Part of this paper was published as: Effects of alcohol controls: Nordic research traditions. Drug
and Alcohol Review 23:43-53, 2004.
EFFECTS OF ALCOHOL CONTROLS:
LESSONS FROM A HALF-CENTURY OF NORDIC SOCIAL EXPERIMENTATION1
Robin Room
Centre for Social Research on Alcohol and Drugs
Stockholm University
Sveaplan
106 91 Stockholm, Sweden
robin.room@sorad.su.se
Introduction
The focus of this paper is on studies of the impact of alcohol control changes in Nordic
countries, and particularly in Finland, Norway and Sweden, which have been carried out in the
last half-century. This tradition of studies has recently been extensively reviewed (Mäkelä et al.,
2002), and this paper relies on that review as its canon of studies -- with the addition of several
new analyses published in the same volume (Room, 2002) and the recent Swedish Saturdayopening study (Norström & Skog, 2001, 2002).
In the paper, some consideration is also given to the equivalent traditions of such studies
in Canada and Australia. There is no attempt here at a full review of the results from these
traditions. Instead, the general contours of the Canadian and Australian research traditions are
considered, in comparison to the studies in Finland, Sweden and Norway.
Our discussion is limited to studies of discontinuous changes in the physical availability
of alcohol. The focus on studies of discontinuous change excludes studies of the effects of
gradual changes in alcohol controls -- for instance, of year-by-year changes in the number of
alcohol sales outlets. Excluded also are studies of the effects of changes in the prices or taxes
for alcoholic beverages, though an analysis in this mode may be regarded as the earliest modern
alcohol control study in Canada (Seeley, 1960), and there is an important Australian study of the
effects of a tax levy which had a specific alcohol policy purpose (Gray et al., 1999). Finally,
studies of the effects of changes in drinking-driving laws are excluded, although this is an
important literature in its own right in all of the countries considered. However, the effect on
drinking-driving casualties is often used as an outcome variable in studies which are included
here.
Nordic traditions of studying the impact of changes in alcohol control2
The modern tradition of studies of the impact of alcohol controls may be said to have
Prepared for presentation at an international research symposium, “Preventing Substance Use, Risky Use and
Harm: What Is Evidence-Based Policy?”, held in Fremantle, Western Australia 24-27 February, 2003. In part, this
paper draws on a presentation, “Studying Effects of Alcohol Controls: Canadian and Nordic Experiences”, presented
at a conference on Canadian Alcohol Experiences and Nordic Perspectives, Oslo, Norway, 12-13 December, 2002.
The paper draws on the work of my colleagues in a Nordic project (Room, 2002), and in particular on a review
paper by Mäkelä, Rossow & Tryggvesson (2002)
2
This section draws on Olsson et al. (2002).
1
1
started with the commitment, early in the history of the Finnish Foundation for Alcohol
Studies, to study the effects of changes in the Finnish alcohol control system, and in fact to
base changes in the alcohol control system on prior studies of the effects of the changes
(Bruun, 1991). The commitment to this rationalistic and experimental approach proved fitful
in the succeeding decades. But the early Finnish commitment to this approach established
what eventually became a tradition of such studies, starting with Pekka Kuusi’s classic
controlled experimental study of the effects of opening of liquor stores in country towns
(Kuusi, 1957), and studies of the effects of the “buyer surveillance” system under which
social workers for the Finnish alcohol monopoly made home visits to customers with
suspiciously large purchases (Bruun & Sääski, 1955).
Finnish social alcohol research was organized after 1950 as a department of the state
alcohol monopoly. With a sociologist, Pekka Kuusi, as the director of the Finnish alcohol
monopoly, it was natural that studies of the effects of alcohol control measures received an early
emphasis in the research program. The present-day Alcohol and Drug Research Group of
STAKES in Helsinki carries on the tradition of policy impact studies thus initiated, as the
successor to the Social Research Institute for Alcohol Studies.
In 1959, what is now the National Institute for Alcohol and Drug Research (SIRUS) was
founded in Norway, and policy impact studies have been a central task for it. In the other three
Nordic countries, alcohol policy impact research has been carried out on a more ad-hoc basis. In
Sweden, projects were initiated and funded by government commissions, the alcohol retail
monopoly (Systembolaget) and more recently the Public Health Institute (FHI). Different
national research councils have also provided funding to individual researchers or groups of
researchers for impact studies. In 1999 the Centre for Social Research on Alcohol and Drugs
(SoRAD) came into existence as a Swedish equivalent of the Finnish and Norwegian research
groups.
In Finland, Norway and Sweden, alcohol policies were seen as part of the welfare state,
and evidence-based knowledge acquired by scientific methods was seen as a necessary element
in the social planning of the welfare state. In line with this belief in science and progress, alcohol
policy impact studies were considered to be an instrument for the implementation of effective
alcohol policies. The vision was reinforced by the notion that the state had responsibilities in
providing funds specifically for alcohol research. Studies of changes in tax or price levels, in
opening or closing days or hours for stores and taverns, of the opening of new outlets, of the
introduction of new beverages, or of strikes which temporarily limited alcohol availability, have
therefore been a part of the Nordic alcohol research agenda.
