Substance Use & Misuse, 49:1531–1545, 2014 C 2014 Informa Healthcare USA, Inc. copyright ISSN: 1082-6084 print / 1532-2491 online DOI: 10.3109/10826084.2014.913382

ORIGINAL ARTICLE

Trends in Consumption of Alcoholic Beverages and Policy Interventions in Europe: An Uncertainty “Associated” Perspective Allaman Allamani, Nadia Olimpi, Pasquale Pepe and Francesco Cipriani Tuscany Regional Health Agency, Firenze, Italy POLICY MEASURES AND ALCOHOLIC BEVERAGE CONSUMPTION TRENDS: AN APPARENTLY INCONSISTENT RELATIONSHIP

Having qualitatively investigated, both the temporal curves of alcoholic beverage consumption trends and the introduction of preventive alcohol policy measures in six European countries during the 1960s–2000s, drinking control policy measures often appeared to operate as co-factors of change, while during some periods of time they were not even present even if effective consumption changes were occurring. Study limitations are noted.

Alcohol has also been increasingly recognized as being an important health determinant in Europe, resulting in numerous health and social consequences (Edwards et al., 1994; Rehm & Scafato, 2011). As responses to alcohol drinking-related problems, preventive alcoholic beverages control policies, have had a long tradition within the public health field in the Northern European countries, while the perception of alcoholic beverages as potentially producing community problems, with the introduction of policy measures, has began to spread only in the 1970s and even the 1980s in the Southern European countries (Allamani et al., 2011). The promulgation of the first European Alcohol Action Plan certainly constituted an additional step to promote the idea of alcohol drinking prevention in Europe (World Health Organization, 1992). Different restrictive, and sometime liberal methods including price and tax policy, regulation of physical availability, advertising regulations, education and information programs, and preventive actions that mobilize communities, as well as control of public drinking and of drunk driving, were identified as being effective alcohol control policy measures to affect both consumption and harm (Babor et al., 2003, 2010; Holder et al., 2000; Holmila, 1997; ¨ Norstr¨om, 2002; Osterberg & Karlsson, 2002; Pridemore, Chamlin, & Andreev, 2013; Pridemore & Snowden, 2009; Wagenaar, 1986; and, for an overview, Anderson, 2009; Anderson, Møller, & Galea, 2012; Treno, Marzell, Gruenenwald, & Holder, 2014). One problem that interferes with the promulgation of policies and their effectiveness is that alcoholic beverage control policies make sense in cultures where people address alcohol as a social and health problems, while they appear to be less needed in societies where alcohol consumption and its direct or indirect consequences gets

Keywords alcoholic beverage preventive policy measures, consumption curve, qualitative method, long alcohol waves, time lag

DRINKING TRENDS AND ALCOHOLIC BEVERAGE CONTROL POLICIES IN EUROPE DURING 1960–2008

Europe has a long history of diverse traditions and meanings regarding alcoholic beverages, dating back to ancient Greece and Rome. Contemporary Europe has the highest consumption of alcoholic beverage in the world (Møller & Anderson, 2012). During the decades following the World War II, a process of gradual convergence regarding alcohol consumption began throughout Europe. In fact, the Northern countries manifested a general increase, the Mediterranean countries had an overall decrease (particularly in wine consumption), and the eastern and central countries of the European Union have been experiencing an intermediate drinking pattern (Allamani et al., 2011; Leifman, 2002; World Health Organization, 2011). Table 1 and Figure 1 show the recorded consumption of total consumption of alcoholic beverages, from 1961 to 2008, for the 12 AMPHORA study European countries (AMPHORA, 2013; World Health Organization, 2011).

Address correspondence to Allaman Allamani, Agenzia Regionale di Sanit`a Toscana, Firenze, Italy; E-mail: [email protected]; [email protected].

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FIGURE 1. Recorded alcohol consumption trends in 12 European countries. Adult (15+ years) liters of pure alcohol per capita, 1961–2008. (source: World Health Organization, 2011).

little public attention (Room, 1999). Also, the enforcement of measures and their interplay with the responsiveness of the different populations vary according to nations and cultures, making it difficult to compare the effects ¨ of similar interventions in different areas (Osterberg & Karlsson, 2002). Moreover, the different measures appear

TABLE 1. Recorded alcohol consumption trends in 12 European countries Countries

1961

1970

1980

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2008

Austria Finland France Hungary Italy Netherlands Norway Poland Spain Sweden Switzerland United Kingdom

11.0 2.9 26.0 9.0 19.2 3.7 3.7 6.3 14.6 6.0 12.3 7.1

13.9 5.8 21.6 11.5 19.7 7.7 4.7 7.6 16.1 7.2 14.0 6.7

13.8 7.9 19.2 16.9 16.7 11.3 5.9 11.5 18.5 6.7 13.4 9.6

12.6 9.5 15.8 16.2 11.0 9.9 5.0 8.3 13.6 6.4 13.1 9.5

13.7 8.6 13.6 12.3 9.3 10.1 5.7 8.3 11.5 6.0 11.4 10.4

12.4 10.3 11.6∗ 11.8 7.4 9.3 6.8 11.1 10.0∗∗ 6.9 10.8 10.9

Note: Liters of pure alcohol per capita, adult (15+ years) (World Health Organization, 2011). ∗ 2007. ∗∗ 2006.

not to have the same characteristics, and may not share the same strength and lag time for their effects, temporary or more permanent ones, to be manifested in terms of patterns in alcohol consumption changes (see Karlsson, Lin¨ ¨ demann, & Osterberg, 2012;Karlsson & Osterberg, 2001). Although most of the afore-mentioned effective alcoholic beverage control policy measures are based on scientific evidence in an experimental laboratory context, it is not always obvious that they are also able to show effectiveness at the country level. We believe, it can be helpful to qualitatively investigate at the country level if the introduction of a restriction measure or permissive measure, is able to, respectively, correspond to a reduction or increase in consumption. The outcome of this investigation may help to formulate hypotheses, which would be quantitatively analyzed. AIM AND METHOD OF THIS STUDY

The observation of the curves of the alcoholic beverages consumption temporal trends in a country allows some understanding of their pattern when, e.g., consumption trends are increasing, decreasing, or mixed with peaks and drops.1 This statement can be made for various types of 1

It is useful to consider that the contemporary scientism ideology of collecting and moving from relevant, representative, measureable data, to appropriate methodological analysis which leads to knowing from

