Substance Use & Misuse, Early Online:1–7, 2014 C 2014 Informa Healthcare USA, Inc. Copyright ISSN: 1082-6084 print / 1532-2491 online DOI: 10.3109/10826084.2014.913438
ORIGINAL ARTICLE
Contextual Factors and Alcohol Consumption Control Policy Measures: The AMPHORA Study Background Fabio Voller and Allaman Allamani Subst Use Misuse Downloaded from informahealthcare.com by University of Maastricht on 06/30/14 For personal use only.
Regional Health Agency, Region of Tuscany, Florence, Italy Drinking alcoholic beverages is rooted in European history. Alcoholic beverages have and continue to have a range of functions for both individuals as well as systems. In some cultures the prevailing function of drinking is its use as an intoxicant, or mood-changer or enhancer. In other cultures the value of an alcoholic beverage (mainly wine) is in its connection with meals. Patterns of alcohol consumption in Europe have continued to change starting from the 1960s, some years after the end of World War II (World Health Organization, 2011). Examples are a general increase in consumption in the Northern countries and a decrease in drinking (particularly wine) in the Mediterranean countries. Eastern and Central Europe have manifested an intermediate consumption pattern. Regarding the prevalence of types of beverages, Finland and Poland changed from being spirit drinking countries to becoming beer drinking countries, Spain turned from wine to beer, France and Italy’s drinkers proportionally drank less wine, while Sweden’s drinkers drank more wine. Alcohol is commonly recognized as being one of the most important health determinants in Europe, resulting in numerous health and social consequences.1 Two classic indicators of chronic and acute harmful health consequences of drinking are, respectively, mortality from alcohol drinking-related chronic liver disease and liver cirrhosis, and the number of persons harmed or killed in transport injuries (see Edwards et al., 1994). Here too, important changes have occurred. For example, World Health Organization (WHO) data show that the traditional North–South gradient—Southern European countries having up to 5–6 times higher cirrhosis mortality than Northern countries in the 1970s and earlier (Ramstedt, 2002; World Health Organization, 2011)—has become weaker over time.
Drinking alcoholic beverages is deeply rooted in European cultural and economic history, and European consumption trends have varied over time during the decades following WW II. How and why such consumption patterns have changed, and what are the roles that societies’ transformations play in these changes are the AMPHORA project’s focus. Preventive alcohol consumption control policies have been developed for a long time; during different eras, in different ways and in different countries. How have and do formal policies affect such changes? These questions stimulated a group of 40 researchers from 12 European countries and 14 institutions to investigate the interactions between selected socio-demographic and economic factors, alcohol control policy measures, alcohol consumption and alcohol consumption-related harm that occurred in 12 European countries between 1960 and 2008. Keywords Europe, preventive alcohol consumption control policies, socio-demographic and economic factors, AMPHORA project
INTRODUCTION
Europe is a complex geographical, historical, cultural, political, religious and economical entity endowed with differences and similarities. Europe has a long history of diverse traditions and meanings concerning drinking cultures, alcohol consumption-related harms and prevention policies. It is the heaviest alcoholic beverage drinking region in the world with a broad range of types of drinkers. (see Anderson & Baumberg, 2005; Room, 1992; Heath, 1995; Heather 2006; Olsson, Olafsdottir, & Room, 2002; ¨ Osterberg & Karlsson, 2002; Rehm et al., 2003; Plant & Plant, 2006; Room & M¨akel¨a, 2000).
Address correspondence to Fabio Voller, Agenzia regionale di sanit`a della Toscana Osservatorio di epidemiologia – Dirigente Via Dazzi 1 Firenze, 50141, Italy; E-mail: [email protected] 1 The reader is referred to Hills’s criteria for causation would be helpful. These were developed in order to help assist researchers and clinicians determine if risk factors were causes of a particular disease or outcomes or merely associated. (Hill, A. B. (1965). The environment and disease: associations or causation? Proceedings of the Royal Society of Medicine 58: 295–300.). Editor’s note
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Responses to Alcohol Consumption Control Policies in Europe: A Composite Picture
Numerous preventive alcohol control policies, which have been developed in response to alcohol consumptionrelated problems, have been associated with effectiveness as well as cost-effectiveness (Anderson, 2009; Anderson, Møller, & Galea, 2012). The scientific generalizable evidence comes only from studies carried out in Nordic and English speaking countries. Some observations however, especially those coming from Southern Europe, stress the importance that other factors may have in changing the drinker’s consumption and patterns of drinking. A further problem that may interfere with the promulgation of control policies, and their effectiveness, is that alcohol consumption control policies make sense in cultures where people address alcohol consumption and its actual and potential short term as well as longer term consequences as being a social and health problem, while they are understood less in societies where alcohol and its use and misuse receives little or less public attention (Room, 1999). Government measures in these latter societies sometimes appear to be more popular, more symbolic than being responsive to the real needs of the population. Finally, the enforcement of measures and their interplay with informal control may vary greatly according to nations and cultures, making it difficult to compare the effects of similar interventions in different areas ¨ (Osterberg & Karlsson, 2002) as well as during different times in the same area. For example, it is well known that the level of law enforcement in Mediterranean countries is lower than in Scandinavian countries. This might contribute to explaining the transnational variation in the relation between alcohol consumption control policies and alcoholic beverage consumption changes. The levels and qualities of “law abindingness” of both individuals as well as systems is yet another potentially relevant factor which merits study and which, to date, has not been sufficiently considered as influencing a policy’s effectiveness. Alcohol consumption control policy has an old Nordic tradition (Olsson et al., 2002). During the last century, the traditional policies of Nordic countries, as well as of Britain and of Ireland, were based on restriction strategies like high taxes, age limits, regulations of advertising and licensing, and (for the Nordic countries) compre¨ hensive state alcohol off-premise monopoly (Osterberg & Karlsson, 2002). Notwithstanding these official restraints, a general increase in consumption of alcoholic beverages has been observed in these countries since the 1960s. A contribution to this increase has often been attributed to the dismantling of the traditional alcoholic beverage control system, after entering the European Union in the 1990s (Holder et al., 1998; Norstr¨om, 2002; Sulkunen, Sutton, Tigerstedt, & Warpenius, 2000; Room, 2002; Room, Babor, & Rehm, 2005)—even if doubts have been raised by some (Holder, 2000). In addition, the remarkable increase in British alcoholic beverage consumption could be ascribed to a more liberal attitude of governments since the 1960s (Plant & Plant, 2006).
