I .
'o
IL
POLICY ALTERNATIVES FOR ALCOHOL CONTROL The suggestion in the current issue of this Journal and elsewhere that alcoholism can and should be approached as a problem of public health control techniques, rather than as a matter of individual pathologies," 2 is attractive and enlightened. As with many other social problems, prevention appears to be far more cost effective than treatment. The public interest in reduction of alcoholism and alcoholrelated mortality is probably best served by attacking the problem at the point of greatest leverage. And "blaming the victim" is currently unfashionable among those concerned with public policy3-even in those instances in which the victim is clearly responsible for his own plight, as in those cases of automobile injury which result from the victim's failure to fasten his seat belt. Yet it is far from clear that a concerted policy of reducing alcoholism and alcohol-related disease by controlling the distribution and consumption of alcohol is, at this time, either feasible or desirable. We know very little about the costs and benefits, either absolute or relative, of various control mechanisms, and effective techniques for inducing health-related behavioral changes through educational or informational strategies remain to be identified.4 The history of alcohol control in this country and some others, moreover, is the history of the imposition of the tastes and preferences of one group on others; put another way, questions of equity and the rights of individuals and groups are involved. There can be no question of the substantial covariation among rates of per capita alcohol consumption, the incidence of alcoholism, and the incidence of alcohol-related mortality, most notably from cirrhosis.`8 Another study of this relationship appears in the current issue of the Journal.9 Reductions in per capita consumption, achieved through the imposition of control measures, have been found, in several instances, to lead to reductions in both cirrhosis mortality and arrests for alcohol-connected offenses-in the short run.'° Effective strategies to reduce per capita consumption thus might appear to offer the hope of reducing the incidence of alcoholism. Possible strategies to reduce per capita consumption fall into three general categories: taxation; restrictions on distribution; and education.* Increased taxation of alcoholic beverages could be expected, by raising the net cost to consumers, to reduce demand-assuming that the price *
Measures which
apply
to the
behauior of' those who have
already consumed excessive amounts of alcohol are not properly control strategies, and are therefore not considered in this discussion. Policies such as criminal prohibitions against public drunkenness tend to be more punitive than preventive; moreover, they generally don't work very well. More sophisticated measures, such as those that would impose criminal liability on bartenders or hosts 1340
AJPH
DECEMBER. 1975.
Vol. 65. No. 12
elasticity of demand is non-negligible, and that higher prices would discourage consumption.11 Restrictions on distribution, such as reducing the number of retail outlets for alcoholic beverages or further limiting the hours they are permitted to remain open, would create noneconomic costs in time and inconvenience which might also be expected to discourage consumption. Educational activities would attempt to induce consumers to turn 'away from alcohol spontaneously, even in the absence of such external constraints. Since there is no mutual exclusivity among these three strategies, any combination of them might also be
attempted. It is significant to note that all three strategies have already been implemented to a considerable extent in the United States, for reasons largely unrelated to the control of alcoholism, and that the rates of both per capita consumption and alcoholism have continued to rise.10 12 Precise estimates for existing levels of expenditure on alcohol education are hard to come by, but they must certainly run in the tens of millions of dollars. While the tax rates on alcoholic beverages are lower in the United States than in most Western nations-as are taxes on almost all "luxury" items-alcohol is among the most heavily taxed of all U.S. consumer commodities.10 The remnants of Puritan and prohibitionist sentiment have encumbered liquor retailers with restrictions more severe than those placed on the purveyors of any other legal product.10 The failure of these restrictions to have a visible impact does not, of course, imply per se that they are alcoholism on inappropriate or necessarily ineffective. More and better restrictions might be preferable. But there are some very sound reasons for being pessimistic about the potential for such devices to ever have much of an impact on alcoholism problems, and those reasons also hint at the undesirability of current control strategies. While it is true that alcoholism tends to rise with increases in per capita consumption, it is also true that, in any social grouping or class, only a fraction of those who consume alcohol ever become alcoholics-or suffer any significant ill effects.13 14 There is some evidence that the consequences of moderate levels of alcohol consumption may even be salutary for some individuals.15 Denial of access to alcohol may displace addictive behavior onto other substances, such as barbiturates, with, at best, no net social who serve excessive quantities of' alcohol to individuals who then become involved in automobile accidents, may have more promise as strategies f'or preventing individual incidents of' drunkenness. Thev approach the problem of chronic alcoholism only marginally. and also fall outside the "reducing alcoholism by reducing per capita consumption" paradigm.