Unplanned disruptions, such as strikes, tend to happen with short notice. If they are to be
studied with specially collected data, only a short time can be spent on study design, construction
of the necessary measuring instruments, and data collection. In such cases, existing longitudinal
studies and panel data may form the most valuable resources for studying the effects of changes
in alcohol control. Such data sets are usually the result of long-standing and coherent research
projects, in many cases carried out by national alcohol research institutes. The benefits of settled
institutes in Finland and Norway have also been that researchers have been able to attend to
research questions that arise from sudden policy changes. A majority of the Nordic alcohol
policy impact studies have been carried out by specific alcohol institutes or as governmentally
funded projects.
The Canadian tradition of studies of the effects of alcohol controls
2
Over 30 studies of Canadian experience which fit into our criteria for inclusion have been
identified. Examining the studies’ authors and provenance, one characteristic immediately
becomes clear. Most of the studies were conducted by staff of the Addiction Research
Foundation of Ontario (ARF), and in fact a single ARF scientist, Reginald Smart, is an author of
about 40% of the studies. The search strategy used, involving heavy dependence on ARF library
files (now in the CAMH library), may have inflated this dominance, but it is unlikely that more
than a few additional studies will come to light.
Through most of its history 1949-1998, ARF played a unique role in Canadian alcohol
and drug research (Room, 1999). Formally, ARF was an agency of the province of Ontario, and
90% or more of its funding came from the province. But there was no institution with a
comparable research capability in any other province. In fact, alcohol research elsewhere in
Canada was mostly carried out by individual faculty members and their students. Canadian
federal funding for alcohol research has never been significant. The result has been that ARF
filled many of the functions of a national research centre, although it did not have that formal
status, nor much funding which would legitimate these functions. Put the other way, since
studies of the effects of alcohol policy interventions were not part of the core territory of any
academic discipline, and since Canadian governments rarely funded studies of the effects of their
changes in alcohol controls, if a study of any sort was going to be done, it would have to be done
by ARF.
Most of the studies of Canadian experience considered here (like many of the Nordic
studies reviewed by Mäkelä et al., 2002) fall in the category of “natural experiment” studies.
That is, the policy change was made without any prior reference to researchers or consideration
of making the change in such a way as to facilitate studying it. In some cases, the analyses of
Canadian natural experiments were able to identify and use control sites for comparisons (e.g.,
Smart, 1979).
A few of the studies fall into the category of quasi-experimental studies, with prior
involvement of the researchers, and measurements made prior to the change rather than
retrospectively. The earliest Canadian study (Dewar and Sommer, 1965), carried out with
funding from the Saskatchewan government, is as much a model of how such a study should be
carried out as the pioneer Finnish study (Kuusi, 1957). Other studies with prior involvement of
the researchers, and often with funding from the alcohol control system, include studies of
introducing the use of credit cards for alcohol store sales (Wells et al., 1999; Macdonald et al.,
1999), and studies of introducing beer sales at sporting events (Fisher & Single, 1984; West et
al., 1996). Unfortunately, these studies were not able to use control sites.
In general, the Canadian studies have been hampered by limited resources for fieldwork.
If before-and-after surveys have been used at all, sample sizes have been limited. Many of the
studies have relied instead on published annual figures from health or police records for their
outcome data. Such a design can give valuable information about the effects of the policy
change, but not about the process and intermediators through which any effects occur.
Prior to Trolldal’s analyses (2002), only one study of a Canadian alcohol control change
(Adrian et al., 1996) appears to have used modern time-series analysis methods. In general, there
is a need to move toward stronger research methods in future work on Canadian materials.
The Australian tradition of studies of the effects of alcohol controls
Substantial social research on alcohol is a relatively recent Australian phenomenon.
Until the advent of the two national alcohol and drug research centers in 1986, as part of the
3
effort of the Australian national drug strategies, the few studies of the effects of alcohol controls
had mostly been carried out in association with state alcohol and drug authorities. As in Canada,
there is one researcher, D. Ian Smith, who worked at the Western Australian Alcohol and Drug
Authority, who has a hand in almost half of the Australian studies.
Australian researchers, perhaps reflecting the general political culture, started from a
position of skepticism about the effects of alcohol controls. Claims in the early studies of no
effects (Raymond, 1969; Aitken et al., 1976) were challenged by later reanalyses of the
experience (Smith, 1998a; Mäkelä, 1976; see Ward, 1976). Smith’s work in the 1980s marked
the point at which Australian studies of alcohol control became integrated into the developing
international literature (e.g., Smith, 1989). Smith’s studies, which demonstrate both the potential
and the limits of analyses relying on available tax, health and police records, often did find
significant effects from changes which increased availability, although some of the conclusions
have been challenged (Stockwell & Gruenewald, 2001).
More recently, the major stimulus to Australian studies of the effects of alcohol control
changes has been the efforts of Aboriginal communities to win local exceptions to the general
Australian rules of high availability (Wright, 1997). These efforts have met strong resistance
from local alcohol retailers, and result has been a series of studies of the effects of increasing
controls, with the evaluation researcher, as d’Abbs (2002) has recently discussed, often thrust
into the role of an actor in these community disputes. With a recent contribution to this literature
(Gray et al., 2000), along with studies in the general urban environment (Chikritzhs et al., 1997;
Chikritzhs and Stockwell, 2002), the National Drug Research Institute, one of Australia’s two
national alcohol and drug research centers, has become an important contributor to the literature.