Regarding the Eastern countries of Europe, like Hungary and Poland, where alcohol consumption reached a peak by the end of the 1970s (World Health Organization, 2011), preventive measures might have reduced the increase in alcohol consumption during the following decade, preceding the transition towards a market economy (Moskalewicz & Simpura, 2000). The new trend towards liberalization that started in the 1990s may have contributed to reversing this decrease. Among Southern European countries, formal restrictions regarding alcoholic beverages consumption were less numerous, and were endorsed and introduced more recently than in the North. They have hardly been or have only partially been enforced, reflecting the weak position of their governments on this issue (Norstr¨om, 2002). Nonetheless, starting from the 1950s in France, and the 1970s in Italy and Spain, alcohol consumption decreased unexpectedly and dramatically; a decrease due to a heavy drop in wine consumption (World Health Organization, 2011). This decreasing drinking trend, initially, together with the peculiar Southern European drinking pattern, was described by researchers with colorful expressions like “impossible dream” (Room 1992) or “Mediterranean Mysteries” (Simpura, 1998). However two studies, one in France and one in Italy (Sulkunen, 1989; Allamani & Prina 2007), concluded that some of the relevant determinants were usefully catagorizable as unplanned policy measures. For unplanned policy measures we mean targeted, measurable social, demographic and economic factors that are not planned by governmental health authorities (see AMPHORA, 2013) These factors were in fact able to explain the decrease of wine consumption that preventive alcoholic beverage control policies could not, as the latter were not present between at least 1960s–1970s. These determinants are: urbanization, industrialization, population structure, changes in the choice of food items, female employment and education, family organization and the role of alcoholic beverages with meals at home, and health awareness. In general, in order to explain the changes in the consumption of alcoholic beverages, different authors have proposed factors other than alcohol control policies, including: demography, international trade and markets, modernization and globalization, health awareness and urbanization, industrialization, in-country migration, changes in the family structure, decline in religiosity, the weakening of traditional ways of drinking, the desire of groups to distinguish themselves by adopting ‘new’ drinking habits, and big socio-political events2 (see Alexander, 2
This relatively new term, introduced into the intervention literature, This relatively new term, introduced into the intervention literature by Friedman et al. (Samuel R. Friedman, Diana Rossi, Peter L. Flom. (2006). “Big events” and networks: Thoughts on what could be going on. Connections 27(1): 9–14.) refers to major events such as mega—disasters, natural, as well as man-made, famine, conflict, genocide, disparities in health, epidemics, mass migrations, economic recessions, etc. which effect adaptation, functioning and quality-of-life of individuals as well as systems. Existential threat, instability and chaos
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THE AMPHORA STUDY BACKGROUND
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2008; Gual & Colom 1997; Hupkens, Knibbe, & Drop, 1993; Knibbe, Drop, & Hupkens, 1996; Michalak, Trocki, & Bond, 2007; Friedman, Rossi, & Braine, 2009). Even a sophisticated sociological hypothesis of self-generating “long alcohol waves”3 affecting the observed consumption changes was proposed (Skog, 1986). In summary, during the years 1960–2008, both planned and unplanned factors affected both alcoholic beverage consumption and alcohol consumption-related harm. The most dramatic cases are the:
• decrease in wine consumption, which began in the Southern European countries during the 1960s-1970s, that was influenced by a number of unplanned determinants and not by any of the formal, legislated preventive alcohol policies (Cipriani & Prina, 2007), and the • increase in alcoholic beverage consumption experienced in the Nordic countries, despite still active, albeit weakened, alcoholic beverage consumption-related policies. The Research Questions and the Creation of the Research Group
Such outcomes give rise to a series of questions:
• How and why can, and do, alcoholic beverage consumption change?4 • How do alcoholic beverage control policies affect these changes? • How do changes in alcoholic beverage consumption occur without any alcohol-related policy, that is, as a consequence of unplanned contextual factors? The AMPHORA study explores viable answers to these questions supporting the hypothesis that alcoholic beverage consumption control policies alone do not explain changes in alcohol consumption, and alcoholconsumption-related harm. These changes can only be explained when other contextual factors such as social, cultural, economic, religious, demographic, “globalizing”-related, and other factors, currently unknown, are considered simultaneously. These questions were debated by a number of researchers, on “the edges” and in the corridors of two Kettil Bruun Society symposia held in Helsinki in 2004 and Riverside, USA in 2005. Thanks and acknowledgments are to be given to CEARC (Consortium for European Alcohol Research Centers) which first gave credit to the ideas of this study; and during a NERUDA (Network of European Researchers in the Use of Drugs and Research) meeting in Helsinki in 2004. Two workshops were also organized by the late Eva Buiatti, director of ARS (Agenare major dimensions and loss of control over one’s life is experienced. Editor’s note. 3 “In addition to short-term fluctuations, alcohol consumption may show very long waves, with wavelengths of 50 to 70 years or even more” (Simpura, Karlsson, and Lepp¨anen, 2002). 4 The reader is referred to Tilly, Charles (2006). Why. Princeton University Press, Princeton, NJ, for a stimulating analysis about generic “causative” reasons given in the West and to Tilly, Charles (2008). Credit and Blame Princeton University Press, Princeton, NJ, for an important analysis about “blame.” Editor’s note.
