Drinking in Context

Patterns, Interventions, and Partnerships

Gerry Stimson, Marcus Grant, Marie Choquet, Preston Garrison, Gerry Stimson, Marcus Grant, Marie Choquet, Preston Garrison

• Publisher: Routledge
• Year: 2013
• Print ISBN: 9781138967977
• eBook ISBN: 9781135918903
• Topic: Psicologia
• Subtopic: Dipendenze in psicologia

Drinking beverage alcohol is a widespread source of individual and social pleasure in most countries around the world. Yet, some drinking patterns can lead to serious physical, mental, and social harms. Drinking in Context is intended to complement existing volumes dealing with international alcohol policy by focusing on three main themes: drinking patterns, targeted interventions, and partnership development.

An understanding that patterns of drinking are important predictors of outcomes has led to a growing realization that alcohol policies and prevention strategies need to focus on excessive or irresponsible drinking. As a result, there has been a shift towards interventions that address the targeted reduction of harm. These approaches recognize socio-cultural differences and avoid trying to impose a one-size-fits-all solution. In this context, multi-stakeholder partnerships offer an excellent opportunity to promote the complex mix of measures required by each society. Shared responsibilities lead to shared solutions.

1
New Solutions to
Changing Problems

At the start of its Constitution, the World Health Organization (WHO; 2004d) defines health as “a state of complete physical, mental, and social wellbeing.” This focus on the positive attributes of health as a resource for living, rather than on the presence or absence of disease and infirmity, has profound implications for health planning and for social policy generally. Although the definition distinguishes between physical, mental, and social wellbeing, it does not suggest that any one of these is preeminent. Thus, in considering any public policy related to health, its implications need to be assessed in all three of these domains.

Generally, the global trend has been toward embracing this broad definition of health. Although sudden outbreaks of infectious diseases, such as of severe acute respiratory syndrome (SARS) epidemic in 2002–2003, may temporarily focus attention upon immediate concerns for physical health, most significant health priorities of modern times are not treated as merely physical diseases. Cultural contexts and lifestyle issues are at the center of programs to prevent heart disease, the world's biggest killer, and underpin efforts to promote immunization programs. Initiatives to prevent accidents and injuries involve multi-stakeholder partnerships; and working to prevent the spread of HIV/AIDS requires the commitment of the whole of society.

The same is true of alcohol policy. Drinking beverage alcohol is a widespread source of individual and social pleasure in most countries around the world. Yet, some drinking patterns can lead to serious physical, mental, and social harms. Although the health sector has an important role in preventing these harms and providing treatment services, finding the most appropriate place for alcohol in society is a collective responsibility involving all sectors, both public and private.

DRINKING PROBLEMS IN A
CHANGING SOCIAL CONTEXT

Although moderate or low alcohol consumption has been linked with clear health benefits (see, for example, National Institute on Alcohol Abuse and Alcoholism, 2003; Zakhari, 1997), certain drinking patterns are associated with a range of physical and social harms. These include both chronic health consequences (such as toxic effects on liver, heart, and other organs) and acute outcomes (such as traffic crashes, injuries, and alcohol poisoning). Clearly, the negative effects of harmful drinking are not confined to individual consumers but may have serious social impacts, affecting family and community functioning, public order, and economic productivity (for example, Blanchard & Kopp, 2001; Gmel & Rehm, 2003; Klingemann & Gmel, 2001).

Drinking patterns (described in greater detail in Chapter 2)—or how people drink and the social context in which they drink—are powerful predictors of drinking outcomes, whether positive or negative, and are influenced by culture. Culture, meanwhile, is hardly static. Globalization, urbanization, and other socioeconomic processes are transforming local conditions across borders and challenging traditional norms of behavior. The cultural context of drinking profoundly influences both problems and responses.

The prevalence of alcohol problems is changing globally, with increases in some areas and decreases in others. The 2004 Global Status Report on Alcohol published by WHO concluded that “globally, alcohol problems exert an enormous toll on the lives and communities of many nations” (WHO, 2004b, p. 67). According to recent research (Rehm et al., 2003; WHO, 2004b), the total national disease burden attributable to alcohol abuse is the highest in the transition economies of the former Soviet bloc, where heavy chronic and episodic drinking remains dangerously prevalent, followed by the established markets in Northern America, Europe, and the Western Pacific. WHO has also identified persistent and rising trends of detrimental drinking patterns in the populous developing countries of Asia, Latin America, and Africa, where means to address concomitant problems are limited, as well as among certain population groups internationally, especially the world's young people.