Comparing the research traditions
Canadian and Nordic alcohol researchers have been in regular contact with each other
since the very beginnings of ARF and the Finnish Foundation over 50 years ago. In the late
1950s, a formal exchange arrangement for study visits was concluded between these two
institutions. In the succeeding years, Canadian and Nordic researchers established close contacts
particularly in the area of alcohol policy studies. The 1975 volume, Alcohol Control Policies in
Public Health Perspective (Bruun et al., 1975) was a landmark in this regard, involving Finnish,
Norwegian and Canadian researchers; its 1994 successor, Alcohol Policy and the Public Good
(Edwards et al., 1994), included also Swedish researchers. In between, Finnish and Canadian
researchers collaborated also in the International Study of Alcohol Control Experiences (Mäkelä
et al., 1981). Reflecting the later start of Australian traditions of social research on alcohol, as
well as the tyranny of distance, it is only more recently that there has been regular participation
from Australia in such international collaborative projects and in international research meetings
such as those of the Kettil Bruun Society for Social and Epidemiological Research on Alcohol.
In view of the growing involvement of researchers from all five countries in “invisible
colleges” of researchers, it is interesting to note how divergent the research topics have been in
the studies of alcohol control changes (Table 1). The main drivers of this divergence,
presumably, have been the differences in the details of the control systems and in the policy
debate about them. Studies of discontinuous changes in alcohol controls are dependent in the
first place on the political will to make a discontinuous change, even on an experimental basis.
Secondly, there is a need for both the researchers and their funding or institutional environment
to be convinced that studying the change would be interesting and worthwhile.
4
Many of the Nordic studies are focused on a short list of discontinuous and relatively
dramatic changes. These offer the best scope for the evaluation researcher to find substantial
changes in the outcome measures, even if the samples are small or there is a lot of noise in the
indicators. Eight events in the Nordic countries account for 62% of the studies: the Finnish
liberalization of 1968/69 (beer into the groceries); the end of rationing and the advent and
disappearance of medium beer in Sweden; and four liquor store strikes.
The Canadian literature is less concentrated, although almost one-third of the studies
concern the lowering and then raising of the minimum drinking age limits that occurred in
several provinces in Canada in the 1970s. The Australian literature is heavily concentrated in
another direction: on studies of changes in closing hours and days.
Topics which are shared between the Nordic, Australian and Canadian literatures include
the effects of introducing a category of light beer, and the effects of alcohol supply strikes.
Other topics are shared by a smaller range of national literatures. The effects of introducing
self-service in off-sale stores, for instance, has been studied in both Sweden and Canada. While
releasing beer into the grocery stores has been studied in Finland and Sweden, it is releasing
wine into the grocery stores which has been studied in Canada (Quebec); and while the effects of
opening new outlets has been studied for off-premise stores in Finland and Norway, it was for
on-premise “liquor by the drink” in Canada.
As already indicated, the central focus of the Australian literature, unmatched in any of
the other four countries, has been on the effects of changes in closing hours for on-premise or
off-premise purchases. At least in part, this reflects the preoccupation in Australian alcohol
control history with restrictive opening hours for on-premise consumption (Room, 1988). A
number of Smith’s studies are of the effects of the gradual dismantling of the Australian
traditions of “six o’clock closing” and Sunday closing in the postwar era. It is interesting,
however, that the Australian focus on closing times has come to fore again in the context of
Aboriginal efforts to limit damage to Aboriginal communities from drinking. Other measures
included in this new wave of alcohol control have often included bans or controls on the sale of
the cheapest forms of alcohol (commonly wine, given the preference for wine in the structure of
Australian alcohol taxes).
There is no equivalent in the Canadian literature for the substantial Nordic and Australian
traditions of studies of Saturday or Sunday opening or closing, though there would have been the
opportunity, for instance, to study the effects of Sunday opening as it came to the Canadian
provinces. Neither the Nordic nor the Canadian literatures have focused on the effects of alcohol
control changes on indigenous populations (except for a research note by Smart, 1979), although
at least in Canada there would have been ample opportunity for studies like the recent Australian
tradition.
Conversely, the Canadian and Australian literatures include several topics for which there
is no Nordic equivalent. The effects of various Finnish changes in wine availability -- wider
availability of fruit wines, sale of wines under 4.7% in grocery stores -- appear not have been
studied. Introducing credit cards in off-sale stores and the effects of changes in advertising bans,
for instance, could have been studied in one or another Nordic country, as they were in Canada.
And only a recent Icelandic study (Ragnarsdóttir et al., 2002) has looked at the effects of changes
in closing hours, as a number of Australian studies have done, although such studies would have
been possible in other Nordic countries and in Canada.
5
The general findings from the Nordic studies3
Focussing now on the Nordic traditions of studies, let us consider what can be concluded
from them. Drawing on and extending a summary table from a review of the Nordic studies
(Mäkelä et al., 2002), Table 2 presents a brief overview of the results of the different studies.
Our focus here is not only on the effects in the total population, but also particularly on
differential effects in different subgroups of the population.
