PREVENTING ALCOHOL PROBLEMS: POPULAR APPROACHES ARE
INEFFECTIVE, EFFECTIVE APPROACHES ARE POLITICALLY IMPOSSIBLE1
Robin Room
Centre for Social Research on Alcohol and Drugs
Stockholm University
In my presentation today I set out to answer a number of questions. The questions are
the following:
(1) Why do young people drink and get drunk?
(2) What are we trying to prevent with prevention programs in the alcohol field?
(3) What are the different strategies of prevention?
(4) What is the evidence of their effectiveness?
(5) What strategies are most politically popular, and how do they relate to those which
are most effective?
(6) What conclusions can we draw for future programs and initiatives?
Why do young people drink and get drunk?
First, why do young people drink? More importantly, from the point of view of harm,
why do young people get drunk? – because most of the problems related to young people’s
drinking are from intoxication, not just from taking a sip or one drink.
Though all of us were teenagers once, and thus know something about the experience
of being young, formal empirical knowledge about what impels children and teenagers to get
drunk, and what meaning it holds for them, is rather limited. The experience of intoxication
is eventually spread widely enough among teenagers that it has to be seen and interpreted not
only in pathological but also in normalizing terms -- as part of the process of growing up.
In this framing, adolescence is seen as a period of experimentation and identity
formation. Part of this developmental process includes seeking new sensations and taking at
least some risks, with a particular focus on behaviours which are supposed to be for adults
and thus serve as markers of adulthood. Thus adolescents learn about and experiment with
new behaviours as various as sexuality and driving an automobile, including experimenting
near or at the edge of the various dangers that may accompany these “adult” behaviours.
Motives for experimenting with drinking and intoxication -- as also with other psychoactive
substances -- vary. Motives which are commonly mentioned in the literature include
rebellion, sensation-seeking, providing pleasure, alleviating boredom, satisfying curiosity,
facilitating social bonding, attaining peer status, or as an escape/coping mechanism (Amos et
al., 1997; Arnett, 1992; Banwell & Young, 1993; Franzkowiak, 1987; Igra & Irwin, 1996;
Wilks, 1992). In terms of some of these motivations, drinking is thus a functional behaviour.
However, drinking is also a behaviour heavily weighted with symbolic significance.
Youthful drinking is often a performance in front of an audience of associates and others,
staking a claim to a valued identity, and expressing solidarity in a group or marking off social
boundaries (Room, 1994). Choices about drinking – which type of beverage and which brandname, as well as when and how much to drink --- are potent ways of identifying with a
cultural style (Polhemus, 1994), of marking a symbolic distinction from those who are outside
Presented at the 13th Alcohol Policy Conference, “Preventing Alcohol Problems among
Youth: Policy Approaches”, Boston, Mass., 13-16 March, 2003. This presentation is revised
from a paper with the same title, pp. 21-35 in: De geest uit de fles.... National congres over
een ontluikend alcoholmatigingsbeleid: Verslag. Woerden, Netherlands: NIGZ, 2001.
1
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the circle or “too young,” and of performing for an audience of other youth
The prevention literature pays too little attention to the collective and symbolic
aspects of drinking and intoxication. Drinking is predominantly done in groups, and is often
incidental to another social activity, such as dancing, clubbing, partying, or following a
particular style of music (Thornton, 1995). “Peer influence” is often more a matter of the
attraction of a particular social group for the teenager than it is a matter of pressure from
anyone specifically to drink or become intoxicated.
During the slow transition into adulthood, then, drinking at all and drinking to
intoxication can symbolize freedom and autonomy, providing youth with a seemingly adult
status (Jessor, 1992; Jessor & Jessor, 1977). Positive lifestyle advertisements and
sponsorships contribute to general favourable associations and expectancies (Wyllie et al.,
1998b). Messages about not drinking “until you are old enough” have a double edge,
reinforcing the status of drinking or smoking as claims on adult status. In the context of the
social acceptance of drinking among adults, youth see messages that they should behave
differently as hypocritical and, thus, are likely to reject them (D’Emidio-Caston & Brown,
1998).
