Presented at Annual Alcohol Epidemiology Symposium of the Kettil Bruun Society, Lausanne, June, 2010. I received no funding to prepare this paper.
Abstract: Northern European and English-speaking (Temperance) epidemiologists completely dominate alcohol policy worldwide. Their view of – and policies towards – alcohol vary diametrically from indigenous Southern European polices. Yet, despite modern epidemiological research that establishes firmly the advantages of drinking a la Southern Europe, Northern epidemiologists persist in recommending – and Southern European governments increasingly solicit and welcome – Northern control policies. Ironically, at the same time, alcohol taxation and importation policies have been liberalized in Scandinavia, with the remarkable result – counter to alcohol policy theory – that alcohol consumption and problems have not increased, and may be decreasing. A typology for alcohol policy arguments for ignoring and rejecting Southern attitudes and policies toward alcohol is developed, and the coming crisis in European alcohol policy is foretold.
Four Lines of Defense Against Southern European Advantages in Drinking
When confronted with obvious advantages in Southern drinking (e.g., less public and antisocial drunkenness), policy theorists from Northern (or “Temperance” – see Peele, 2010) nations employ an escalating set of defenses to deny these:
1. Differences are illusory. At the most basic level, epidemiologists have simply refused to accept such differences as less public drunkenness between, say, Norway and Italy because these have been based on cultural studies (as well as obvious observations that result from walking the streets of Oslo and Rome) rather than quantitative epidemiological research.
2. Any advantages are offset by costs. A standard argument has been that while there are differences between Northern and Southern drinking, and these represent advantages for the South, such benefits are undercut by chronic disease states caused by the regular Southern drinking as opposed to more typical binge drinking in the North. The obvious example is cirrhosis.
3. Advantages are disappearing. A third fallback for those who oppose the idea that Southern drinking is advantageous is that, while some benefits may be apparent, these are disappearing, and can be discounted on this basis.
4. Universal science overrides advantages. A final line of defense is that universal law – notably that increased consumption inevitably leads to more alcohol problems – refutes policies encouraging even balanced and moderate consumption.
The European Comparative Alcohol Study (ECAS)
In 2002, a team of Nordic epidemiologists published the results of the European Comparative Alcohol Study (ECAS) in the volume, Alcohol in Postwar Europe(Norström, 2002). The results established definitively that drinking in Southern Europe yields superior health outcomes. Although Southern European countries consumed more alcohol, as a group they (a) had far less binge drinking, (b) experienced fewer alcohol-related social problems, (c) had substantially lower rates of alcohol-related mortality than Northern nations.
Less binge drinking. Southern nations demonstrably consume less alcohol in binges, as expressed in Table 5.3 in Alcohol in Postwar Europe.
ECAS refuted the most basic, #1 form of denial of national differences in drinking by showing, for instance, that British male drinkers are four times as likely to binge drink as French men, and binge at three times the rate of Italian men. Similar differences exist between Nordic and Southern European men, and also between Nordic and Southern women.
Substantially lower alcohol-related mortality. ECAS did not find that more Southern Europeans die from alcoholic cirrhosis. Also, since far more deaths are caused by alcohol-related accidents and violence, lesser binge drinking in Southern Europe translates into far lower mortality rates due to drunkenness in these nations. Since Southern drinkers consume more alcohol, ECAS found an inverse relationship between consumption and alcohol-related mortality across Europe. From Table 6.6:
Clearly, Southern European drinking is less usually fatal.
Rehm in Italy: “You drink better than we do; adopt our alcohol policies”
Jürgen Rehm is the most distinguished international alcohol epidemiologist cum policy advocate (he delivered the keynote address at the 2010 Kettil Bruun Society annual conference). He attained this position through his voluminous research and writing, capped by his heading the team calculating the “Global burden of disease and injury and economic cost attributable to alcohol use and alcohol use disorders” (Rehm et al., 2009).
Also in 2009, Rehm (2009) was invited by Italian public health authorities to present at Alcohol Prevention Day in Rome. Although Rehm’s message concerned the bottom-line heath damage and injuries caused by alcohol, in fact the subtext of his message in Rome was how much lower were such damages in Italy than in Europe as a whole. In particular, Rehm and his colleagues calculated that the percentage of net deaths attributable to alcohol in 2004 was 5 percent for Italy, compared with 12 percent overall for Europe.
This result answered two advanced levels of denial of Southern European drinking advantages: the #2 level that alcohol causes more chronic disease and related overall mortality in the South, and the #3 theorem, that whatever advantages Southern drinking has relative to Northern Europe are disappearing. Since the global burden mortality figures were computed for 2004, they show good continuity with the 1995 mortality results reported by ECAS, indicating that they were not temporary. At the same time, Rehm et al.’s affirmation of these alcohol mortality differences favoring Southern Europe answers the ECAS research group’s tendency to disparage the validity of the Southern European alcohol mortality data base.