In the first place, in the Nordic experience, big changes in the physical or financial
availability of alcohol can clearly produce big effects. The Swedish changes of 1955 and the
Finnish changes of 1968 produced immediate large increases in the population’s level of alcohol
consumption, and had big effects also on indicators of alcohol-related problems. On the other
hand, a comparison of the effects of the increased availability of beer in Finland in 1968 with
that in Iceland in 1989 suggests that the magnitude of the effect depends also on other
circumstances of the time. The change in Finland in 1968 has been seen in terms of a belated
opening of the doors to pent-up demand from a new “wet generation” (Mäkelä, 1978; Sulkunen,
1979), whereas in Iceland there was a fair degree of de-facto availability of beer before the legal
change. At least as importantly for short-term effects, the Finnish economy was flourishing in
1968, while Iceland was moving into a recession in 1989.
The effects of smaller changes in availability, however, seem more variable, and often
negligible in terms of the effects on total consumption. A series of Norwegian studies of the
effects of restricting beer sales to local monopoly stores, and of opening new wine and spirit
monopoly stores, found little or no effect on the total alcohol consumption. In terms of the total
consumption, the effects of opening or closing monopoly stores on Saturdays have been
relatively modest -- the 3.4% increase from Saturday opening found in the most recent Swedish
study (Norström and Skog, 2001; 2002) is at the upper level of the range of results.
Differential impacts on different population segments
The concentration in Nordic policy discussions on the “total consumption model”
(Sutton, 1998; Sulkunen et al, 2000) has often meant that the primary attention, in evaluating the
effects of changes in controls, has been on the effect on total alcohol consumption. Often, this
was taken as the crucial proxy measure for changes in alcohol-related harm due to the change in
alcohol controls.
But it is clear that total alcohol consumption is not always a good proxy measure for the
effects of the policy change. In the first place, the effect on the drinking of different demographic
segments is not always the same. In the second place, there are often variations in the effects on
people with different patterns of drinking. In the third place, the effect on different alcoholrelated problems often differs, and may differ from the effect on the total alcohol consumption.
We shall discuss each of these points in turn.
Variations by demographic segment. A clear example of such variation is the effect of
taking medium beer out of Swedish grocery stores in 1977. This was the most significant of the
restrictive changes in Swedish alcohol policy over a period of about 5 years (1976-1981),
including prohibition of alcohol advertisements in 1978, Saturday closing in 1981, and increases
in real prices of alcohol during 1979-1984. The policy measures were not age-specific, but a
major aim of the changes had been to combat youthful heavy drinking. Medium beer had been
most popular among young people, and its removal, in particular, had some success in reducing
3
This and the following two sections draw heavily on Room et al. (2002).
6
young people’s drinking. However, Ramstedt’s analysis (2002) suggests that there were also
some effects in reducing alcohol-related harm in some older segments of the population.
Conversely, the introduction in Denmark of a 15-year-old minimum age of off-premise
purchase is, obviously, an age-specific measure, but it turned out that there were declines in
drinking also among older teenagers. Møller (2002) interprets this broader effect as reflecting
the public discussion which surrounded the adoption of the minimum age legislation. His
findings remind us that the effects of policy changes should not be interpreted in mechanical
terms; public sentiment and reaction to the measures may also play an important role in their
effects, and a new law may have an effect as much through the public attention, debate and
discussion which surround it as through its direct action (Hingson et al., 1988).
There are clear findings in a number of the analyses in this volume that effects of alcohol
control changes on women have often been different from their effects on men. The advent of
legal beer in Iceland seems to have had a gender-specific result, as judged from the survey data
(Ólafsdóttir & Leifman, 2002): men’s consumption of alcohol rose (particularly young men’s),
but not women’s. There was a non-significant rise in teenage girls’ consumption, but no net
effect for women as a group.
The Finnish policy change of 1968, on the other hand, had big effects on both women’s
and men’s drinking (Mäkelä, 2002a; Mustonen & Sund, 2002). In absolute terms the increase
among men was much greater than among women. But the details of the changes among women
differed from those among men. In proportion to their drinking patterns prior to the change,
men’s median frequency of drinking increased more than women’s, while women’s median
annual amount of consumption increased more than men’s. Both the absolute and the relative
size of the changes in frequency and amount of consumption varied by age, and were much
smaller among older respondents than among younger.
There was also a difference in the size of changes, in absolute terms, for both frequency
and volume of consumption by level of education. Median frequency increased by 21 units
among those in the higher education group, but by only 3 in those with low education, and there
were similar differences in the change in volume. But these changes were proportional to the
initial frequency and volume levels of the educational groups.
There are variations between studies in the effects of policy changes in the city and in the
countryside. Among Icelandic men (Ólafsdóttir & Leifman, 2002), the advent of beer seems to
have had a more lasting effect on consumption in the city (Reykjavik) than in the countryside,
perhaps reflecting a more severe effect of economic recession in the countryside. On the other
hand, in proportion to prior consumption, the median annual consumption rose more in the
Finnish countryside than in urban areas, in the wake of the 1968 changes (Mäkelä, 2002a),
reflecting the much greater difference in availability which the changes made in the countryside.
Again, the much greater preexisting level of consumption in urban areas meant that the absolute
amount of increase was much greater in urban areas.