TABLE 1. European countries involved in the study Northern countries
Central countries
Western countries
Eastern countries
Southern countries
Sweden Norway Finland
Austria Switzerland
UK Netherlands
Hungary Poland
France Spain Italy
zia Regionale di Sanita’, Health Agency of the Region of Tuscany, Florence) during October 7th-8th, 2006 and during September 28th–29th, 2007. Since 2007 ARS endorsed the project “Drinking trends and country preventive policies.” It was subsequently entered into the AMPHORA project as work package 3, under the new name of “Cultural Determinants and Alcohol Policies” (Anderson, Braddick, Reynolds, & Gual, 2012; AMPHORA, 2013) The Countries Involved in the Study
The study focuses on the period 1960–20085 and was conducted between 2009 and 2012. It includes 12 countries: Austria, Finland, France, Hungary, Italy, Netherlands, Norway, Poland, Spain, Sweden, Switzerland, and the United Kingdom, representing Central, Eastern, Northern, Southern, and Western Europe (Table 1). These countries are diverse: geographically, culturally, socially, economically, religiously, and politically as well as historically in terms of influentual individual and systemic stakeholders. The values, functions, and practices attributed to alcoholic beverages, are grouped according to a geographical classification. This geographical classification is also a cultural classification, because each country as well as each group of countries can be identified with a drinking culture. However, in each country, there may also be many drinking subcultures. Also, the differences among country’s drinking cultures have been weakening over time, as discussed earlier. Nonetheless, the country/cultural equivalence has still the advantage of retaining a relative clarity (Figure 1). Study Aims and the Study Hypotheses
This study is based on the thesis, evidenced by the specific literature that alcoholic beverage control policies that were designed to prevent-limit consumption and its associated behaviors do not, on their own, adequately explain changes in alcoholic beverage consumption and in alcohol consumption-related harms. These changes can only be reasonbly explained when other unplanned contextual factors, such as social, cultural, economic, religious, demographic, among others, are considered simultaneously. Therefore, this study’s aims were to identify changes in the contextual factors that are most strongly correlated with changes in alcoholic beverage consumption, drinking patterns, and related harms between 1960 and 2008 in the 12 countries in Europe (Allamani et al., 2011). Changes 5
Comparable European data on alcoholic beverage consumption are only available from 1960.
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FIGURE 1. European countries involved in the study.
in prevention policies designed to control and to limit alcohol consumption generally, for selected targeted populations and associated with specific behaviors, (i.e., driving) over the same time period were also studied in some countries. A country-bound variable combination of the impact of (a) preventive alcoholic beverage consumption control policies and (b) unplanned determinants occurring during the period 1960–2005, that have not been part of alcohol policy measures, would explain the changes in alcoholic beverage consumption and alcohol consumption-related harm, instead of the intervention of a specific alcohol policy alone. The combination of (a) and (b) can vary from countries; where (a) may be quite relevant (as in Finland) to countries where (b) may be most prominent (as in Italy). If results support this study’s working hypothesis, this broader perspective would allow, at the minimum, to specify which economic, social and cultural changes in addition to more traditional stakeholder alcohol policy measures, actually influence consumption patterns
and levels temporarily or more permanently. However, perhaps more important, a study incorporating such factors would also allow relevant individual and systemic policy making stakeholders to:
• estimate in which circumstances- internal and external ones, micro to macro levels- alcoholic beverage control policies are likely to be more effective and in which less; • Consider the “costs” of “irrelevant” policies for human and non-human resources, as well as to be aware of the potential regressive effects • sensitize policy makers to potential and existing social, economic, political, religious or cultural developments that require new and more specific prevention initiatives based upon the most appropriate and efficacious documentation.6 6
The reader is asked to consider that with the advent of artificial science and its theoretical underpinnings (chaos, complexity, and uncertainty theories) it is now posited that much of human behavior is complex, dynamic, multi-dimensional, level/phase structured, non-linear, law-driven and bounded (culture, time, place, age, gender, ethnicity, etc.). “Control,” however it is defined and delineated, entails levels and
THE AMPHORA STUDY BACKGROUND
The Hypotheses were the following: 1. Changes in unplanned factors, such as family structure, employment, education and the urbanization process, which represent the social dimensions of family, work, and economy, and which are not part of health prevention policies, are able to affect alcoholic beverage consumption and its directly or indirectly related harms. 2. Alcoholic beverage control policies have only a partial effect on alcoholic beverage consumption and its temporary or more permanent-related harms. 3. Unplanned factors changes are able to explain those consumption and harm changes that cannot be explained by alcoholic beverage policy measures.
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when and if appropriate interventions are needed, that this study was not designed to:
• describe the underpinnings of the legislated alcoholic beverage control policies and their operation and expected outcomes; • pinpoint the roles of stakeholders-individuals and systems—in implementing alcoholic beverage consumption policies, and consider the challenges for effective policy making, implementation and assessment; • denote a country’s and culture’s law abidingness- compliance with laws and regulations; • understand the necessary conditions for the unplanned factors-processes to operate or not to operate.
