The world of drinking: national alcohol control experiences in 18 countries

Abstract

Between 2004 and 2007 a series of commissioned articles were published in the journal Addiction, under the general theme of: 'National Alcohol Experiences' [1–19]. These papers were written by leading experts from around the globe, representing 18 countries in total. The contributors were asked to write about current alcohol issues in their respective countries, specifically in reference to epidemiology, prevention, treatment, research and policy [1]. These papers were commissioned in part to facilitate international communication in the field, but also to demonstrate that 'the world of drinking is still one of very diverse experiences' [1]. To the casual observer these papers might appear to be a rather unsystematic and arbitrary collection of qualitative essays that have very little in common. However, upon more careful reading of this series, there appears to be much more that is worth considering, not only in terms of the experiences different countries have with alcohol, but also how they deal with alcohol from a public health perspective. As Addiction concludes this series with a final contribution from Japan [19], we think it is appropriate to synthesize what we have learned individually and collectively from this diverse set of papers. This paper utilizes a case-series method to synthesize the current alcohol issues across the 18 countries. Emergent themes were identified by the authors in five areas (history, epidemiology, treatment, prevention/policy and research). The fact that the individual papers were written from a broad national perspective by very knowledgeable observers is both a strength and a weakness of this series. Key informants may not be either accurate or objective, and the issues they identify may not be representative of anything more than their own personal or professional views. Nevertheless, the authors were chosen for their expertise and broad international experience, which is apparent from even a casual reading of their ability to put their own country's alcohol experiences in an appropriate cultural and historical context. Our purpose in writing this paper is therefore to identify common themes, discuss unique developments and explore the implications for research and policy. Most of all, we are interested in these papers as case studies of what happens when one tries to answer the question: what impact does the modern alcohol control infrastructure have on the health of the populations it is intended to serve? Countries invest in surveillance systems, alcohol research, treatment programs, prevention initiatives and alcohol control policies for a reason. Typically, the purpose is to reduce human suffering caused by alcohol, and to prevent further problems. After summarizing what we have learned from these country reports in each of the designated categories, we will return to these fundamental questions of public health and social welfare in our closing statement. . . . during the frontier period of Australia's settlement alcohol was used to engage Aboriginal people, to exchange for sexual favours, as payment for labour and to incite fighting as street entertainment (Midford [7], p. 891). The dictum that those who ignore the lessons of history are likely to repeat its mistakes takes on new relevance in the historical and cultural backgrounds described at the beginning of each of these papers. Several authors note the symbolic value that alcohol has assumed at various times. In India, during the first part of the 20th century [6] drinking came to be associated with British colonialism, and this led to an emphasis on abstinence from alcohol that has continued in some states to the present day. In South Africa [13], the growth of illegal outlets (shebeens) during the second half of the 20th century came to symbolize resistance to apartheid, and may have contributed to the growth of problem drinking. In Nigeria, alcohol has recently come to symbolize the 'perennial religious divide' between Muslims and Christians where alcohol availability has become a source of conflict in northern parts of the country [10]. As in India, Nigeria and other countries, public attitudes can be very ambivalent towards alcohol, with some segments of the population favoring prohibition or major restrictions on availability, and others favoring a more tolerant attitude toward drinking. In almost all countries, alcohol's cultural symbolism has been incorporated into the national mythology. For example, alcohol was used historically to control the Australian Aboriginal people and this contributed to the 'drunken Aborigine' stereotype that persists today [7]. As suggested in these papers [6,10,13], history teaches that while the determinants of contemporary drinking patterns and beverage preferences can be complex, they can also be explained by a combination of influences, including the availability of local agricultural products for brewing, the presence or absence of religious injunctions, the level of economic development and, in many low- and middle-income (LAMI) countries, the expanding influence of the global alcohol producers who are increasingly targeting 'emerging markets' such as India, Nigeria, China and Brazil with highly sophisticated western marketing techniques. History also draws attention to what have been called the 'long waves' of alcohol consumption that characterize fluctuations in drinking patterns and per capita consumption. These trends take place over decades, often gradually but sometimes in rapid shifts in beverage preferences or styles of drinking. In Spain and France, two of the so-called 'wet cultures', there have been significant declines in per capita consumption during the latter part of