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• Why are alcohol policies needed?
• Balancing benefits and harms
• Building alcohol policies
• Elements of sustainable alcohol policies
• A regulatory framework for effective policies
• Considerations for successful regulation
• Direct regulatory options
• Indirect regulatory options
• Drinking patterns, targeted interventions, and partnerships
• Drinking patterns
• Patterns, policy, and prevention
• Targeted interventions
• Partnerships
• Steps for developing sustainable and balanced policies
• Conclusion
• References

Over recent years there has been growing recognition that not all people drink alike, and not all who do experience the same harms and benefits from their drinking (Grant & Litvak, 1998). Some are teetotalers, who, for religious, health, or other reasons abstain from alcohol (International Center for Alcohol Policies, 2000a; World Health Organization, 2004). Many are moderate drinkers, who enjoy the occasional drink with a meal, at a social gathering, or as a means of relaxation. Still others cannot control their drinking or drink often, excessively, and to intoxication.

It should be acknowledged that for most people, moderate drinking is a source of pleasure—it can be part of everyday life adding to its enjoyment (Peele & Grant, 1999). There is also evidence suggesting that for some groups of individuals drinking may contribute to overall health. These two factors together have contributed to a gradual shift in how alcohol policies are viewed around the world.

Why are alcohol policies needed?

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Most individuals who consume alcohol do so without harmful outcomes. They drink because it gives them pleasure and because of alcohol’s effects as a social lubricant, a marker of celebration around important life events, and because of its ritualistic role in a number of religions (Heath, 1995, 2000; MacAndrew & Edgerton, 1969; Marshall, 1979). Whereas most of those who drink do so responsibly and moderately, the misuse or irresponsible consumption of alcohol has the potential to impose harm on both individuals and society through a range of health and social problems.

The main goal of alcohol policies is to help minimize harms and maximize benefits. Alcohol policies are also intended to weigh the rights and responsibilities of individuals against those of society as a whole. To be effective, alcohol policies rely on creating a balance in a number of different areas that apply to individuals and society alike.

At the individual level, policies are needed to:

• safeguard wellbeing and health and offer protection from harm;
• increase understanding of harms and benefits;
• change behavior, encouraging positive and discouraging negative drinking patterns;
• improve the ability to make informed decisions;
• provide reasonable access to commodities;
• ensure personal choice and freedom without unduly impinging upon the freedoms of others.

At the societal level, alcohol policies are intended to:

• change behavior by encouraging positive and discouraging negative patterns;
• reduce the burden of harm due to alcohol misuse;
• decrease cost to society;
• provide treatment and support services for those who are harming themselves or have been harmed by others’ abuse of alcohol;
• ensure public safety;
• create an informed society.

Particular attention in the development of policy approaches is required in areas where there is at once potential for positive and for negative outcomes. These include:

• responsiveness to changes in the role of alcohol in society, especially under conditions of social and economic transformation;
• unencumbered access and availability while protecting those at risk for harm;
• responsible practice around advertising and promotion;
• education for the public;
• provision of health care to those who need it;
• responsible service of alcohol;
• product quality and integrity.

The challenge in developing policies that can address these areas is to create an approach broad enough in scope and emphasis to involve and satisfy the concerns of all sectors, public and private, governmental and nongovernmental.

Balancing benefits and harms

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As with a range of other commodities that are integrated into everyday life (e.g., automobiles, medications, or dietary supplements), it is the dual nature of alcohol that raises the need to regulate its use through policy. Therefore, balanced approaches around alcohol require creating an environment in which benefits are maximized and the potential for harm minimized, both for the individual and for society at large. It is important to lay out what is included in an assessment of benefits and harms in order to provide a context within which policies can be constructed.

Potential benefits

The positive contribution of beverage alcohol to society takes a number of forms, some quantifiable, others less so. Some of these benefits are economic in nature, others have a direct impact on society and health.

• Economic and social benefits around alcohol include those derived from direct and indirect employment in its manufacture and distribution.
• The retail, tourism, and hospitality industries are a significant source of employment and revenue.
• Local production has an important economic impact in both developed and developing countries, particularly in rural areas.
• Alcohol contributes strongly to government revenue in the form of taxation and excise duty and represents an important component of the balance of trade in many countries. Where alcohol retail is controlled through state-run monopolies, sales are a source of net profit for the government.

With regard to health and social outcomes, benefits of alcohol consumption are generally associated with moderate and responsible drinking patterns (National Institute on Alcohol Abuse and Alcoholism, 2003):

• Among the best described are benefits for cardiovascular health, especially for middle-aged men and older women (Ashley, 2000; English et al., 1995; Rehm & Gmel, 2003).
• There is evidence of benefits for conditions such as osteoporosis, diabetes, cognitive function, and other health conditions among some individuals (e.g., Charles, Laitinen, & Kardinaal, 1999; de Vegt et al., 2002; Diaz, O'Neill, Silman, & European Vertebral Osteoporosis Study Group, 1997; Felson, Zhang, Hannan, Kannel, & Kiel, 1995; Kao, Brancati, Boland, Watson, & Puddey, 1998; Rapuri, Gallagher, Balhorn, & Ryschon, 2000; Smeets-Goevaers et al., 1998; Wannamethee, Camargo, Manson, Willett, & Rimm, 2003).
• Less easily quantifiable are quality-of-life benefits derived through enjoyment and relaxation and the role of alcohol as a “social lubricant,” enhancing meals, celebrations, and other social occasions (Baum-Baicker, 1985; Chick, 1999; Grant & Peele, 1999; Pashall, Freistheler, & Lipton, 2005; Saffer, 2002).
• Moderate alcohol consumption contributes to the reduction of social costs, primarily through its positive effect on cardiovascular disease (McKee & Britton, 1998; Mukamal et al., 2001; Mukamal & Rimm, 2001; Murray et al., 2002; Puddey, Rakic, Dimmitt, & Beilin, 1999). This is largely attributable to reduced overall mortality and morbidity rates, and consequently to lowered healthcare costs (Xie, Rehm, Single, Robson, & Paul, 1998).

Potential harms

As with benefits, harms related to alcohol consumption cover a range of economic, social, and health outcomes, both for those who drink and for others around them. Irresponsible, excessive, or abusive drinking patterns contribute to social costs through lost productivity, absenteeism, and poor workplace performance, as well as to the cost of healthcare due to injury resulting from one’s own or others’ drinking. In general, negative outcomes are closely linked with high-risk and excessive drinking patterns (e.g., Stockwell, Hawks, Lang, & Rydon, 1996).

• Harms related to alcohol consumption include increased likelihood of accident and injury in the workplace, at home, on the road, and in a range of venues (Cherpitel, 1996; Chochinov, 1998; International Center for Alcohol Policies, 2002c, 2003a; Nelson & Wechsler, 2003).
• Social harms may include an association with violence and aggression, unwanted sexual activity, pregnancy, and sexually transmitted diseases (Ferrins-Brown et al., 1999; International Center for Alcohol Policies, 2000b, 2002c; Singh, Masih, Satpathy, Duseja, & Chawla, 2001; Single, 1997; Stockwell, Chikritzhs, & Brinkman, 2000).
• Negative health outcomes for most people who drink are associated with patterns of excessive drinking and the effects of alcohol abuse. They include, among other problems, certain forms of cardiovascular disease, liver cirrhosis, dementia, alcohol dependence, and injury (Galanis et al., 2000; McKee & Britton, 1998; Murray et al., 2002; Puddey et al., 1999; Rehm, Sempos, & Trevisan, 2003; Thomas & Rockwood, 2001; Zuccala et al., 2001).

Some social costs are the result of public disorder and violence. Public drunkenness and the law enforcement costs associated with it are further contributors. Medical and healthcare costs, both short- and long-term, are a major contributor as a result of morbidity attributable to certain patterns of drinking (Rehm & Gmel, 2003; Reynaud, Gaudin-Colombel, & Le Pen, 2001).

At the same time, thorough calculations of cost need to factor in the saved lives, lowered healthcare costs, and increased productivity attributable to moderate alcohol consumption. It should be noted that every policy approach has implications for both cost and benefit and that the net outcome is often a tradeoff between them. Before policies aimed at reducing social costs are put in place, several questions must be answered:

• Do the benefits of implementing a particular policy outweigh the costs, or vice versa?
• Does the particular policy take into account some of the less easily quantifiable variables?
• What is the most cost-effective approach to policy implementation?

Therefore, in addition to costs, quantifiable benefits also factor into a balanced social and economic calculation. Costs and benefits must be weighed carefully when deciding on the optimal policy approach (Collins & Lapsley, 2002; Gmel, Gutjahr, & Rehm, 2003; Single, 1996; Single & Easton, 2001; Xie et al., 1998). The aim of policy is ultimately to reduce cost to society by reducing harm and increasing benefit.

Building alcohol policies 

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Traditional alcohol policies have relied on the premise that there is a fixed and predictable relationship between the level of average per capita alcohol consumption across a population and the incidence of problems—whether social or medical—within it (Babor & Del Boca, 2003; Edwards et al., 1994; Ledermann, 1952; Ledermann & Tabah, 1951; Saunders & DeBurgh, 1999). Under this premise, therefore, reducing the level of consumption across an entire population should, by definition, lead to a reduction in the incidence of problems. The appealing simplicity of this relationship has been translated extensively into a range of policy applications over the last several decades, still evident in approaches in a number of countries around the world.

In general, control policies rely on restricting access to and availability of beverage alcohol across entire populations in individual jurisdictions. Specific measures that are applied include increasing pricing through taxation and duties, restricting licensing hours or banning the sale of alcohol on certain days, limiting the density of retail and serving outlets within a given area, imposing age limits, controlling sales through state-run monopolies, and even complete prohibition. Several indirect measures, including restrictions and bans on advertising, have been applied with the same goal in mind.

A major weakness of broad population-based measures is their inability to differentiate between individuals whose drinking is associated with harmful outcomes and those whose drinking is not (Grant & Litvak, 1998; Midanik, 1994; Norström, 2001; Rehm & Gmel, 1999; Single et al., 1994; Stockwell, Lang, & Rydon, 1993). By their very nature, such approaches address the lowest common denominator and lack the flexibility to respond to the needs of groups and individuals whose drinking may be particularly problematic.

Another weakness of control measures is that they are neither equally culturally relevant nor equally appropriate in all settings. They fail to take into account the important role alcohol plays in societies around the world and the fact that it is tightly woven into the fabric of normal social life in many of them. Drinking has been an integral part of many cultures since before recorded history and offers a colorful panorama of traditions, uses, myths, and practices (e.g., Heath, 1995, 2000; Marshall, 1979). Each region of the world is characterized by its own idiosyncratic array of beliefs, attitudes, and rituals around alcohol and views on its appropriate place within everyday life. As a result, a one-size-fits-all approach cannot be applied in every setting and its effectiveness is likely to vary (Norström, 2002; Ramstedt, 2001; Rossow, 2001).

A new approach is therefore needed to address the role of alcohol in society and the potential risks and benefits associated with its consumption. To be sustainable and effective, alcohol policies should recognize the role drinking plays in everyday life. They need to be practical and relevant to the lives of those they target, and applicable to populations, as well as to individuals, and within a variety of cultural contexts.

Elements of sustainable alcohol policies

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The choice of policy at a broad level goes hand in hand with its translation into specific areas where approaches can be implemented. The following is an outline of areas to be addressed in building alcohol policies. Some may be more relevant or of higher priority than others, depending on the particular situation and context. How approaches are developed will also depend heavily on a particular culture and the role of alcohol within it.