The focus of the Rehm presentation was on accidental injury and death, and so he noted by way of explaining Italy’s relative alcohol-mortality advantage that alcohol-related injuries are “traditionally low in Italy.” But – despite having confirmed the alcohol-related-mortality advantage in Italy (and by extension Southern Europe), while also affirming their persistence over time – Rehm then hinted at its transience: “with the increase of binge drinking in Europe among youth and young adults, this picture may change” (in other words, a level #3 denial).
Rehm then devotes his attention to instructing Italians on how to reduce such injuries, even as he has noted Italians are distinctly superior to other Europeans in avoiding them. He justifies his recommendations as follows: “Italy should continue its efforts to reduce alcohol-attributable disease burden to keep its low alcohol-attributable injury rates.” In other words, Italy can use proven methods to do what it already does better than the countries in which they were developed. Rehm particularly concentrates on “ways to reduce alcohol attributable traffic injury” by presenting “evidence for a beneficial effect of no drinking up to 21 years of age.” The evidence he presents for the benefit of this rise is from Ontario and Sweden.
Radical Rehm and Potential Problems with the Rehm Approach
It might seem odd that a foreign expert would come to a country whose current practices and outcomes are superior to those for Europe overall, and advise them to changes these practices and policies in line with those of countries that less successfully manage their drinking. Rather, it might seem preferable to identify and encourage Italy’s successful indigenous approaches to the problem. But Rehm devotes NO effort or time to current Italian approaches to drinking which result in the lower binge rates uncovered in Italy (and Southern Europe) by ECAS, along with the low alcohol-related injury rates he discusses.
This omission takes on added weight when we turn to another recent analysis by Rehm, with Benedikt Fischer (2010), elucidating “Harm reduction in an open and experimenting society.” Rehm in this place notes (as he has elsewhere) that alcohol harm reduction can be traced to “patterns and practices of drinking [that] predominantly influence the alcohol-related harm experienced.” Of course, Rehm’s noting that patterns of drinking are more important than amount consumed – as discovered by ECAS – reminds us of how odd his own approach is in not analyzing what it is about the Italian situation that produces its more moderate (than Scandinavian and English-speaking nations’) style of drinking.
The absence of such thinking is everywhere evident in public health policy re alcohol – indeed, suggestions that moderate alcohol consumption patterns might be encouraged are often scorned and denigrated in the policy field. But, if Rehm’s analysis is correct, then not offering any insights or suggestions for creating such moderation indicates that alcohol policy advocates have nothing to say about the primary determinant of alcohol problems, costs, and health consequences.
Rehm and Fischer (2010) comment on the state of the alcohol policy field:
despite changes of language and examples, the interventions proposed are often still the same as 40 years ago within a supposedly different paradigm [i.e., harm reduction]. As some accepted truths of the field (that is, that higher availability of alcohol leads to more harm under all circumstances) have been empirically challenged (example: Sweden has experienced much higher availability of alcohol in the past years, but not necessarily higher consumption or alcohol-attributable harm), the global strategy will need a much closer examination of what interventions produce which effects under what circumstances. . . . [parenthetical statements in original]
The examination Rehm and Fischer call for is one Rehm himself seems incapable of or unwilling to undertake. Thus radical Rehm (2010) here seems to be critiquing hidebound Rehm (2009), since his presentation in Rome deserves all of the criticisms he and Fischer direct at the field’s traditional thinking.
Rehm and Science
What about the scientific value of imposing on Southern Europe the results gleaned from policy-related research in Scandinavian and English-speaking nations? We may begin by wondering whether it is realistic to suggest raising the drinking age in Italy – where the drinking ages for consumption in public outlets and purchasing alcohol are 16, and where children of any age may drink with their parents at restaurants – ultimately to a 21-year-old limit.
Is it scientifically valid to transplant results discovered in one cultural setting to very different drinking cultures? But analyzing the potential effects of grafting Temperance-nation alcohol policies onto Italian culture requires consideration of how alcohol is consumed in Italy – and how drinking practices are taught and learned there – which Rehm and alcohol policy advocates won’t do. Fortunately, one Southern European, Italian Allaman Allamani (2002), offered such insights in his synopsis of the ECAS results. For Allamani, “alcoholic beverages – mainly wine – are. . . an integral part of meals and family life” in Italy. Could raising the drinking age disturb the delicate balance Allamani describes whereby in Italy alcohol “is perceived as a social vehicle.”
But there is a more subtle aspect of alcohol that raising the drinking age and transferring other Temperance-nation attitudes into the Italian setting might affect. According to Allamani, “In the Northern countries, alcohol is described as a psychotropic agent. It helps one to perform, maintains a Bacchic and heroic approach, and elates the self.” This view of alcohol’s potency is not present in Italy, where, “Typically, wine is not connected to the topic of control and does not elicit any image of either achievement or performance.” In other words, conveying an image of alcohol as dangerous and forbidding could actually lead Italians to drink less moderately, and to have more alcohol-related mishaps (see Peele, 2010).
