies in EU Member States and Norway (Helsinki, Stakes).

Eisenbach-Stangl, I., Uhl, A., Karlsson, T. & Österberg, E. () Austria, in: Österberg, E. &Karlsson, T. (Eds.) Alcohol Policies in EU Member States and Norway (Helsinki, Stakes).

Gefou-Madianou, D in collaboration with Karlsson, T. & Österberg, E. () Greece, in:Österberg, E. & Karlsson, T. (Eds.) Alcohol Policies in EU Member States and Norway(Helsinki, Stakes).

Hemström, Ö. Alcohol-related deaths contribute to socioeconomic differentials in mortal-ity in Sweden. Stockholm University and Karolinska Institutet, Centre for Health EquityStudies. Accepted for publication in European Journal of Public Health.

Hemström, Ö. Informal alcohol control in six EU countries. Stockholm University andKarolinska Institutet, Centre for Health Equity Studies. Submitted to ContemporaryDrug Problems.

Hemström, Ö. Attitudes towards alcohol policy in six EU countries. Stockholm Universityand Karolinska Institutet, Centre for Health Equity Studies. Submitted toContemporary Drug Problems.

223

Hope, A., Byrne, S., Karlsson, T. & Österberg, E. () Ireland, in: Österberg, E. &Karlsson, T. (Eds.) Alcohol Policies in EU Member States and Norway (Helsinki, Stakes).

Karlsson, T. & Österberg, E. () Belgium, in: Österberg, E. & Karlsson, T. (Eds.) AlcoholPolicies in EU Member States and Norway (Helsinki, Stakes).

Karlsson, T. & Österberg, E. () Finland, in: Österberg, E. & Karlsson, T. (Eds.) AlcoholPolicies in EU Member States and Norway (Helsinki, Stakes).

Karlsson, T. & Österberg, E. () France, in: Österberg, E. & Karlsson, T. (Eds.) AlcoholPolicies in EU Member States and Norway (Helsinki, Stakes).

Karlsson, T. & Österberg, E. () Luxembourg, in: Österberg, E. & Karlsson, T. (Eds.)Alcohol Policies in EU Member States and Norway (Helsinki, Stakes).

Karlsson, T. & Österberg, E. () The Netherlands, in: Österberg, E. & Karlsson, T. (Eds.)Alcohol Policies in EU Member States and Norway (Helsinki, Stakes).

Karlsson, T. & Österberg, E. () Norway, in: Österberg, E. & Karlsson, T. (Eds.) AlcoholPolicies in EU Member States and Norway (Helsinki, Stakes).

Karlsson, T. & Österberg, E. () Portugal, in: Österberg, E. & Karlsson, T. (Eds.) AlcoholPolicies in EU Member States and Norway (Helsinki, Stakes).

Karlsson, T. & Österberg, E. () Spain, in: Österberg, E. & Karlsson, T. (Eds.) AlcoholPolicies in EU Member States and Norway (Helsinki, Stakes).

Karlsson, T. & Österberg, E. () Sweden, in: Österberg, E. & Karlsson, T. (Eds.) AlcoholPolicies in EU Member States and Norway (Helsinki, Stakes).

Karlsson, T. & Simpura, J. () Living Conditions, Alcohol Consumption and DrinkingPatterns in EU Member States and Norway, to , available in www-format: URL:<http://www.stakes.fi/hyvinvointi/ahtu>.

Kümmler, P., Jünger, S., Kraus, L., Karlsson, T. & Österberg, E. () Germany, in: Öster-berg, E. & Karlsson, T. (Eds.) Alcohol Policies in EU Member States and Norway(Helsinki, Stakes).

Leifman, H. (a) Validity problems in alcohol surveys with special emphasis on thecomparative six country ECAS survey. Stockholm University, SoRAD. Submitted toContemporary Drug Problems.

Leifman, H. (b) A comparative analysis of drinking habits in six EU countries in theyear . Stockholm University, SoRAD. Submitted to Contemporary Drug Problems.

Leppänen, K., Sullström, R. & Suoniemi, I. () The Consumption of Alcohol in FourteenEuropean Countries, A Comparative Econometric Analysis (Helsinki, Stakes).

Österberg, E. & Karlsson, T. (Eds.)() Alcohol Policies in EU Member States and Norway(Helsinki, Stakes).

Österberg, E. & Karlsson, T. () Alcohol policies on the EU-level, in: Österberg, E. &Karlsson, T. (Eds.) Alcohol Policies in EU Member States and Norway (Helsinki, Stakes).

Österberg, E. & Karlsson, T. () Studying alcohol policies in national and historicalperspectives, in: Österberg, E. & Karlsson, T. (Eds.) Alcohol Policies in EU Member Statesand Norway (Helsinki, Stakes).

Österberg, E. & Karlsson, T. () Trends in alcohol policies in the ECAS countries, in:Österberg, E. & Karlsson, T. (Eds.) Alcohol Policies in EU Member States and Norway(Helsinki, Stakes).