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Declaration of Interest
In order to make the investigation possible, different variables were identified. The selected dependent variables included alcoholic beverage consumption and alcohol-consumption-related harm (identified in liver mortality and transport mortality). The independent variables were (a) alcoholic beverage control policy measures, planned by governments to control consumption and drinking patterns, and alcohol-consumption-related harms; (b) unplanned determinants of consumption changes, i.e., a number of social, cultural, economic, and demographic factors that are not planned by governments and health authorities in order to specifically control alcoholic beverage consumption, but that may nevertheless affect consumption. The collection of country data, as well as the identification of the adequate analytical methods in order to test the aforementioned hypotheses, have been a substantial part of the study, that involved forty researchers. A major result of the project has been to have systematized available data related to 33 demographic, social, economic, health, political, religious nutritional variables, and to 11 categories of alcoholic beverage control policy measures for each of the 12 AMPHORA study countries involved during the period 1960–2008. This huge amount of data is available to the scientific community for possible further investigations that may go beyond the outcomes of this study. A caveat is necessary. As one reviews the study’s outcomes and considers its actual and potential implications both for needed effective policy making and assessing qualities of perception, awareness, expectations, judgment, decisionmaking which is or is not implemented, learning or not learning from whatever is done or not done, ceasing the behaviour or beginning, anew, etc. within interfering or enabling contexts, and with whatever formal as well as informal policies, would be such a process. There are a number of important issues to consider and which are derived from this: (1) Using linear models/tools to study non-linear processes/phenomena can and does result in misleading conclusions and can therefore also result in inappropriate intervention; (2) the concepts prediction and control have different meanings and dimensions than they do in the more traditional linear “cause and effect” paradigms; (3) uncertainty, unpredictability and the lack of real control, and not just attempts at influencing, are the dimensions of reality. (Buscema, M. (1998), Artificial Neural Networks, Substance Use & Misuse, 33(1–3); Ormerod, Paul, (2005) Why most things fail: Evolution, extinction and economics. Faber & Faber, UK; Miller, Matt, (2010) The tyranny of dead ideas; New York: Henry Holt & Co.) Editor’s note
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article. THE AUTHORS Fabio Voller, Ph.D., is a Sociologist at the Epidemiology Observatory of the Region of Tuscany Health Agency. He has worked on epidemiological studies of lifestyle, alcohol consumption, psychoactive drug use, mental health and health in prison in the Tuscan population. Among his publications, he is the co-author of a number of monographs about the health consequences of alcohol consumption in Italy. He is a work package 3 leader of the European Commission-funded AMPHORA project. Allaman Allamani, M.D., Psychiatrist; Family Therapist; Researcher. He has been coordinator of the Alcohol Centre, Florence Health Agency (1993–2009); since 2009 he has been consultant to the Region of Tuscany Health Agency for research on social epidemiology and prevention policy First non-alcoholic trustee of Italian Alcoholics Anonymous (1997–2003). He is a member of the editorial board of “Substance Use and Misuse.” Coordinator of a few Italian projects on alcohol prevention and policies, he has co-lead work package 3 of the European Commission-funded AMPHORA project. Author and co-author of more than 170 articles, editor and co-editor of 16 books.
GLOSSARY
Preventive Alcohol Control Policies: Governmental actions that are developed in response to alcohol consumption-related problems.
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Socio-demographic and Economic Factors: Targeted, and measurable social, demographic, and economic factors that are not planned by governmental health authorities, and that are able to explain the changes of alcoholic beverage consumption which are not explainable through the preventive alcoholic beverage control policies. AMPHORA Project: The AMPHORA project, with its work package 3 which is described in this paper, partially funded by the European Commission for 2009–2012, involved 12 European countries, investigated the part that preventive alcohol policies and country contextual factors have in changes of alcoholic beverage consumption and related harm.
REFERENCES Allamani, A., & Prina, F. (2007). Why the decrease in consumption of alcoholic beverages in Italy between the 1970s and the 2000s? Shedding light on an Italian mystery. Contemporary Drug Problems, 34, 187–197. Alexander, B. K. (2008). The globalisation of addiction: A study in poverty of the spirit. Oxford: Oxford University Press. Allamani, A., Voller, F., Decarli, A., Casotto, V., Pantzer, K., Anderson, P., . . . Gmel, G. (2011). Contextual determinants of alcohol consumption changes and preventive alcohol policies: A 12-country European study in progress. Substance Use & Misuse, 46(10), 1288–1303. AMPHORA Workpackage3. (2013). Report of an analysis of European alcohol-related cultural, social and policy interactions and their impact on alcohol consumption and alcohol-related harm http://amphoraproject.net /w2box /data /Deliverables /AMPHORA WP3 D3.2.pdf Anderson, P., & Baumberg, B. (2005). Alcohol in Europe. A report for the European Commission. England: Institute of Alcohol Studies. Anderson, P. (2009). Evidence for the effectiveness and cost- effectiveness of interventions to reduce alcohol-related harm. Copenhagen: World Health Organization Regional Office for Europe. Anderson, P., Møller, L., & Galea, G. (2012). Alcohol in the European Union. Consumption, harm and policy approaches. Copenhagen: World Health Organisation, Regional Office for Europe. Anderson, P., Braddick, F., Reynolds, J., & Gual, A. (Eds.) (2012). Alcohol Policy in Europe: Evidence from AMPHORA. http://amphoraproject.net/view.php?id cont=45. Cipriani, F., & Prina, F. (2007). The research outcome: Summary and conclusions on the reduction in wine consumption in Italy. Contemporary Drug Problem, 34(2), 361–378. Edwards, G., Anderson, P., Babor, T., Casswell, S., Ferrence, R., Giesbrecht, N., . . . Skog, O. J. (1994). Alcohol Policy and the Public Good. Oxford: Oxford University Press. Gual, A., & Colom, J. (1997). Why has alcohol consumption declined in countries of Southern Europe? Addiction, 92(Supplement 1), S21–S31. Heath, D. B. (ed.) (1995). International Handbook on Alcohol and Culture. Westport, Connecticut: Greenwood Press. Heather, N. (2006). Britain’s Alcohol Problem and what the UK Government is (and is not) doing about it. Addiciones, 18–3. ¨ Holder, H. D., Kuhlhorn, E., Nordlund, S., Osterberg, E., Romelsj¨o, A., & Ugland, T. (1998). European integration and Nordic Alcohol Policies. Aldershot: Ashgate.