A comprehensive discussion of areas in need of attention is included in the Geneva Partnership on Alcohol: Towards a Global Charter (International Center for Alcohol Policies, 2000c), a document outlining a platform for policy development in the alcohol field and drafted through an international consultation and consensus process (International Center for Alcohol Policies, 2000c):

• The role of alcohol in society:

All cultures and societies place restrictions on alcohol consumption, either by law or custom, varying from place to place. Under conditions of rapid social change, cultural norms and societal customs may become undermined by social disruption and economic changes and may not keep pace with changes in drinking patterns (pp. 1–2).

• Freedom of access and availability:

Consumers should be able to obtain legally produced and marketed beverage alcohol. Access may be limited by laws, regulations and the standards that individuals, families, communities and the beverage alcohol industry impose upon themselves. Limitations on access should deter inappropriate drinking patterns, particularly where others are put at risk. Access to beverage alcohol should be limited for children and youth; the exact age for access in each country can only be decided by the local or national authorities.

In those societies, or sub-populations, in which new patterns of problematic drinking are emerging, or in which traditional wisdom on drinking may be poor or absent, a special focus should be placed on providing education, guidance and other initiatives on whether or how to drink (p. 2).

• Responsible practices around advertising and promotion:

It is recognized…that the advertising and promotion of beverage alcohol may need more careful regulation than that for some other products. (...)

Beverage alcohol industry members should promote only the responsible consumption of their products and should not encourage irresponsible or inappropriate consumption. Advertising and promotional activities should not, for example, create an impression that the drinking of alcohol is a requirement for success, or present a negative portrayal of those who abstain; nor should they be targeted at children or those who do not have the legal right to buy or consume alcohol.

Regulatory bodies, which may involve the beverage alcohol industry, as well as effective self-regulatory standards within the industry, should govern beverage alcohol advertising, packaging and promotion. Where self-regulatory codes for advertising and promotion of alcohol beverages do not exist, the beverage alcohol industry should take steps to encourage their development and enforcement, especially in emerging markets. When self-regulation is shown not to be effective, governments should intervene with legislation or regulation (p. 3).

• Comprehensive information and education:

People should have access to full and accurate information on the characteristics of beverages, including their alcohol content. Accurate information should also be available on the effects of drinking alcohol including the fact that effects may differ depending on the amounts consumed, patterns of consumption, the differing characteristics of consumers, and the circumstances under which consumption occurs. Those who provide such information, including governments, the beverage alcohol industry, the health sector, educators and the media, should present it in a clear, accurate and balanced manner. Individuals who choose to consume beverage alcohol should take into account information about related risks, harms and benefits (p. 3).

• Healthcare and education of healthcare providers:

Based on scientific evidence, the health sector should provide education to the public about the harms associated with inappropriate consumption of alcohol and about appropriate patterns of drinking. The health sector should acknowledge the potential benefits of moderate alcohol consumption for those populations where this has been shown to be the case. (. . .) The beverage alcohol industry should support health sector initiatives through collaborative programs (p. 4).

• Responsible service of beverage alcohol:

Those who deal directly with consumers, including beverage alcohol retailers and the hospitality industry, should put in place responsible serving and selling practices. (...) Drinking environments which support moderate alcohol consumption should be encouraged (p. 4).

• Ensuring product quality and integrity:

In order to protect consumers from adulterated or contaminated beverages, governments should adopt product quality standards and prevent illicit production and illegal trade. Beverage alcohol producers have a responsibility to ensure that their products meet high standards of quality and integrity (p.4).

A regulatory framework for effective policies

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Effective alcohol policies are closely related to policies on a range of other issues with an impact on societies and populations around the world. Alcohol consumption is linked to health and social outcomes, and, as such, needs to be viewed within the broad context of healthcare, education, and social policies. Similarly, alcohol is a commodity like many others, subject to trade and fiscal considerations. These are relevant both within individual jurisdictions and across countries and regions—the result of a globalized system of trade. Finally, certain aspects of alcohol consumption have relevance within the judicial system, ranging from the enforcement of legal drinking ages and blood alcohol limits, to crime and violence around the supply and consumption of alcohol.

Therefore, it should be acknowledged that alcohol policies must operate within a well-defined regulatory framework. Establishing this legal framework is the domain of governments that must balance individual freedoms against the wellbeing and safety of society. Laws that govern the sale and supply of alcohol have an impact on individual consumers, the communities in which they live and on society more broadly. The legal framework within which alcohol is managed provides an operating environment with a powerful influence over its physical and social status.

All countries in which the sale and supply of alcohol are permitted impose regulatory measures that affect manufacturers, retailers, and consumers. There is wide variation in the approaches taken to regulation across countries. This variability is often a reflection of different cultures and experiences with alcohol.

Even within a well-defined regulatory framework, there is room for balance with other approaches. With regard to beverage alcohol, self-regulation by producers, particularly in matters to do with advertising and marketing, is often a viable option and an alternative to the imposition of restrictions (International Center for Alcohol Policies, 2001c, 2002b; Nelson, 1997; Pedlow, 1998). It is important to note that government regulation and self-regulation are not mutually exclusive, but can exist side by side. Where self-regulation is ineffective, regulation may be necessary.

The importance of a well-organized and efficient regulatory framework lies in its capacity to assist in maximizing benefits and minimizing harm. However, it is also important to recognize the limitations of the impact of regulation on human behavior and to ensure that regulation does not result in unintended adverse consequences.

Many variables affect why, when, and with whom individuals choose to drink, determining the likely outcomes of any drinking occasion. Although many of these variables are influenced by legal frameworks, they are not controlled by them. Therefore, regulations need to be carefully targeted and judiciously applied if they are to be helpful.

Considerations for successful regulation

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The following factors are critical for ensuring the effectiveness of any alcohol-specific regulatory framework and need to be carefully considered before regulations are developed and implemented:

1. What is the objective of the proposed regulation?

It is important to clarify from the outset the intended outcome being sought through regulation/legislation. Regulation is best seen as necessary either when other options for managing an issue have failed or in cases where it is the most sensible and sustainable approach based on available evidence.

2. What are the alternatives to regulation?

Careful consideration needs to be given to alternative strategies that may achieve the same goal at less cost and without imposing undue restrictions on the individual or the community. In some cases, these strategies may involve targeted interventions aimed at reducing harm, in others, a viable alternative to government regulation may be self-regulation by the industry. In many instances, it is realistic and pragmatic to consider the possibility of partnerships with others interested in reducing harms, rather than reaching for a new set of regulations.

3. Is there public support for the proposed regulation?

If regulations are to be made to work in the public interest, they require active support from the community. It is important that the option of regulation should reflect the views of the community and the reality of what the majority of the population wants. Consultation and participation of the community is key to the success of any regulatory measures. Regulations implemented in response to unrepresentative pressure from special interest groups are not likely to be sustainable or popular.

4. Is the proposed regulation consistent with local culture?

While the experiences of other countries or communities can provide useful guidance when considering a regulatory framework, it is important to recognize that they may not always be culturally appropriate. Regulatory approaches can only be effective if they are compatible with a particular culture and the prevailing views on alcohol’s role within it.

5. Once imposed, can regulations be effectively enforced?

Unless resources are available to monitor and enforce a particular regulation, its impact is likely to be negligible or even non-existent.

Direct regulatory options

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Alcohol is subject to regulation in a number of areas that are under the jurisdiction of governments for implementation and enforcement. They include the following measures that are implemented to differing degrees within individual regulatory frameworks.

Pricing and taxation

Like most other commodities, beverage alcohol—beer, wine, and distilled spirits—is subject to taxation. Taxes are levied by national, federal, state, or local (county or city) governments, often in combination with each other. The main purpose of taxation is to generate government revenue. However, governments also use taxes on beverage alcohol for several other purposes: to attempt to reduce abuse and harm by making alcohol less accessible; to create trade barriers; and to encourage the purchase of domestic over imported products (Farrell, Manning, & Finch, 2003; Hurst, Gregory, & Gussman, 1997; Kenkel & Manning, 1997; Kuo, Heeb, Gmel, & Rehm, 2003; Lehto, 1997; Manning, Blumberg, & Moulton, 1995).

In creating alcohol policies, governments must weigh commercial freedoms and consumers’ rights of access to a product against protecting their citizens. This includes determining levels of taxation that do not impose an undue burden on consumers and restrict their choices or penalize producers by restricting fair trade practices.

Some governments use pricing through taxation as a means to limit the demand for alcohol by raising its cost, making it less accessible to consumers (Chaloupka, Grossman, & Saffer, 2002; Godfrey, 1989; Österberg, 1995). The effectiveness of taxation as a public health and social tool for reducing consumption, abuse and problems has been much debated. There is evidence that increasing the price of alcohol limits its purchase by some people (for discussion, see Babor et al., 2003). However, there is also evidence that it does not effectively target those who abuse alcohol and have risky drinking patterns, and that these individuals are generally not likely to respond to changes in pricing (Heyman, 1994, 2000; Kenkel, 1996; Manning et al., 1995). Like any policy measure that addresses the general population, taxation is a blunt tool and does not differentiate between problematic and unproblematic drinking patterns.

Perhaps the most compelling evidence against taxation as an effective policy measure against abuse comes from countries where taxation rates have traditionally been high. In many of these, such as the Nordic countries or those in Eastern Europe, alcohol consumption and harmful drinking patterns remain high (Hibell et al., 2000; Norström, 2001; Österberg & Karlsson, 2003). Binge drinking continues as the predominant pattern of drinking, bringing with it a range of health and social harms for adults, as well as for young people (e.g., Hibell et al., 2000, 2004; Norström, 2002).

High taxation rates can also result in a number of unintended consequences (Härstedt, 2004; Leifman, 2001; Lyall, 2003; Nordlund & Österberg, 2000):

• increased cross-border trade of alcohol from neighboring countries where taxes (and effectively prices) are lower;
• growth in black market trade in smuggled and counterfeit beverage alcohol, often of dubious quality;
• movement away from commercial beverages toward home production, again raising the possibility of low-quality products.

As a result, while increased taxation may reduce the purchase and consumption of commercially produced alcohol, it may also contribute to harmful drinking patterns of other beverage types, both licit and illicit (Gruenewald & Treno, 2000). Furthermore, a government hoping to increase its revenue through taxation of beverage alcohol may actually see revenue fall as non-taxed beverages are substituted for those that are taxed (Popham, Schmidt, & de Lint, 1975; Strategy in Focus & The Henley Centre for Forecasting, 1991).

Access and availability

Controlling alcohol consumption by limiting availability and access to it is a common approach to addressing problems. Controls are generally implemented through a regulatory framework and exist to some degree in virtually every country. There is evidence that some measures are more effective that others. However, the ability of such regulation to achieve its intended goal relies heavily on its enforcement. As a result, many measures, while mandated, may be largely ineffective due to insufficient mechanism to ensure that they are, indeed, implemented and upheld.

The more commonly used regulatory measures include regulating the density of outlets serving or selling alcohol, restrictions on hours of operation or days when alcohol can be obtained, and the institution of state-run monopolies to regulate all aspects of access and availability. The effectiveness of these measures, their reliance on enforcement, and their relevance in a world where alcohol policies often transcend national borders have been debated (e.g., Hauge & Amundsen, 1994; Hauge & Nordlie, 1984; Irgens-Jensen, 1984; Leppänen, 1979; Mäkelä, Rossow, & Tryggvesson, 2002; Norström & Skög, 2003; Olsson & Wikström, 1982; Raistrick, 1999; Smart & Mann, 1995). There is evidence that many of these measures may result in unintended consequences, including those listed above with relation to taxation and pricing.

However, there are several areas in which regulation of alcohol availability, consumption, sale, and service has been effective in helping to reduce the potential for harm. The results of these approaches have been well documented and are proven examples of good practice.