Further research is needed to understand better the societal and individual factors behind
differences between sociodemographic categories in the effects of policy changes.
Variations by drinking pattern and amount. Clearly, when policies have a substantial
impact on drinking in the population, they tend to have the strongest effect on heavier drinkers, if
the effect size is measured in terms of the absolute level of change. In Mäkelä’s analyses
(Mäkelä, 2002a, 2002b), controlling for the regression-to-the-mean effect, the difference in
change between the Finnish and the control samples is greater for the heavier drinkers than for
7
the lighter. Mustonen and Sund’s analysis (2002), however, adds the nuance that much of this
Finnish increase was actually in relatively low-consumption occasions. Since the data on what
happened with the introduction of beer in Iceland is not panel data, we do not have a direct
measurement of whose drinking changed how much. However, it is suggestive that among
Icelandic men (Ólafsdóttir & Leifman, 2002), the consumption level of the highest-consuming
10% of the population had increased between 1988 and 1992 by almost eight times the increase
among moderate consumers.
Many other phenomena in nature have a distribution which, like the distribution of
alcohol consumption among drinkers in a population (Skog, 1991), take a roughly lognormal
shape. General discussions of such distributions point out that these distributions are often the
net effect of processes where the amount of change on the variable from a given stimulus is
roughly proportional to the previous position on the variable (Aitchison and Brown, 1957). In
general, it seems that this is the case for alcohol policy changes: in rough terms, drinkers tend to
be affected by policy changes about proportionately to their existing drinking level. Thus, if
lighter drinkers increase their drinking by one-half, heavier drinkers also increase theirs by about
one-half. From the perspective of the added harm to be expected from added drinking, what
happens to heavier drinkers will usually be more crucial. For chronic consequences where the
risk curve rises more steeply among heavy drinkers, such as liver cirrhosis, increased drinking by
light drinkers becomes relatively unimportant. The same absolute amount of increase in drinking
among heavier drinkers would be more important, since the increase in risk is greater due to the
steeper risk curve. However, the concentration of the effect in heavy drinkers goes beyond this.
Since the actual increase tends to be proportional, so that the increase is greater in absolute terms
among heavier drinkers, the effect of a policy change on heavier drinkers becomes the dominant
effect for such consequences.
For problems related to occasions of intoxication, such as injuries from traffic crashes,
violence, or other causes, the question of the differential effect of the policy changes on different
types of drinking occasions becomes important. Drinking heavily, at least occasionally, is quite
widespread in the population, producing what has often been described as the “prevention
paradox”: these kinds of problems, in particular, are also quite widely spread among drinkers
(Skog, 1999). For problems such as traffic crashes, the effects of the 1968 Finnish policy change
was presumably muted by the fact that there was a bigger increase in low-consumption occasions
than in high-consumption occasions. However, Mustonen and Sund’s analysis (2002) shows that
there was, nevertheless, an increase also in high-consumption occasions.
Indirect evidence that policy changes often have their greatest impact on heavier drinkers
can be derived from analyses of the effects of changes on health and social problem indicators.
The opening of alcohol monopoly stores in previously dry areas of Finland in the 1950s resulted
in a larger increase in drinking among those already drinking frequently than among infrequent
drinkers (Kuusi, 1957). The 46% increase in consumption in Finland between 1968 and 1969
was accompanied by a 58% increase in deaths from alcohol-specific causes (Mäkelä et al.,
2002). Rationing in Sweden seems to have had a particularly strong effect in holding down
drinking by the most vulnerable heavy drinkers. Thus the end of rationing, which brought a 25%
increase in per-capita consumption, brought a 438% increase in deaths from delirium tremens
(Norström, 1987).
Variations by type of problem. As the examples just given illustrate, the effect of policy
changes on rates of alcohol-related health and social harms is often greater than the effect on the
8
total alcohol consumption level. In fact, in a number of instances in the Nordic material, policies
appear to have had an impact on the kinds of problems associated with troublesome or social
marginal drinkers, even when there was no measurable effect on the overall drinking level.
Thus the analysis of the 1982 Norwegian liquor store strike (Rossow, 2002) shows that
the strike had a clear effect on admissions to the detox centre in downtown Oslo, and also an
effect on reported violent crimes, although the effect on overall consumption was probably
modest. These findings are in accordance with findings in several other studies of liquor store
strikes in Finland, Sweden and Norway: generally, domestic disturbances and alcohol-related
crimes decreased, as did indicators of public drunkenness (arrests or detox admissions), while
moderate drinkers were hardly affected by the strike.
The results of Nordic experiments with closing or opening liquor stores on Saturdays,
also, were often an effect on domestic disturbances or manifestations of public drunkenness, but
little effect on the overall consumption level.
On the other hand, introducing round-the-clock serving hours in Reykjavik
(Ragnarsdóttir et al., 2002) had a particularly dramatic effect on the numbers of cases of
suspected drunk driving, greater proportionally than the effect on numbers of emergency-room
admissions for injuries from fights. In this case, the effect was greater for the indicator normally
more associated with the settled population, although the possibility that this was due to greater
police vigilance cannot be ruled out.