Holder, H. D. (2000). Overall Changes and Consequences in Alcohol Use and Problems and Prospects for the Future in Sweden. In H. D. Holder (Ed.), Sweden and the European Union. Stockholm: The Swedish Alcohol Retailing Monopoly; the National Institute of Public Health. Almqvist & Wiksell International. Hupkens, C. L. H., Knibbe, R. A., & Drop, M. J. (1993). Alcohol consumption in the European community: Uniformity and diversity in drinking patterns. Addiction, 88, 1391–1404. Knibbe, R. A., Drop, M. J., & Hupkens, C. L. H. (1996). Modernization and geographical diffusion as explanations for regional differences in the consumption of wine and beer in the European community. Substance Use & Misuse, 31(11–12), 1639–1655. Michalak, L., Trocki, K., & Bond, J. (2007). Religion and alcohol in the US National Alcohol Survey: How important is religion for abstension and drinking? Drug and Alcohol Dependence, 87, 268–280. Moskalewicz, J., & Simpura, J. (2000). The supply of alcoholic beverages in transitional conditions: The case of Central and Eastern Europe. Addiction, 95(4 Suppl.), S505–S522. Norstr¨om, T., editor (2002). Alcohol in Postwar Europe: Consumption, Drinking Patterns, Consequences and Policy Responses in 15 European Countries. Stockholm: National Institute of Public Health. Almqvist & Wiksell. Ollson, B, Olafsdottir, H, & Room R (2002). Nordic tradition of studying the impact of alcohol problems. In R. Room (Ed.), The effect of Nordic Alcohol Policies. NAD Publications 42. Hapakaino Oy, Helsinki. ¨ Osterberg, E. & Karlsson, T. (2002). Alcohol policies in the ECAS countries, 1950–2000. In T. Norstr¨om (Ed.), Alcohol in Postwar Europe: Consumption, drinking patterns, consequences and policy responses in 15 European Countries (pp. 11–48). National Institute of Public Health. Stockholm: Almqvist & Wiksell. Plant, M., & Plant Moira (2006). Binge Britain. Alcohol and the national response. Oxford: Oxford University Press. Ramstedt, M. (2002). Alcohol-related mortality in 15 European countries in the post-war period. In T. Norstr¨om (Ed.), Alcohol in postwar Europe: Consumption, drinking patterns, consequences and policy responses in 15 European countries (pp. 137–156). National Institute of Public Health. Stockholm: Almqvist & Wiksell. Rehm, J., Room, R., Monteiro, M., Gmel, G., Graham, K., Rehn, N., . . . Jernigan, D. (2003). Alcohol as a risk factor for global burden of disease. European Addiction Research, 9, 157–164. Room, R. (1992). The impossible dream. Routes to reducing alcohol problems in a temperance culture. Journal of Substance Use, 4, 91–106. Room, R. (1999). The idea of Alcohol Policy. Nordic Studies on Alcohol and Drugs, 16(English Supplement), S7–S20. Room, R. (2002). A hazardous commodity with culture bound effects: Policy implications of ECAS. In T. Norstr¨om (Ed.), Alcohol in postwar Europe: Consumption, drinking patterns, consequences and policy responses in 15 European countries (pp. 23–219). National Institute of Public Health, Stockholm: Almqvist & Wiksell. Room, R., Babor, T., & Rehm, J. (2005). Alcohol and public health. Lancet, 365, 519–530. Room, R., & M¨akel¨a, K. (2000). Typologies of the cultural position of drinking. Journal of Studies on Alcohol, 61(3), 475–483. Friedman, S. R., Rossi, D., & Braine, N. (2009). Theorizing “big events” as a potential risk environment for drug use, drug-related harm and HIV epidemic outbreaks. International Journal of Drug Policy, 20, 283–291.
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Simpura, J. (1998). Mediterranean mysteries: Mechanisms of declining alcohol consumption. Addiction, 93(9), 1301–1304. Simpura, J., Karlsson, T., & Lepp¨anen (2002). European trends in dirnking patterns and their socio-economic background. In T. Norstr¨om (Ed.), Alcohol in Postwar Europe: Consumption, Drinking Patterns, Consequences and Policy Responses in 15 European Countries (pp. 83–114). National Institute of Public Health. Stockholm: Almqvist & Wiksell. Skog, O.-J. (1986). Long waves of alcohol consumption: A social network perspective on cultural change. Social Networks, 8, 1–32.
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Sulkunen, P. (1989). Drinking in France 1965–1979. An analysis of Household Consumption Data. British Journal of Addiction, 84, 61–72. Sulkunen, P., Sutton, C., Tigerstedt, C., & Warpenius, C. (2000). Introduction. In P. Sulkunen, C. Sutton, C. Tigerstedt, C. Warpenius (Eds.), Broken Spirits. NAD Publication, 39, Hakapaino Oy, Helsinki. World Health Organization (2011). Global Information System on Alcohol and Health (GISAH) [online database]. Geneva: World Health Organization (http://who.int/globala/alcohol).
ORIGINAL ARTICLE
Contextual Factors and Alcohol Consumption Control Policy Measures: The AMPHORA Study Background Fabio Voller and Allaman Allamani Subst Use Misuse Downloaded from informahealthcare.com by University of Maastricht on 06/30/14 For personal use only.
Regional Health Agency, Region of Tuscany, Florence, Italy Drinking alcoholic beverages is rooted in European history. Alcoholic beverages have and continue to have a range of functions for both individuals as well as systems. In some cultures the prevailing function of drinking is its use as an intoxicant, or mood-changer or enhancer. In other cultures the value of an alcoholic beverage (mainly wine) is in its connection with meals. Patterns of alcohol consumption in Europe have continued to change starting from the 1960s, some years after the end of World War II (World Health Organization, 2011). Examples are a general increase in consumption in the Northern countries and a decrease in drinking (particularly wine) in the Mediterranean countries. Eastern and Central Europe have manifested an intermediate consumption pattern. Regarding the prevalence of types of beverages, Finland and Poland changed from being spirit drinking countries to becoming beer drinking countries, Spain turned from wine to beer, France and Italy’s drinkers proportionally drank less wine, while Sweden’s drinkers drank more wine. Alcohol is commonly recognized as being one of the most important health determinants in Europe, resulting in numerous health and social consequences.1 Two classic indicators of chronic and acute harmful health consequences of drinking are, respectively, mortality from alcohol drinking-related chronic liver disease and liver cirrhosis, and the number of persons harmed or killed in transport injuries (see Edwards et al., 1994). Here too, important changes have occurred. For example, World Health Organization (WHO) data show that the traditional North–South gradient—Southern European countries having up to 5–6 times higher cirrhosis mortality than Northern countries in the 1970s and earlier (Ramstedt, 2002; World Health Organization, 2011)—has become weaker over time.