Although the international scope of the above data may obscure the diversity within each geographical grouping, these findings are in accord with recent country-level and regional work (for example, Connor, Broad, Rehm, Vander Hoorn, & Jackson, 2004; Grant, 1998; Hao, Chen, & Su, 2005; Norström, 2002; Parry, 2000; Parry et al., 2005; Saxena, 1997; U.S. Department of Health and Human Services, 2000). It must be noted, however, that the majority of available epidemiological studies originate in developed countries. Data from developing markets remain limited and inconsistent. Overall, the prevalence of alcoholrelated problems internationally is changing, especially in regions with high levels of urbanization and growing disposable incomes (in developing countries) and among young people and women (in both developing and developed countries).

For example, increased urbanization in parts of Africa, Asia, and Latin America n the past several decades has diminished the influence of many traditional constraints on drinking behavior. In both urban and rural areas of the developing world, weakening or changing social controls allow for increased consumption within traditionally low-drinking or abstaining populations, such as young people and women.

Although the overall volume of drinking in emerging economies remains lower than in the developed countries, the prevalence of problem drinking is rising (Jernigan, 2001; Parry, 2000; Rehm, Greenfield, & Rogers, 2001; Riley & Marshall, 1999; Room et al., 2002; Saxena, 1997). The magnitude of resultant negative outcomes is hard to estimate. However, it is likely that they are growing in many countries, including China and India, the world's two most populous states (Benegal, 2005; Cochrane, Chen, Conigrave, & Hao, 2003; Hao et al., 2005; Isaac, 1998; Yucun & Zuxin, 1998). In China, for example, rates of alcohol-related chronic diseases and alcohol dependence have been increasing since the 1980s, particularly among the country's minority and urban communities. Epidemiological studies on the causes and scope of the country's alcohol-related problems, however, remain limited (Cochrane et al., 2003; Hao et al., 2005; Yucun & Zuxin, 1998).

Among the lower socioeconomic strata in poverty-stricken areas, excessive drinking may have substantial detrimental effects on productivity and thus on already meager family incomes. In many African countries, heavy alcohol consumption among such populations contributes to a variety of additional concerns, including domestic violence, an association between some excessive drinking patterns and the spread of HIV/AIDS, and health problems from counterfeit or low-quality alcohol (Haworth & Acuda, 1998; Haworth & Simpson, 2004; Riley & Marshall, 1999). Although the exact scale of these problems is unknown, it is reasonable to predict that they will worsen with further economic development and in the absence of adequate responses (for example, Room et al., 2002; WHO, 2004b).

Although endowed with more resources, developed countries face their own evolving set of challenges. As a result of growing gender equality, alcohol consumption among women is on the rise. Whereas the prevalence of alcohol-related problems among women and girls remains lower than among their male counterparts worldwide, this gender disparity is shrinking in many established economies, especially among the younger generations (for example, Bloomfield et al., 1999; Currie et al., 2004; Hibell et al., 2004; McPherson, Casswell, & Pledger, 2004). In some countries, such as Japan, this is a new cultural phenomenon that demands adjustments to established approaches to alcohol problems and prevention efforts (Higuchi, Suzuki, Matsushita, & Osaki, 2004; Suzuki et al., 2003).

As in developing countries, heavy episodic drinking among young people is a pressing concern. The negative consequences of youthful drinking are particularly evident in the statistics of acute health and social outcomes, such as traffic crashes, public disorder, and alcohol poisoning (for example, Brown & Tapert, 2004; Engels & Knibbe, 2000; Jernigan, 2001).

A number of large-scale studies in the United States and Europe have traced the status of and changes in this group's drinking behavior. In the United States, the overall consumption rates among high school and college-age youths remained fairly constant in the past 5 to 10 years (Johnston, O'Malley, Bachman, & Schulenberg, 2005; Substance Abuse and Mental Health Services Administration, 2004). The European data, meanwhile, exhibit broad cultural differences among young people in various countries and are a testament to the link between drinking patterns and drinking outcomes. According to the European School Survey Project on Alcohol and Other Drugs (ESPAD) (Hibell et al., 2004), alcohol-related problems among youths are the highest in areas where consumption is traditionally irregular but where drinkers often engage in episodes of excessive intake (for example, in northern European countries). Nevertheless, a trend toward harmonization of drinking habits is discernable among European youths (Currie et al., 2004; Hibell et al., 2004).

In broad terms, therefore, changing social conditions in both developing and developed countries are creating situations in which it is possible that alcohol problems could increase if appropriate public policies are not introduced. Given the range of problems and contexts, it is clear that there is no single solution, or even any fixed combination of solutions, that will be universally applicable. One size does not fit all.