ALCOHOL TRENDS AND POLICIES

time trends, like flu morbidity, gross domestic product and employment changes, the stock exchange quotations, or the course of fever in a medical record. Observing these curves is also possible to hypothesize the effect on trends due to a preventive vaccination campaign, or to a package of reforms that act on taxes, or to the permissive or restrictive measures on the availability of consumption of alcoholic beverages. An important aspect in order to evaluate the impact of various interventions is whether the planned measures have been carried out along all points of the chain of persons who have the responsibility to enforce the measure, and whether the measures have been taken regularly by receivers. In the case of administration of a medicament, in fact, there is a standard procedure, for example, starting from the solubilization of the drug provided by the packaging set up by the pharmaceutical industry, to its insertion into the syringe, and in a drip placed in the vein of the patient by the nurse, according to the rules. But in the field of social interventions the implementation of the measures and their reception by the population, technically referred to as “enforcement,” are subject to numerous factors involved in the approval of the governmental norm, its implementation in the community on the part of local officials, and the support that the public opinion may give to that norm in particular, and to the government in general (Karlsson et al., 2012; Nordlund & Østhus, 2013). These factors and their enabling as well as interfering influential individual and systemic stakeholders, with their

which understanding can be created in order to effectively intervene, if and when necessary, can be flawed by the reality of studying within the realities of uncertainties, randomness, unpredictabilities, and lack of necessary controls over a myriad of known-visible, unknown-hidden, and unknowable interacting phenomenon and processes during any given time and place. The reader interested in the implications of such everpresent realities when planning, implementing, and assessing effective interventions are referred to: Diacu, Florin, 2010, Mega disasters: The science of predicting the next catastrophe. Princeton: Princeton University Press; 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; the work of the cyberneticist Heinz Von Foerster who posited that there are two types of questions: legitimate questions and illegitimate questions. The former are those for which the answer is not known. It is these questions, and the work which they stimulate, which are associated with breakthroughs in needed knowledge. An illegitimate question is one for which the answer is known. Answers are known to most questions which are traditionally asked. Heinz Von Foerster, Patricia M. Mora, and Lawrence W. Amiot, “Doomsday; Friday, 13 November, A.D, 2026,” Science, 132, 1960. pp. 1291–1295, and the work of the urban planners Horst Rittel and Melvin Webber (1973) who suggested that problems can and should be usefully categorized into two types: “tame problems” and “wicked problems” The former are solved in a traditional linear analytic known and tried “water fall paradigm”; gather data, analyze data, formulate solution, implement solution. The latter “wicked problems” can only be responded to individually, each time anew, with no ultimate, repeatable solution. Rittel, H. and Webber, M. (1973). “Dilemmas in a General Theory of Planning”. Policy Sciences, Vol. 4, pp 155-169. Man’s range of “appetites” are complex, dynamic, non-linear, multi-dimensional and bounded (time, place, “big events”, age, gender and gender identity, ethnicity, religion and religiosity, SEC, etc.) Editor’s note.

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agendas, goals, objectives, and temporary as well as ongoing activities, may be uncontrollable. Another question is how long it takes for the effect of the measure to be implemented. The simplest case is that of an antibiotic administered to a patient with fever: the trial, which took place earlier in the laboratory, has allowed the doctor to calculate the average time in which the drug is distributed in the body and determines its effect. Unlike pharmacological studies, and of the studies on the harmful effects, both immediate and delayed, of use of alcoholic beverages (Shield, Kehoe, Gmel, Rehm, & Rehm, 2012), the area of the time lag of preventive interventions is a field still open to new studies. Moreover, a similar question arises about the duration that the effect of an alcohol consumption control policy measure could maintain: a year? two years? more years? And under what necessary operating conditions (endogenous as well as exogenous, micro to macro levels, qualities, intensities, etc.)? Even the observation of changes of the temporal trend curve, after the introduction of a measure, raises questions. For example, one can observe the fall of fever following the introduction of a new antibiotic in the treatment of a patient with fever. Or, it can be observed that the introduction of a restrictive policy is associated with its “bringing down” the consumption curve, which was first growing up. But if the measure introduced does not appear to clearly change the direction of the trend—as, for example, it may happen in the case of the administration of an antibiotic during the descending phase of the fever, or of a restrictive policy introduced during a decreasing consumption period—the attention can only be placed on small variations in the curve, which could indicate that the introduced measure only partially contributes to the on-going trend—since other factors are presumably operating. As part of the study AMPHORA, work-package 3 (AMPHORA, 2013), the authors of this article examined the curves of the total consumption of alcoholic beverages between 1961 and 2008, using the recorded consumption figures provided by WHO (2011). Also the six country main alcoholic beverage control policy measures selected in the AMPHORA study, in agreement with the local experts (even if consensualizing a binary static process and anticipated outcome raises numerous issues for effective interventions) were used (see AMPHORA, 2013; Baccini & Carreras, 2014); such measures were also considered for their quality to be permissive or restrictive. Ultimately, we examined whether the introduction of an alcoholic beverage control policy measure was associated with a change in the direction of the consumption trend, or with a continuation of the on-going trend, or was not associated with any change. In another part of the study, a quantitative analysis of the relationship between policies and consumption was carried out (see Baccini & Carreras, 2014; Buscema, Massini, & Maurelli, 2014). The observations that we have developed in this article are qualitative and are based on an empirical approach, not using mathematical and statistical analyses; they retain their descriptive function simply based on

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observation. The observation of these trends over time should not be considered as supporting the post hoc propter hoc fallacious principle of causal link—i.e., since by definition causes preceding their effects do if shortly after the introduction of the measure a change occurs, this is attributed to the agent previously introduced—In fact, temporality is only one of the criteria for concluding that an observed association is representative of a causal relationship and is not in an evidence for a causal connection because of the myriad of alternative explanations (Hill, 1965). Instead, these observations should be viewed as being a useful tool to make appropriate working hypothesis to be subsequently evaluated with appropriate mathematical–statistical methods. Among the 12 countries of the AMPHORA project, only six countries, from which we had experienced a preliminary contribution to the drafting of a previous presentation (Allamani et al., 2011), have been studied. The countries are representative of Northern Europe: Finland, Norway; Central Europe: Switzerland, Eastern Europe: Poland; Mediterranean Europe: Spain and Italy. CONSUMPTION TIME TRENDS AND THE INTRODUCTION OF CONTROL POLICY MEASURES IN SIX EUROPEAN COUNTRIES: A DESCRIPTION Nordic Countries, Finland

In Finland, three trend phases in total registered alcohol consumption, liters of pure alcohol per inhabitant 15 years and older (source: World Health Organization, 2011) can be observed during the period 1961 to 2008 (see Figure 2).