Legal drinking age

There is evidence to support the imposition of regulations with regard to the minimum legal age for purchase and consumption of alcohol (Grube, 1997; International Center for Alcohol Policies, 1998/2002d; Wagenaar, Murray, & Toomey, 2000). It is important to recognize that different countries set different age limits, often based on historical practice and cultural attitudes toward alcohol and the transition from childhood to adulthood (International Center for Alcohol Policies, 1998/2002d). However, clarity with regard to a legal threshold for alcohol consumption provides a very important message regarding the status of alcohol as an adult product. Current concern in many countries about underage drinking reinforces the importance of this issue (for further discussion, see MODULE 12: Legal Age Limits).

Blood alcohol concentration level

It is well known that alcohol in the bloodstream impairs reaction time and the ability to execute certain motor tasks, including driving a motor vehicle. The association between the level of alcohol in the bloodstream of a driver and the likelihood of that driver being involved in a crash has been documented (e.g., Borkenstein et al., 1964; Moskowitz, Burns, & Williams, 1985; U.K. Ministry of Health, 1995; Zador, 1991). Imposing a legal maximum allowable blood alcohol concentration (BAC) level for drivers has had a demonstrable impact on the number of motor-vehicle crashes in which alcohol is a contributor (Homel, 1988; McKnight & Voas, 2001; Ross, 1992; Shults et al., 2001). Similar regulations apply to the operation of airplanes, ships and commercial vehicles, and other modes of transportation. While the threshold for legal BAC levels differs across countries, the impact of applying these limits has been similar (International Center for Alcohol Policies, 2002a). Regulation has been critical to the success of this initiative, but public support both within communities and from the beverage alcohol industry has contributed significantly. As with other similar measures, the effectiveness of BAC regulations relies heavily on proper enforcement (for further discussion, see MODULE 15: Drinking and Driving and MODULE 15: Drinking and Driving).

Responsible service of alcohol

Well-managed drinking environments can enhance the pleasure derived from a drinking occasion and reduce the risks of harm associated with alcohol abuse. The introduction of regulations requiring bar staff training has been shown to have a positive impact on customer satisfaction and the reduction of harmful outcomes (e.g., Holder & Wagenaar, 1994; International Center for Alcohol Policies, 2002c; McKnight & Streff, 1994; Saitz, 1987). The same is true of measures that curtail the service of alcohol to intoxicated patrons. The need to ensure adequate enforcement of regulations regarding on-premise consumption is vital, not only to the enjoyment of patrons, but also to their safety (Graham & Homel, 1997; Graham et al., 2004; Graham, Schmidt, & Gillis, 1995). These measures are most effective when coupled with enforcement (McKnight & Streff, 1994; for further discussion, see also MODULE 4: Responsible Hospitality).

Indirect regulatory options

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Alcohol advertising and marketing

There is considerable debate regarding the impact of alcohol advertising on drinking patterns, particularly as it relates to young people (e.g., Calfee & Scheraga, 1994; Fisher, 1993; International Center for Alcohol Policies, 2002b; Nelson, 2001). At the core of the issue is whether or not advertising encourages young people to drink and to engage in harmful drinking practices. The research findings are mixed, but in most countries this remains an issue of public concern (International Center for Alcohol Policies, 2002b).

The various aspects of product marketing—including advertising, labeling, consumer promotion, packaging and merchandising—are an integral part of promoting different brands of virtually every consumer good. Ensuring that product marketing is consistently “legal, decent, honest and truthful” (International Chamber of Commerce, 2004, p. 4) is in the best interest of producers, retailers, consumers, and governments alike. This includes both “traditional” marketing approaches and “new” approaches through the electronic media such as the Internet or telecommunications.

An important part of public policy is how to ensure the integrity and standards around all product marketing. In particular, when a product has the potential to be misused and may confer harm as well as benefit, marketing standards are needed.

At the same time, marketing is a commercial right in most countries, provides consumers with information and choices, and is helpful to businesses in selling their products. Therefore, at the heart of the issue is the need to balance commercial freedoms against the safety and wellbeing of consumers. More broadly, how marketing is regulated reflects the respective roles, rights, and responsibilities of the state and the private sector within a given culture. Certain depictions or marketing approaches that are acceptable in some cultures may be frowned upon in others. The line between what is humorous and what may be offensive is largely defined by culture.

Industry self-regulation of marketing

Central to the marketing of beverage alcohol is how standards can be met, and whose responsibility it is to enforce compliance. There are those who believe that the responsibility is primarily that of government, while others view it as the domain of the industry itself. However, industry self-regulation and government regulation are not mutually exclusive. They are compatible and can even be complementary. The two approaches can be balanced against each other, depending on particular needs.

The objective of self-regulation is to ensure that marketing and advertising adhere to certain standards for conduct, thereby reducing the need for government intervention through regulation and restrictions. At the heart of self-regulation are the concepts of good corporate citizenship and corporate social responsibility (Grant & O'Connor, 2005; International Center for Alcohol Policies, 2001c).

Several requirements can help ensure that self-regulation in the advertising and marketing of beverage alcohol is effective. These requirements may be met by individual companies, by industry sectors, or by the industry as a whole, and include:

• developing adequate standards;
• understanding and acceptance of the standards by those involved in marketing;
• advising marketing professionals about these standards;
• ensuring, enforcing, and/or monitoring compliance with the standards;
• implementing a mechanism for handling complaints from consumers, industry bodies, and other relevant parties;
• ensuring the transparency of complaints procedures and informing consumers about them.

For those wishing to explore the development of self-regulatory standards, two ICAP documents offer guidance to setting up and implementing self-regulatory practices: Self-regulation and Alcohol: A Toolkit for Emerging Markets and the Developing World and Suggested Framework for Responsibility. Codes for conduct developed by a number of industry entities already exist and have been implemented in a number of countries around the world (see ANNEX 2: Industry Codes of Practice for Self-regulation; see also International Center for Alcohol Policies, 2001c, 2002b).

It should be noted, however, that where industry self-regulatory codes around marketing exist, government also has a role to play. This is especially important where self-regulation is partial, absent, or ineffective—or where it is not sufficiently enforced either by companies themselves or by a body set up for this purpose.

Drinking patterns, targeted interventions, and partnerships

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To be sustainable and effective alcohol policies should recognize the role drinking plays in everyday life. They need to be practical and relevant to the lives of those they target, applicable to populations and individuals, and sensitive to a variety of cultural contexts. An approach is therefore required that is responsive to the needs of the real world.

This approach is based on three key elements that integrate the evidence base around alcohol issues, the need for pragmatism, and the collective responsibility of all those with a stake in reducing the potential for harm and increasing benefit to the individual as well as to society. These three elements are:

• drinking patterns as a sound scientific basis for outcomes,
• targeted interventions that address specific “at-risk” populations and potentially harmful contexts, and
• partnerships that allow the inclusion of the public and private sectors, the community, and civil society all working towards a common goal.

The development and implementation of alcohol policies is a shared responsibility among many diverse partners, each with a specific role to play. Who these partners are and how they may work together toward a common goal is discussed in a later section. However, there are certain steps that can be recommended to ensure that policies are well thought out, relevant, and implemented in a way that is meaningful and appropriate:

• Identify relevant stakeholders and build partnerships with them, striving to create a broad base of support.
• Develop a comprehensive strategy that can reasonably be executed.
• Agree on areas in which there is common ground among the potential partners and on their relative priority.
• Evaluate and, if necessary, modify policy to ensure effectiveness once it has been implemented.

Drinking patterns

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Alcohol consumption is associated with a broad range of outcomes, both positive and negative (Grant & Litvak, 1998; International Center for Alcohol Policies, 2004b). Some are related to health, others to the social aspects of drinking. The consequences individuals are likely to experience from their drinking are a direct result of their so-called “drinking patterns.” There is growing recognition that drinking patterns are a more reliable predictor of outcomes than just quantity of alcohol consumed. In other words, how people drink is at least as important as how much they drink.

Drinking patterns have important implications in a number of areas:

• For the purposes of policy, it is important to know how people drink and what makes up their drinking styles. Different groups of people drink in different ways. Looking across large groups of individuals and entire populations reveals only gross averages that may not correspond to the reality of drinking behavior.
• Effective prevention requires an understanding of how people actually drink. Not all those who drink are likely to experience the same outcomes. Therefore, because of factors that place them at increased risk or because of their particular drinking pattern, some individuals need special attention and approaches that may not be appropriate for others.
• Research into drinking patterns has yielded a wealth of information about how people drink as individuals and as social or cultural groups. More research is needed to further enhance our understanding of drinking patterns.

What are drinking patterns?

Drinking patterns describe the many ways in which people drink (Single & Leino, 1998). While it is important to know how much people drink, more detail is needed to fully describe their drinking behavior, predict its possible outcomes, and, to the extent possible, minimize the potential for harm (Plant & Plant, 1997). The following are some of the dimensions of drinking patterns.

1. Temporal variations

When drinking occurs is partly a reflection of drinking culture and partly of the acceptability of alcohol consumption in general. For many people, drinking is a leisure activity, usually associated with weekends, holidays, and time away from working hours. Variations are closely related with potential outcomes, both positive and negative.

Temporal variations also include the “rhythm” of drinking—whether it occurs in a single episode or is spread out over time; the amount consumed at each occasion is another important facet. Heavy drinking occasions are a better predictor for harmful outcomes than moderate drinking. Patterns involving drinking rapidly to intoxication (often referred to as binge drinking) are generally more likely to be associated with negative health and social consequences (Grant & Litvak, 1998; Midanik, 1994; Norström, 2001; Single, 1996; Single et al., 1994; Stockwell et al., 1993).

2. Settings and activities associated with drinking

Where drinking takes place is an important component of drinking patterns. It may occur within the home, in bars and restaurants, at sporting events or celebrations, and in a range of other venues. Some societies integrate drinking into everyday life, as part of meals and social gatherings, largely within the home. Others confine drinking to special occasions. Celebrations and festivities (often religious) may be the only drinking occasions, and alcohol may be used to mark an event. In many cases, excessive drinking is associated with these occasions (Heath, 2000).

The settings and venues within which drinking takes place have an impact on potential outcomes. For example, drinking outside the home increases the likelihood that subsequent travel will be involved. Under these circumstances, road traffic crashes are a possible consequence of drinking and driving, and may have implications for public safety. Drinking in certain types of bars and outlets may similarly increase the likelihood that violent incidents may occur.

3, Personal characteristics of drinkers

Who the drinkers are also contributes to the drinking patterns picture. In general, men are more likely to drink (and to drink more) than women. Various social factors have bearing on how people drink. For example, religiosity is often seen as a protective factor against heavy drinking, and socioeconomic status and education are related to how, what, and how much people drink in virtually every society.

At the individual level, age, gender, health status, and experience with drinking are contributors to the likelihood of positive or negative effects (International Center for Alcohol Policies, 2001a). Young people and older individuals may be more susceptible to the effects of alcohol. Men and women may experience the effects of alcohol differently because of differences in physiology and alcohol metabolism. Similarly, genetic predisposition to alcohol dependence or the inability to metabolize ethanol play a role with regard to outcomes for certain groups of people. A more detailed discussion can be found in ICAP Blue Book ANNEX 2: The Basics about Alcohol.

4. Types of beverages

What people drink is another important component of drinking patterns. Certain cultures have preferences for certain beverages—there are predominantly wine-, beer-, or spirits-drinking cultures. Various novelty drinks may be popular among some groups of individuals, and, in some cases, “Western” beverages may displace traditional drinks. In addition, certain groups may consume specific beverage types preferentially for social and economic reasons (Haworth & Simpson, 2004).