the 20th century, as well as changes from predominantly wine consumption to a broader mix of beverage preferences [4,16]. These changes seem to be independent of the alcohol policies implemented in these countries, and are perhaps more attributable to changes in population demographics and life-style choices. Long-term consumption trends have also been observed in countries such as India which, before independence, experienced a general increase in alcohol consumption and problems, culminating in the imposition of strong temperance measures following independence in 1947. Other countries (e.g. Australia, South Africa) give similar evidence of how drinking epidemics have precipitated the implementation of remedial alcohol control measures, such as taxation and prohibition laws. Other long waves suggested in these reports include the homogenization of drinking patterns across northern and southern European countries, and the general increase in alcohol consumption in countries experiencing rapid economic development, such as India and China. However, history also shows that economic development and the emergence of a middle class can have a salutary influence on alcohol problems, as in Australia, which gradually imposed controls on its frontier drinking culture. Spain is becoming famous for its unending weekend nights where people can buy drinks easily all night long, and can drink both in bars and off premises. Because alcohol is cheap, the weather allows year-round outdoor drinking and the 'wet culture' is permissive, these new habits have spread at enormous speed throughout the whole country (Gual [16], p. 1073). Epidemiological data can provide an empirical foundation to develop prevention, treatment and policy responses to alcohol-related problems, and related surveillance methods can be used to monitor the extent to which the policy response reduces the disease burden. In the papers written for this series, we can see clearly how epidemiological methods, such as disease surveillance and descriptive analyses of drinking patterns and alcohol-related problems, have been used at the national level to inform governments of what is happening in their countries. Are problem rates increasing or decreasing? Are drinking patterns changing for the better or the worse? What is happening epidemiologically in the wet versus dry countries? In the descriptive panorama provided in these papers, a number of themes are evident, while at the same time unique aspects of individual drinking cultures are also noteworthy. The overarching message from these papers is that we have definitely made progress in our ability to collect this type of data. Most of the reporting countries now have some capability to monitor alcohol consumption and the distribution of drinking problems at a national level. Two main epidemiological trends emerge from the data presented in these papers. First, binge drinking is increasing and nowhere else is this more evident than in the United Kingdom and Spain. Binge drinking in Spain is captured most appropriately by the Botellón phenomenon [16]. The literal translation of Botellón is 'big bottle' and it is essentially an outdoor drinking party where young people listen to music and socialize in public spaces with alcoholic beverages. Botellóns provide a lower-cost alternative to drinking in bars and clubs. Particularly when linked to holidays, they can draw people from a large geographic area in numbers estimated to be as large as 70 000 people. Public binge drinking has also become problematic in the United Kingdom [5], with increasing reports of public drunkenness. By one estimate there are 7 million hazardous and harmful drinkers in England and Wales. Even in France [4], once the land of alcoolisme sans ivresse (alcoholism without drunkenness), there are reports that binge drinking has increased, although perhaps not quite to the levels reported in Spain and the United Kingdom. Interestingly, the increase in binge drinking in France was linked by Craplet [4] to a shift in the meaning of alcohol consumption, from its traditional value as a food to that of an intoxicant consumed for its psychoactive effects. A second epidemiological theme in these papers is the decreasing gender differences in rates of drinking, although this trend varies across different countries and subgroups. For example, gender differences in rates of alcohol use among youth are diminishing in Spain [16] and the United States [14], and rates of drinking among women are increasing in Sri Lanka [2]. The 'bag-in-box' phenomenon has been used to describe the increasing rates of drinking in Swedish women over 50 years of age [11]. In Japan, the percentage of women who were current drinkers in 1968 was 19%. This increased to 64% by 2003 [19]. We can only hypothesize that the unintended consequence of increasing gender equality may partially explain increasing rates of alcohol use among women. Midford [7] argues that the increased rates in female drinking, at least in Australia, could be related to aggressive efforts by the alcohol industry to market alcohol to women. . . . services remain insufficient to meet demand, poorly distributed geographically and fragmented between health and social welfare sectors (Parry [13], p. 427). The development of specialized treatment services is often the first step taken to build a national response to alcohol-related problems. In what is barely a capsule summary of the treatment issues in each country, these papers nevertheless provide an appreciation for the role of government policy in the organization and delivery of treatment services. Some countries (e.g. Sri Lanka, Nigeria) have virtually no formal treatment services [2,10], whereas others (e.g. South Africa, India) have been struggling with how