gain.1" Moreover, patterns of alcohol usage vary dramatically across social, cultural, ethnic, and economic lines, and those subcultures with relatively small proportions of abstainers tend to have relatively low rates of alcoholism.13 14 Impeding the flow of alcohol to actual or potential alcoholics through the use of control mechanisms will also impede its use by those for whom moderate consumption is a valued element of social life-and is likely to do so in a relatively inequitable manner. A dramatic increase in the taxation of alcoholic beverages, for instance, would be felt much more strongly by the poor than the middle class, and might represent a significant financial and social hardship for those among the poor who do not abuse alcohol but value it. Ironically, for such individuals, higher rates of alcohol taxation would necessitate that they spend a higher proportion of their finite disposable incomes on alcohol. More to the point, those historical instances adduced by proponents of alcohol control as evidence that taxation can reduce consumption and alcoholism have tended to be short lived, as increases in per capita income soon overtake the demand-dampening impact on the taxes.10 Growth in per capita income remains the strongest single predictor of growth in per capita consumption in modern societies, suggesting that, for most individuals, alcoholic beverages are a highly discretionary commodity.9' 12 Tax policies have induced shifts in consumption patterns from one type of alcohol to another (spirits to beer, for instance),14 but with no obvious effect on alcoholism. There is no evidence that those prone to alcohol abuse share a similar take-it-or-leave-it attitude. This is the crucial behavioral question relative to alcohol control strategies: whether price and nonprice elasticities of demand for alcohol are uniform throughout the population, or whether elasticity is much lower among the "abuser" tail of the "log-normal distribution" of consumers. There is no hard evidence on this question that would support the beliefs of control strategy proponents. The weight of intuitive evidence runs directly opposite. Gross correlations between per capita consumption and alcoholism rates are, for these purposes, too highly aggregated and too subject to the ecological fallacy. Unless one subscribes a priori to the "single drop of rum" theory, it is clear that higher taxation would reduce consumption among those for whom consumption does good but no harm, and especially the poor within that group, without its being at all clear whether it would reduce alcoholism. Similarly, further constraints on the retail distribution of alcoholic beverages would inconvenience the large proportion of the population that uses alcohol beneficially, without any clear evidence to expect an impact on alcoholism. More importantly, the history of alcohol control through regulation of distribution in this country is manifestly one of corruption and discrimination against lower class consumers. The considerable monopoly rents that regulation generates make corruption in the distribution of licenses and the enforcement of their provisions almost inevitable; like other sumptuary laws, those pertaining to liquor control have been differentially enforced across
socioeconomic lines, occasioning considerable legitimate resentment in minority communities." Educational strategies for alcohol control raise different, more complex questions. Most broadly, the problem is the generic one of inducing behavioral changes that will be conducive to improved health in a population that seems strongly attached to its vices. Here alcohol consumption falls into the same category as tobacco smoking, overeating, and participation in excessively stressful environments. At the moment, there appears to be no easy-or hard-way to prevail on any significant proportion of individuals at risk to modify behaviors of this kind. Attitudinal changes produced by education have been demonstrated, but no connection has been proven between these changes and behavior. Additional research in this area has increasingly been recognized as a major priority for public health.17 Even the Congress appears finally to have caught on.18 The problem is central to alcohol control, though by no means limited to it. While the long range imperative is clear, there is little ground for short run optimism. In the immediate future, then, Beauchamp's call for a policy of alcohol control appears to lack desirable mechanisms for translation into specific policies. This is more as a result of the unwieldiness of available policy alternatives than the machinations of the political-industrial complex that profits considerably from the distribution and consumption of alcoholic beverages. More narrowly gauged, less global alternatives offer some prospects for change. Rigid law enforcement may reduce the frequency with which alcohol abuse is connected with driving."1 Increased energy prices may well