In addition, a significant portion of all alcohol actually consumed around the world can be classified as “noncommercial” (Haworth & Simpson, 2004; see also MODULE 21: Noncommercial Alcohol). The production and consumption of these beverage types are steeped in tradition and culture. Some noncommercial alcohol is illicitly produced and available through the black market, other beverages are produced specifically for home consumption or for limited trade. While many home-produced beverages are of high quality, they are not subject to the same controls as commercially produced alcohol. In the case of illicit alcohol, low quality and contamination may represent a public health issue.

5. Culture and drinking patterns

The role and significance of alcohol differs across cultures, as do tolerance for drinking and related behaviors and outcomes and the acceptability of drinking among different groups—for example, women, older adults, and young people (Heath, 2000, 1995; MacAndrew & Edgerton, 1969). Cultural differences play a significant role in the potential outcomes of drinking.

Drinking patterns and outcomes

A solid relationship between drinking patterns and a range of health and social outcomes has been established. It is clear that in both cases alcohol consumption is associated with both benefits and harms. Some of these are long-term (chronic) outcomes, while others are short-term (acute). Whether the outcomes for an individual will be positive or negative is strongly correlated with his or her pattern of drinking.

The various health benefits that have been described for alcohol consumption generally relate to moderate drinking patterns (National Institute on Alcohol Abuse and Alcoholism, 2003):

• Compared to abstainers, moderate drinkers have lower mortality rates (Doll & Peto, 1995; Holman & English, 1996; Holman, English, Milne, & Winter, 1996; Trevisan, Schisterman, Mennotti, Farchi, & Conti, 2001).
• The cardio-protective effects of moderate drinking have been well documented, especially for middle-aged men, although the effects may extend to other groups, including post-menopausal women (Ashley, 2000; M.J. Ashley, Rehm, Bondy, Single, & Rankin, 2000; Baer et al., 2002; Hines & Rimm, 2001; Mukamal, 2003; Mukamal & Rimm, 2001; Murray et al., 2002; Rehm, Rehn et al., 2003; Rimm, Williams, Fosher, Criqui, & Stampfer, 1999; Sillanaukee, Koivula, Jokela, Pitkajarvi, & Seppa, 2000; Trevisan, Ram et al., 2001).
• Moderate alcohol consumption may also protect against certain types of stroke (Meister, Whelan, & Kava, 2000).
• There is evidence that moderate drinking may aid in delaying the onset of osteoporosis in older women (Bainbridge, Sowers, Lin, & Harlow, 2004; Williams, Cherkas, Spector, & MacGregor, 2005).
• Benefits for some individuals with type II diabetes have been reported (Kao et al., 1998; Nakanishi, Suzuki, & Tatara, 2003; Wannamethee et al., 2003).
• In older individuals, moderate drinking may decrease the risk of vascular dementia and improve cognitive function and memory (Brust, 2002; Cassidy et al., 2004; Galanis et al., 2000; Mukamal et al., 2003; Peele & Brodsky, 2000; Truelsen, Thudium, & Gronbaek, 2002; Zuccala et al., 2001).
• Other possible positive effects of moderate drinking may include decreasing risk for macular degeneration and pancreatic disease (Hiratsuka & Li, 2001; Obisesan, Hirsch, Kosoko, Carlson, & Parrott, 1998; Stevens, Conwell, & Zuccaro, 2004).

There is evidence that other aspects of drinking patterns are also important influences on health benefits. For example, drinking that accompanies meals may be especially beneficial to health (Trevisan, Ram et al., 2001; Trevisan, Schisterman et al., 2001).

Heavy or reckless drinking patterns have been correlated with certain increased risks to health:

• Excessive drinking patterns increase the risk for accidents and injuries (Cunningham et al., 2003; Gutjahr, Gmel, & Rehm, 2001).
• Cardiomyopathy is often a long-term outcome of alcohol abuse, leading to congestive heart failure; heavy drinking is also related to certain types of stroke (Flesch, Rosenkranz, Erdmann, & Bohm, 2001; Hillbom, Juvela, & Numminen, 1999; Meister et al., 2000; Nicolas et al., 2002; Reynolds et al., 2003; Rotondo, Di Castelnuovo, & de Gaetano, 2001; Walsh et al., 2002).
• Although the relationship still remains inconclusive, drinking may be related to breast cancer in some women, especially those with a family history of the disease (Ashley et al., 1997; Ginsburg, 1999; Hamajima et al., 2002; Smith-Warner et al., 1998; Vachon, Cerhan, Vierkant, & Sellers, 2001).
• Individuals with a long history of heavy drinking are at risk for developing cirrhosis of the liver (Donato et al., 2002; Lieber, 2003; Mann, Smart, & Govoni, 2003; Meister et al., 2000).
• Heavy and abusive drinking is related to the development of alcohol dependence in some individuals (Jennison, 2004).
• Pregnant women with heavy drinking patterns increase the risk of their children being born with fetal alcohol symptom (FAS) and various birth defects (Day et al., 1999; Goldschmidt, Richardson, Stoffer, Geva, & Day, 1996; Jones & Smith, 1973; Kesmodel, Wisborg, Olsen, Henriksen, & Secher, 2002; Meister et al., 2000; Sampson, Gallager, Lange, Chondra, & Hogan, 1999; Stratton, Howe, & Battaglia, 1996).
• Patterns of heavy drinking have been linked to oral and upper digestive tract cancers (Ashley et al., 1997; Gronbaek et al., 1998; Holman et al., 1996; Seitz et al., 2001; Seitz, Poschl, & Simanowski, 1998).
• Cognitive impairment, alcoholic dementia, and neurological damage have all been described for individuals with heavy and abusive drinking patterns (Thomas & Rockwood, 2001; Whelan, 2003).

While most of these harms are related to heavy drinking, there are certain individuals for whom even low to moderate levels of drinking may be related to adverse outcomes. This includes the individuals who are alcohol dependent or biologically predisposed to dependence, as well as those whose alcohol metabolism is impaired.

Social benefits of alcohol consumption—especially those linked to moderate drinking patterns—have been described.

• Relaxation and stress reduction are often cited as benefits of drinking (Grant & Peele, 1999; Peele & Brodsky, 2000).
• A subjective assessment of quality of life for many people includes drinking as one of a number of pleasurable activities (Orley, 1999; Strandberg, Strandberg, Salomaa, Pitkala, & Miettinen, 2004).
• Improved sociability and interaction generally accompany drinking (Brodsky & Peele, 1999; Orcutt, 1993).
• A positive correlation between moderate drinking, earning potential, and job performance has been described (Peele & Brodsky, 2000).

Certain drinking patterns carry with them negative social outcomes.

• Impaired job performance and a loss of productivity may result from heavy or abusive drinking (Anderson & Larimer, 2002; International Center for Alcohol Policies, 2003a; Joeman, 1991; McFarlin & Fals-Stewart, 2002).
• There is a potential increase in the risk for interpersonal violence and aggression, as well as for problematic relationships for some people, especially among heavy drinkers (Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002; Murdoch, Pihl, & Ross, 1990; Pernanen, 1991).
• Negative social outcomes include social costs of heavy or abusive alcohol consumption (Devlin, Scuffham, & Bunt, 1997; Sindelar, 1998).

Drinking patterns, policy, and prevention

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Due to their association with a range of outcomes, drinking patterns are valuable factors in helping to identify individuals or groups likely to develop problems. As a result, understanding the nature of particular patterns of drinking allows prevention approaches to be developed that specifically target problems and individuals who may be at risk.

A focus on drinking patterns allows tailoring of policies to particular groups rather than providing them in a one-size-fits-all fashion.

• Different information and recommendations around drinking can be provided for particular groups of people (e.g., men, women, pregnant women, older adults, those at risk for alcohol dependence, and young people).
• Targeting particular drinking patterns (e.g., heavy frequent drinking) is more effective at addressing particular problems and risks than are approaches addressing population-wide consumption levels.
• The effectiveness of policies differs across cultures. Patterns-based policy measures allow responsiveness to particular cultures or conditions.

For the purposes of policy, drinking patterns have important implications for a number of areas:

• It is important to know how people drink at an individual or group level and what makes up their particular drinking styles. If policies are to be relevant and realistic, it is not sufficient to look only at entire populations, which reveals only average measures of drinking and outcomes.
• Research into drinking patterns has yielded a wealth of information about how people drink as individuals and also as cultural groups. More such research is needed to further enhance the understanding of drinking patterns.
• Effective prevention requires a thorough understanding of how people actually drink. Not all of those who drink are likely to experience the same outcomes. Therefore, because of their particular drinking patterns, some individuals need special attention that may not be needed (or appropriate) for others.

Targeted interventions 

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A greater understanding that patterns of drinking are reliable predictors of outcomes has led to a gradual realization that alcohol policies and prevention strategies focusing on entire populations often fail to achieve their goal of reducing harm associated with excessive or irresponsible drinking. As a result, there has been a gradual shift of focus in the alcohol policy field on the targeted reduction of harm (e.g., Buning, Gorgulho, Melcop, & O'Hare, 2003).

This approach is a pragmatic one. It recognizes that that drinking is a normal activity in many cultures, that most people drink because they enjoy it, and that severely restricting access to alcohol is not a realistic or viable option. Many behaviors are risky but some people will always continue to willingly engage in them. At the same time, it is possible to manage these risks and to reduce the potential for harm (Martinic & Leigh, 2004).

The aim of reducing harm in a targeted way is to ensure that ,when people drink, they do so in as safe a manner as possible and that their drinking does not cause harm to themselves or to others. The key to intervention strategies lies in a balance between education, early intervention, and selective enforcement within a reasonable regulatory framework.

One of the strengths of the targeted harm reduction approach lies in its flexibility, allowing the design of policies and interventions specifically for individuals and groups at risk for harm without adversely affecting the choices of those who are not. It acknowledges that some patterns of alcohol consumption are compatible with a healthy lifestyle and may enhance individual and societal wellbeing. At the same time, it recognizes that irresponsible and excessive patterns of drinking have the potential to cause considerable harm.

• At a societal level, the targeted intervention approach advocates the promotion of those patterns of alcohol consumption that have been shown to be consistent with generally healthy lifestyles.
• At an individual level, this approach supports strategies aimed at reducing the possible consequences of harmful drinking patterns, without unnecessarily limiting or restricting the choices of those whose drinking is not associated with adverse outcomes.

An integrative and comprehensive approach to alcohol policy based on harm reduction and targeted interventions rests on a number of key criteria:

• the provision of balanced information on both benefits and harms;
• a sound evidence base founded on the best available scientific data;
• an approach that is palatable and easy for the public to understand;
• a focus on issues that correspond to actual, familiar and representative drinking behaviors;
• the recognition that alcohol consumption is an integral part of many societies and may be associated with both positive and negative outcomes;
• an approach that addresses the potential for harm in a non-judgmental way;
• strengthening individual responsibility at the same time as enforcing external controls;
• involvement of individuals and their communities in all aspects and levels of policy development, and consistency with other approaches and measures that are being used.

The targeted interventions approach relies on the principles of harm reduction. It is a pragmatic one, recognizing that risks are inherent in many behaviors, but that it is nevertheless possible to reduce and manage many of them. The approach also acknowledges that it is possible to preserve the ability and right of individuals to enjoy drinking, while at the same time reducing the potential for problems.

The key to the approach lies in a balance between targeted education, early intervention, and selective enforcement strategies. The objective lies in equipping individuals with the skills they need to make informed decisions about drinking patterns and potential outcomes and in making the drinking environment safer. This is achieved by focusing on settings and patterns that increase the potential for harm.

The Modules section of the ICAP Blue Book addresses particular areas in which such approaches can be applied and the considerations that should enter into their development.