The first phase of consumption increases between 1961 and 1968, occurred with no policy measures being introduced, to which they could be attributed (Figure 2). The first control policy measures introduced in the country during the study period were two permissive policies: the Alcohol Act, and the Act on medium strength beer, which were approved in 1968 but went into effect in January 1969 and included an increase in the availability of medium strength beer, lowered age limits for buying alcohol beverages, and opening of monopoly liquor stores in the previously dry countryside. After the introduction of these two measures, which were designed to loosen the previous limitations to purchase alcohol beverages, the pro capita consumption of the equivalent of pure alcohol per inhabitant aged 15 years and older increased from 3.9 in 1968 to 5.7 in 1969. During the second plateau phase (1975–1996), the introduction of a restriction measure in 1975, with an increase in price of alcoholic beverages, appeared to be contemporary to a change in the direction of the reduction trend, with a reduction in consumption from 8.4 in 1974 to 8.0 in 1975. With the subsequent permissive Alcohol Act, effective with January 1, 1995, the monopoly on production, import, export, and wholesale was abolished. This measure appears to have been associated with the already on-going increase of Finnish alcohol consumption, from 8.2 in 1994 to 8.3 in 1995. The following years, but 1996, showed a further increasing trend. In 2004, when taxation on alcoholic beverages was lowered, the previous trend consumption continued to increase, with an apparently unaffected slope. Nordic Countries, Norway

(a) From 1961 to 1974, there was a remarkable increase of consumption, which can be subdivided into three periods: (1) a constant increase between 1961 and 1968, from 2.9 in 1961 to 3.9 in 1968; (2) a sharp raise between 1968 and 1969 (from 3.9 to 5.7); and (3) another constant increase from 1969 to 1974 (from 5.7 to 8.4). (b) Between 1975 to up to 1996, alcohol consumption reached a sort of irregular plateau, from 8.4 L in 1975 to 8.2 L in 1996; in this period, a fluctuation was observed between 1985 and 1996, with a peak at 9.5 L per capita in 1990. (c) Between 1997 and 2008, alcohol consumption increased again, from 8.6 L in 1997 to 10.3 L in 2008. During the period from 1960 to 2008, 104 countrywide alcoholic beverage control policy measures were introduced in Finland, according to national experts (Voller, Maccari, Pepe, & Allamani, 2014). The six most relevant alcoholic beverage control policy measures were singled out to better analyze the effect of policies within each country and across the 12 countries (see AMPHORA, 2013, Part 1, Collection and selection of alcoholic beverage control policy measure; AMPHORA, 2013, Part 2, Finland). The selected two restrictive, and the four permissive measures, are listed in Table 2.

In Norway too, three trend phases in total registered alcohol consumption, liters of pure alcohol per inhabitant 15 years and older (source: World Health Organization, 2011) can be observed during the period 1961–2008 (see Figure 3). (a) From 1961 to 1977, alcohol consumption increased from 3.7 to 5.7; (b) From 1978 up to 1993, there was a sort of plateau from 5.1 to 4.5 (c) From 1994 to 2008, we can observe an increasing trend again from 4.7 to 6.7 Regarding the period from 1960 to 2008, 35 control policy measures were introduced in Norway, according to national experts (Voller et al., 2014). However, a smaller number of main policy measures, which was consensually set at 6, were considered (see AMPHORA 2013, Part 1, Collection and selection of alcoholic beverage control policy measure; AMPHORA, 2013, Part 2, Norway). Two are permissive, and four are restrictive measures. The first part of the consumption increase, between 1961 and 1969, occurred with no liberal policy measures being introduced, to which it could be attributed (Table 3). Actually in 1963, a special tax (særavgift) on spirits,

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TABLE 2. The selected six main alcoholic beverage control policy measures in Finland, 1960–2008 (source: AMPHORA, 2013, Part 2, Finland) 1. Alcohol Act (459/1968, effective as of 1 January, 1969): the off-premise age limit was lowered from 21 to 20 years for buying high alcohol content beverages and from 21 to 18 years for purchasing moderate alcohol content beverages (max 22% alcohol by volume). 2. Act on Medium Strength Beer (462/1968, effective as of 1 January, 1969): medium beer license to groceries: State alcohol monopoly Alko could grant grocery stores and cafes, and not just in the state retail alcohol monopoly Alko, the right to sell medium beer containing at most 4.7% alcohol by volume. 3. 1975 price increases to be attributed to taxes. 4. 1995 Alcohol Act: on January 1, 1995, due to Finland’s membership in the European Union, the new Alcohol Act abolished the monopoly on production, import, export, and wholesale of alcoholic beverages. It granted domestic wine farmers the right or license to sell their products off-the premises (but only products containing 13% alcohol by volume or less) at the production site. Grocery stores and cafes were allowed to sell not only beer, but also other beverages produced by fermentation like ciders, and long drinks (a drink composed of one liquor and one mixer like tonic water) containing less than 4.7% alcohol by volume. All alcoholic beverages could be served on-premise from 9 a.m. onwards. 5. 2004 taxation; Taxation on beer was lowered with 32%, the taxation on wine was cut with 10%, intermediate products with 40%, and distilled spirits with 44%. 6. 2008 alcohol excise duty increases: Alcohol excise duties were increased in January 2008. The tax on distilled spirits went up by 15% and, on other beverages by 10%. Alcohol taxes were also increased in January 2009 and September 2009. In both cases, taxes went up by 10% for all alcoholic beverages. 12 2008: alcohol e xcis e duty incre as e (R)

10 1975: price incre as e (taxe s ) (R)

2004: low e re d taxation (P )

8 1969: low e re d age lim its (P) 1995: Alcohol Act (P ) 6

1969: m e dium be e r lice ns e to groce rie s and cafè (P ) 4

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FIGURE 2. Recorded alcohol consumption trends in Finland and main policy measures. Adult (15+ years) liters of pure alcohol per capita, 1961–2008 (source: World Health Organization, 2011). P, permissive measure; R, restrictive measure.