induce a shift in drinking from bars and restaurants to the home. Perceived preferences of light drinkers may further encourage the alcohol industry's trend toward production of beverages with lower absolute alcohol content, thus reducing per capita consumption of absolute alcohol. Yet in terms of the overall problem of alcohol abuse and alcoholism, these remain marginal approaches to the problem. Students of alcohol usage and alcohol control often point with distaste to the enormous, and seemingly random, variation of regulations and prohibitions embodied in the laws of this country's 50 states and thousands of political subdivisions. It has generally been agreed that a uniform national policy of alcohol control would be substantially neater and more sensible.1' 20 Yet, given the present state of knowledge about the effectiveness of control mechanisms, greater uniformity has only neatness to recommend it. The existing American crazy quilt can be seen, instead, as a kind of complex natural experiment. To be sure, there are a large number of independent variables, but the variation is sufficiently great, and the techniques of multivariate statistical analysis are sufficiently sophisticated, to suggest that this natural experiment should be employed for planned research and evaluation rather than be prematurely foreclosed on the basis of inadequate information. So promising and straightforward is the simple syllogism of reducing alcoholism by reducing total social consumption that it is painful to realize that there appears to be no way to make it work in the near future. Over the EDITORIALS
1341
longer run, however, the prospect is so appealing that future research and experimentation should be strongly supported. Systematic research into alcohol control policy is only beginning, but its ultimate potential is too great to ignore. However, research on the cause of alcoholism as addictive behavior must also continue. The correlations between per capita consumption and alcoholism deaths due to cirrhosis do not prove the causal factors in addictive behavior in a portion of the exposed population. Before any alternative policies are rejected, it is necessary that we know more about the causes of the behavioral relationships they presuppose.
Bruce C. Vladeck, PhD Assistant Professor of Public Health Robert J. Weiss, MD Director Center for Community Health Systems Columbia University New York REFERENCES 1. Beauchamp, D. E., Public Health: Alien Ethic in a Strange Land? (Commentary). Am. J. Public Health 65:1338-1339, 1975. 2. Beauchamp, D. E. The Alcohol Alibi: Blaming Alcoholics. Transaction 98:12-17, 1975. 3. Ryan, W. Blaming the Victim. Vintage Books, New York, 1971. 4. Friedman, K. M. Cigarette Smoking and Public Policy (Editorial). Am. J. Public Health 65:979-980, 1975. 5. deLint, J. The Prevention of Alcoholism. Prev. Med. 3:24-35, 1974. 6. Schmidt, W., and deLint, J. Estimating the Prevalence of Alcoholism from Alcohol Consumption and Mortality Data. Q. J. Stud. Alcohol. 31:957-964, 1970.
7. Terris, M. Epidemiology of Cirrhosis of the Liver. Am. J. Public Health 58:5-12, 1968. 8. Popham, R. E. Indirect Methods of Alcoholism Prevalence Estimation: A Critical Evaluation. In Alcohol and Alcoholism, edited by Popham, R. E. Addiction Research Foundation, Toronto, Ontario, 1970. 9. Brenner, M. H. Trends in Alcohol Consumption and Associated Illnesses. Am. J. Public Health 65:1279-1292, 1975. 10. Wilkinson, R. The Prevention of Drinking Problems. Oxford University Press, New York, 1970. 11. Niskanen, W. A. Taxation and the Demand for Alcoholic Beverages. The RAND Corporation, Santa Monica, 1960. 12. Efron, V., Keller, M., and Gurioli, C. Statistics on Consumption of Alcohol and on Alcoholism. Rutgers University Press, New Brunswick, New Jersey, 1974. 13. Cahalan, D., Cisin, I. H., and Crossley, H. M. American Drinking Practices. Social Research Group. George Washington University, Washington, DC, 1967. 14. National Institute on Alcohol Abuse and Alcoholism. Alcohol and Health: New Knowledge. Second Special Report to the U.S. Congress, Ch.X. U.S. Government Printing Office, Washington, DC, 1974. 15. National Institute on Alcohol Abuse and Alcoholism. Alcohol and Health: New Knowledge. Second Special Report to the U.S. Congress, Ch. V, Pt. 4. U.S. Government Printing Office, Washington, DC, 1974. 16. Light, D. Costs and Benefits of Alcohol Consumption. Transaction 98:13-24, 1975. 17. U.S. Department of Health, Education, and Welfare, Assistant Secretary for Health. Forward Plan for Health, 1976-1980. 1974. 18. Public Law 93-641, Sec. 1502 (10), 1974. 19. National Institute on Alcohol Abuse and Alcoholism. Alcohol and Health: New Knowledge. Second Special Report to the U.S. Congress, Ch. VI. U.S. Government Printing Office, Washington, DC, 1974. 20. Chafetz, M. E. Introduction. In Alcohol and Health: New Knowledge. National Institute on Alcohol Abuse and Alcoholism. U.S. Government Printing Office, Washington, DC, 1974.