However, there are several overarching principles that guide the reduction of harm in a targeted fashion:

1. The focus of prevention efforts is on at-risk drinking, not on overall alcohol consumption

Focusing on risky or excessive drinking patterns requires that special attention be paid to those whose drinking may be problematic. For example, it is possible to identify problem drinkers and offer interventions that are aimed at changing their drinking behavior (see MODULE 18: Screening and Brief Intervention). Programs that enable such individuals to return to responsible drinking patterns may also be a viable approach.

However, harm reduction also targets those, whose drinking is generally moderate and unproblematic but may be hazardous on occasion. Drinking to intoxication and binge drinking may fall into this category (see MODULE 5: Drunkenness and MODULE 6: Binge Drinking). Much can be achieved when dealing with such individuals through the provision of information on what constitutes “risk” and what the parameters are around “low-risk” drinking. The development of responsible drinking guidelines, information on standard units/standard drinks, and education for the general public about how these can be implemented and strengthened are useful approaches (see MODULE 1: Alcohol Education,MODULE 19: Drinking Guidelines :Drinking Guidelines, and MODULE 20: Standard Drinks; see also International Center for Alcohol Policies, 2003b, 2004a).

2. Drinking and related activities can be made safer, both for drinkers and for others around them

Various measures have been developed in an attempt to reduce harm for individuals whose alcohol consumption may increase the risk associated with activities accompanying drinking. For example, measures have been developed to target specifically those who drink and drive through the enforcement of drink-drive legislation and BAC limits or through the use of random breath testing (see MODULE 15: Drinking and Driving and MODULE 16: Blood Alcohol Concentration Limits). Other initiatives aimed at drinking and driving also include designated driver programs and the provision of alternative transportation for people who have been drinking. Similarly, interlock devices, installed in automobiles, that can only be deactivated by providing a breath test have been used to prevent repeat offenders from driving while intoxicated.

Ensuring the quality of beverage alcohol is another targeted measure aimed at reducing the potential for harm, with special relevance to developing countries and those where illicit trade in alcohol is well established. Testing for harmful contaminants and counterfeit products have shown promise in a number of countries (see MODULE 21: Noncommercial Alcohol; see also Haworth & Simpson, 2004).

3. Targeted interventions for reducing harm focus on settings where drinking occurs

Drinking takes place in settings, public and private, that differ widely across different cultures. Cafés, restaurants, bars, taverns, shebeens, beer gardens, open public spaces, festivals, religious functions—all provide venues for drinking.

Approaches have been identified that can make these settings safer and reduce the risk for harm and injury. For example, the introduction of special glassware that crystallizes when shattered can reduce the risk for injury in drinking venues where fighting may break out. Modifying the physical space in which alcohol is consumed can also offer ways to reduce harm through seating arrangements, partitions and lighting. A powerful intervention method includes the training of staff in serving and retail establishments to recognize signs of intoxication among patrons and to deal effectively with problematic situations (see MODULE 4: Responsible Hospitality and MODULE 14: Public Order and Drinking Environments).

4. Targeted interventions for reducing harm rely on education as an approach to changing behavior

Alcohol education has been used as a means of changing drinking patterns and behaviors. While there has been criticism of the effectiveness of certain education-based strategies, there are clear examples of successful approaches (see MODULE 1: Alcohol Education). It is important to recognize that alcohol education is a broad concept that includes both formal approaches and informal ones, such as education imparted through family and experience.

Education also includes approaches that provide and promote information about drinking patterns and levels and recommendations around them, such as official guidelines, campaigns against drunk-driving and designated driver initiatives, and a range of other measures shown to be effective at raising awareness and changing behavior (see MODULE 19: Drinking Guidelines and MODULE 20: Standard Drinks; see also International Center for Alcohol Policies, 2003b).

5. Targeted interventions for reducing harm are sensitive to cultural differences and contexts

Because they focus on settings, situations, and at-risk individuals, targeted interventions aimed at reducing harm that may be associated with certain drinking patterns can be tailored to the needs of specific drinking cultures and contexts. These approaches are flexible and can easily be adapted to take into account particular drinking patterns and practices.

Examples of cultural diversity can be found in targeted interventions directed, for example, at indigenous populations in many countries (see MODULE 8: “At-risk” Populations; see also International Center for Alcohol Policies, 2001a).

Partnerships

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Along with drinking patterns and targeted interventions for reducing harm, the third pillar for the development of sustainable, pragmatic, and effective policies around alcohol is the inclusion of all stakeholders with a role to play in their development and execution. Policies that have broad-based support are more likely to succeed and more likely to be acceptable to a wider section of those they are intended to reach.

Weighing rights and responsibilities

Active partnership is integral to the development of sound policy approaches. It is arguably the case that weighing the balance between rights and responsibilities lies at the heart of sensible and sustainable alcohol policies. Individuals value their right to purchase and consume alcohol without the imposition of onerous restrictions. Similarly, those in the business of producing and selling it also cherish their right to do so. At the same time, individuals, communities, and societies wish to be provided with a level of protection against the harmful outcomes of certain drinking behaviors and practices. The responsibility for ensuring such protection while guaranteeing individual and societal rights is a shared one.

Partners in alcohol policy development

Traditionally the domain of governments, alcohol policy development, implementation, and enforcement have gradually shifted into the communal sphere where other (often non-traditional) players have an equal stake. In an increasingly globalized world, economic, health, and social issues often transcend the confines of national borders.

Sustainable policy approaches rely on the involvement of all of the following stakeholders:

• government at the regional, national, and local levels;
• intergovernmental organizations;
• the private sector, including employers and shareholders;
• nongovernmental and civil society organizations;
• healthcare professionals and the research community;
• members of society at the individual and group level, including educators, family, clergy, and law enforcement personnel;
• media.

Governments

Governments have a clear role to play in the development of alcohol policies. One of their primary responsibilities is to ensure that their citizens are safe. Therefore, governments are instrumental in formulating, implementing, and enforcing legislation and regulations about alcohol. Yet, to be both effective and acceptable, policies must also reflect or be sensitive to the views of other sectors. Governments have a responsibility to ensure that a balance is struck between pursuing the safety and welfare of society as a whole and protecting the rights of the individual.

In recent years, the concept of public-private partnership has gained a foothold in the development of government policy, and a growing role has emerged for the private sector as an active participant in the formulation and implementation of socially responsible policies.

Intergovernmental organizations

Alcohol policies in a globalized world often transcend the physical boundaries of individual countries. As a result, intergovernmental organizations are increasingly involved in various aspects of health and social policy development, as well as in trade and commercial issues. Many areas previously in the domain of national governments are now increasingly addressed by intergovernmental organizations in an attempt to harmonize approaches.

However, it is important to bear in mind that the cultural idiosyncrasies of alcohol—still strong despite any convergence of drinking patterns—require that global approaches be tempered with an understanding of local contexts and social and cultural needs. Even in countries within the same geographic region and with similar cultures, differences in infrastructure and socioeconomic disparities mean that the priority attributed to alcohol problems and the allocation of resources to address them are likely to be widely divergent.

The private sector

The private sector at large is increasingly a player in policy development and implementation. The beverage alcohol industry is no exception; it has responsibilities to its shareholders, its employees, consumers, and the wider community within which it operates. Corporate responsibility in areas ranging across production, environmental issues, trade practices, and marketing is increasingly seen as an essential part of the business mission, strategy, and operations. This responsibility extends beyond just producers and includes both retailers and the hospitality sector (Grant & O'Connor, 2005).

By implementing direct approaches to prevention and also through their related bodies—such as social aspects organizations (SAOs) and trade associations—the producers of beverage alcohol are involved in addressing the reduction of harm around alcohol consumption. With regard to policy, they are an active voice in the development of initiatives and also subject to standards, their own or governmentally imposed, that regulate their practices. Shared ownership in development and implementation of policies is an effective means of ensuring commitment and involvement. Those in the retail and hospitality sectors, who have direct contact with consumers, also have a key role to play.

Nongovernmental and civil society organizations

Nongovernmental organizations (NGOs) and civil society groups can also play a significant role in the formulation of alcohol policies and can be particularly important at the community level. The main strength of these organizations lies in their local expertise and links with actors and networks that can be mobilized quickly. Especially in developing countries, these organizations have the best access to poorly served constituencies that are often hard to reach through official government channels. In many instances, NGOs represent the voice of the very communities alcohol policies are intended to target.

Healthcare and research communities

Effective policies and approaches to prevention rely on the availability of the best possible access to care, treatment, and research. They also include making available the best possible and most balanced information on drinking patterns and potential outcomes. Raising awareness among the public is the domain of the healthcare and research communities, as is tailoring information to the needs of individuals.

Research scientists and public health experts are responsible for ensuring that the results of research are made available and that this information is balanced. It is essential that research be conducted in a way that is free from any ideological or political influences. As undue influence may be exerted by sources of funding for research, complete transparency is needed that discloses the full nature of any financial relationship (see International Center for Alcohol Policies, 1998). Such transparency should also be applied to other influences—ideological, political, religious—that may have similar bearing on research and influence recommendations and conclusions.

Society

To be effective, alcohol policies need to involve those for whom they have been developed, namely individuals and society at large. Useful policies make sense and correspond to the actual experience of people, the role of alcohol in a given society, and how it is perceived. It is important to acknowledge that certain groups—such as families, educators, and clergy—play an important part in building up awareness around alcohol and influence how people learn about drinking (Houghton & Roche, 2001). All of these have a role to play in implementing policy approaches. At the end of the day, however, the final decision whether or not to drink rests with the individual.

The media

The media, in all forms and outlets, also play an important role with regard to policy. In addition to reporting about alcohol issues, they have several key functions: advertising, education, depictions of drinking in everyday life, and serving as a forum for discussion of alcohol policy (Partanen, 1988). It is essential that reporting in the media be accurate and fair, and that the translation of complex scientific and health information, including information about drinking patterns and outcomes, be balanced.

The relationship between media portrayals around alcohol, societal attitudes, and culture has been central to much of the policy debate (Angelin, Johnson, Giesbrecht, & Greenfield, 2000; Lemmens, Vaeth, & Greenfield, 1999). The promotion and advertising of beverage alcohol should be conducted responsibly, without promoting or encouraging irresponsible or inappropriate behavior (International Center for Alcohol Policies, 2001c, 2002b). Ensuring such practices is as much the responsibility of the media as of alcohol producers and governments.

Building partnership

Effective handling of partnerships is as much about managing relationships, as it is about the concrete issues involved in alcohol policy. It relies on mutual respect among all relevant parties with an interest in and a contribution to offer to the process, at the same time allowing room for legitimate differences.

In alcohol policy, as in other areas, ample common ground exists; the key is to be able to identify it. Working together relies on transparency, which, in turn, fosters both respect and trust. Where partners have common interests, such as reducing the potential harm related to alcohol consumption, transparency should not be an obstacle.

Comprehensive and balanced alcohol policies are a benefit shared by all those affected by them. A prerequisite for cooperation and partnership is the recognition that benefits need not always be identical for all parties.

The success of partnerships may rely on facilitation and negotiation by a third party able to bring together diverse viewpoints and help overcome obstacles that often stand in the way of dialogue. The third party should be credible to those involved, able to garner support from all stakeholders, and, in its own right, able to offer technical expertise and commitment necessary to develop and implement the process.

The implementation of partnerships in the area of policy development relies on a series of steps that can help increase the probability of success:

1. Identify relevant stakeholders and build partnerships

A number of prerequisites for the development of working partnerships for policy exist:

• Identify partners with a key role to play in the implementation of alcohol policies from the public and private sectors, as well as the community.
• Build a broad base of support for the approach; the broader the base, the more likely it is that the approach will succeed.
• Explore the willingness of parties to become involved in a consensual process and to contribute resources—technical or financial—as needed.