Though it may be normative, youthful drinking nevertheless carries with it
considerable social, health and casualty problems. These may include a start on patterns
which lead later in life to alcohol dependence or to chronic physical and mental health
problems. But foremost among the problems are the relatively immediate consequences,
particularly, as we have noted, adverse consequences of intoxication. These include
substantial numbers of deaths and permanent disabilities among youth due to accidents or
violence related to drinking. In the WHO estimates of the global burden of disease and
disability, alcohol accounts for 3.9% of the years of life prematurely lost and 9.2% of the
burden of disability (years lived with disability) in developed countries (Ezzati et al., 2002).
Much of this devastation results from casualties among youth. Among those aged 15-29, an
estimated 12.8% of male deaths and 8.3% of female deaths in European established market
economies are attributable to alcohol (Rehm et al., 2001). Youthful intoxication thus often
leaves behind a trail of personal suffering and interpersonal and social problems.
What are we trying to prevent?
I turn now to the question, what are we trying to prevent? My primary argument is for
a focus on the immediate; in this the situation for alcohol differs from that for tobacco. While
the longer term must be kept in mind, there are several good reasons for putting the greatest
weight in youth alcohol problems prevention work on the more immediate potential harms.
First, preventing a proximal harm is inherently an easier task than preventing a distal harm.
Most commonly, the effects of any intervention decays over time: in the long run, there is just
too much “noise” from the intervening activities and events of everyday life. For instance, a
youth prevention program has a much better chance of preventing a tragedy from driving
home drunk after an upcoming high-school prom than it has of preventing a death from liver
cirrhosis in a 50-year-old. Secondly, a youth audience will be more open to prevention
messages about immediate problems in their lives than to messages about how to prevent
problems which may or may not occur when they are in their 60s (USDHHS, 1994). Thirdly,
more strategies are available for preventing harms related to the immediate drug use event or
pattern than are available for preventing long-term chronic conditions (Room, 1974). While
the main way of preventing liver cirrhosis is by affecting the person’s cumulative amount of
drinking, preventing a drinking-driving casualty can be accomplished not only by affecting
the driver’s drinking, but also by such means as providing an alternative driver or transport,
relocating the prom, or even by seat-belts and airbags.
My second argument concerns the issue of the target behaviour. A youth prevention
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program focussed on alcohol can aim to prevent or postpose drinking at all; to prevent or
postpone risky drinking such as intoxication; or to prevent or postpone harms from drinking
or intoxication. The aims of such programs are to a considerable degree conditioned by the
society’s expectations about youth drinking. If the legal drinking age is high, then it is likely
that programs aimed at youth in their early or middle teens will aim to prevent or postpone
drinking at all. Harm reduction strategies may run into political difficulty in this environment,
since they are predicated on a recognition that many youths are already drinking.
A difficulty with the literature evaluating the effectiveness of youth prevention
programs on alcohol issues is that much of it has been produced in exactly this societal
environment -- in the U.S., which has had a uniform minimum legal drinking age of 21 since
the mid-1980s. On the other hand, the average age of actually starting drinking in the U.S. is
about the same as in many other developed societies – the early teens. Much of the
evaluation literature available for reviewing thus evaluates programs which might be seen as
starting with a handicap, in assuming that the target audience is not already drinking. This
handicap must be kept in mind as we review the often negative tenor of findings from the
evaluation literature.
What are the different strategies, and what is the evidence on their effectiveness?
Let us now turn to strategies of alcohol prevention, and evidence on their
effectiveness. Simplifying somewhat, there are seven main strategies to minimize alcohol
problems. One strategy is to educate or persuade people not to use or about ways to use so as
to limit harm. A second strategy, a kind of negative persuasion, is to deter drinking-related
behaviour with the threat of penalties. A third strategy, operating in the positive direction, is
to provide alternatives to drinking or to drink-connected activities. A fourth strategy is in one
way or another to insulate the use from harm. A fifth strategy is to regulate availability of the
drug or the conditions of its use. Prohibition of supply may be regarded as a special case of
such regulation. A sixth strategy is to work with social or religious movements oriented to
reducing alcohol problems. And a seventh strategy is to treat or otherwise help people who
are in trouble with their drinking.