PERSPECTIVE ON A CURRENT PUBLIC HEALTH CONTROVERSY Numerous controversies have marked the evolution of improvements in the public's health, many major ones having centered on whether individuals must do something themselves to avoid damage from everyday environmental hazards, or whether available actions should be adopted that extend protection to all. The public and professional turbulence about whether smallpox, cholera, typhoid, and childbed fever could and should be controlled are early illustrations. The means of such control have usually been the center of the storm. Examples include quarantines; inoculations; closing down contaminated wells; making obstetrics sanitary; pasteurization of milk; fluoridation of water; and, more recently, controlling some motor vehiclerelated injuries. In public health, as developing scientific knowledge makes possible the control of an environmental source of morbidity and mortality, attempts at control of the damage Dr. Haddon is President of the Insurance Institute for Highway Safety, Washington, DC, and headed, in 1966-1969, what is now the National Highway Traffic Safety Administration. 1342
AJPH DECEMBER, 1975, Vol. 65, No. 12
to people often center initially on modifying or stimulating actions of individuals. Typically, this proves to be a nuisance and insufficiently successful. Later, more effective community-wide measures are often chosen, usually requiring decisions to mandate the necessary environmental changes. These work better because they protect everyone, and because, coming later, they are usually built on more advanced knowledge. Evolution from obstrusive to unobtrusive protective mechanisms is characteristic in our society. And each transition requires technical expertise on the issues. A wide variety of factors complicates this transition. Not the least of these are opposing special interests and the customary presence of misleading folklore concerning the measures involved, especially with respect to the safety, reliability, and efficacy of the proposed measure. Controversies centering on measures for controlling damage from environmental hazards typically go on for decades-until society becomes sufficiently informed to take corrective action. Dr. Leon Robertson's paper, "Safety Belt Use in Automobiles with Starter-Interlock and Buzzer-Light Sys-
'o
IL
POLICY ALTERNATIVES FOR ALCOHOL CONTROL The suggestion in the current issue of this Journal and elsewhere that alcoholism can and should be approached as a problem of public health control techniques, rather than as a matter of individual pathologies," 2 is attractive and enlightened. As with many other social problems, prevention appears to be far more cost effective than treatment. The public interest in reduction of alcoholism and alcoholrelated mortality is probably best served by attacking the problem at the point of greatest leverage. And "blaming the victim" is currently unfashionable among those concerned with public policy3-even in those instances in which the victim is clearly responsible for his own plight, as in those cases of automobile injury which result from the victim's failure to fasten his seat belt. Yet it is far from clear that a concerted policy of reducing alcoholism and alcohol-related disease by controlling the distribution and consumption of alcohol is, at this time, either feasible or desirable. We know very little about the costs and benefits, either absolute or relative, of various control mechanisms, and effective techniques for inducing health-related behavioral changes through educational or informational strategies remain to be identified.4 The history of alcohol control in this country and some others, moreover, is the history of the imposition of the tastes and preferences of one group on others; put another way, questions of equity and the rights of individuals and groups are involved. There can be no question of the substantial covariation among rates of per capita alcohol consumption, the incidence of alcoholism, and the incidence of alcohol-related mortality, most notably from cirrhosis.`8 Another study of this relationship appears in the current issue of the Journal.9 Reductions in per capita consumption, achieved through the imposition of control measures, have been found, in several instances, to lead to reductions in both cirrhosis mortality and arrests for alcohol-connected offenses-in the short run.'° Effective strategies to reduce per capita consumption thus might appear to offer the hope of reducing the incidence of alcoholism. Possible strategies to reduce per capita consumption fall into three general categories: taxation; restrictions on distribution; and education.* Increased taxation of alcoholic beverages could be expected, by raising the net cost to consumers, to reduce demand-assuming that the price *
Measures which
apply
to the
behauior of' those who have
already consumed excessive amounts of alcohol are not properly control strategies, and are therefore not considered in this discussion. Policies such as criminal prohibitions against public drunkenness tend to be more punitive than preventive; moreover, they generally don't work very well. More sophisticated measures, such as those that would impose criminal liability on bartenders or hosts 1340
AJPH
DECEMBER. 1975.