increased from 64% to 65% (according to AMPHORA work-package 3 dataset2 ), should have affected a reduction in consumption, but this was not the case. While the 1970 law abolishing coerced treatment for alcoholics parallels a slight increase in consumption, the introduction of 2

Available on request to the authors.

the 1973 permissive policy measure paralleled the already increasing trend. The 1975 total ban on advertising for all alcoholic beverages paralleled an on-going increase in consumption, which had a temporary drop only in 1978. The 1981 restrictive taxes increase was promulgated when there was an already descending consumption curve. The introduction of the 1985 program of education about intoxication

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TABLE 3. The selected six main alcoholic beverage control policy measures in Norway, 1960–2008 (source: AMPHORA, 2013, Part 2, Norway) 1. 1970. A law that was used to put alcoholics into coerced treatment was abolished. At the same time, more treatment facilities were made available. 2. 1973. The prohibition against on-premises sale of spirits on Saturdays was repealed. 3. 1975. Total ban on advertising all alcoholic beverages. Two stages: in 1975, ban on ads in newspapers, magazines, journals etc. In 1977. Ban included illuminated advertisement, poster advertisements, advertisements on restaurant fixtures, and equipment. There were no commercial TV or Radio stations at the time, and when they were established they came under the total ban. 4. 1981. Excise duty increased. The excise duty on alcoholic beverages has been adjusted almost annually by the Parliament, but usually just to make sure that the real price of alcohol beverages has followed the real price of other consumer goods. The increase in 1980 was bigger than usual. In general, the excise taxes in Norway has been high during the whole period (1960–2008), compared to other countries. 5. 1985. Education about Intoxication and pregnancy. The campaign aimed at reducing the consumption of alcohol during pregnancy. Health workers were used to give information directly to pregnant women 6. 1998. The attitude on alcohol monopoly (Vinmonopolet) changed from being a tool for alcoholic beverage control policy to a tool for consumer policy. The result was a rapid increase in outlets and sales.

Eastern Europe, Poland

and pregnancy was associated with an ongoing increasing trend. The 1998 introduction of a permissive alcohol monopoly policy measure appears to have been associated with a further increase of total consumption of alcoholic beverages.

In Poland, the consumption of alcoholic beverages (total registered alcohol consumption, liters of pure alcohol per inhabitant 15 years and older—source: World Health Organization, 2011) can be divided in three main periods.

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7 1975: total ban on adve rtis ing all alcoholic be ve rage s (R)

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1970: no alcoholics in coe rcions m ore tre atm e nt facilitie s available

1998: alcohol m onopoly attitude change d tow ards cons um e r policy (P )

1981: e xcis e duty incre as e d (R)

5 1973: on-pre m is e s s ale of s pirits 1985: e ducation on alcohol and pre gnancy (R) on Saturday allow e d (P )

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FIGURE 3. Recorded alcohol consumption trends in Norway and main policy measures. Adult (15+ years) liters of pure alcohol per capita, 1961–2008 (source: World Health Organization, 2011). P, permissive measure; R, restrictive measure.

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TABLE 4. The selected six main alcoholic beverage policy measures in Poland, 1960–2008 (source: AMPHORA, 2013, Part 2, Poland) 1. 1960–1982. Act against alcoholism, 1959. State monopoly for spirits distribution; Spirits sales in separated outlets; Limitations in places for selling alcohol; only Central Administration gave permission for wine and spirits selling. 2. 1982. Law on upbringing in society and counteracting alcoholism, 1982. Separate state enterprise (PONAL) has to deal with off-premises alcohol distribution. For the whole country centrally, yearly defined number of alcohol outlets. Yearly defined national plans of sales of all alcoholic beverages. Many limitations for alcohol selling places. 3. 1984. Liquidation of state enterprise PONAL, Ministry of Domestic Trade could designate alcohol distribution and sale to more enterprises. Centrally planned number of outlets did not covered alcoholic beverages below 4.5%. 4. 1990. (Parliament amendment to Law on upbringing in sobriety. . .) Liquidation of the state monopoly in bulk sales of alcohol. 5. 1993. (Parliament amendment to Law on upbringing in sobriety. . .) Competence regarding number of alcohol outlets shifted from central to local level; General regulation for licensing rules and licensing payment (competence regarding number of alcohol outlets were shifted from central—every year on limits for whole country decided state government—to local level—community level. Most of local governments decided very fast to increase the number of outlets). 6. 1996. (Parliament amendment to Law on upbringing in sobriety. . .) Beer was excluded from the rule of sale alcohol in separate outlets only.

(a) Between 1961–1980, there was an important increase, from 6.3 L to 11.5 L; (b) From 1981 to 2000, there was a plateau from 8.7 to 8.3; (c) A new period started in 2001, from 7.5 L in 2001 to 11.1 L per capita in 2008.

sensually set at 6, were considered appropriate to better analyze the effect of policies within each country and across the 12 countries (see AMPHORA, 2013, Part 1, Collection and selection of alcoholic beverage control policy measure; AMPHORA, 2013, Part 2, Poland). The six main control policies selected included two restrictive ones, and four permissive measures. They are all listed in Table 4. The restrictive 1960 “Act against alcoholism,” operating at the beginning of the study period, is associated with a 3-year period of a slight decrease in alcohol

During the period from 1960 to 2008, 58 control policy measures were introduced in Poland, according to Polish experts (Voller et al., 2014). However, a smaller number of the most relevant policy measures, which was con-

12 1984: alcoholic be ve rage s be low 4,5% not ce ntrally planne d (P ) 10

1993: num be r of alcohol outle ts com pe te nce s hifte d from ce ntral to local le ve l (P )

8 1982: law on upbringing in s ocie ty and counte racting alcoholis m (R)

1996: s ale of be e r not only in the s e parate outle ts for alcohol (P )

6 1990: liquidation of the s tate m onopoly in bulk s ale s (P ) 1960-1982: Act agains t alcoholis m (R) 4

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FIGURE 4. Recorded alcohol consumption trends in Poland and main policy measures. Adult (15+ years) liters of pure alcohol per capita, 1961–2008 (source: World Health Organization, 2011). P, permissive measure; R, restrictive measure.