In recent decades, there have been efforts to form partnerships, often involving both
official agencies and grassroots groups to work on alcohol problems, at the level of the local
community. These community action projects typically use one or more of the strategies
outlined above and discussed below. In the present terms, then, community action is not
itself a strategy, but rather is a mode of working which uses one or more of the prevention
strategies. The tradition of evaluated community action projects (Giesbrecht et al., 1990;
Greenfield and Zimmerman, 1993; Holmila, 1997; Holder 1998) is able to show a modest
record of success, depending in part on the strategies adopted. Although the community often
wants the project oriented specifically to affecting patterns among youth, there is a good
argument, as discussed below, for embedding any youth program in a broader effort not
limited to youth.
We will consider in turn the seven strategies and the evidence on their effectiveness.
Education and persuasion
In principle, education can be offered in a variety of venues, but it is usually education
in schools which first comes to mind in the prevention of alcohol problems, particularly
among youth. Community-based prevention programs also may include an educational
component.
Education offers new information or ways of thinking about information, and leaves it
to the listener to draw conclusions concerning beliefs and behaviour. However, most alcohol
education programs go beyond this. A commonplace of the North American evaluative
literature on alcohol education is that “knowledge-only” approaches do not result in changes
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in behaviour (Botvin, 1995). School-based alcohol education has thus usually had a
persuasional element along with the information provision, aiming to influence students in a
particular direction.
Persuasion is directly concerned with changing beliefs or behaviours, and may or may
not also offer information. Mass-media campaigns aimed at persuasion have been a very
common component of prevention programs for alcohol-related problems, but persuasion can
be pursued also through other media and modalities. Most such campaigns are aimed at the
drinker, but some are aimed at those around or responding to the drinker. Prototypical
examples are campaigns with the theme, “friends don’t let friends drive drunk”.
In most societies, public-health-oriented persuasion about alcohol must compete with
a variety of other persuasional messages, including those intended to sell alcoholic beverages.
The evidence that alcohol advertising influences teenagers and young adults towards
increased drinking and problematic drinking is becoming stronger (Wyllie et al., 1998a;
1998b). Even where alcohol advertising is not allowed on the mass media, these messages
are conveyed to consumers and potential consumers in a variety of other ways.
Evidence on effectiveness As we have noted, the literature on effectiveness of
educational approaches is dominated by U.S. school-based studies. In general, despite the
best efforts of a generation of researchers, this literature has had difficulty showing
substantial and lasting effects (Paglia and Room, 1999). There is a good argument from
general principles for alcohol education in the context of consumer and health education, but
there is little evidence from the formal evaluation literature at this point of its effectiveness
beyond the short term.
Persuasional media campaigns have also been a favourite modality in many places in
recent decades for the prevention of alcohol problems. In general, evaluations of such
campaigns have been able to demonstrate impacts on knowledge and awareness about
alcohol, but can show only modest success in affecting attitudes and behaviours . As with
school education approaches, there are hints in the literature that success may come more
from influencing the community environment around the drinker -- in terms of attitudes of
significant others, or popular support for alcohol policy measures -- than from directly
persuading the drinker him/herself. Thus, media messages can be effective as agenda-setting
mechanisms in the community, increasing or sustaining public support for other preventive
strategies (Casswell et al., 1989).
There is now new experience to bring to bear here, though, from the state-financed
anti-smoking campaigns in California and in Florida. These have been very hard-hitting,
often directly attacking the tobacco industry, with message such as “the tobacco industry is
not in business for your health”. The government doing this offered an unusual spectacle, one
which apparently attracted the attention of teenagers; there have been noticeable affects on
teenage smoking rates, at least in the short term (Sly et al., 2001). But by the same token, the
campaigns have proved very difficult to sustain politically -- under pressure from the tobacco
industry, the Florida campaign’s teeth were pulled by the governor.
Deterrence
In its broadest sense, deterrence means simply the threat of negative sanctions or
incentives for behavior -- a form of negative persuasion. Criminal laws deter in two ways: by
general deterrence, which is the effect of the law in preventing a prohibited behavior in the
population as a whole, and specific deterrence, which is the effect of the law in discouraging
those who have been caught from doing it again (Ross, 1982). A law tends to have a greater
preventive effect and to be cheaper to administer to the extent it has a strong general
deterrence effect.
Prohibitions on driving after drinking more than a specified amount are now in effect
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in most nations (Hurst et al., 1997, pp. 555-556). In many societies, there have also been laws
against public drunkenness (being in a public place while intoxicated), and against obnoxious
behavior while intoxicated. Other common prohibitions are concerned with producing or
selling alcoholic beverages outside state-regulated channels, and with drinking and public and
other aspects of drinking under a specified minimum age.