Vol. 65. No. 12
elasticity of demand is non-negligible, and that higher prices would discourage consumption.11 Restrictions on distribution, such as reducing the number of retail outlets for alcoholic beverages or further limiting the hours they are permitted to remain open, would create noneconomic costs in time and inconvenience which might also be expected to discourage consumption. Educational activities would attempt to induce consumers to turn 'away from alcohol spontaneously, even in the absence of such external constraints. Since there is no mutual exclusivity among these three strategies, any combination of them might also be
attempted. It is significant to note that all three strategies have already been implemented to a considerable extent in the United States, for reasons largely unrelated to the control of alcoholism, and that the rates of both per capita consumption and alcoholism have continued to rise.10 12 Precise estimates for existing levels of expenditure on alcohol education are hard to come by, but they must certainly run in the tens of millions of dollars. While the tax rates on alcoholic beverages are lower in the United States than in most Western nations-as are taxes on almost all "luxury" items-alcohol is among the most heavily taxed of all U.S. consumer commodities.10 The remnants of Puritan and prohibitionist sentiment have encumbered liquor retailers with restrictions more severe than those placed on the purveyors of any other legal product.10 The failure of these restrictions to have a visible impact does not, of course, imply per se that they are alcoholism on inappropriate or necessarily ineffective. More and better restrictions might be preferable. But there are some very sound reasons for being pessimistic about the potential for such devices to ever have much of an impact on alcoholism problems, and those reasons also hint at the undesirability of current control strategies. While it is true that alcoholism tends to rise with increases in per capita consumption, it is also true that, in any social grouping or class, only a fraction of those who consume alcohol ever become alcoholics-or suffer any significant ill effects.13 14 There is some evidence that the consequences of moderate levels of alcohol consumption may even be salutary for some individuals.15 Denial of access to alcohol may displace addictive behavior onto other substances, such as barbiturates, with, at best, no net social who serve excessive quantities of' alcohol to individuals who then become involved in automobile accidents, may have more promise as strategies f'or preventing individual incidents of' drunkenness. Thev approach the problem of chronic alcoholism only marginally. and also fall outside the "reducing alcoholism by reducing per capita consumption" paradigm.
gain.1" Moreover, patterns of alcohol usage vary dramatically across social, cultural, ethnic, and economic lines, and those subcultures with relatively small proportions of abstainers tend to have relatively low rates of alcoholism.13 14 Impeding the flow of alcohol to actual or potential alcoholics through the use of control mechanisms will also impede its use by those for whom moderate consumption is a valued element of social life-and is likely to do so in a relatively inequitable manner. A dramatic increase in the taxation of alcoholic beverages, for instance, would be felt much more strongly by the poor than the middle class, and might represent a significant financial and social hardship for those among the poor who do not abuse alcohol but value it. Ironically, for such individuals, higher rates of alcohol taxation would necessitate that they spend a higher proportion of their finite disposable incomes on alcohol. More to the point, those historical instances adduced by proponents of alcohol control as evidence that taxation can reduce consumption and alcoholism have tended to be short lived, as increases in per capita income soon overtake the demand-dampening impact on the taxes.10 Growth in per capita income remains the strongest single predictor of growth in per capita consumption in modern societies, suggesting that, for most individuals, alcoholic beverages are a highly discretionary commodity.9' 12 Tax policies have induced shifts in consumption patterns from one type of alcohol to another (spirits to beer, for instance),14 but with no obvious effect on alcoholism. There is no evidence that those prone to alcohol abuse share a similar take-it-or-leave-it attitude. This is the crucial behavioral question relative to alcohol control strategies: whether price and nonprice elasticities of demand for alcohol are uniform throughout the population, or whether elasticity is much lower among the "abuser" tail of the "log-normal distribution" of consumers. There is no hard evidence on this question that would support the beliefs of control strategy proponents. The weight of intuitive evidence runs directly opposite. Gross correlations between per capita consumption and alcoholism rates are, for these purposes, too highly aggregated and too subject to the ecological fallacy. Unless one subscribes a priori to the "single drop of rum" theory, it is clear that higher taxation would reduce consumption among those for whom consumption does good but no harm, and especially the poor within that group, without its being at all clear whether it would reduce alcoholism. Similarly, further constraints on the retail distribution of alcoholic beverages would inconvenience the large proportion of the population that uses alcohol beneficially, without any clear evidence to expect an impact on alcoholism. More importantly, the history of alcohol control through regulation of distribution in this country is manifestly one of corruption and discrimination against lower class consumers. The considerable monopoly rents that regulation generates make corruption in the distribution of licenses and the enforcement of their provisions almost inevitable; like other sumptuary laws, those pertaining to liquor control have been differentially enforced across