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TABLE 5. The selected six main alcoholic beverage control policy measures in Switzerland, 1960–2008 (source: AMPHORA, 2013, Part 2, Switzerland) 1. 1968. Dissolution of the previous cartel by which only specialized shops could sell spirits (with stable and high prices), because of concurrence of newly appearing self-service supermarkets and discounters –> spirits sale for cheap prices, sometimes as “stool pigeon” offers. 2. 1980. (i) Partial revision of Law on Spirits (“gebrannte Wasser”): because of changes on the market (appearance of discounters): (a) no “stool pigeon” offers allowed –> prohibition of spirits selling under effective costs; (b) restrictions on (retail-) market; (c) restrictions on advertising (no comparison of prices; no “lifestyle”-advertising); (d) restrictions on (retail-) market (Neudefinition der Handelskonzessionen”/ “Kleinhandelsbeschr¨ankungen”). 3. 1999. A complex massive set of legislations: (a)—July 99: Lowering of taxes on foreign spirits, i.e. a unification of taxation for all domestic and foreign spirits (29 Swiss Francs per liter 100% alcohol). Before, there have been more taxes on foreign spirits (32–58 Swiss Francs) than on domestic ones (26 Swiss Francs), which was not possible anymore because of international treaties (WTO). Removal of the prohibition to distil potatoes and grain –> more liberal market (b) 1999 Within revision of the Federal Constitution (Schweizerische Bundesverfassung), abolition of the so-called Bed¨urfnisklausel, which was a step toward more economic liberties. This article (“Bed¨urfnisklausel”) has allowed the cantons (departments) to restrict the assignment of permissions for opening new establishments and sell alcohol in the restaurant industry if there was “no need” for such 4. 2002. National control on minimum age-limits for buying alcoholic beverages (no alcohol sold to < 16 years old; wine, beer and cider sold to < 18 years old; spirits (including alcopops !) only for 18+ years old); before there were differences between cantons (departments). 5. 2004. Increased taxes on alcopops (“Sondersteuer”: 300% tax increase, compared to other spirits’ taxations) as 6th measure. 6. 2005. Lowering of limit for drunk driving from .8 to .5 per-mille.

consumption (from 6.3 in 1961 to 6.2 in 1964), followed by a steep increasing curve (Figure 4). The 1982 restrictive law on upbringing in society and counteracting alcoholism was preceded by a 1981 law (according to AMPHORA work-package 3 dataset3 ) that had heavily increased the prices of alcoholic beverages. The direction of the consumption trend had a contemporary no Table inversion, from 11.5 in 1980 to 8.7 in 1981 and 8.5 in 1982. By and large, the 1984, 1990, and 1996 permissive laws appear to be associated with the already increasing consumption trends. During the third period, the consumption growth of total consumption of alcoholic beverages, two minor permissive measures were introduced in 2001 and 2003, according to AMPHORA work-package 3 dataset.4 Central Europe, Switzerland

In Switzerland too, three trend phases in total registered alcohol consumption, liters of pure alcohol per inhabitant aged 15 and older (source: World Health Organization, 2011) can be observed during the period 1961–2008 (see Figure 5). In Switzerland, the trend of alcohol consumption had three waves: (a) During 1961 to 1973, the alcohol consumption rose from 12.3 in 1961 to 14.8 in 1973. (b) During 1974–1989, there was a sort of decreasing plateau from 14.5 in 1974 to 13.2 in 1989. (c) From 1990 to 2008, consumption began to decrease, from 13.1 in 1990 to 10.8 in 2008. For the period from 1960 to 2008, 39 country-wide alcoholic beverage control policy measures were intro3 4

Available on request to the authors. Available on request to the authors.

duced in Switzerland, according to Swiss experts (Voller et al., 2014). The six most relevant alcoholic beverage control policy measures were singled out to better analyze the effect of policies within each country and across the 12 countries (see AMPHORA, 2013, Part 1, Collection and selection of alcoholic beverage control policy measures; AMPHORA, 2013, Part 2, Switzerland). Four selected measures were restrictive and two were permissive (Table 5). The first part of the consumption increase, between 1961 and 1967, occurred with no liberal policy measures being introduced, to which it could be attributed. The permissive 1968 measure appears to be associated with the total alcohol consumption trend, which had already been increasing since 1961 (Figure 5). The restrictive 1980 law was associated with increases in consumption from 13.3 in 1979 to 13.4 both in 1980 and in 1981. The complex permissive 1999 law was associated with a temporary increase in consumption, from 11.1 in 1998 to 11.4 in 2000. The 2002, 2004, and 2005 restrictive laws were associated with the on-going decrease in consumption. Southern European Countries: Spain

In Spain, total registered alcohol consumption, liters of pure alcohol per inhabitant 15 years and older (source: World Health Organization, 2011) reached its peak (19.6 L) in 1976, the year after Franco’s death, and the establishment of the parliamentary monarchy, and has gradually decreased down to 10.0 in 2006 (Figure 6). During the period from 1961 to 2006, the total alcohol consumption can be divided in two main periods (Figure 6).

(a) In 1961–1976, there was an overall increase, from 14.6 in 1961 to 19.6 in 1976. (b) From 1977, an overall decreasing trend begun, from 18.9 in 1977 to 10.0 in 2006.

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2005: low e ring of lim it for drunk driving from 0,8 to 0,5 pe r-m ille (R) 14 2002: national control on m inim un age -lim its for buying alcohol be ve rage s (R) 12

10

1968: dis s olution of the carte l by w hich only s pe cialis e d s hops can s e ll s pirits , w ith s table and high price s (P )

1980: prohibition of s pirits s e lling unde r e ffe ctive cos ts ; re s trictions on m ark e t and adve rtis ing (partial re vis ion of Law on Spirits ) (R)

1999: low e ring of taxe s on fore ign s pirits ; abolition of "Be dürfnis k laus e l" that allow e d cantons to re s trict the as s ignm e nt of pe rm is s ions for ope ning ne w e s tablis hm e nts and s e ll alcohol in the re s taurant indus try (P )

8

2004: incre as e d taxe s on alcoholpops (R)

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FIGURE 5. Recorded alcohol consumption trends in Switzerland and main policy measures. Adult (15+ years) liters of pure alcohol per capita, 1961–2008 (source: World Health Organization, 2011). P, permissive measure; R, restrictive measure.