Evidence on effectiveness Drinking-driving legislation, such as “per-se” laws
outlawing driving while at or above a defined blood-alcohol level, has been shown to be
effective in changing drivers’ behavior and reducing rates of alcohol-related problems (Ross,
1982; Edwards et al., 1994, pp. 153-159; Hingson, 1996). The effect is through both general
and specific deterrence. The quickness and certainty of punishment, as well as its severity,
are important in the deterrent value (too much severity tends to undercut its quickness and
certainty). Drinking-driving is an ideal area for applying general deterrence, since the gains
from breaking the law are limited, and automobile drivers typically have something to lose by
being caught. However, we are now approaching the limit of what can be accomplished with
general deterrence of drinking driving. Most of the countermeasures which our cultures will
allow has already been taken.
Many English-speaking and Scandinavian countries have had a tradition of
criminalizing drinking in public places or public drunkenness as such, but the trend has been
to decriminalize public drunkenness. Though there are few specific studies, criminalizing
public drunkenness may not be very effective in changing the behavior of those who have
little to lose. This principle may also apply to laws deterring aspects of youthful drinking,
although there is little in the alcohol literature on deterrence with teenage populations.
Deterrence works best on those with more to lose.
Providing and encouraging alternative activities
Another strategy, in principle involving positive incentives, is to provide and seek to
encourage activities which are an alternative to drinking or to activities closely associated
with drinking. This includes such initiatives as making soft drinks available as an alternative
to alcoholic beverages, providing locations for sociability as an alternative to taverns, and
providing and encouraging recreational activities as an alternative to leisure activities
involving drinking. Job-creation and skill development programs are other examples.
Providing alternative activities such as sports and recreational programs has been a
particularly common strategy with youth populations.
Evidence on effectiveness “Boredom” and “because there’s nothing else to do” are
certainly among the reasons that are quite often given for drinking. And there are often good
reasons of general social policy for providing and encouraging alternative activities. But
Klaus Mäkelä once noted, the problem with alternatives to drinking is that drinking combines
so well with so many of them. Soft drinks are indeed an alternative to alcoholic beverages
for quenching thirst, but they may also serve as a mixer in an alcoholic drink. Involvement in
sports may go along with drinking as well as replace it. Historically, there are some clear
substitutions, for instance of coffee for alcohol in the classic temperance era in Norway
(Skog, 1985). But in the modern era such effects are hard to find. The few evaluation
studies of providing alternative activities, again from a restricted range of societies, have
generally not shown lasting effects on drinking behavior (Moskowitz et al., 1983; Norman et
al., 1997), though they undoubtedly often serve a general social purpose in broadening
opportunities for the disadvantaged (Carmona and Stewart, 1996).
Insulating use from harm
A major social strategy for reducing alcohol-related problems in many societies has
been measures to separate the drinking, and particularly heavy drinking, from potential harm
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-- making the world safe for (and from) drunks, as it has sometimes been put. This
separation can be physical (in terms of distance or walls), it can be temporal, or it can be
cultural (e.g., defining the drinking occasion as "time out" from normal responsibilities).
These "harm reduction" strategies, as they are called in the context of illicit drugs, are often
built into cultural arrangements around drinking, but can also be the object of purposive
programs and policies (Moore and Gerstein, 1981, pp. 100-111 ).
A variety of modifications of the driving environment affect casualties associated with
drinking and driving, along with other casualties. These include mandatory use of seat belts,
airbags, and improvements in the safety of road vehicles and roads. Many other practical
measures to separate intoxication episodes from casualties and other adverse consequences
have been put into practice, though usually without formal evaluation.
Other harm-reduction projects have aimed to reduce potential casualties and other
harms associated with drinking in bars and nightclubs. Often these projects have been aimed
particularly at youth-oriented drinking places. Australian and Canadian community projects
have worked with bar and nightclub owners and staff to reform serving practices to reduce
rates of drinking-related violence (Graham and Homel, 1997; Hauritz et al., 1998; Wells et
al., 1998).
Harm reduction approaches can be politically sensitive, particularly when they are
aimed at underaged youth, since they involve accepting facts which are unwanted and not
admitted.