socioeconomic lines, occasioning considerable legitimate resentment in minority communities." Educational strategies for alcohol control raise different, more complex questions. Most broadly, the problem is the generic one of inducing behavioral changes that will be conducive to improved health in a population that seems strongly attached to its vices. Here alcohol consumption falls into the same category as tobacco smoking, overeating, and participation in excessively stressful environments. At the moment, there appears to be no easy-or hard-way to prevail on any significant proportion of individuals at risk to modify behaviors of this kind. Attitudinal changes produced by education have been demonstrated, but no connection has been proven between these changes and behavior. Additional research in this area has increasingly been recognized as a major priority for public health.17 Even the Congress appears finally to have caught on.18 The problem is central to alcohol control, though by no means limited to it. While the long range imperative is clear, there is little ground for short run optimism. In the immediate future, then, Beauchamp's call for a policy of alcohol control appears to lack desirable mechanisms for translation into specific policies. This is more as a result of the unwieldiness of available policy alternatives than the machinations of the political-industrial complex that profits considerably from the distribution and consumption of alcoholic beverages. More narrowly gauged, less global alternatives offer some prospects for change. Rigid law enforcement may reduce the frequency with which alcohol abuse is connected with driving."1 Increased energy prices may well induce a shift in drinking from bars and restaurants to the home. Perceived preferences of light drinkers may further encourage the alcohol industry's trend toward production of beverages with lower absolute alcohol content, thus reducing per capita consumption of absolute alcohol. Yet in terms of the overall problem of alcohol abuse and alcoholism, these remain marginal approaches to the problem. Students of alcohol usage and alcohol control often point with distaste to the enormous, and seemingly random, variation of regulations and prohibitions embodied in the laws of this country's 50 states and thousands of political subdivisions. It has generally been agreed that a uniform national policy of alcohol control would be substantially neater and more sensible.1' 20 Yet, given the present state of knowledge about the effectiveness of control mechanisms, greater uniformity has only neatness to recommend it. The existing American crazy quilt can be seen, instead, as a kind of complex natural experiment. To be sure, there are a large number of independent variables, but the variation is sufficiently great, and the techniques of multivariate statistical analysis are sufficiently sophisticated, to suggest that this natural experiment should be employed for planned research and evaluation rather than be prematurely foreclosed on the basis of inadequate information. So promising and straightforward is the simple syllogism of reducing alcoholism by reducing total social consumption that it is painful to realize that there appears to be no way to make it work in the near future. Over the EDITORIALS
1341
longer run, however, the prospect is so appealing that future research and experimentation should be strongly supported. Systematic research into alcohol control policy is only beginning, but its ultimate potential is too great to ignore. However, research on the cause of alcoholism as addictive behavior must also continue. The correlations between per capita consumption and alcoholism deaths due to cirrhosis do not prove the causal factors in addictive behavior in a portion of the exposed population. Before any alternative policies are rejected, it is necessary that we know more about the causes of the behavioral relationships they presuppose.
Bruce C. Vladeck, PhD Assistant Professor of Public Health Robert J. Weiss, MD Director Center for Community Health Systems Columbia University New York REFERENCES 1. Beauchamp, D. E., Public Health: Alien Ethic in a Strange Land? (Commentary). Am. J. Public Health 65:1338-1339, 1975. 2. Beauchamp, D. E. The Alcohol Alibi: Blaming Alcoholics. Transaction 98:12-17, 1975. 3. Ryan, W. Blaming the Victim. Vintage Books, New York, 1971. 4. Friedman, K. M. Cigarette Smoking and Public Policy (Editorial). Am. J. Public Health 65:979-980, 1975. 5. deLint, J. The Prevention of Alcoholism. Prev. Med. 3:24-35, 1974. 6. Schmidt, W., and deLint, J. Estimating the Prevalence of Alcoholism from Alcohol Consumption and Mortality Data. Q. J. Stud. Alcohol. 31:957-964, 1970.
