Prevention of alcoholrelated problems

Robin Room

Education and persuasion Evidence on effectiveness

Deterrence

Evidence, on effectiveness

Pro.vid.i.ng,and,, encouraging., alternative., activities

Evidence, on, effectiveness

Insulating, use , from , , harm Evidence, on effectiveness Regulating, the availability and conditions of, use The,, effectiveness,of specific types „of, reg.u.la.ti.on„of availability

Social, andreNgiousmPYements,, and, community,, action Evidence, on effectiveness

Treatment, andother help

Evidence,, ,on, effectiveness

B.u.ilding,,an,,int.egrate.d., societalalcohol „policy Chapter,, References

In most developed societies and many developing societies, alcohol consumption is widely distributed in the population, with abstainers in a minority among adults. Those qualifying to be diagnosed with an alcohol use disorder are a minority of drinkers in such societies.

On the other hand, alcohol is causally implicated in a wide variety of health and social problems. The Global Burden of Disease study estimates that alcohol accounts for 10.3 per cent of the total health-related loss of disability-adjusted life-years in developed societies. (1) In terms of where this burden appears in the health system, while psychiatric conditions (including dependence) and chronic physical disease are both important, casualties often play a predominant role. A recent study in Canada calculated that injuries and other acute causes of death accounted for 66 per cent of all potential years of life lost due to alcohol. (2)

The public health importance of acute effects of a particular episode of intoxication underlies what is often described as the 'prevention paradox'. In many societies, a fairly substantial proportion of the population (particularly of males) gets intoxicated at least occasionally, and by that fact is at risk of experiencing and causing social and health harm from drinking.(3) Preventing alcohol problems thus requires looking beyond the considerably smaller segment of the population diagnosable with an alcohol use disorder, or the even smaller segment receiving treatment for such a disorder.

A complication in preventing alcohol problems is that there is also evidence of a health benefit from drinking in terms of reduced cardiovascular disease. This benefit is, however, important mainly for men over 45 and women past menopause, and can be attained with a pattern of very light regular drinking, as little as a drink every second day.(4) There is thus little potential conflict between taking alcohol as a preventive heart medication and any prevention policy short of total prohibition.

Simplifying somewhat, there are seven main strategies to minimize alcohol problems:

1. educate or persuade people not to use or about ways to use so as to limit harm;

2. deter drinking-related behaviour with the threat of penalties—a kind of negative persuasion;

3. operating in the positive direction, provide alternatives to drinking or to drink-connected activities;

4. somehow insulate the use from harm;

5. regulate availability of the drug or the conditions of its use—prohibition of supply may be regarded as a special case of such regulation;

6. work with social or religious movements oriented to reducing alcohol problems;

7. treat or otherwise help people who are in trouble with their drinking.

We will consider in turn these strategies and the evidence on their effectiveness. Education and persuasion

In principle, education can be offered to any segment of the population in a variety of venues, but it is usually education of youth in schools which first comes to mind in the prevention of alcohol problems. Community-based prevention programmes, which are often also directed at adults, also may include an educational component.

Education offers new information or ways of thinking about information, and leaves it to the listener to draw conclusions concerning beliefs and behaviour. However, most alcohol education programmes go beyond this. A commonplace of the North American evaluative literature on alcohol education is that 'knowledge-only' approaches do not result in changes in behaviour.(5) School-based alcohol education has thus usually had a persuasional element, aiming to influence students in a particular direction.

Persuasion is directly concerned with changing beliefs or behaviours, and may or may not also offer information. Mass-media campaigns aimed at persuasion have been a very common component of prevention programmes for alcohol-related problems, but persuasion can be pursued also through other media and modalities.

In most societies, public-health-oriented persuasion about alcohol must compete with a variety of other persuasional messages, including those intended to sell alcoholic beverages. The evidence that alcohol advertising influences teenagers and young adults towards increased drinking and problematic drinking is becoming stronger/6,.7) Even where alcohol advertising is not allowed on the mass media, these messages are conveyed to consumers and potential consumers in a variety of other ways.

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