Regarding the period from 1960 to 2008, 54 countrywide alcoholic beverage control policy measures were introduced in Spain, according to Spanish experts (see Voller et al., 2014). However, reducing this number to the main alcoholic beverage control policy measures, which was consensually set at 6, was considered appropriate to better analyze the effect of policies within each country and across the 12 countries (see AMPHORA, 2013, Part 1, Collection and selection of alcoholic beverage control policy measure; AMPHORA, 2013, Part 2, Spain). The six selected measures are all restrictive (see Table 6). During the first period of the consumption increase, between 1961 and 1975, no liberal policy measures were introduced. No alcoholic beverage control policy measure was introduced before 1982, but minor measures such as creating a few alcohol treatment programs in the 1960s (birth of Alcoholic Anonymous Spain in 1960, first alcoholic patients hospitalization in 1963), according to AMPHORA work-package 3 dataset5 , were introduced. Both the six main alcoholic beverage control policy measures, which were introduced in 1982, 1988, 1989, 1990, 1992, and 1998, as well as a minor 1978 TV and radio ban of advertising alcoholic beverages before 9.30 pm (see AMPHORA work-package dataset), were introduced when a decreasing consumption trend was already on-going. 5

Available on request to the authors.

Southern European Countries: Italy

In Italy, the trend of total registered alcohol consumption, liters of pure alcohol per inhabitant aged 15 and over (source: World Health Organization, 2011) showed two periods (Figure 7). (a) An initial irregular plateau period (1961–1972) with 19.2 in 1961, and 19.5 in 1972. (b) In a second period (1973–2008), the total consumption of alcoholic beverages dropped from 19.9 L pure alcohol per capita (15 year and over) in 1973 to 7.4 L in 2008. Regarding the period from 1960 to 2008, 43 countrywide control policy measures were introduced in Italy according to national alcohol experts (Voller et al., 2014). The six most relevant alcoholic beverage control policy measures were singled out to better analyze the effect of policies within each country and across the 12 countries (see AMPHORA, 2013, Part 1, Collection and selection of alcoholic beverage control policy measure; AMPHORA, 2013, Part 2, Italy). The six measures to be used for analysis are all restrictive measures. They are described in Table 7. During both the plateau of consumption period (1961–1973) and the subsequent decreasing period starting in 1974, no alcoholic beverage control policy measure was introduced before 1988, but, according to

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TABLE 6. The selected six main alcoholic beverage control policy measures in Spain, 1960–2008 (source: AMPHORA, 2013, Part 2, Spain) 1. 1982. Minimum age 16 years at national level 2. 1988. Ban on advertising alcoholic beverages >20◦ 3. 1989. Ban on selling alcohol in public education centers 4. 1990. Ban on bringing and selling alcohol in sport events 5. 1992. First drink driving BAC law: motor vehicles .8 g/L; transport of goods .5 g/L transport of passengers and hazardous material .3 g/L 6. 1998. Drink driving BAC law motor vehicles .5 g/L (breath alcohol conc. .25 mg/L); transport of goods, passengers, hazardous material, novice drivers .3 g/L (breath alcohol conc. .15 mg/L).

20 1988: ban on adve rtis ing alcoholic be ve rage s > 20° (R) 18 1990: ban on bringing and s e lling alcohol in s port e ve nts (R)

16

1998: drink driving BAC law (low e ring lim its ) (R)

1982: m inim um age 16 ye ars at national le ve l (R) 14

12 1989: ban on s e lling alcohol in public e ducation ce ntre s (R) 10 1992: firs t drink driving BAC law (R) 8

6

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R restrictive measures.

FIGURE 6. Recorded alcohol consumption trends in Spain and main control policy measures. Adult (15+ years) liters of pure alcohol per capita, 1961–2006 (source: World Health Organization, 2011). R, restrictive measures.

AMPHORA work-package 3 dataset6 , minor measures such as the creation of a few alcoholic treatment programs in the 1970s (birth of Alcoholic Anonymous Italy in 1974, treatment of alcoholism in the National Health Service allowed in 1988). The five main restrictive alcoholic beverage control policy measures, approved in 1988, 1991, 1998, 1990, and 2001 were introduced when a decreasing trend was already on-going. However, when the 1999 VAT tax for all the alcoholic beverages was introduced, there was a tem6

Available on request to the authors.

porary increase in consumption, from 8.9 in 1999 to 9.3 in 2000. DISCUSSION

Considering the relationship between the curves of the total consumption of alcoholic beverages and the introduction of control policy measures, this analysis documents that changes in consumption occurred for all the countries reviewed, except Poland—increase in the Nordic countries and Switzerland in the 1960s, and a tendency to decrease trend in Spain, and especially in

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ALCOHOL TRENDS AND POLICIES

TABLE 7. The selected six main alcoholic beverage control policy measures in Italy, 1960–2008 (source: AMPHORA, 2013, Part 2, Italy) 1. 1988. A Ministerial Decree (10/8/88) established a BAC level of .8 g/L as the threshold above which driving was not permitted. 2. 1991. According to national law 25 August 1991, Police or Mayors can prohibit the sale of beverages with more than 21% alcohol by volume (and sometimes less than 21%) during concerts, sporting events, or other events with a massive presence of younger people in order to prevent public disorder. 3. 1995. The excise tax for beer was set at 2,710 Italian lire per hL (€ 1,40), for other intermediate products at 87,000 Italian lire (€ 44.93), for spirits at 1,146,000 Italian lire (€ 591.46) per anhydrous hectoliter. Wine tax was kept at zero. 4. 1998. The Italian highway society code prohibited the sale of alcoholic beverages containing more than 21% alcohol by volume from 10 p.m. to 6 a.m. in bars and restaurants on motorways. This prohibition became article 14 of the 2001 Italian Alcohol Draft Law, with fines between 2,500 and 5,000 Euros for transgressors. 5. 1999. A VAT tax of 20% has been applied to all alcoholic beverages including wine. 6. 2001. A general policy law concerning alcohol and alcohol drinking -related problems was also aimed at regulating the advertising of alcoholic beverages, and at setting BAC level threshold at .5 g/L for drivers.