best to configure their limited resources for optimal advantage [6,13]. In South Africa, the optimal mix of specialized and generalist (i.e. primary care) services is an important issue, as is the separation of services along private/public lines. In other LAMI countries (e.g. Nigeria), there is a tendency to establish in-patient programs in psychiatric hospitals first, and only later is it considered possible to expand services to the primary care sector. Treatment services in Germany have evolved over the past century, with a heavy emphasis on long-term residential rehabilitation programs [3]. Only recently has there been a shift to out-patient programs. Slovenia is another country with a relatively well-developed treatment system, which includes clubs for alcoholics organized in different settings, such as health care, social welfare, employment settings and in the community. Russia may have one of the most extensive treatment systems in the world, but this seems to have been neglected in recent years [15]. Some of these accounts suggest that treatment services expand and contract for quite arbitrary reasons, such as the growth of alcohol treatment following an initial investment in treating heroin addiction in Spain [16], and a contraction of tertiary services in South Africa [13] when emphasis was shifted to management of alcohol problems in primary care. There is virtually no discussion of the public health aims of treatment services, or how the performance of a service system can be improved to ameliorate alcohol problems at the population level. . . . the history of Thai alcohol policy indicates that economic interest, especially revenue generation, has been the most important consideration (Thamarangsi [17], p. 783). The policy issues mentioned by these observers differ among countries. In contrast to the emphasis most countries place on treatment services, many observers in this series admit to a total or relative absence of systematic alcohol policy, particularly in the LAMI countries. In countries such as Nigeria [10], 'much of what passes for prevention involves mainly the distribution of posters and awareness campaigns among young people'. In South Africa, programs directed at pregnant women and drinking drivers are given priority, and a new law forbidding the supply of liquor in lieu of wages indicates that some of the forgotten supply-side problems that once plagued the industrialized countries are still prevalent in LAMI countries. Prevention programs in Japan are, in part, the responsibility of local governments, and are delegated to community welfare and health centers and mental health centers, which are distributed widely in the country. Early intervention is one area where there seems to be some investment. Progress is also reported in the enforcement of driving under the influence (DUI) legislation, and Australia appears to be at the forefront of random breath testing of drivers. Countries such as Slovenia have rather uncoordinated and haphazard collections of alcohol policies, with exceptions in some areas such as drink driving policy [9]. Reasons for ineffective policies and lax enforcement include the prevailing 'wet' drinking culture and the influence of the alcohol lobby. The alcoholic beverage industry is mentioned as an obstacle to effective alcohol policy in India, Nigeria, the United Kingdon, Thailand, South Africa, India and Mexico. A related theme, reiterated in many of these reports, is that commercial and economic interests take precedence over public health and public safety concerns in the determination of alcohol policy. This is perhaps reflected most strikingly in the UK report [5], which describes how an industry public relations organization, the Portman Group, was included as the key partner agency to tackle 'binge drinking'. At the same time, sophisticated marketing campaigns linking commercial beers such as Guinness with power, adventure, male sexuality and success are pervasive reminders that industry promises of self-regulation of advertising are not being honored. Contrary to the generally pessimistic reports about alcohol policies, the case of Australia [7] provides cause for optimism. Taxation, considered by many observers as a valuable tool for prevention, reflects actual alcohol content of the beverage, thereby encouraging consumption of low alcohol beverages. Evidence also suggests that Australia's policies limiting hours of sale and high-volume purchases have been successful in reducing harm. Local community accords with the retail trade seem to reduce alcohol-related violence, and drink-driving countermeasures have been particularly successful. Another country where alcohol policy has been successful is Sweden. A tradition of high alcohol taxes and restrictions on availability has kept per capita consumption low, which in turn has reduced most indicators of alcohol-related problems. However, with Sweden's entry into the European Union, economic pressures have mounted to liberalize free trade in alcohol, which in turn has led to a change from restrictions on price and availability to an emphasis on more focused preventive measures at the municipal level. An important policy issue that plagues many of the LAMI countries, but also some of the more developed nations, is the availability of illicit alcohol often produced in the context of the informal market at the local level. Observers in India, Sri Lanka, Mexico, Nigeria and other countries point to the difficulty in reducing consumption when controls on the legal market may drive consumers to the illicit market as an alternative. One of the most dramatic examples of the vicissitudes of alcohol policy is the case of the Gorbachev era in Russia [15]. In 1985 a wide-ranging campaign of reforms resulted in an