Implications of the Nordic studies for alcohol policy
From a policy perspective, it is the effects on drinking problems rates which really
matter. From this perspective, the extent to which the drinking of different segments of the
population rises and falls in concert remains a question which is intellectually interesting (e.g.,
Gmel and Rehm, 2000), but is not crucial for policy. The crucial issue for some outcomes, such
as liver cirrhosis, is the effects of different policy interventions on those who are already or may
become heavy drinkers. For other outcomes, such as alcohol-related injuries, the population at
risk is much broader, but still considerably less than the whole population of drinkers. Pointing
this out has sometimes been taken as an argument for a shift away from general policy
instruments that affect all drinkers, and towards more narrowly-targeted instruments (Stockwell
et al., 1997).
But the evidence from the Nordic policy impact literature does not support this argument.
The changes with the biggest effects on alcohol problems rates in the 50 years of Nordic
experience we are considering were the Finnish changes of 1968, and probably three Swedish
changes: the abolition of the motbok in 1955, the tax increases in the three years after that, and
the policy changes in the era of the repeal of medium-strength beer (1976-1981). All these
policy changes applied to and affected all drinkers, but had their strongest effects on problematic
drinkers. Conversely, narrowly-focused interventions, such as the adoption of a minimum
purchase age in Denmark, often turn out to have effects beyond the population at which they
were aimed.
Thus, “narrow-cast” policies may have effects on a broader population than their target
group. And, as the Nordic experience underlines, policies aimed at the total population often
turn out to have stronger effects on problematic drinking than on other drinking. The issues of
the scope of effect and differential impacts of a policy thus should not simply be assumed.
Rather, they are matters for empirical investigation.
9
The future of studies of changes in alcohol policies – Nordic and otherwise
The Nordic countries are in a changing alcohol policy environment. The internal freemarket provisions of the European Union continue to erode the integrity of the Nordic alcohol
control systems. A legal decision in early February, 2003 under EU free-market rules has
overturned Sweden’s ban on the advertising of alcoholic beverages in print media (Ritter, 2003).
The Nordic cross-border allowances within the EU for bringing in alcohol for personal use are to
be raised to the full high EU levels at the beginning of 2004. Denmark has announced a 44% cut
in its spirits taxes for October 2003 (http://www.skm.dk/slutfil.php3?SlutFilId=2911), although Danish
spirits taxes are already considerably lower than in other Nordic countries (Karlsson &
Österberg, 2001). The accession of Estonia to the EU will bring low-tax alcohol within an hour
of Helsinki. The border traffic threatens not only the relatively high-tax structures in Finland,
Sweden and Norway; in the end, it is seen as threatening, too, the other main pillar of the
traditional system of alcohol control in these three countries: the state retail monopoly systems.
In Skåne, in southern Sweden, already only about 30% of the alcohol consumed is bought
through the state stores.
While further liberalizations may be harmful for public health, they open up opportunities
for researchers. Much of the literature which we have been reviewing, in fact, has been made
possible by the long march of liberalization of the Australian, Canadian and Nordic systems over
the last 50 years. But the problem for future researchers may be that at some point the
liberalization may go so far that there is no longer the political will even to fund their studies.
There is no substantial tradition of studies of the effects of alcohol control, for instance, in
Germany or Denmark, let alone in Italy or Greece.
Taken together, the five national traditions of studies of the effects of alcohol controls,
along with U.S. studies, have made a crucial contribution to policy-relevant research in the
alcohol field. In a forthcoming international collaborative review, the authors offer their
collective judgement of the literature’s evidence on the effectiveness of different policy
strategies (Babor et al., forthcoming). Looking across the available strategies, those which
regulate the availability of alcohol in form, time and place – the alcohol control policies which
are studied in the literatures we consider here -- are among the strongest strategies which are
available for limiting the harms from drinking. As the Nordic experience makes clear, this does
not mean that each little detail of policy necessarily makes much difference in every
circumstance. But there is a consistent pattern of findings that controls of alcohol availability
matter in terms of limiting alcohol-related harm, and that they are one of the few strategies which
both matter and are potentially politically available in a liberal modern state.
Given this, it is an important task to build on the literatures we have been considering in
future work. Examining the divergent shapes of the Australian, Canadian and Nordic literatures
helps us to identify many interesting topics for future research – including not only research on
forthcoming changes but also retrospective studies of the effects of past changes. Looking over
the study designs which have been used, it is clear that there is room for improvement here, too,
in every country’s literature. Though there have been advances in research technology in the last
50 years, it is not a lack of suitable study methods which accounts for the main weaknesses in the
literature. Rather, the problem has often been one of insufficient resources to do a good study.
Studies have often lacked control sites, even where one could have been identified and used.
“Before” and “after” surveys have been used quite commonly in Nordic studies, but with sample
sizes too small to pick up any effect less than the highly dramatic. In future work, it will be
important, too, to give attention to studying differential effects in diverse population subgroups,
10
which holds implications for sample sizes. The message of the literature on the effects of
alcohol controls is that total consumption in the population matters quite a lot, but it is not the
only intermediator between alcohol consumption and rates of alcohol problems.
In a wider frame, the literature on the effect of changes in alcohol controls offers a good
starting point for rethinking public health approaches to limiting the damage from psychoactive
substances generally (Room, forthcoming). Neither for nicotine nor for the drugs under
international control has there been anything like the length and breadth of experimentation with
controlling availability, short of prohibition, which there has been for alcohol. In the context of
rethinking control of psychoactive substances more generally, these traditions of studies of the
effects of changes in alcohol controls thus have a wider significance.