Italy, in the 1960s–1970s and 1980s—during periods where no known alcoholic beverage control policy measure was present. This is surprising, considering that the literature has reported that changes in drinking patterns, in the absence of specific policies, was associated only with Mediterranean countries (see Allamani et al., 2011; Room, 1992; Simpura, 1998), in which alcohol has traditionally been considered to be and consumed as a “food” and not as an intoxicating substance. In all these situations, in order to explain changes in consumption, it is necessary to resort to additional factors that are not legislated policies, that have been identified as contextual factors,

i.e. social, demographic, economic, cultural, and political variables (AMPHORA, 2013). This analysis also showed that in all of the countries reviewed many alcoholic beverage policies, when they were introduced, were in line with the direction of changes in drinking patterns. The restrictive policies, for example, were instituted during a period of declining drinking, and the permissive policies were instituted during periods of growth. In these cases, it is possible to assume that the promulgation of such policies by the government authorities “operated” to confirm the consumption changes that were already occurring in the population, possibly as a result of

25

20

1991: prohibition of s ale of be ve rage s w ith m ore than 21% alcohol by volum e (s om e tim e s le s s than 21%) during e ve nts w ith m as s ive pre s e nce of younge r pe ople (conce rts , s porting e ve nts , e tc.) (R)

15 1998: prohibition of s ale of alcoholic be ve rage s w ith m ore than 21% alcohol by volum e from 10 p.m . to 6 a.m . in bars and re s taurants on m otorw ays (R) 10 1988: BAC lim it (R) 2001: policy law , als o aim e d at re gulating the adve rtis ing and s e tting low e r BAC (R)

1995: e xcis e tax for be e r, othe r inte rm e diate product and s pirits (no w ine ) (R)

5

1999: V AT tax to all alcoholic be ve rage s including w ine (R) 2007

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FIGURE 7. Recorded alcohol consumption trends in Italy and main control policy measures. Adult (15+ years) liters of pure alcohol per capita, 1961–2008. Source: World Health Organization, 2011). R, restrictive measure.

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the country’s prevailing opinion (see Nordlund & Østhus, 2013). From the simple observation of the curves, one can only assume that these policies may have contributed together with other factors to the on-going changes, while a quantitative analysis would be needed to more fully comprehend the extent of such a contribution. Decisive changes in the curves at the time of the introduction of some permissive and restrictive policies are observed especially in the case of Finland and Poland. These changes could allow one to hypothesize a link of effective causation between policies and the drinking changes, which should be tested with quantitative analysis. In Finland, after the introduction of the liberalizing measures in 1969, that loosened the previous limitations to purchase alcohol beverages, the pro capita consumption of pure alcohol per inhabitant age 15 and older increased from 3.9 in 1968 to 5.7 in 1969. Also, the introduction of a restriction measure in 1975, with an increase in price of alcoholic beverages, appeared to be contemporary to a change in the direction of the reduction trend, with a notable reduction in consumption from 8.4 in 1974 to 8.0 in 1975. In Poland, the restrictive 1960 “act against alcoholism” was associated with a 3-year-period decrease in alcohol consumption (from 6.3 in 1961 to 6.2 in 1964). The 1982 restrictive law on “upbringing in society and counteracting alcoholism” was preceded by a 1981 law, increasing the prices of alcoholic beverages. The direction of the consumption trend had a contemporary notable inversion, from 11.5 in 1980 to 8.5 in 1982. Sometimes the introduction of a policy was not associated with any change in the consumption curve. This is evident in the case of Norway. The introduction of the 1985 program of education on intoxication and pregnancy was associated to an already increasing trend. This could be in support of the conclusions of some authors, about the low effectiveness of health education in the alcohol consumption preventive area (Anderson et al., 2012). Finally, the analysis has shown that in some cases clear changes in the consumption curve occurred at the time of introduction of the policies, but in the opposite direction than what was planned for and expected. In Norway, the 1975 total ban on advertising for all alcoholic beverages paralleled an on-going increase in consumption, that decreased temporarily only in 1978. In Switzerland, the 1980 restrictions on advertising alcoholic beverages and on retail market were associated with increases in consumption. In Italy, when the 1999 VAT tax for all the alcoholic beverages was introduced, there was a temporary increase in consumption, from 8.9 in 1999 to 9.3 in 2000. These observations may raise some doubts on the effectiveness of advertising restrictive measures, but one should also consider the concomitant effect of economic and sociopolitical factors. In general, policies cannot be assumed to be the only factors and processes responsible for the alcohol consumption changes. One of the aims of the AMPHORA project was to demonstrate the relevance of the impact

of sociodemographic and economic factors in a country (Allamani, Pepe, Baccini, Massini, & Voller, 2014; Allamani et al., 2011; AMPHORA, 2013, and the articles in this special issue). However, other aspects can be identified, which were only partially taken into account by the AMPHORA study: factors of migration, religious and political, major sociopolitical events, i.e. “big events,”7 and cultural activities. Some distinguished authors (Room, 1991; Skog, 1986) have also developed the hypothesis that neither the policy measures nor the contextual factors may be able to explain the changes in alcohol consumption, which would otherwise be dominated by self-generating long alcohol waves: “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). The hypothesis of the long waves derives from the Russian economist Nikolai Kondratieff, who about 90 years ago identified cycle-like phenomena in world economy, with the period of the wave averaging at 50, and ranging from approximately 40 to 60 years, during three phases alternate, i.e. expansion, stagnation, and recession (Devezas, 2006; Moody & Nogrady, 2010, http://en.wikipedia.org/wiki/Nikolai Kondratiev). However, some authors also tried to interpret Kondratieff waves as arising from periodical technological innovations, from demographics, and from a generation-learning model (with two generation making about 60 years). Both in the AMPHORA study and in this analysis, periods of 50 years were under investigation. For Finland, Norway, Poland, and Switzerland, three time cycles were singled out, consisting of alcohol consumption growth, a plateau phase, and further growth (decrease in the case of Switzerland). For Spain and Italy, two cycles were identified: growth or plateau for about 15 years at first, and decree line for the next 35 years. However, further studies comparing the relevance of the self-generating alcohol waves and the impact of political and socioeconomic factors are needed. Study Limitations

This study is a qualitative observation of the relationship between total consumption of alcoholic beverages and alcohol control policies in six European countries that are part of the AMPHORA project. Sociodemographic, economic, religious, and cultural factors, as well as big sociopolitical events were excluded by our analysis. 7

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 are major dimensions and loss of control over one’s life is experienced. Editor’s note.