estimated 25% reduction in alcohol consumption, which was followed by dramatic increases in life expectancy among males. With the abandonment of reform efforts several years later, alcohol consumption again increased, along with the incidence of chronic health problems. Clearly, these observations demonstrate the potential value of alcohol policy as an instrument of public health, and the challenges presented when powerful interest groups are threatened by policies that work. Research concerning alcohol issues has received very limited government funding, with the clinical aspect of the research being undertaken with practically no grant[s] (Čebašek-Travnik [9], p. 12). An important contribution of the papers in this series is the way in which the constructive role of alcohol research is illustrated, especially in LAMI countries. For example, in South Africa [13] qualitative and quantitative research has documented the role of alcohol in sexual risk behaviors, and epidemiological studies have increased public awareness of fetal alcohol spectrum effects. Countries such as the United Kingdom and Sweden appear to be using empirical data increasingly to improve clinical practice [5,11]. In many of the LAMI countries, the infrastructure for alcohol research is weak or non-existent. For example, there has been a loss of trained manpower in Nigeria because of out-migration or competition for jobs in the private sector, but in some countries the deficiency can be corrected by collaboration among non-governmental organizations, academics and international organizations such as the World Health Organization. One encouraging development is described in the report from South Africa [13], which suggests that there has been significant growth in alcohol research with the establishment of a research unit at the Medical Research Council. In addition to the amount of research, several observers provide interesting information about research priorities. In Japan, where there is virtually no epidemiological or policy research [19], significant emphasis is placed on the investigation of genetic variations in alcohol dehydrogenase (ADH) and ALDH2 as a deterrent to alcohol dependence (the so-called flushing response). Germany has had a long tradition in alcohol research, but it was only in the past 15 years that long-term funding was initiated by the federal government, which established research networks in the areas of neurobiology, epidemiology, early intervention and treatment. The need for a viable research infrastructure would seem particularly acute in countries such as China, where effective alcohol controls are weak or non-existent, and alcohol consumption is increasing dramatically [8]. As in other LAMI countries, funding for alcohol research is low, and there is virtually no investment in intervention or policy research. If research is the answer to the prevention or treatment of alcohol-related problems, surely the United States would be the most abstinent or temperate nation on earth. As the dominant engine of scientific findings on alcohol, the United States nevertheless seems to be as impotent as other countries in translating research findings into effective prevention policy [14]. At the beginning of this paper we raised the question: ‘What impact does the modern alcohol control infrastructure have on the health of the populations it is intended to serve?’. Although the papers in this series on national alcohol experiences were not necessarily designed to answer this question, it is clear that most of them provide insights into the meaning and purpose of how different nation states respond to alcohol-related problems. Each country has its own culture, history and mix of subpopulations that help to form its national alcohol experiences, and ultimately the mix of its alcohol policies. By investing in surveillance systems, treatment programs, prevention initiatives, alcohol control initiatives and alcohol research, countries attempt to build a foundation to deal with the human suffering caused by alcohol, and to prevent further problems. Most countries have developed their own mix of treatment and prevention services, and have struggled with the integration of addiction services with medical and social welfare programs. Some countries admit to great regional diversity in the way services are organized and the governmental agencies providing oversight. These variations suggest the need for both cross-national and intranational research on comparative service systems, not only to describe the nature of these treatment and prevention services, but also to evaluate their performance from a public health perspective. The insights noted above concerning the role of different historical, social and cultural factors on alcohol consumption and alcohol-related problems suggest that research that focuses solely on the immediate causes and consequences of alcohol consumption, particularly genetic and biomedical research, will miss some of the most important lessons required to inform effective policy options. Despite the apparent progress evident in different parts of the world, the question of whether the modern infrastructure (surveillance, treatment, prevention, research) has a population-level impact remains unanswered, although an examination of these national alcohol experiences does provide some interesting suggestions. Until the policy-makers and alcohol experts achieve a greater sense of mission and purpose, nation states will continue to struggle with the question of how best to configure a rational response to the problems of alcohol. The writing of this paper was supported in part from grants from the National Institute on Drug Abuse (T32 DA 07209) and the National Institute on Alcohol Abuse and Alcoholism (P60AA003510-30).