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17
Table 1. Studies of alcohol control changes since 1955: Finland, Sweden, Norway &
Canada
Finland
Sweden
Norway
Canada
Australia
-
(far-North 2a
prohibition &
rationing;
privatization)
-
2
-
(all re Quebec)
-
System change
(buyer
2
surveillance)
(rationing) 5
Alc. class in groceries:
Class of beer +/Wine added
New class of beer
(light, exc. As marked)
Cheap wine ban
(10 re 1969)
(6 re med. beer)
13
-
7
-
-
-
1
-
-
Ban on reduced-price
drinks (“happy hours”)
-
3b
(1 re strong)
-
3c
1d
1m
4n
-
-
1e
-
(off-prem.) 1
-
(off-prem.) 4
(on-prem.) 2f
-
Self-service in stores
-
1
-
1g
-
Credit cards in stores
-
-
-
2h
-
Opening/closing day:
Saturday
Sunday
Closing hours changes
3
-
6
-
4
-
-
-
5o
12p
8
(2 strikes) 8
(6 strikes) 5i
1q
New outlets
Alcohol supply strikes
(2 strikes)
13
( 1 strike)
Advertising ban
-
-
-
4j
-
Alcohol in sports
arenas
Lowering/raising age
limit
Total no. of studies
-
-
-
2k
-
-
-
-
13l
32
27
19
38
18
(3 states)
2r
23
Table 1 (cont’d)
References for Nordic studies:
See Mäkelä et al., 2002; also studies in Room, 2002, and Norström & Skog, 2001, 2002.
References for Canadian studies:
a: Smart, 1979; Trolldal, 2002.
b: Adrian et al., 1996; Smart, 1986; Trolldal, 2002.
c: Adrian & Jull, 1990; Whitehead & Szandorowska, 1977; Mann et al., 1997.
d: Giesbrecht & Macdonald, 1981
e: Smart & Adlaf, 1986.
f: Dewar & Sommer, 1962; Smart & Docherty, 1976.
g: Smart, 1974.
h: Macdonald et al., 1999; Wells et al., 1999.
i: Single, 1979; Smart, 1977b; Harper et al., 1981a, 1981b, 1981c.
j: Makowsky & Whitehead, 1991; Ogborne & Smart, 1980; Smart, 1976; Smart & Cutler, 1976.
k: Fisher & Single, 1984; West et al., 1996.
l: Smart, 1977a; Smart & Adlaf, 1983; Smart & Finley, 1976; Smart & Schmidt, 1975; Smart &
Vingilis, 1981; Smart & White, 1972; Schmidt & Kornaczewaki 1975; Whitehead et al.,
1975; Williams et al., 1975; Whitehead, 1976; Whitehead, 1977; Shattuck & Whitehead
1976; Bako et al., 1976.
References for Australian studies
m: Mugford, 1984
n: d’Abbs et al., 1996, 1999; d’Abbs & Togni, 1998; Gray et al., 2000
o: Smith, 1978, 1980, 1987a, 1988c, 1990
p: Raymond, 1969; Smith 1987b, 1988a, 1988b, 1988d; McLaughlin & Harrison-Stewart, 1988;
d’Abbs et al., 1993, 1996; Chikritzhs et al., 1997; Douglas, 1998; Gray et al., 2000;
Chikritzhs & Stockwell, 2002
q: Aitken et al., 1976; Mäkelä, 1976; Ward, 1976.
r: Smith & Burvill, 1986, 1987
19
Table 2. Summarizing the results of Nordic alcohol impact studies (revised from Mäkelä et al., 2002)
Country
& period
Effects on total
consumption
Abolition of the Swedish rationing system
Sweden
- Increase (25%)
1955
Effects of buyer surveillance system
Finland
1949-52,
1955
Differential effects by demography, by drinking
patterns and on harms
- Heavy consumers’ consumption increased most after the abolition
- Alcohol-related harm increased relatively more than consumption
- No better development in drinking among those abusers who were
exposed to sanctions
- The end of purchase registering resulted in easier access to alcohol
among abusers
Introduction of new types of beer in grocery stores
Finland
- Strong increase in
- Greater relative increase in consumption for women, in previously dry
1969
total consumpareas, among younger adults
(beer <4.8% in
tion (46%)
- Bigger increases in consumption among those already drinking heavily
groceries)
- Sales of medium beer
- Frequency of light drinking occasions increased the most
increased by 242%
- Many abstainers started drinking
- Alcoholics replaced spirits with beer
- A strong increase in morbidity, mortality and arrests for
drunkenness
- Arrests for drunkenness increased particularly among youth (<18 years)
and among women
Finland
- No visible effect on public drunkenness
1993/94
- Among the young, beer consumption increased, but not total
(removed)
consumption.