Drinking alcoholic beverages is deeply rooted in European cultural and economic history, and European consumption trends have varied over time during the decades following WW II. How and why such consumption patterns have changed, and what are the roles that societies’ transformations play in these changes are the AMPHORA project’s focus. Preventive alcohol consumption control policies have been developed for a long time; during different eras, in different ways and in different countries. How have and do formal policies affect such changes? These questions stimulated a group of 40 researchers from 12 European countries and 14 institutions to investigate the interactions between selected socio-demographic and economic factors, alcohol control policy measures, alcohol consumption and alcohol consumption-related harm that occurred in 12 European countries between 1960 and 2008. Keywords Europe, preventive alcohol consumption control policies, socio-demographic and economic factors, AMPHORA project
INTRODUCTION
Europe is a complex geographical, historical, cultural, political, religious and economical entity endowed with differences and similarities. Europe has a long history of diverse traditions and meanings concerning drinking cultures, alcohol consumption-related harms and prevention policies. It is the heaviest alcoholic beverage drinking region in the world with a broad range of types of drinkers. (see Anderson & Baumberg, 2005; Room, 1992; Heath, 1995; Heather 2006; Olsson, Olafsdottir, & Room, 2002; ¨ Osterberg & Karlsson, 2002; Rehm et al., 2003; Plant & Plant, 2006; Room & M¨akel¨a, 2000).
Address correspondence to Fabio Voller, Agenzia regionale di sanit`a della Toscana Osservatorio di epidemiologia – Dirigente Via Dazzi 1 Firenze, 50141, Italy; E-mail: [email protected] 1 The reader is referred to Hills’s criteria for causation would be helpful. These were developed in order to help assist researchers and clinicians determine if risk factors were causes of a particular disease or outcomes or merely associated. (Hill, A. B. (1965). The environment and disease: associations or causation? Proceedings of the Royal Society of Medicine 58: 295–300.). Editor’s note
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Responses to Alcohol Consumption Control Policies in Europe: A Composite Picture
Numerous preventive alcohol control policies, which have been developed in response to alcohol consumptionrelated problems, have been associated with effectiveness as well as cost-effectiveness (Anderson, 2009; Anderson, Møller, & Galea, 2012). The scientific generalizable evidence comes only from studies carried out in Nordic and English speaking countries. Some observations however, especially those coming from Southern Europe, stress the importance that other factors may have in changing the drinker’s consumption and patterns of drinking. A further problem that may interfere with the promulgation of control policies, and their effectiveness, is that alcohol consumption control policies make sense in cultures where people address alcohol consumption and its actual and potential short term as well as longer term consequences as being a social and health problem, while they are understood less in societies where alcohol and its use and misuse receives little or less public attention (Room, 1999). Government measures in these latter societies sometimes appear to be more popular, more symbolic than being responsive to the real needs of the population. Finally, the enforcement of measures and their interplay with informal control may vary greatly according to nations and cultures, making it difficult to compare the effects of similar interventions in different areas ¨ (Osterberg & Karlsson, 2002) as well as during different times in the same area. For example, it is well known that the level of law enforcement in Mediterranean countries is lower than in Scandinavian countries. This might contribute to explaining the transnational variation in the relation between alcohol consumption control policies and alcoholic beverage consumption changes. The levels and qualities of “law abindingness” of both individuals as well as systems is yet another potentially relevant factor which merits study and which, to date, has not been sufficiently considered as influencing a policy’s effectiveness. Alcohol consumption control policy has an old Nordic tradition (Olsson et al., 2002). During the last century, the traditional policies of Nordic countries, as well as of Britain and of Ireland, were based on restriction strategies like high taxes, age limits, regulations of advertising and licensing, and (for the Nordic countries) compre¨ hensive state alcohol off-premise monopoly (Osterberg & Karlsson, 2002). Notwithstanding these official restraints, a general increase in consumption of alcoholic beverages has been observed in these countries since the 1960s. A contribution to this increase has often been attributed to the dismantling of the traditional alcoholic beverage control system, after entering the European Union in the 1990s (Holder et al., 1998; Norstr¨om, 2002; Sulkunen, Sutton, Tigerstedt, & Warpenius, 2000; Room, 2002; Room, Babor, & Rehm, 2005)—even if doubts have been raised by some (Holder, 2000). In addition, the remarkable increase in British alcoholic beverage consumption could be ascribed to a more liberal attitude of governments since the 1960s (Plant & Plant, 2006).
Regarding the Eastern countries of Europe, like Hungary and Poland, where alcohol consumption reached a peak by the end of the 1970s (World Health Organization, 2011), preventive measures might have reduced the increase in alcohol consumption during the following decade, preceding the transition towards a market economy (Moskalewicz & Simpura, 2000). The new trend towards liberalization that started in the 1990s may have contributed to reversing this decrease. Among Southern European countries, formal restrictions regarding alcoholic beverages consumption were less numerous, and were endorsed and introduced more recently than in the North. They have hardly been or have only partially been enforced, reflecting the weak position of their governments on this issue (Norstr¨om, 2002). Nonetheless, starting from the 1950s in France, and the 1970s in Italy and Spain, alcohol consumption decreased unexpectedly and dramatically; a decrease due to a heavy drop in wine consumption (World Health Organization, 2011). This decreasing drinking trend, initially, together with the peculiar Southern European drinking pattern, was described by researchers with colorful expressions like “impossible dream” (Room 1992) or “Mediterranean Mysteries” (Simpura, 1998). However two studies, one in France and one in Italy (Sulkunen, 1989; Allamani & Prina 2007), concluded that some of the relevant determinants were usefully catagorizable as unplanned policy measures. For unplanned policy measures we mean targeted, measurable social, demographic and economic factors that are not planned by governmental health authorities (see AMPHORA, 2013) These factors were in fact able to explain the decrease of wine consumption that preventive alcoholic beverage control policies could not, as the latter were not present between at least 1960s–1970s. These determinants are: urbanization, industrialization, population structure, changes in the choice of food items, female employment and education, family organization and the role of alcoholic beverages with meals at home, and health awareness. In general, in order to explain the changes in the consumption of alcoholic beverages, different authors have proposed factors other than alcohol control policies, including: demography, international trade and markets, modernization and globalization, health awareness and urbanization, industrialization, in-country migration, changes in the family structure, decline in religiosity, the weakening of traditional ways of drinking, the desire of groups to distinguish themselves by adopting ‘new’ drinking habits, and big socio-political events2 (see Alexander, 2