2. Identify issues of interest and areas of common ground

The needs and priorities of countries, communities, or populations in which stakeholders have an interest should drive the issues that are identified for action:

• Identify and explore issues of interest to each of the potential partners.
• Assess areas of overlap and common ground regarding priorities and approaches in order to set the agenda for action.
• Explore the willingness among parties to play a key role in policy design and implementation.

3. Strategy specification and implementation

Once potential partners and areas of common interest have been identified, a comprehensive strategy for policy formulation needs to be developed and executed jointly:

• Select a strategy supported by evidence of effectiveness that can also command public support.
• Identify human and financial resources needed and establish budget.
• Identify key individuals to be involved in implementation.
• Develop a timeline with clearly defined milestones and reporting mechanisms for monitoring progress.
• Prepare a consolidated action plan for implementation, including a delineation of roles and responsibilities.

4. Evaluation and feedback

The effectiveness of the approach should be evaluated after it has been in place for an appropriate period of time; needed modifications should be implemented

• Evaluation criteria and methodology should be identified before implementation.
• Qualitative feedback should be considered in addition to quantitative measurements.
• Evaluation of the extent to which outcomes match original goals is needed.
• Areas in which modification is required should be identified.

Steps for developing sustainable and balanced policies 

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Those who desire to develop and implement alcohol policies may draw upon a series of steps that are offered in Building Blocks Action Checklist. The checklist lays out the elements of what is needed to build successful and comprehensive policies. Not all of the steps are equally applicable in all situations and how they are implemented depends largely on the stage of policy development that already exists. They describe a sequence that can be applied by governments, nongovernmental entities, the private sector, or any other group with an interest in policy development.

The following is an overview of the elements needed and the output that is to be achieved in each of the ten building blocks (International Center for Alcohol Policies, 2001b).

1. Cultural context

This building block sets the scene, assessing the cultural context where policy development is intended. Attention is paid to the drinking culture and the role of alcohol in society, as well as to societal norms.

Output: An account of drinking patterns, which identifies important historical, societal, and cultural trends in shaping contemporary drinking behavior.

2. Existing policy stocktake

Attention is focused on current/existing policies and on formal and informal mechanisms that influence them. The legal framework is considered, as are the roles of NGOs, intergovernmental organizations, the beverage alcohol industry, and others in developing, implementing, and enforcing existing policies.

Output: A detailed audit of the current policy profile of the country, including an analysis of the main policy directions, any inconsistency in policy components, and any current proposals for policy change.

3. Issues identification

This process is crucial to the development and implementation of alcohol policies and hinges upon a thorough review of key issues that are of relevance and concern to those identified as the primary stakeholders in policy development. The identification of key issues allows those ultimately responsible for shaping policies an opportunity for input.

Output: A prioritized list of key issues, reflecting the views of major stakeholders.

4. Partnership

The establishment of working partnerships is essential to the success of this model for policy development. Partners should include representatives from the public and private sectors, and special attention should be given to maintaining dialogue and cooperation between them.

Output: A functioning partnership, with an agreed agenda for action.

5. Community participation

Public input and participation are crucial if policies are to be effective and sustainable. It is necessary to ensure that measures are in keeping with community norms and practices and that the rights of all are respected, while at the same time ensuring their safety.

Output: Effective mechanism for facilitating flow of community views into partnership process, with effective feedback to the community.

6. Goal and outcome clarification

Policy goals and objectives should be agreed, resulting from a careful review of the issues identified earlier. More detailed outcomes need to be specified; these should be quantifiable, measurable, and achievable within a realistic timeframe.

Output: Clear statement of overall policy goals with specific outcomes and a method for assessing whether they are being achieved.

7. Strategy specification

Strategies need to be selected that will lead to the desired outcomes. These strategies should be consistent with the expectations of the public and should be supported by evidence.

Output: Consolidated action plan, specifying strategies, timelines, resources, and target audiences.

8. Implementation

The actions to be taken in order to implement the agreed policy options should be described. Specifically, timelines need to be agreed upon from the outset, with well-defined milestones and reporting mechanisms put in place. Agreement is needed among stakeholders regarding specific responsibilities.

Output: Experience in implementing agreed strategies, reflected in reports on progress.

9. Evaluation

Evaluation of the outcomes that have been achieved is a critical component of building policies. Particular attention is needed to the way in which the outcomes fit with the overall goals established for the policy and individual objectives identified through the partnership approach. Any unanticipated outcomes that may arise from the implementation process should also be taken into account.

Output: Series of monitoring reports covering all phases of implementation of each strategy from inputs to outcomes.

10. Feedback

The final step allows for feedback and review, focusing on the utility of the model implemented. The impact of partnership needs to be reviewed, as well as its capacity to persist over time as an instrument for designing and implementing policy.

Output: A sustainable mechanism that will ensure the continuing life of the partnership and its involvement in alcohol policy development.

Conclusions

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The main aim of alcohol policies is to ensure the wellbeing of members of society by maximizing benefits and minimizing potential for harm that may be associated with drinking. To be effective, alcohol policies rely on creating a balance between the rights of individuals and those of society. Such balance can be created in a number of different ways.

A focus on patterns of drinking allows attention to be placed on areas where the potential for harm is greatest and on individuals who are most at risk. Targeted interventions allow responsible drinking behaviors to be encouraged, while discouraging excessive and irresponsible ones.

A second element for achieving balance is the recognition that safeguarding the wellbeing of society is not the sole domain or responsibility of any single sector. Balanced alcohol policies rely on the involvement of governments, the private sector, and individuals alike. Broad-based involvement can help ensure that policies are realistic, correspond to the reality of people’s drinking and the cultural role of alcohol, and increase the sense of ownership of different groups when it comes to ensuring the success of policy approaches.

Finally, balanced policies are founded on the belief that more can be achieved through cooperation and partnership than can be effected in isolation. Yet, such cooperation needs to be governed by certain rules and standards of ethical conduct, its parameters need to be agreed upon, and it must be pervaded by a sense of mutual trust and transparency.

The integrative approach to alcohol policies proposed here relies on these principles. The Blue Book Modules that follow apply this approach to individual issues that need to be addressed in a comprehensive policy on alcohol. Similarly, initiatives that have been successfully implemented and can be replicated elsewhere are featured in the online database Initiatives Reporting: Industry Actions to Reduce Harmful Drinking.

References

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Anderson, B. K., & Larimer, M. E. (2002). Problem drinking and the workplace: An individualized approach to prevention. Psychology of Addictive Behaviors, 16, 243–251.

Angelin, L., Johnson, S., Giesbrecht, N., & Greenfield, T. (2000). Alcohol policy content analysis: A comparison of public health and alcohol industry trade newsletters. Drug and Alcohol Review, 19, 203–212.

Ashley, M. J. (2000). Balancing the risk and benefits of moderate drinking. In A. Varley (Ed.), Towards a global alcohol policy: Proceedings of the Global Alcohol Policy Conference, Syracuse, NY, USA, August 2000 (pp. 16–19). London: Institute of Alcohol Studies.

Ashley, M. J., Ferrence, R., Room, R., Bondy, S., Rehm, J., & Single, E. (1997). Moderate drinking and health: Implications of recent evidence. Canadian Family Physicians, 43, 687–694.

Ashley, M. J., Rehm, J., Bondy, S., Single, E., & Rankin, J. (2000). Beyond ischemic heart disease: Are there other health benefits from drinking alcohol? Contemporary Drug Problems, 27, 735–777.

Babor, T. F., & Del Boca, F. K. (Eds.). (2003). Treatment matching in alcoholism. Cambridge, U.K.: Cambridge University Press.

Babor, T. F., Caetano, R., Casswell, S., Edwards,G., Giesbrecht, N., Graham, K., et al. (2003). Alcohol: No ordinary commodity. Research and public policy. Oxford, U.K.: Oxford University Press.

Bachman, J. G., Safron, D. J., Sy, S. R., & Schulenberg, J. E. (2003). Wishing to work: New perspectives on how adolescents' part-time work intensity is linked to educational disengagement, substance use, and other problem behaviours. International Journal of Behavioral Development, 27, 301–315.

Baer, D. J., Judd, J. T., Clevidence, B. A., Muesing, R. A., Campbell, W. S., Brown, E. D., et al. (2002). Moderate alcohol consumption lowers risk factors for cardiovascular disease in postmenopausal women fed a controlled diet. American Journal of Clinical Nutrition, 75, 593–599.

Bainbridge, K. E., Sowers, M., Lin, X., & Harlow, S. D. (2004). Risk factors for low bone mineral density and the 6-year rate of bone loss among premenopausal and perimenopausal women. Osteoporosis International, 15, 439–446.

Baum-Baicker, C. (1985). The psychological benefits of moderate alcohol consumption: A review of the literature. Drug and Alcohol Dependence, 15, 305–322.

Borkenstein, R. F., Crowther, R. F., Shumate, R. P., Ziel, W. B., Zylman, R., & Dale, A. (Eds.). (1964). Role of the drinking driver in traffic accidents. Bloomington, IN: Indiana University, Department of Police Administration.

Brodsky, A., & Peele, S. (1999). Psychosocial benefits of moderate alcohol consumption: Alcohol's role in a broader conception of health and well-being. In S. Peele & M. Grant (Eds.), Alcohol and pleasure: A health perspective (pp. 187–207). Philadelphia: Brunner/Mazel.

Brust, J. C. (2002). Wine, flavonoids and the "water of life." Neurology, 59, 1300–1301.

Buning, E., Gorgulho, M., Melcop, A. G., & O'Hare, P. (2003). Alcohol and harm reduction: An innovative approach for countries in transition. Amsterdam, Netherlands: International Coalition on Alcohol and Harm Reduction.

Calfee, J., & Scheraga, C. (1994). The influence of advertising on alcohol consumption: A literature review and an econometric analysis of four European nations. International Journal of Advertising, 13, 287–310.

Cassidy, K., Kotynia-English, R., Acres, J., Flicker, L., Lautenschlager, N. T., & Almeida, O. P. (2004). Association between lifestyle factors and mental health measures among community-dwelling older women. Australian and New Zealand Journal of Psychiatry, 38, 940–947.

Chaloupka, F. J., Grossman, M., & Saffer, H. (2002). The effects of price on alcohol consumption and alcohol-related problems. Alcohol Research and Health, 26, 22–34.

Charles, P., Laitinen, K., & Kardinaal, A. (1999). Alcohol and bone. In I. Macdonald (Ed.), Health issues related to alcohol consumption (2nd ed.). Oxford, U.K.: Blackwell Science.

Cherpitel, C. J. (1996). Drinking patterns and problems and drinking in the event: An analysis of injury by cause among casualty patients. Alcoholism: Clinical and Experimental Research, 20, 1130–1137.

Chick, J. (1999). Can light or moderate drinking benefit mental health? European Addiction Research, 5, 74–81.

Chochinov, A. (1998). Alcohol "on board," man overboard: Boating fatalities in Canada. Canadian Medical Association Journal, 159, 259–260.

Collins, D. J., & Lapsley, H. M. (2002). Counting the cost: Estimates of social costs of drug abuse in Australia in 1998–1999. Canberra, Australia: Commonwealth Department of Health and Ageing.

Cunningham, R., Walton, M. A., Maio, R. F., Blow, F. C., Weber, J. E., & Mirel, L. (2003). Violence and substance use among an injured emergency department population. Academic Emergency Medicine, 10, 764–775.