Evidence on effectiveness Drinking-driving countermeasures are a prime example of
an approach in terms of insulating drinking behavior from harm, since they seek to reduce
alcohol-related traffic casualties without necessarily stopping or reducing alcohol use (Evans,
1991). There is substantial evidence of the success of a range of such countermeasures,
including environmental change approaches as well as deterrence (Forsyth, 1996; Zajac,
1997). Some environmental measures which reduce road casualties in general -- e.g.,
requiring wearing of seat-belts in cars, providing sidewalks separated from the road -- may
prevent casualties associated with intoxication even more than other casualties.
The first results from the projects aiming at reducing alcohol-related violence in
youth-oriented bars have been positive (Hauritz et al, 1998; Graham et al, 2003). However,
the Australian experiences raise the question of how the early gains of such projects can be
continued and institutionalized. The server intervention training literature suggests that this is
effective only when backed up by enforcement and potential sanctions if servers ignore the
training.
Regulating the availability and conditions of use
In terms of the substantial harms to health and public order they can cause, alcoholic
beverages are not ordinary commodities. Governments have thus often actively intervened in
the markets for such beverages, far beyond usual levels of state intervention in markets for
commodities.
Total prohibition can be viewed as an extreme form of regulation of the market. In
this circumstance, where noone is licensed to sell alcohol, the state has no formal control over
the conditions of the sales which nevertheless occur, and there are no legal sales interests,
controlled through licensing, to cooperate with the state in the market's regulation.
With a general prohibition, typically the consumption of alcohol does fall in the
population, and there are declines also in the rates of the direct consequences of drinking such
as cirrhosis or alcohol-related mental disorders (e.g., Teasley, 1992; Moore and Gerstein,
1981). But prohibition also brings with it characteristic negative consequences, including the
emergence and growth of an illicit market, and the crime associated with this. Partly for this
reason, prohibition for adults is not now a live option in any developed society, although it is
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in some other societies. However, a minimum drinking age can be regarded as a form of
prohibition specifically for youth.
Alcohol controls are typically enforced through control or licensing of the sellers, not
of the drinkers. This makes them potentially relatively cheap and effective to implement.
The features of alcohol control regimes, regulating the legal market in alcohol, vary greatly.
Special taxes on alcohol are very common, imposed often as much for revenue as for public
health considerations. In addition to minimum age limits forbidding sales to underage
customers, many jurisdictions forbid sales to the already intoxicated. Often the regulations
include limiting the number of sales outlets, restricting hours and days of sale, and limiting
sales to special stores or drinking-places. Rationing of alcohol purchases -- limiting the
amount individuals can buy in a given time-period -- has also been used as a means of
regulating availability. Regulations restricting or forbidding advertising of alcoholic
beverages attempt to limit or channel efforts by private interests to increase demand for
particular alcoholic beverage products. Such regulations potentially complement education
and persuasion efforts. State monopolization of sales of some or all alcoholic beverages at
the retail and/or wholesale level has also been commonly been used as a mechanism to
minimize alcohol-related harm (Room, 1993).
The countries north of the Baltic Sea, of course, have had relatively strong alcohol
control systems for many years. But they exemplify how difficult it has become in the
present era to retain such a level of control. Difficulties exist at both ideological and practical
levels. The doctrine of consumer sovereignty -- the idea that we should be able to purchase
whatever we like, whenever we like, as long as we have money in our pocket -- is very
strong. Trade agreements and dispute resolution mechanisms limit the ability of nations and
localities to use alcohol control regulations. For instance, European Union rules have forced
Sweden to allow the advertising in print of at least beer and wine, and the French ban on
alcohol advertising and promotion in electronic media has also been under attack (Financial
Times, 2000). In the current round of World Trade Organization negotiations, the European
Union is asking the U.S. and Canada, among other nations, to remove market restrictions on
alcohol, threatening, for instance, the existence of government alcohol monopolies
(http://www.polarisinstitute.org/gats/main.html). Lower alcohol taxes elsewhere, especially
when combined with the very high personal allowances for travelers crossing borders within
the European Union, create pressures to reduce taxes. And as new private interests enter the
market, they become a political constituency for the “ratchet mechanism” (Mäkelä et al.,
1981) of market liberalizations.