This relatively new term, introduced into the intervention literature, This relatively new term, introduced into the intervention literature by Friedman et al. (Samuel R. Friedman, Diana Rossi, Peter L. Flom. (2006). “Big events” and networks: Thoughts on what could be going on. Connections 27(1): 9–14.) refers to major events such as mega—disasters, natural, as well as man-made, famine, conflict, genocide, disparities in health, epidemics, mass migrations, economic recessions, etc. which effect adaptation, functioning and quality-of-life of individuals as well as systems. Existential threat, instability and chaos
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THE AMPHORA STUDY BACKGROUND
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2008; Gual & Colom 1997; Hupkens, Knibbe, & Drop, 1993; Knibbe, Drop, & Hupkens, 1996; Michalak, Trocki, & Bond, 2007; Friedman, Rossi, & Braine, 2009). Even a sophisticated sociological hypothesis of self-generating “long alcohol waves”3 affecting the observed consumption changes was proposed (Skog, 1986). In summary, during the years 1960–2008, both planned and unplanned factors affected both alcoholic beverage consumption and alcohol consumption-related harm. The most dramatic cases are the:
• decrease in wine consumption, which began in the Southern European countries during the 1960s-1970s, that was influenced by a number of unplanned determinants and not by any of the formal, legislated preventive alcohol policies (Cipriani & Prina, 2007), and the • increase in alcoholic beverage consumption experienced in the Nordic countries, despite still active, albeit weakened, alcoholic beverage consumption-related policies. The Research Questions and the Creation of the Research Group
Such outcomes give rise to a series of questions:
• How and why can, and do, alcoholic beverage consumption change?4 • How do alcoholic beverage control policies affect these changes? • How do changes in alcoholic beverage consumption occur without any alcohol-related policy, that is, as a consequence of unplanned contextual factors? The AMPHORA study explores viable answers to these questions supporting the hypothesis that alcoholic beverage consumption control policies alone do not explain changes in alcohol consumption, and alcoholconsumption-related harm. These changes can only be explained when other contextual factors such as social, cultural, economic, religious, demographic, “globalizing”-related, and other factors, currently unknown, are considered simultaneously. These questions were debated by a number of researchers, on “the edges” and in the corridors of two Kettil Bruun Society symposia held in Helsinki in 2004 and Riverside, USA in 2005. Thanks and acknowledgments are to be given to CEARC (Consortium for European Alcohol Research Centers) which first gave credit to the ideas of this study; and during a NERUDA (Network of European Researchers in the Use of Drugs and Research) meeting in Helsinki in 2004. Two workshops were also organized by the late Eva Buiatti, director of ARS (Agenare major dimensions and loss of control over one’s life is experienced. Editor’s note. 3 “In addition to short-term fluctuations, alcohol consumption may show very long waves, with wavelengths of 50 to 70 years or even more” (Simpura, Karlsson, and Lepp¨anen, 2002). 4 The reader is referred to Tilly, Charles (2006). Why. Princeton University Press, Princeton, NJ, for a stimulating analysis about generic “causative” reasons given in the West and to Tilly, Charles (2008). Credit and Blame Princeton University Press, Princeton, NJ, for an important analysis about “blame.” Editor’s note.
TABLE 1. European countries involved in the study Northern countries
Central countries
Western countries
Eastern countries
Southern countries
Sweden Norway Finland
Austria Switzerland
UK Netherlands
Hungary Poland
France Spain Italy
zia Regionale di Sanita’, Health Agency of the Region of Tuscany, Florence) during October 7th-8th, 2006 and during September 28th–29th, 2007. Since 2007 ARS endorsed the project “Drinking trends and country preventive policies.” It was subsequently entered into the AMPHORA project as work package 3, under the new name of “Cultural Determinants and Alcohol Policies” (Anderson, Braddick, Reynolds, & Gual, 2012; AMPHORA, 2013) The Countries Involved in the Study
The study focuses on the period 1960–20085 and was conducted between 2009 and 2012. It includes 12 countries: Austria, Finland, France, Hungary, Italy, Netherlands, Norway, Poland, Spain, Sweden, Switzerland, and the United Kingdom, representing Central, Eastern, Northern, Southern, and Western Europe (Table 1). These countries are diverse: geographically, culturally, socially, economically, religiously, and politically as well as historically in terms of influentual individual and systemic stakeholders. The values, functions, and practices attributed to alcoholic beverages, are grouped according to a geographical classification. This geographical classification is also a cultural classification, because each country as well as each group of countries can be identified with a drinking culture. However, in each country, there may also be many drinking subcultures. Also, the differences among country’s drinking cultures have been weakening over time, as discussed earlier. Nonetheless, the country/cultural equivalence has still the advantage of retaining a relative clarity (Figure 1). Study Aims and the Study Hypotheses
This study is based on the thesis, evidenced by the specific literature that alcoholic beverage control policies that were designed to prevent-limit consumption and its associated behaviors do not, on their own, adequately explain changes in alcoholic beverage consumption and in alcohol consumption-related harms. These changes can only be reasonbly explained when other unplanned contextual factors, such as social, cultural, economic, religious, demographic, among others, are considered simultaneously. Therefore, this study’s aims were to identify changes in the contextual factors that are most strongly correlated with changes in alcoholic beverage consumption, drinking patterns, and related harms between 1960 and 2008 in the 12 countries in Europe (Allamani et al., 2011). Changes 5
Comparable European data on alcoholic beverage consumption are only available from 1960.