ALCOHOL TRENDS AND POLICIES

Only total registered official data from World Health Organization are considered. Therefore any information about beer, wine, and spirits, as well as about the unrecorded alcohol, is not taken into account. This has certainly restricted the terms of our analysis and our conclusions. The alcohol consumption control policy measures considered were the six main policy measures selected in the AMPHORA project (see Voller et al., 2014). However, authors have drawn on AMPHORA data base where a larger number of policy measures are listed. Declaration of Interest

The authors declare no conflicts of interest. The authors alone are responsible for the content and writing of the article. Funding

The research leading to these results has received funding from the European Community’s Seventh Framework Program (FP7/2007–2013) under grant agreement no. 223059—Alcohol Measures for Public Health Research Alliance (AMPHORA). Partners in AMPHORA are: (1) Coordination: Hospital Clinic de Barcelona (HCB), Spain; (2) Agenzia Regionale di Sanit`a della Toscana (ARS), Italy; (3) Alcohol & Health Research Unit, University of the West of England, UK; (4) Anderson, Consultant in Public Health, Spain; (5) Anton Proksch Institut (API), Austria; (6) Azienda Sanitaria Locale della Citt`a di Milano (ASL MILANO), Italy; (7) Budapesti Corvinus Egyetem (BCE), Hungary; (8) Central Institute of Mental Health (CIMH), Germany; (9) Centre for Applied Psychology, Social and Environmental Research (ZEUS), Germany; (10) Chemisches und Veterin¨aruntersuchungsamt Karlsruhe Technische Universit¨at (CVUAKA), Germany; (11) Dutch Institute for Alcohol Policy (STAP), Netherlands; (12) Eclectica snc di Amici Silvia Ines, Beccaria Franca & C. (ECLECTICA), Italy; (13) European Centre for Social Welfare Policy and Research (ECV), Austria; (14) Generalitat de Cataluna (Gencat), Spain; (15) Institute of Psychiatry and Neurology (IPIN), Poland; (16) Institute of Psychiatry, King’s College London (KCL), UK; (17) Istituto Superiore di Sanit`a (ISS), Rome, Italy; (18) Institut za raziskave in razvoj (UTRIP), Slovenia; (19) IREFREA, Spain; (20) Liverpool John Moores University (LJMU), UK; (21) National Institute for Health and Welfare (THL), Finland; (22) Nordiskt valf¨ardscenter (NVC), Finland; (23) Norwegian Institute for Alcohol and Drug Research (SIRUS), Norway; (24) State Agency for Prevention of AlcoholRelated Problems (PARPA), Poland; (25) Stockholms Universitet (SU), Sweden; (26) Swiss Institute for the Prevention of Alcohol and Drug Problems (SIPA), Switzerland; (27) Technische Universitat Dresden (TUD), Germany; (28) Trimbos-instituut (TRIMBOS), Netherlands; (29) University of Bergen (UiB), Norway; (30) Universiteit Twente (UT), Netherlands; (31) University Maastricht (UM), Netherlands; (32) University of York (UoY), UK.

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THE AUTHORS 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 Tuscany Regional 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 many articles, and editor and co-editor of 16 books. Nadia Olimpi, M.D., She works at Epidemiology Observatory of Tuscany Regional Health Agency. She’s co-author in reports of Regional Agency about the epidemiology of main lifestyle risk factors for health and scientific articles.

Pasquale Pepe, MSc, is a Senior Statistician at the Epidemiology Observatory of the Tuscany Regional Health Agency. He has worked for several years on medical statistics, clinical trials, and epidemiological studies. He has co-authored more than 30 articles. He has worked in the statistical analysis of data of the AMPHORA project.

Francesco Cipriani, MD, Medical epidemiologist, nutritionist, and gastroenterologist, is Director of the Tuscany Regional Health Agency (Italy) since October 2011, where he also has been chief of the Epidemiology Observatory since January 2009. He was Director of the Epidemiology Unit of the Local Health Authority in Prato, Italy, and also worked in the epidemiology services of the Florence Local Health Authority and the Centre for Oncological Study and Prevention, carrying out regional, national, and international multi-centric epidemiological studies about nutrition, life styles, addictions, alcohol and alcoholism, tumors, injuries, road traffic accidents,

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and environmental problems. He has published more than 130 studies.

Glossary

Alcoholic beverage preventive policy measures: Restrictive country-wide measured introduced by the government in order to prevent and reduce the harms associated with drinking alcoholic beverages. Consumption curve: The yearly temporal trend curve of alcoholic beverages consumption. Qualitative method: Observational method not involving mathematical and statistical analyses. Long alcohol waves: Long-term supposedly selfgenerating fluctuations of alcohol consumption, of about 50–70 years. Time lag: Time between the occurrence of an intervention or event and the manifestation of the hypothesized related effect. REFERENCES Allamani, A., Pepe, P., Baccini, M., Massini, G., & Voller, F. (2014). Europe. An analysis of changes in the consumption of alcoholic beverages: the interaction among consumption, related harms, contextual factors and alcoholic beverage control policies. Substance Use & Misuse, 49. 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. Allamani, A., Voller, F., Pantzer, K., Eisebach-Stangl, I., Elekes, Z.,  (2010). Preventive alcohol policies Gmel, G., . . . Wieczorek, L. and unplanned effects related to alcohol consumption changes in Europe (1960s–2000s). Paper presented at 36th Annual Alcohol Epidemiology Symposium of the Kettil Bruun Society, Lausanne, May 31–June 4, 2010. AMPHORA Workpackage3. (2013). Report of an analysis of European alcohol-related cultural, social and policy interactions and their impact on alcohol consumption and alcoholrelated harm. from http://amphoraproject.net/w2box/data/ Deliverables/AMPHORA WP3 D3.2.pdf Anderson, P. (2009). Evidence for the effectiveness and costeffectiveness of interventions to reduce alcohol-related harm. Copenhagen, Denmark: 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, Denmark: World Health Organization, Regional Office for Europe. Babor, T. F., Caetano, R., Casswell, S., Edwards, G., Giesbrecht, N., Graham, K., . . . Rossow, I. (2003). Alcohol: No ordinary commodity. Oxford, New York: Oxford University Press. Babor, T. F., Caetano, R., Casswell, S., Edwards, G., Giesbrecht, N., Graham, K., . . . Rossow, I. (2010). Alcohol: No ordinary commodity. Research and public policy (2nd ed.). Oxford: Oxford University Press. Baccini, M., & Carreras, G. (2014). Analyzing the effect of policy measures and socio-demographic factors on alcohol consumption in Europe within the AMPHORA project: Statistical methods. Substance Use & Misuse, 49.

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