Sweden
- Consumption of
- Medium beer most popular among youth
1965 (< 4.6%
medium beer
- Hospitalizations for alcohol diagnoses fell among teenagers when
medium beer
increased heavily
medium beer removed from groceries
in groceries);
- Total consumption
- Motor vehicle accidents declined significantly among teenagers and
1977
increased by 15%
middle-aged and older with medium beer removal
(removed)
Sweden
1967-68
(strong beer in
groceries)
- Sales of strong beer
increased
by
1124%
- Total consumption rose
by ~5%
Abolition of beer in grocery stores
Finland
- Slight decrease in
1975-77
volume
Norway
1972, 1975,
1981
- No significant
change in total
consumption
- Persons taken into custody for drunkenness: no clear effect, nor for
young people
- The young not affected
- In some municipalities the use of illegal and non-beverage alcohol
rose
- Shift from medium beer to other alcoholic beverages
- Same for youth
- Purchases of beer decreased particularly among women
20
Country
& period
Effects on total
consumption
Legalization of beer sales
Iceland
- Rise in total con1989
sumption of ~1520% when beer
introduced
- Effect dampened by
recession
Introduction of light beer
Norway
No effect on total
1985
consumption
Opening of new wine/ liquor stores
Finland 1951
Norway
1961, 1968,
1971, 1991
- No changes
Differential effects by demography, by drinking
patterns and on harms
- Increase in beer consumption more due to increase in quantity
drunk per occasion than increase in frequency
- Intoxication frequency decreased among men but not among women
- Biggest increase in consumption for men
- For men, net increase in mean consumption greater among heavier than
lighter drinkers.
- Big increase in consumption for boys (13-19 years old)
- Shift from spirits to beer
- No significant change in the number of abusers
- Increase in persons detained without having caused a disturbance
- Volume and frequency increased among men but not among
women or youth
- Frequency increased more among frequent drinkers; no effect on nondrinkers
- Older men (>50) and men in white collar jobs less affected
- Beer and wine replaced spirits and illicit beverages, especially among
boys and women
- No effect on quantities drunk per occasion
- Slight increase in consumption among women and elderly and in
intoxication among women
- Purchases: more often but less at a time
- Wine consumption increased and use of moonshine decreased
- No changes in consequences were observed
Introduction of self-service in monopoly stores
Sweden
- Increase in sales
1989
figures of 17%, ½
due to actual
increases in
purchases by
local residents
Saturday closing/opening
Finland
- A decrease in sales
- Arrests for drunkenness decreased on Saturdays, particularly among
1977, 1978
from monopoly
people aged 30+ years and among the homeless
stores and an
- Illegal sales increased; use of non-beverage alcohol did not
increase in retail
- No effects on monthly totals of harm rates
sales  a slight
total decrease
Norway
- Modest decrease in
- Purchases: less often but more at a time
1984
sales of spirits
- Detoxification centre: a significant decrease in admission on
Saturdays and Sundays, and a larger proportion of illegal and
non-beverage alcohol
- Decrease in police arrests for public drunkenness on Saturdays but
increase in the other days
21
Country
& period
Effects on total
consumption
Differential effects by demography, by drinking
patterns and on harms
Sweden
1981, 1982
- No change
Sweden 2000
- 3.4% increase with
Saturday opening
- Less public drunkenness
- More frequent customers most affected
- Purchases: less often but more at a time
- No change in emergency visits or injuries in traffic accidents
- Less domestic disturbances
- Increase in outdoor assaults
- Increases in assaults not significant except in northern Sweden.
- Significant increase in drinking-driving, but may reflect increased
policing
Longer serving hours
Iceland
1999
- 13% rise in Emergency Room admissions, including 24% for accidents,
34% for fights
- Increases in ER admissions limited to men
- 80% increase in drinking-driving cases, may reflect changes in policing
Introduction of age-of-purchase limit (15 for off-sales)
Denmark
- Drop of 36% in reported consumption by pupils aged under 15
1998
- Drop among pupils aged ~15-17 of 17%
- Discussion around new law sensitized parents to teenage drinking?
Alcohol store strikes
Finland
- Sales decreased by
- Few reported being affected
1972, 1985
one-third
- Men were affected more than women
- Frequent drinkers were affected more than infrequent drinkers
- Alcoholics’ consumption decreased
- Consumption of strong home brews and moonshine increased
- Young (<35) and white collar workers used alternative sources of
alcohol the most
- Use of non-beverage alcohol increased, especially in 1972
- Alcohol-related crimes decreased
- Arrests for drunkenness decreased by one-half; in 1972 more but 1985
less among socially integrated; more among men aged over 30
Norway
- Sales decreased by
- Increase in home production and smuggled spirits, especially
1978
one-fourth,
among heavy consumers
consumption by
- Women more affected
5-10%
- Number of patients in detoxification centres decreased
- Police reports on drunkenness and domestic disturbances decreased
- Decrease in accidents, especially falls and in low socioeconomic status
areas
Norway
- Spirits & wine sales
- 41% fall in detox centre admissions during strike
1982
for year down
- Violent crime rate down 9.2% in year of strike
(100-day strike)
~20%, total sales
- Arrests for disorderly conduct and for drinking-driving for year not
of alcohol down
significantly affected
10%
Sweden
- Moderate drinkers hardly affected
1963
- Alcoholics strongly affected
- Effects were similar among men and women
- Decrease in police interventions due to drunkenness; no differences
between age groups; area closest to Denmark least affected
- Decrease in accidents among both moderate and heavy drinkers
- Number of patients in alcohol clinics decreased
22