7. Terris, M. Epidemiology of Cirrhosis of the Liver. Am. J. Public Health 58:5-12, 1968. 8. Popham, R. E. Indirect Methods of Alcoholism Prevalence Estimation: A Critical Evaluation. In Alcohol and Alcoholism, edited by Popham, R. E. Addiction Research Foundation, Toronto, Ontario, 1970. 9. Brenner, M. H. Trends in Alcohol Consumption and Associated Illnesses. Am. J. Public Health 65:1279-1292, 1975. 10. Wilkinson, R. The Prevention of Drinking Problems. Oxford University Press, New York, 1970. 11. Niskanen, W. A. Taxation and the Demand for Alcoholic Beverages. The RAND Corporation, Santa Monica, 1960. 12. Efron, V., Keller, M., and Gurioli, C. Statistics on Consumption of Alcohol and on Alcoholism. Rutgers University Press, New Brunswick, New Jersey, 1974. 13. Cahalan, D., Cisin, I. H., and Crossley, H. M. American Drinking Practices. Social Research Group. George Washington University, Washington, DC, 1967. 14. National Institute on Alcohol Abuse and Alcoholism. Alcohol and Health: New Knowledge. Second Special Report to the U.S. Congress, Ch.X. U.S. Government Printing Office, Washington, DC, 1974. 15. National Institute on Alcohol Abuse and Alcoholism. Alcohol and Health: New Knowledge. Second Special Report to the U.S. Congress, Ch. V, Pt. 4. U.S. Government Printing Office, Washington, DC, 1974. 16. Light, D. Costs and Benefits of Alcohol Consumption. Transaction 98:13-24, 1975. 17. U.S. Department of Health, Education, and Welfare, Assistant Secretary for Health. Forward Plan for Health, 1976-1980. 1974. 18. Public Law 93-641, Sec. 1502 (10), 1974. 19. National Institute on Alcohol Abuse and Alcoholism. Alcohol and Health: New Knowledge. Second Special Report to the U.S. Congress, Ch. VI. U.S. Government Printing Office, Washington, DC, 1974. 20. Chafetz, M. E. Introduction. In Alcohol and Health: New Knowledge. National Institute on Alcohol Abuse and Alcoholism. U.S. Government Printing Office, Washington, DC, 1974.
PERSPECTIVE ON A CURRENT PUBLIC HEALTH CONTROVERSY Numerous controversies have marked the evolution of improvements in the public's health, many major ones having centered on whether individuals must do something themselves to avoid damage from everyday environmental hazards, or whether available actions should be adopted that extend protection to all. The public and professional turbulence about whether smallpox, cholera, typhoid, and childbed fever could and should be controlled are early illustrations. The means of such control have usually been the center of the storm. Examples include quarantines; inoculations; closing down contaminated wells; making obstetrics sanitary; pasteurization of milk; fluoridation of water; and, more recently, controlling some motor vehiclerelated injuries. In public health, as developing scientific knowledge makes possible the control of an environmental source of morbidity and mortality, attempts at control of the damage Dr. Haddon is President of the Insurance Institute for Highway Safety, Washington, DC, and headed, in 1966-1969, what is now the National Highway Traffic Safety Administration. 1342
AJPH DECEMBER, 1975, Vol. 65, No. 12
to people often center initially on modifying or stimulating actions of individuals. Typically, this proves to be a nuisance and insufficiently successful. Later, more effective community-wide measures are often chosen, usually requiring decisions to mandate the necessary environmental changes. These work better because they protect everyone, and because, coming later, they are usually built on more advanced knowledge. Evolution from obstrusive to unobtrusive protective mechanisms is characteristic in our society. And each transition requires technical expertise on the issues. A wide variety of factors complicates this transition. Not the least of these are opposing special interests and the customary presence of misleading folklore concerning the measures involved, especially with respect to the safety, reliability, and efficacy of the proposed measure. Controversies centering on measures for controlling damage from environmental hazards typically go on for decades-until society becomes sufficiently informed to take corrective action. Dr. Leon Robertson's paper, "Safety Belt Use in Automobiles with Starter-Interlock and Buzzer-Light Sys-