The effectiveness of specific types of regulation of availability. The last 25 years
have seen the development of a burgeoning literature on the effects of alcohol control
measures. Specific types of regulation of the alcohol market, and the evidence on their
effectiveness, are discussed below.
Minimum age limits: As noted above, a minimum age limit is a partial
prohibition, applied to one segment of the population. There is a strong evaluation literature
showing the effectiveness of establishing and enforcing minimum-age limits in reducing
alcohol-related problems (Edwards et al., 1994, pp. 138-139). However, this literature is
North America-based, focuses mostly on youthful driving casualties, and mostly evaluates
reduction from and increases to age 21 as the limit, a higher minimum-age limit than in most
societies. The applicability of the literature’s findings in other societies and where youth
cultures are less automobile-focused has been little tested. However, a recent Danish study
shows some reduction in youth drinking when alcohol sales to those under 15 were forbidden,
although the pattern of results suggests this may have been attributable at least as much to the
public discussion around alcopops and the new minimum-age law, and the effects of these on
parents, as to the minimum-age law itself (Møller, 2002).
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Taxes and other price increases: Generally, consumers show some response to
the price of alcoholic beverages, as of all other commodities. If the price goes up, the drinker
will drink less; data from developed societies suggests this is at least as true of the heavy
drinker as of the occasional drinker (Edwards et al., 1994, pp. 118-119). Studies have found
that alcohol tax increases reduce the rates of traffic casualties, of cirrhosis mortality, and of
incidents of violence (Cook, 1981; Cook and Moore, 1993). American studies suggest that
alcohol taxes affect the behaviour of young drinkers more than that of older drinkers
(Grossman et al., 1995).
Limiting sales outlets, and hours and conditions of sale: There is a substantial
literature showing that levels and patterns of alcohol consumption, and rates of alcoholrelated casualties and other problems, are influenced by such sales restrictions, which
typically make the purchase of alcoholic beverages slightly inconvenient, or influence the
setting of and after drinking (Edwards et al., 1994, pp. 125-142). Enforced rules influencing
“house policies” in drinking places on not serving intoxicated customers, etc., have also been
shown to have some effect (Saltz, 1997).
Monopolizing production or sale: Studies of the effects of privatizing retail
alcohol monopolies have often shown some increase in levels of alcohol consumption and
problems, in part because the number of outlets and hours of sale typically increase with
privatization (Her et al., 1999). From a public health perspective, it is the retail level which is
important, while monopolization of the production or wholesale level may facilitate revenue
collection and effective control of the market.
Rationing sales: Rationing the amount of alcohol sold to an individual
potentially directly impacts on heavy drinkers, and has been shown to reduce levels both of
intoxication-related problems such as violence, and of drinking-history-related problems such
as cirrhosis mortality (Schechter, 1986; Norström, 1987). But while a form of rationing -- the
medical prescription system -- is well accepted in most societies for psychoactive
medications, it has proved politically unacceptable nowadays for alcoholic beverages in
developed societies.
Advertising and promotion restrictions: Many societies have regulations on
advertising and other promotion of sales of alcoholic beverages (Hurst et al., 1997, pp. 552554). While it is well accepted that advertising can strongly affect consumer choices between
products on the market, it has proved difficult to measure the effects of advertising on
demand for alcoholic beverages as a whole, in part because the effects are likely to be
cumulative and long-term, making them difficult to measure. However, the evidence on the
effects of advertising and promotion on consumer behaviour has become stronger in the
recent literature (Hill & Casswell, 2001).
Allying with social and religious movements
Substantial reductions in alcohol-related problems have often been the result of
spontaneous social and religious movements which put a major emphasis on quitting
intoxication or drinking.
While some of the biggest historical reductions in alcohol problems rates have
resulted from spontaneous and autonomous social or religious movements, support or
collaboration from a government can easily be perceived as official cooptation or
manipulation (Room, 1997). Thus there is considerable question about the extent to which
such movements can or should become an instrument of government prevention policies.
Evidence on effectiveness: In the short term, movements of religious or cultural
revival can be highly effective in reducing levels of drinking and of alcohol-related problems.