Day, N. L., Zuo, Y. L., Richardson, G. A., Goldschmidt, L., Larkby, C. A., & Cornelius, M. D. (1999). Prenatal alcohol use and offspring size at 10 years of age. Alcoholism: Clinical and Experimental Research, 23, 863–869.

Department of Health. (1995). Sensible drinking: A report of an interdepartmental working group. Wetherby, U.K.: Author.

de Vegt, F., Dekker, J. M., Groeneveld, W. J., Nijpels, G., Stehouwer, C. D., Bouter, L. M., et al. (2002). Moderate alcohol consumption is associated with lower risk for incident diabetes and mortality: the Hoorn Study. Diabetes Research and Clinical Practice, 57(1), 53-60.

Devlin, N. J., Scuffham, P. A., & Bunt, L. J. (1997). The social costs of alcohol abuse in New Zealand. Addiction, 92(11), 1491-1505.

Diaz, N. M., O'Neill, T. W., Silman, A. J., & European Vertebral Osteoporosis Study Group. (1997). Influence of alcohol consumption on the risk of vertebral deformity. Osteoporosis International, 7, 65–71.

Doll, R., & Peto, R. (1995). Mortality and alcohol consumption. British Medical Journal, 310, 470.

Donato, F., Tagger, A., Gelatti, U., Parrinello, G., Boffetta, P., Albertini, A., et al. (2002). Alcohol and hepatocellular carcinoma: The effect of lifetime intake and hepatitis virus infections in men and women. American Journal of Epidemiology, 155, 323–331.

Edwards, G., Andersen, P., Babor, T. F., Caswell, S., Ferrence, R., & Giesbrecht, N. (1994). Alcohol policy and the public good. New York, NY: Oxford University Press.

English, D. R., Holman, C. D., Milne, E., Winter, M. J., Hulse, G. K., & Coode, G. (1995). The quantification of drug-caused morbidity and mortality in Australia. Canberra, Australia: Commonwealth Department of Human Services and Health.

Farrell, S., Manning, W. G., & Finch, M. D. (2003). Alcohol dependence and the price of alcoholic beverages. Journal of Health Economics, 22, 117–147.

Felson, D. T., Zhang, Y., Hannan, M. T., Kannel, W. B., & Kiel, D. P. (1995). Alcohol intake and bone mineral density in elderly men and women. The Framingham Study. American Journal of Epidemiology, 142, 485–492.

Ferrins-Brown, M., Dalton, S., Maslin, J., Hartney, E., Kerr, C., & Orford, J. (1999). “Have a sip of this:” The impact of family on the drinking patterns of untreated heavy drinkers living in the West Midlands, U.K. Contemporary Drug Problems, 26, 413–437.

Fisher, J. C. (1993). Advertising, alcohol consumption, and abuse: A worldwide survey. Wesport, CT: Greenwood Press.

Flesch, M., Rosenkranz, S., Erdmann, E., & Bohm, M. (2001). Alcohol and the risk of myocardial infarction. Basic Research in Cardiology, 96, 128–135.

Galanis, D. J., Joseph, C., Masaki, K. H., Petrovitch, H., Ross, G. W., & White, L. (2000). A longitudinal study of drinking and cognitive performance in elderly Japanese American men: The Honolulu-Asia Aging Study. American Journal of Public Health, 90, 1254–1259.

Ginsburg, E. S. (1999). Estrogen, alcohol and breast cancer risk. Journal of Steroid Biochemistry and Molecular Biology, 69, 299–306.

Gmel, G., Gutjahr, E., & Rehm, J. (2003). How stable is the risk curve between alcohol and all-cause mortality and what factors influence the shape? A precision-weighted hierarchical meta-analysis. European Journal of Epidemiology, 18, 631–642.

Godfrey, C. (1989). Factors influencing the consumption of alcohol and tobacco: The use and abuse of economic models. British Journal Addiction, 84, 1123–1138.

Goldschmidt, L., Richardson, G. A., Stoffer, D. S., Geva, D., & Day, N. L. (1996). Prenatal alcohol exposure and academic achievement at age six: A nonlinear fit. Alcoholism: Clinical and Experimental Research, 20, 763–770.

Graham, K., & Homel, R. (1997). Creating safer bars. In M. Plant, E. Single & T. Stockwell (Eds.), Alcohol: Minimising the harm. What works? (pp. 171–192). New York: Free Association Books.

Graham, K., Osgood, D. W., Zibrowski, E., Purcell, J., Gliksman, L., Leonard, K., et al. (2004). The effect of the Safer Bars programme on physical aggression in bars: Results of a randomized controlled trial. Drug and Alcohol Review, 23, 31–41.

Graham, K., Schmidt, G., & Gillis, K. (1995). Circumstances when drinking leads to aggression: An overview of research findings. Contemporary Drug Problems, 23, 493–557.

Grant, M., & Litvak, J. (Eds.). (1998). Drinking patterns and their consequences. Washington, DC: Taylor & Francis.

Grant, M., & O'Connor, J. (Eds.). (2005). Corporate social responsibility and alcohol: The need and potential for partnership. New York: Brunner-Routledge.

Gronbaek, M., Becker, U., Johansen, D., Tonnesen, H., Jensen, G., & Sorensen, T. I. (1998). Population based cohort study of the association between alcohol intake and cancer of the upper digestive tract. British Medical Journal, 317, 844–847.

Grube, J. W. (1997). Preventing sales of alcohol to minors: Results from a community trial. Addiction, 92(Suppl. 2), S251–S260.

Gruenewald, P. J., & Treno, A. J. (2000). Local and global alcohol supply: Economic and geographic models of community systems. Addiction, 95(Suppl. 4), S537–S549.

Gutjahr, E., Gmel, G., & Rehm, J. (2001). Relation between average alcohol consumption and disease: An overview. European Addiction Research, 7, 117–127.

Hamajima, N., Hirose, K., Tajima, K., Rohan, T., Calle, E. E., Heath, C. W., Jr., et al. (2002). Alcohol, tobacco and breast cancer: Collaborative reanalysis of individual data from 53 epidemiological studies, including 58,515 women with breast cancer and 95,067 women without the disease. British Journal of Cancer, 87(11), 1234–1245.

Härstedt, K. (2004). Vår Gar Gränsen? [Where do we set the limit]. Stockholm: Statesn Offentliga Utredningar.

Hauge, R., & Amundsen, A. (1994). Effects of increased availability of alcohol. A study of the effects of opening wine/liquor monopoly outlets in the county of Sogn og Fjordane. SIFA Report Series Nr. 2/94. Oslo, Norway: National Institute for Alcohol and Drug Research.

Hauge, R., & Nordlie, O. (1984). Intoxication and public order offences. In S. Nordlund (Ed.), Effects of Saturday closing of wine/liquor monopoly outlets. SIFA Report Series Nr. 85. Oslo, Norway: National Institute for Alcohol Research.

Haworth, A., & Simpson, R. (Eds.). (2004). Moonshine markets: Issues in unrecorded alcohol beverage production and consumption. New York: Brunner-Routledge.

Heath, D. B. (2000). Drinking occasions: Comparative perspectives on alcohol and culture. Philadelphia: Brunner/Mazel.

Heath, D. B. (Ed.). (1995). International handbook on alcohol and culture. Westport, CT: Greenwood Press.

Heyman, G. M. (1994). Elasticity of demand for alcohol in humans and rats. In L. Green & J. H. Kagel (Eds.), Advances in behavioral economics: Volume 3. Substance use and abuse. Norwood, NJ: Ablex Publishing Corporation.

Heyman, G. M. (2000). An economic approach to animal models of alcoholism. Alcohol Research and Health, 24, 132–139.

Hibell, B., Andersson, B., Ahlström, S., Balakireva, O., Bjarnason, T., Kokkevi, A., et al. (2000). The 1999 ESPAD Report: Alcohol and other drug use among students in 30 European countries. Stockholm: Swedish Council for Information on Alcohol and Other Drugs (CAN).

Hibell, B., Andersson, B., Bjarnason, T., Ahlström, S., Balakireva, O., Kokkevi, A., et al. (2004). The ESPAD report 2003. Alcohol and other drug use among students in 35 European countries. Stockholm: Swedish Council for Information on Alcohol and Other Drugs (CAN) & Pompidou Group at the Council of Europe.

Hillbom, M., Juvela, S., & Numminen, H. (1999). Alcohol intake and the risk of stroke. Journal of Cardiovascular Risk, 6, 223–228.

Hines, L. M., & Rimm, E. B. (2001). Moderate alcohol consumption and coronary heart disease: A review. Postgraduate Medical Journal, 77, 747–752.

Hiratsuka, Y., & Li, G. (2001). Alcohol and eye diseases: A review of epidemiologic studies. Journal of Studies on Alcohol, 62, 397–402.

Holder, H. D., & Wagenaar, A. C. (1994). Mandated server training and reduced alcohol-involved traffic crashes: A time series analysis of the Oregon experience. Accident; Analysis and Prevention, 26, 89–97.

Holman, C. D., & English, D. R. (1996). Ought low alcohol intake to be promoted for health reasons? Journal of the Royal Society of Medicine, 89, 123–129.

Holman, C. D., English, D. R., Milne, E., & Winter, M. G. (1996). Meta-analysis of alcohol and all-cause mortality: A validation of NHMRC recommendations. Medical Journal of Australia, 164, 141–145.

Homel, R. (1988). Random breath testing in Australia: A complex deterrent. Australian Drug and Alcohol Review, 7, 231–241.

Houghton, E., & Roche, A. M. (Eds.). (2001). Learning about drinking. New York: Brunner-Routledge.

Hurst, W., Gregory, E., & Gussman, T. (1997). International survey: Alcoholic beverage taxation and control policies. Ottawa, Canada: Brewers Association of Canada.

International Center for Alcohol Policies (ICAP). (1998). The Dublin principles. Available: http://www.icap.org/portals/0/download/all_pdfs/Other_Publications/dp_english.pdf.

International Center for Alcohol Policies (ICAP). (2000a). Who are the abstainers? ICAP Report 8. Washington, DC: Author.

International Center for Alcohol Policies (ICAP). (2000b). Government policies on alcohol and pregnancy. ICAP Report 6. Washington, DC: Author.

International Center for Alcohol Polices (ICAP). (2000c). Geneva partnership on alcohol: Towards a global charter. Available: www.icap.org/portals/0/download/all_pdfs/Other_Publications/fc_english.pdf.

International Center for Alcohol Policies (ICAP). (2001a). Alcohol and “special populations”: Biological vulnerability. ICAP Report 10. Washington, DC: Author.

International Center for Alcohol Policies (ICAP). (2001b). Building blocks action checklist. Washington, DC: Author.

International Center for Alcohol Policies (ICAP). (2002a). Blood alcohol concentration limits worldwide. ICAP Report 11. Washington, DC: Author.

International Center for Alcohol Policies (ICAP). (2002b). Industry views on beverage alcohol advertising and marketing, with special reference to young people. Prepared for the World Health Organization. Washington, DC: Author.

International Center for Alcohol Policies (ICAP). (2002c). Violence and licensed premises. Washington, DC: Author.

International Center for Alcohol Policies (ICAP). (1998; Updated 2002d). Drinking age limits. ICAP Report 4. Washington, DC: Author.

International Center for Alcohol Policies (ICAP). (2003a). Alcohol and the workplace. ICAP Report 13. Washington, DC: Author.

International Center for Alcohol Policies (ICAP). (2003b). International drinking guidelines. ICAP Report 14. Washington, DC: Author.

International Center for Alcohol Policies (ICAP). (2004a). Alcohol education and its effectiveness. ICAP Report 16. Washington, DC: Author.

International Center for Alcohol Policies (ICAP). (2004b). Drinking patterns: From theory to practice. ICAP Report 15. Washington, DC: Author.