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F. VOLLER AND A. ALLAMANI
FIGURE 1. European countries involved in the study.
in prevention policies designed to control and to limit alcohol consumption generally, for selected targeted populations and associated with specific behaviors, (i.e., driving) over the same time period were also studied in some countries. A country-bound variable combination of the impact of (a) preventive alcoholic beverage consumption control policies and (b) unplanned determinants occurring during the period 1960–2005, that have not been part of alcohol policy measures, would explain the changes in alcoholic beverage consumption and alcohol consumption-related harm, instead of the intervention of a specific alcohol policy alone. The combination of (a) and (b) can vary from countries; where (a) may be quite relevant (as in Finland) to countries where (b) may be most prominent (as in Italy). If results support this study’s working hypothesis, this broader perspective would allow, at the minimum, to specify which economic, social and cultural changes in addition to more traditional stakeholder alcohol policy measures, actually influence consumption patterns
and levels temporarily or more permanently. However, perhaps more important, a study incorporating such factors would also allow relevant individual and systemic policy making stakeholders to:
• estimate in which circumstances- internal and external ones, micro to macro levels- alcoholic beverage control policies are likely to be more effective and in which less; • Consider the “costs” of “irrelevant” policies for human and non-human resources, as well as to be aware of the potential regressive effects • sensitize policy makers to potential and existing social, economic, political, religious or cultural developments that require new and more specific prevention initiatives based upon the most appropriate and efficacious documentation.6 6
The reader is asked to consider that with the advent of artificial science and its theoretical underpinnings (chaos, complexity, and uncertainty theories) it is now posited that much of human behavior is complex, dynamic, multi-dimensional, level/phase structured, non-linear, law-driven and bounded (culture, time, place, age, gender, ethnicity, etc.). “Control,” however it is defined and delineated, entails levels and
THE AMPHORA STUDY BACKGROUND
The Hypotheses were the following: 1. Changes in unplanned factors, such as family structure, employment, education and the urbanization process, which represent the social dimensions of family, work, and economy, and which are not part of health prevention policies, are able to affect alcoholic beverage consumption and its directly or indirectly related harms. 2. Alcoholic beverage control policies have only a partial effect on alcoholic beverage consumption and its temporary or more permanent-related harms. 3. Unplanned factors changes are able to explain those consumption and harm changes that cannot be explained by alcoholic beverage policy measures.
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when and if appropriate interventions are needed, that this study was not designed to:
• describe the underpinnings of the legislated alcoholic beverage control policies and their operation and expected outcomes; • pinpoint the roles of stakeholders-individuals and systems—in implementing alcoholic beverage consumption policies, and consider the challenges for effective policy making, implementation and assessment; • denote a country’s and culture’s law abidingness- compliance with laws and regulations; • understand the necessary conditions for the unplanned factors-processes to operate or not to operate.
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Declaration of Interest
In order to make the investigation possible, different variables were identified. The selected dependent variables included alcoholic beverage consumption and alcohol-consumption-related harm (identified in liver mortality and transport mortality). The independent variables were (a) alcoholic beverage control policy measures, planned by governments to control consumption and drinking patterns, and alcohol-consumption-related harms; (b) unplanned determinants of consumption changes, i.e., a number of social, cultural, economic, and demographic factors that are not planned by governments and health authorities in order to specifically control alcoholic beverage consumption, but that may nevertheless affect consumption. The collection of country data, as well as the identification of the adequate analytical methods in order to test the aforementioned hypotheses, have been a substantial part of the study, that involved forty researchers. A major result of the project has been to have systematized available data related to 33 demographic, social, economic, health, political, religious nutritional variables, and to 11 categories of alcoholic beverage control policy measures for each of the 12 AMPHORA study countries involved during the period 1960–2008. This huge amount of data is available to the scientific community for possible further investigations that may go beyond the outcomes of this study. A caveat is necessary. As one reviews the study’s outcomes and considers its actual and potential implications both for needed effective policy making and assessing qualities of perception, awareness, expectations, judgment, decisionmaking which is or is not implemented, learning or not learning from whatever is done or not done, ceasing the behaviour or beginning, anew, etc. within interfering or enabling contexts, and with whatever formal as well as informal policies, would be such a process. There are a number of important issues to consider and which are derived from this: (1) Using linear models/tools to study non-linear processes/phenomena can and does result in misleading conclusions and can therefore also result in inappropriate intervention; (2) the concepts prediction and control have different meanings and dimensions than they do in the more traditional linear “cause and effect” paradigms; (3) uncertainty, unpredictability and the lack of real control, and not just attempts at influencing, are the dimensions of reality. (Buscema, M. (1998), Artificial Neural Networks, Substance Use & Misuse, 33(1–3); Ormerod, Paul, (2005) Why most things fail: Evolution, extinction and economics. Faber & Faber, UK; Miller, Matt, (2010) The tyranny of dead ideas; New York: Henry Holt & Co.) Editor’s note
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article. THE AUTHORS Fabio Voller, Ph.D., is a Sociologist at the Epidemiology Observatory of the Region of Tuscany Health Agency. He has worked on epidemiological studies of lifestyle, alcohol consumption, psychoactive drug use, mental health and health in prison in the Tuscan population. Among his publications, he is the co-author of a number of monographs about the health consequences of alcohol consumption in Italy. He is a work package 3 leader of the European Commission-funded AMPHORA project. Allaman Allamani, M.D., Psychiatrist; Family Therapist; Researcher. He has been coordinator of the Alcohol Centre, Florence Health Agency (1993–2009); since 2009 he has been consultant to the Region of Tuscany Health Agency for research on social epidemiology and prevention policy First non-alcoholic trustee of Italian Alcoholics Anonymous (1997–2003). He is a member of the editorial board of “Substance Use and Misuse.” Coordinator of a few Italian projects on alcohol prevention and policies, he has co-lead work package 3 of the European Commission-funded AMPHORA project. Author and co-author of more than 170 articles, editor and co-editor of 16 books.
GLOSSARY
Preventive Alcohol Control Policies: Governmental actions that are developed in response to alcohol consumption-related problems.
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Socio-demographic and Economic Factors: Targeted, and measurable social, demographic, and economic factors that are not planned by governmental health authorities, and that are able to explain the changes of alcoholic beverage consumption which are not explainable through the preventive alcoholic beverage control policies. AMPHORA Project: The AMPHORA project, with its work package 3 which is described in this paper, partially funded by the European Commission for 2009–2012, involved 12 European countries, investigated the part that preventive alcohol policies and country contextual factors have in changes of alcoholic beverage consumption and related harm.
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