Alcohol consumption in the U.S. fell by about one-half in the first flush of temperance
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enthusiasm in 1830-1845 (Moore and Gerstein, 1981, p. 35). Rates of serious crime are
reported to have fallen for a while to a fraction of their previous level in Ireland in the wake
of Father Mathew’s temperance crusade (Room, 1983). The enthusiasm which sustains such
movements tends to decay over time, though they often leave behind new customs and
institutions with much longer duration. For instance, though the days when the historic
temperance movement in English-speaking societies was strong are long gone, the movement
had the long-lasting effect of largely removing drinking from the workplace in these societies.
Treatment and other help
Providing effective treatment or other help for these drinkers who find they cannot
control their drinking can be regarded as an obligation of a just and humane society. The help
can take several forms: a specific treatment system for alcohol problems, professional help in
general health or welfare systems, or non-professional assistance in mutual-help movements.
To the extent such help is effective, it is also a means of preventing or reducing future
alcohol-related problems.
Treatments for alcohol problems need not be complex or expensive. The evaluation
literature suggests that brief outpatient interventions aimed at changing cognitions and
behavior around drinking are as effective in most circumstances as longer and more intensive
treatment (Finney and Monahan, 1996, Long et al., 1998). Positive results from such
interventions in a primary health care settings were shown in a WHO study including a
number of countries (Babor and Grant, 1994).
Evidence on effectiveness In terms of the effects of treatment on those who come for
it, there is good evidence of effectiveness of treatment for alcohol problem. Typically, the
improvement rate from a single episode of treatment is about 20% higher than the notreatment condition. Further treatment episodes are often needed. Drinking-driver
remediation programs, a form of compulsory treatment, also show modest effects -- about 89% less recidivism (Wells-Parker et al., 1995). Brief treatment interventions or mutual-help
approaches usually result in net savings in social and health costs associated with the heavy
drinker (at least where health care is not self-paid), as well as improving the quality of life
(Holder et al., 1992; Holder and Cunningham, 1992).
The effectiveness of providing treatment as a strategy for reducing rates of alcohol
problems in a society is more equivocal. In a North American context, it has been argued that
the steep increase in alcohol problems treatment provision and mutual-help group
membership in recent decades has contributed to reducing alcohol problems rates (Smart and
Mann, 1990). But the strength of the evidence for this contention is disputed (Holder, 1997;
Smart and Mann, 1997). A treatment system for alcohol problems is an important part of an
integrated national alcohol policy, but as an instrument of prevention -- of reducing societal
rates of alcohol problems -- it is probably not cost-effective.
In these discussions and analyses, relatively little attention has been paid to the
effectiveness of treatment for youth populations.
The political popularity vs. the effectiveness of the strategies
If we compile a list of the approaches which are most popular with the general public
and with politicians, and a list of the approaches for which there is the greatest evidence of
effectiveness, we can see that there is a problem. The most popular approaches include
education – particularly education of schoolchildren; providing alternatives to drinking; and
providing treatment. In limited areas, such as drinking-driving, deterrence is also popular.
The list of the most effective approaches, on the other hand, includes taxes and
regulating availability, harm reduction approaches that insulate use from harm, and also
deterrence – the only strategy which appears on both lists. But, in terms of new initiatives
9
beyond what is already in place, it is doubtful that direct deterrence of the drinker can be
pushed much farther with popular support.
We may well ask, why is there such a lack of correspondence between what is popular
and what is effective? One simple answer, of course, is that effective strategies are opposed
because they will hurt economic interests. The alcoholic beverage industry has learned that it
can live quite comfortably with school education. Some educational messages, indeed, may
even help its interests. “Drinking is an activity for grown-ups, so don’t do it until you are an
adult”, for instance, cements in the symbolic meaning of drinking as a claim for adult status.
But the lack of correspondence is not only a matter of pressure from economic
interests. As we have already mentioned for controls on availability, strategies which are
effective but unused are often unused because they conflict with competing values and
ideologies. Most of all, the answer to the puzzle often lies in the fact that, in a given society,
the effective strategies which are easily acceptable in the culture are already in place, so that
further steps will push at the boundaries of cultural acceptance. This does not mean that the
further steps are impossible, but it does mean that inherently they will be more difficult for
the political process to take.
Conclusions
Now, to draw some conclusions and recommendations.