Ramstedt, M. (c) Alcohol-related mortality in European countries in the postwarperiod. Stockholm University, SoRAD. Submitted to European Journal of Population.

Ramstedt, M. (d) Alcohol consumption and the experience of adverse consequences –a comparion of six European countries. Stockholm University, SoRAD. Submitted toContemporary Drug Problems.

Ramstedt, M. (e) Per capita consumption and deaths with explicit mention of alcoholin Western European countries. Stockholm University, SoRAD (manuscript).

224

Ramstedt, M. (f) Per capita consumption and pancreatitis mortality in WesternEuropean countries. Stockholm University, SoRAD (manuscript).

Simpura, J. & Karlsson, T. () Trends in Drinking Patterns among Adult Population in 15European Countries, to , A Collection of Country Reports (Helsinki, Stakes).

Thorsen, T. , Karlsson, T. & Österberg, E. () Denmark, in: Österberg, E. & Karlsson, T.(Eds.) Alcohol Policies in EU Member States and Norway (Helsinki, Stakes).

225

RESEARCHERS

Thor Norström (Project Director)Swedish Institute for Social Research, SwedenE-mail: [email protected]

Jussi Simpura (Deputy Project Director)National Research Centre for Welfare and Health, Stakes, FinlandE-mail: [email protected]

Örjan HemströmCentre for Health Equity Studies, SwedenE-mail: [email protected]

Thomas KarlssonNational Research Centre for Welfare and Health, Stakes, FinlandE-mail: [email protected]

Håkan LeifmanCentre for Social Research on Alcohol and Drugs, SwedenE-mail: [email protected]

Kalervo LeppänenNational Research Centre for Welfare and Health, Stakes, FinlandE-mail: [email protected]

Participants of ECAS

Appendix 2

226

Esa ÖsterbergNational Research Centre for Welfare and Health, Stakes, FinlandE-mail: [email protected]

Mats RamstedtCentre for Social Research on Alcohol and Drugs, SwedenE-mail: [email protected]

Ingeborg RossowNOVA, Norwegian Social Science, NorwayE-mail: [email protected]

Ole-Jørgen SkogNorwegian Academy of Science and Letters, NorwayE-mail: [email protected]

Björn Trolldal Centre for Social Research on Alcohol and Drugs, SwedenE-mail: [email protected]

SUPPORT STAFF

Ola Arvidsson (Administration Officer)National Institute of Public Health, SwedenE-mail: [email protected]

Karin MelinderNational Institute of Public Health, SwedenE-mail: [email protected]

Anna MånssonNational Institute of Public Health, SwedenE-mail: [email protected]

Linnéa RaskNational Institute of Public Health, SwedenE-mail: [email protected]

Eva WiklundNational Institute of Public Health, SwedenE-mail: [email protected]

COLLABORATING PARTNERS

Allaman AllamaniCentro Alcologico Integrato, ItalyE-mail: [email protected]

Luc BilsComité de Concertation Alcool-Drogues, BelgiumE-mail: [email protected]

227

Annie BrittonHealth Promotion Sciences Unit, United KingdomE-mail: [email protected]

Michel CrapletNational Association of Prevention from Alcoholism, FranceE-mail: [email protected]

Else de DonderVereniging voor Alcohol- en andere Drugproblemen, BelgiumE-mail: [email protected]

Irmgard Eisenbach-StanglLudwig Bolzmann-Institut für Suchtforschung, AustriaE-mail: [email protected]

Rosa EncarnacãoCentro Regional de Alcoologia do Porto, PortugalE-mail: [email protected]

Henk GarretsenAddiction Research Institute Rotterdam, The NetherlandsE-mail: [email protected]

Dimitra Gefou-MadianouDepartment of Social Policy & Social Anthropology, GreeceE-mail: [email protected]

Christine GodfreyCentre for Health Economics, United KingdomE-mail: [email protected]

Antoni Gual SoléUnitat d’Alcohologia de la Generalitat de Catalunya, SpainE-mail: [email protected]

Ann HopeNational Alcohol Surveillance Project, IrelandE-mail: [email protected]

Ludwig KrausIFT Institute for Therapy Research, GermanyE-mail: [email protected]

Dike van de MheenAddiction Research Institute Rotterdam, The NetherlandsE-mail: [email protected]

Carlos MoraisCentro Regional de Alcoologia do Porto, PortugalE-mail: [email protected]

228

Sturla NordlundNational Institute for Alcohol and Drug Research, NorwayE-mail: [email protected]

Daniele RossiPermanent Observatory on Youth & Alcohol, ItalyE-mail: [email protected]

Thorkil ThorsenCentral Research Unit of General Practice, DenmarkE-mail: [email protected]

European Comparative Alcohol Study – ECAS

This volume summarises the findings from the European ComparativeAlcohol Study – ECAS. The main topics include:

• alcohol policy;• overall alcohol consumption;• drinking patterns;• alcohol-related mortality.

The focus is on the European Union and Norway during the postwar period.

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