MOVING BEYOND THE OLD SOLUTIONS

Because the world is changing and the place of drinking in society is being redefined, the old solutions to alcohol problems may no longer be adequate. In the past, much of the concern regarding alcohol was channeled through civil society, such as temperance movement organizations in Scandinavia and North America, where the focus was on public disorder. This perspective dominated much of the nineteenth century and the beginning of the twentieth century, leading, for example, to the introduction of Prohibition in the United States (Musto, 1997; Thornton, 1991). In the latter part of the twentieth century, the public health community became increasingly active in debates on alcohol policy, with a strong focus on the prevention of physical diseases and injuries attributable to excessive drinking. Most recently, as global concern about “binge” drinking by young people has grown, there has been a reemergence of attention to issues of social disorder.

There are important lessons to be learned from the efforts of the temperance movement and from the scientific work of the public health community. It is clear, however, that today's changing world of alcohol problems requires a balance between the freedom of individuals to drink and the need to protect those most at risk of harm. Because drinking beverage alcohol is deeply integrated into the values, cultures, and economies of so many societies, an adequate response is bound to reflect the diversity and complexity of these different contexts.

Thus, for example, a range of government departments—including trade, finance, agriculture, and education, as well as health—needs to be engaged, together with nongovernmental organizations representing a wide variety of civil society concerns. Equally, scientists and scholars from many different disciplines have insights to offer, as do professional associations. The private sector, including those involved in the production and distribution of beverage alcohol, also have important contributions to make to the process by which societies determine how best to arrange their priorities with respect to alcohol. And, of course, consumers (as well as those who choose not to consume) need to have a voice in this exchange of views. All have valid perspectives, even though some of them may not be easilycompatible with each other. The challenge is to manage the collective responsibility so that the best interests of society as a whole are served.

The process of developing a new generation of alcohol policies is not based on a goal to achieve spurious consensus among parties with legitimate differences, but rather to promote full transparency in policy development, so that none of these differences is ignored. No one has a monopoly on alcohol policy. It is through partnerships, discussed in Chapters 9 and 10, that society can bring together the positive efforts by stakeholders who are not necessarily accustomed to working together, but who have much to teach each other. Such collective and complementary work can achieve much to advance public health.

Although the ongoing public debate about alcohol policy worldwide can leave the impression that population-level activities are at odds with more focused interventions, experience from other fields tells us that a combination of such initiatives can yield more positive results than a single approach. Indeed, public policy in a variety of arenas has evolved as a result of a continuum of activities from policy measures that address society at large to interventions more focused on practical solutions to emerging issues.

For instance, in the arena of environmental policy, much progress has been made over the past several decades as a result of a combination of special interest activism, government regulation, and collective industry action. Operating from a logical premise that pollution can be prevented, environmental groups across the globe have made steady progress in recent decades in establishing what has been described as the new “social ethos” that emphasizes the importance of protecting, conserving, and recycling natural resources.

This larger phenomenon of “green” mandates, both from governments and from the public at large, has been furthered both by public advocacy and by strident cleanup and cost recovery initiatives. The combination of this kind of collective responsibility—sometimes stimulated by governments, sometimes by consumers, and sometimes by the private sector—with steadfast pollution prevention campaigns has reinforced a new “green” social and consumer consciousness. Indeed, businesses around the globe now promote their environmentally conscious products and practices in marketing campaigns and coalesce in industry groups focused on responsible environmental practices and regulatory progress.

Another case in point is the public health issue of obesity and a range of related life-threatening medical conditions. Over the past several years, books such as Fast Food Nation (Schlosser, 2001) and documentaries such as Super Size Me (Spurlock, 2004) have drawn global media attention to links between diet and health—and, more specifically, to obesity-related risk factors su...

Table of contents

• Cover
• Half Title
• Full Title
• Copyright
• Dedication
• Contents
• List of Contributing Authors
• Foreword
• 1 New Solutions to Changing Problems
• 2 Patterns of Drinking and Their Outcomes
• 3 Selecting the Right Interventions: The Need for Assessment
• 4 Opportunities for Targeted and Tailored Interventions
• 5 Targeting Behavior: Alcohol-impaired Driving
• 6 Targeting Drinking Contexts: Public Disorder
• 7 Targeting Groups: Young People
• 8 Feasible Interventions for Minimizing Harm
• 9 Key Players and Partnerships
• 10 Finding Common Ground: Conflict of Interest or Interest in Partnership?
• Conclusions
• Afterword
• Annex
• Index