1. The main goal of any alcohol prevention program for youth should be to reduce
levels of alcohol-related harm, both to the drinker and to others. The means to this end may
be preventing drinking altogether, or limiting or shaping it, or buffering the drinking from
harm. Whatever means the program adopts, the program should be designed on the basis of
an assessment of the dimensions of alcohol-related harm (taking into account delayed harm)
in the target population, and measurement of changes in alcohol-related harm should be
included in the evaluation.
2. There are few examples, indeed, of school-based alcohol education programs with
substantial and lasting effects. But whatever the evaluation literature may conclude, schoolbased alcohol education will continue. In this circumstance, alcohol education curricula
might well be based on general educational principles, rather than framed by ideology.
Students are citizens and potential future consumers, and with respect to these roles it is
appropriate to provide them with biological and social science information about alcohol use
and problems, and to encourage discussion of the intellectual, practical and ethical issues
these problems raise.
3. Educational and persuasion material should be matched to its target audience. In
particular, information aimed at limiting harm from drinking is usually most appropriately
targeted at youth who are already drinking. On the other hand, education and persuasion
campaigns need to be sensitive to the surrounding environment of messages. In the case of
mass media, this environment includes public health messages to adults, program or editorial
content, and advertising and other promotions from alcohol marketers.
Studies have shown that children are attentive to alcohol advertisements, for instance,
and a fair proportion see them as a source of information on real life (Wyllie et al., 1998b).
Product marketing is often attractive to children; a marketing study in the U.S. found that beer
commercials featuring frogs and other animals ranked first among all ads when children were
asked to name their favourite TV ads (Hays, 1998).
4. Though the material on them lies largely outside the formal evaluation literature,
there have been major social movements and shifts in popular sentiment which have greatly
affected rates and patterns of alcohol use and problems. These shifts among adults are
usually reflected in changing rates and patterns among youth. Programs to prevent youthful
alcohol problems are well advised to try to hitch their approach and framing of the issues to
10
current trends among adults and in youth cultures. Put another way, it is extraordinarily
difficult for a demonstration program to achieve change in the opposite direction to prevailing
trends in the population.
5. Regulatory approaches to the alcohol market have shown considerable success in
limiting and shaping youthful drinking. In this circumstance, regulatory authorities can
efficiently enforce limits on youth access as a condition of licences to sell. However, the
success of such regulatory approaches is dependent on a popular consensus supporting them.
Maintaining this consensus may require efforts at public persuasion.
Saltz et al. (1995) note that policy and other environmental approaches to prevention
enjoy some natural advantages. Such approaches are not dependent on persuading
individuals; and their effects may not decay over time. Moreover, policies work directly and
indirectly by reflecting social norms and reflecting what is and is not acceptable. The
positive impact of policies on alcohol consumption as well as subsequent harm is supported
by consistent scientific evidence (Edwards et al., 1994).
6. Community action and other initiatives which combine policy and environmental
measures with educational or persuasional approaches seem more likely to succeed than
initiatives taking only one of the approaches. However, evidence is still lacking of lasting
effects from such combined community approaches.
7. There is a substantial need for well-evaluated trials of approaches which
acknowledge the reality of youthful drinking and intoxication, and either attempt to shape the
use so as to minimize the risk of harm, or attempt to shape the social and physical
environment of use to insulate the use from harm. There will often be a need for an
accompanying campaign to explain to adults the rationale for these harm reduction initiatives.
8. Evaluated prevention demonstration projects are inherently difficult to mount
successfully, requiring staff with different orientations and skills to work together. For many
interventions, a true experiment is impossible or unethical. There is a need to take maximum
advantage of “natural experiments” and other quasi-experimental designs if we are to reach
an adequate knowledge base across the whole range of preventive interventions. If
preventive interventions are to perform well in a cost-effectiveness analysis, they must set
realistic goals and give attention to containing the costs of the intervention.
9. The harms associated with drinking, for young people as for adults, are very
substantial. The harms are not only to the drinker but also to others. This means that, while
drinking brings pleasure to many, and although alcohol is deeply entrenched in most Western
cultures and subcultures, alcohol is not an ordinary commodity, to be treated in the same way
as cornflakes or orange juice. In particular, local, state and national governments should be
free to impose restrictions on the market to limit the harms from drinking, despite how this
may impinge on free trade. The public health interest needs to be represented and taken into
account whenever alcohol is involved in international trade agreements and disputes.
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