The Results of Globalization – Mixing Northern and Southern Drinking
Rehm and Fischer (2010) note that “some accepted truths of the field (that is, that higher availability of alcohol leads to more harm under all circumstances) have been empirically challenged (example: Sweden has experienced much higher availability of alcohol in the past years, but not necessarily higher consumption or alcohol-attributable harm).” Since the availability -> consumption-> problems linkage is the current organizing principle in alcohol policy, this observation is highly challenging to the field. But, as Rehm and Fischer indicate, it as yet has had little impact.
While Rehm had no hesitation in recommending Temperance-based policies for Italians, policy formulators are unwilling to recommend Southern-based styles of drinking as an intervention for Temperance nations. The logic – unassailable but seemingly applied only in transfer of knowledge from South to North – is that it is not possible to inject policies from one drinking culture directly into another. So it is intriguing that, in ways not yet understood, Nordic nations are responding to easier access to alcohol by apparently moderating their drinking.
Systematic examination of changes in alcohol consumption following upon the reduction of taxes on alcohol in Scandinavia and the removal of restrictions on personal importation of alcohol by Nordic nationals returning from Continental Europe have not found consumption to have increased (see Room et al., 2009). In addition, Bloomfield et al. (2010) found that self-reported alcohol problems declinedin Scandinavian regions (i.e., Southern Sweden, Finland, Denmark) where these changes were implemented, but did not decline in a control region, Northern Sweden, where they were delayed.
Although community prevention efforts were undertaken in Sweden to produce just this result, it isn’t possible yet to characterize in a broad way what kind of policies and practices these efforts represented. Nonetheless, we might consider that Northern European drinking is borrowing moderating elements from Southern Europe. Whereas into even the recent past Sweden could be considered a separate drinking culture from the rest of Europe, in our era of globalization, Swedes are today far more familiar with Italian drinking – perhaps observing and practicing the Italian style of drinking themselves on visits to Continental Europe, and certainly being more aware of them.
This globalization of Italian drinking northward is occurring at exactly the same time that Northern sensibilities about alcohol and alcohol policies are being officially invited into Southern nations – as represented by the Rehm presentation described in this article. Recently, I spoke to a group of alcohol researchers in Florence. Prior to my presentation, a government public health official spoke, focusing on the costs incurred by drinking in Italy as revealed in the Rehm et al. Global Burden project. He said nothing about the differences favoring drinking in his country.
Globalization – wither, wherefore?
Rehm’s call for innovative alcohol policy, which seemingly fell on his own deaf ears, indicates that modifications in the prevailing public health paradigm will be reluctantly made – if made at all. At the same time, Southern European authorities seem hellbent on borrowing the alcohol paradigms of their Northern neighbors. For me, these are discouraging developments (or lack of them). On the other hand, unstructured social change in Scandinavian drinking expresses a widespread tendency for humans to modulate their behavior in the face of environmental challenges. Whether alcohol public health specialists will show comparable flexibility – and what the net effects of the crossing patterns of the globalization of alcohol will be – remain to be seen.
Allamani, A. (2002). Policy implications of the ECAS results: A southern European perspective. In T. Norström (Ed.), Alcohol in postwar Europe: Consumption, drinking patterns, consequences and policy responses in 15 European countries. Stockholm: National Institute of Public Health, pp. 196-205.
Bloomfield, K., Wicki, M., Gustafsson, N-K., Mäkelä, P., & Room, R. (2010). Changes in alcohol-related problems after alcohol policy changes in Denmark, Finland, and Sweden. Journal of Studies on Alcohol and Drugs, 71, 32-40.
Norström, T. (Ed.) (2002). Alcohol in postwar Europe: Consumption, drinking patterns, consequences and policy responses in 15 European countries. Stockholm: National Institute of Public Health.
Peele, S. (2010). Alcohol as evil – Temperance and policy. Addiction Research and Theory.
Rehm, J. (2009). Alcohol and disability with special consideration of traffic injury – Analysis, evaluation and consequences. Presentation at Alcohol Prevention Day in Rome. Available athttp://www.epicentro.iss.it/alcol/apd09/Apd09_slide_Rhem.pdf.
Rehm, J., & Fischer, B. (2010). Harm reduction in an open and experimenting society. In EMCDDA, Harm reduction: Evidence, impacts and challenges. Lisbon: European Monitoring Centre for Drugs and Drug Addiction, pp. 79-84.
Rehm, J., Mathers, C., Popova, S., et al. (2009). Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. Lancet, 373, 2223-2233.
Room, R., Osterberg, E., Ramstedt, M., & Rehm, J. (2009). Explaining change and stasis in alcohol consumption. Addiction Research and Theory, 17, 562-576.
- A general change in youthful drinking habits in Italy has been noted by Rehm among others. That is, young people are less likely to drink wine at home with their families, and increasingly drink beer with their cohorts. Does this mean that Italian youth are becoming as drunken as youth in other countries? The 2007 ESPAD results indicate not (in regard to denial theorem #3):
% 15-16-year-olds drunk in past month Denmark 49 UK 33 Ireland 26 Finland 21 France 18 Italy 12 Greece 12 Portugal 11