International Chamber of Commerce (ICC). (2004). ICC framework for responsible food and beverage communications. Available: http://www.iccwbo.org/id990/index.html.

Irgens-Jensen, O. (1984). Effects of Saturday closing of wine/liquor monopoly outlets on the extent of drunken-driving. In S. Nordlund (Ed.), Effects of Saturday closing of wine/liquor monopoly outlets. SIFA reports series Nr. 85. Oslo, Norway: National Institute for Alcohol Research.

Jennison, K. M. (2004). The short-term effects and unintended long-term consequences of binge drinking in college: A 10-year follow-up study. American Journal of Drug and Alcohol Abuse, 30, 659–684.

Joeman, L. (1991). Alcohol at work: The cost to employers. Employment Gazette, 99, 669–671.

Jones, K. L., & Smith, D. W. (1973). Recognition of the fetal alcohol syndrome in early infancy. Lancet, 2(7836), 999–1001.

Kao, W. H., Brancati, F. L., Boland, L. L., Watson, R. L., & Puddey, I. B. (1998). Gender differences in the association of alcohol consumption and the risk of type 2 diabetes mellitus: The Atherosclerosis Risk in Communities (ARIC) study. American Journal of Epidemiology, 147, S60.

Kenkel, D., & Manning, W. (1997). Perspectives on alcohol taxation. Alcohol Health and Research World, 20, 230–238.

Kenkel, D. (1996). New estimates of the optimal tax on alcohol. Economic Inquiry, 34, 296–319.

Kesmodel, U., Wisborg, K., Olsen, S. F., Henriksen, T. B., & Secher, N. J. (2002). Moderate alcohol intake during pregnancy and the risk of stillbirth and death in the first year of life American Journal of Epidemiology, 155, 305–312.

Krug, E. G., Dahlberg, L. L., Mercy, J. A., Zwi, A. B., & Lozano, R. (2002). World report on violence and health. Geneva, Switzerland: World Health Organization.

Kuo, M., Heeb, J. L., Gmel, G., & Rehm, J. (2003). Does price matter? The effect of decreased price on spirits consumption in Switzerland. Alcoholism: Clinical and Experimental Research, 27, 720–725.

Ledermann, S. (1952). [Mortality of economic origin in France: Mortality caused by or increased by alcoholism.]. La Semina Medica, 28, 417–421.

Ledermann, S., & Tabah, F. (1951). Nouvelles données sur la mortalite d’origine alcoolique. Population, G, 41–56.

Lehto, J. (1997). The economics of alcohol. Addiction, 92(Suppl. 1), S55–S59.

Leifman, H. (2001). Homogenization in alcohol consumption in the European Union. Nordissk Alkohol- and Narkotikatidskrift, 18, 15–30.

Lemmens, P. H., Vaeth, P. A., & Greenfield, T. K. (1999). Coverage of beverage alcohol issues in the print media in the United States. American Journal of Public Health, 89, 1555–1560.

Leppänen, K. (1979). Effects of national Saturday closing experiment on alcohol sales. Alkoholpolitiikka, 44, 20–21.

Lieber, C. S. (2003). Relationships between nutrition, alcohol use, and liver disease. Alcohol Research and Health, 27, 220–231.

Lyall, S. (2003, October 13). Something cheap in the state of Denmark: Liquor. The New York Times, p. 4A,

MacAndrew, C., & Edgerton, R. E. (1969). Drunken comportment: A social explanation. Chicago, IL: Aldine.

Mäkelä, P., Rossow, I., & Tryggvesson, K. (2002). Who drinks more or less when policies change? The evidence from 50 years of Nordic studies. In R. Room (Ed.), The effects of Nordic alcohol policies: What happens to drinking and harm when control systems change? Publication No. 42. Helsinki, Finland: Nordic Council for Alcohol and Drug Research.

Mann, R. E., Smart, R. G., & Govoni, R. (2003). The epidemiology of alcoholic liver disease. Alcohol Research and Health, 27, 209–219.

Manning, W. G., Blumberg, L., & Moulton, L. H. (1995). The demand for alcohol: The differential response to price. Journal of Health Economics, 14, 123–148.

Marshall, M. (Ed.). (1979). Beliefs, behaviors and alcoholic beverages: A cross-cultural survey. Ann Arbor, MI: University of Michigan Press.

Martinic, M., & Leigh, B. (2004). Reasonable risk: Alcohol in perspective. New Yotk: Brunner-Routledge.

McFarlin, S. K., & Fals-Stewart, W. (2002). Workplace absenteeism and alcohol use: a sequential analysis. Psychology of Addictive Behaviors, 16, 17–21.

McKee, M., & Britton, A. (1998). The positive relationship between alcohol and heart disease in eastern Europe: Potential physiological mechanisms. Journal or the Royal Society of Medicine, 91, 402–407.

McKnight, A. J., & Streff, F. M. (1994). The effect of enforcement upon service of alcohol to intoxicated patrons of bars and restaurants. Accident: Analysis and Prevention, 26, 79–88.

McKnight, A. J., & Voas, R. B. (2001). Prevention of alcohol-related road crashes. In N. Heather, T. J. Peters, & T. Stockwell (Eds.), International handbook on alcohol dependence and problems (pp. 741–769). Chichester, U.K.: John Wiley & Sons.

Meister, K. A., Whelan, E. M., & Kava, R. (2000). The health effects of moderate alcohol intake in humans: an epidemiologic review. Critical Reviews in Clinical Laboratory Sciences, 37, 261–296.

Midanik, L. T. (1994). Comparing usual quantity/frequency and graduated frequency scales to assess yearly alcohol consumption: Results from the 1990 U.S. National Alcohol Survey. Addiction, 89, 407–412.

Moskowitz, H., Burns, M. M., & Williams, A. F. (1985). Skills performance at low blood alcohol levels. Journal of Studies on Alcohol, 46, 482–485.

Mukamal, K. J. (2003). Alcohol use and prognosis in patients with coronary heart disease. Preventive Cardiology, 6, 93–98.

Mukamal, K. J., Conigrave, K. M., Mittleman, M. A., Camargo, C. A., Stampfer, M. J., Willett, W. C., et al. (2001). Alcohol intake and risk of coronary heart disease in men. American Journal of Epidemiology, 153, S59.

Mukamal, K. J., Kuller, L. H., Fitzpatrick, A. L., Longstreth, W. T., Jr., Mittleman, M. A., & Siscovick, D. S. (2003). Prospective study of alcohol consumption and risk of dementia in older adults. Journal of American Medical Association, 289, 1405–1413.

Mukamal, K. J., & Rimm, E. B. (2001). Alcohol's effects on the risk for coronary heart disease. Alcohol Research and Health, 25, 255–261.

Murdoch, D., Pihl, R. O., & Ross, D. (1990). Alcohol and crimes of violence: present issues. International Journal of Addiction, 25, 1065–1081.

Murray, R. P., Connett, J. E., Tyas, S. L., Bond, R., Ekuma, O., Silversides, C. K., et al. (2002). Alcohol volume, drinking pattern, and cardiovascular disease morbidity and mortality: Is there a U-shaped function? American Journal of Epidemiology, 155, 242–248.

Nakanishi, N., Suzuki, K., & Tatara, K. (2003). Alcohol consumption and risk for development of impaired fasting glucose or type 2 diabetes in middle-aged Japanese men. Diabetes Care, 26, 48–54.

National Institute on Alcohol Abuse and Alcoholism (NIAAA). (2003). State of the science report on the effects of moderate drinking. Rockville, MD: U.S. Department of Health and Social Services.

Nelson, J. P. (1997). Broadcast advertising and U.S. demand for alcoholic beverages: System-wide estimates with quarterly data. Washington, DC: U.S. Federal Trade Commission.

Nelson, J. P. (2001). Alcohol advertising bans: A survey of research methods, results, and policy implications. In M. R. Baye & J. P. Nelson (Eds.), Advances in applied microeconomics. Volume 10: Advertising and differentiated products (pp. 239–295). Amsterdam: JAI Press & Elsevier Press.

Nelson, T. F., & Wechsler, H. (2003). School spirits: Alcohol and collegiate sports fans. Addictive Behaviors, 28, 1–11.

Nicolas, J. M., Fernandez-Sola, J., Estruch, R., Pare, J. C., Sacanella, E., Urbano-Marquez, A., et al. (2002). The effect of controlled drinking in alcoholic cardiomyopathy. Annals of Internal Medicine, 136, 192–200.

Nordlund, S., & Österberg, E. (2000). Unrecorded alcohol consumption: Economics and its effects on alcohol control in the Nordic countries. Addiction, 95(Suppl. 4), S551–S564.

Norström, T. (2001). Alcohol and mortality: The post-war experience in the EU countries. Addiction, 96(Suppl. 1), S1–S129.

Norström, T. (2002). Alcohol in postwar Europe: Consumption, drinking patterns, consequences and policy responses in 15 European countries. Retrieved April 8, 2005, from http://www.fhi.se/templates/Page2cols____616.aspx .

Norström, T., & Skög, O. J. (2003). Saturday opening of alcohol retail shops in Sweden: An impact analysis. Journal of Studies on Alcohol, 64, 393–401.

Obisesan, T. O., Hirsch, R., Kosoko, O., Carlson, L., & Parrott, M. (1998). Moderate wine consumption is associated with decreased odds of developing age-related macular degeneration in NHANES-1. Journal of the American Geriatrics Society, 46, 1–7.

Olsson, O., & Wikström, P. O. (1982). Effects of the experimental Saturday closing of liquor retail stores in Sweden. Contemporary Drug Problems, 11, 325–353.

Orcutt, J. D. (1993). Happy hour and social lubrication: Evidence on mood-setting rituals of drinking time. Journal of Drug Issues, 23, 389–407.

Orley, J. (1999). Pleasure and quality of life. In M. Grant & S. Peele (Eds.), Permission for pleasure: A health perspective (pp. 329–340). Philadelphia: Brunner/Mazel.

Österberg, E. (1995). Do alcohol prices affect consumption and related problems? In H. D. Holder & G. Edwards (Eds.), Alcohol and public policy: Evidence and issues (pp. 145–163). New York: Oxford University Press.

Österberg, E., & Karlsson, T. (2003). Alcohol policies in EU Member States and Norway: A collection of country reports. Helsinki, Finland: National Research and Development Centre for Welfare and Health (STAKES). Available: http://www.stakes.fi/verkkojulk/pdf/AlcoholPoliciesInEUetc.pdf .

Partanen, J. (1988). Communicating about alcohol in the mass media. Contemporary Drug Problems, 15, 281–319.

Pashall, M. J., Freistheler, B., & Lipton, R. I. (2005). Moderate alcohol use and depression in young adults: Findings from a national longitudinal survey. American Journal of Public Health, 95, 453–457.

Pedlow, G. (1998). Alcohol in emerging markets: Identifying the most appropriate role for the alcohol beverage industry. In M. Grant (Ed.), Alcohol and emerging markets: Patterns, problems, and responses (pp. 333–352). Philadelphia: Brunner/Mazel.

Peele, S., & Brodsky, A. (2000). Exploring psychological benefits associated with moderate alcohol use: A necessary corrective to assessments of drinking outcomes? Drug and Alcohol Dependence, 60, 221–247.

Pernanen, K. (1991). Alcohol in human violence. New York: Guilford Press.

Plant, M., & Plant, M. (1997). Alcohol education and harm minimisation. In M. Plant, E. Single & T. Stockwell (Eds.), Alcohol: Minimising the harm. What works? New York: Free Association Books.

Peele, S., & Grant, M. (Eds.). (1999). Alcohol and pleasure: A health perspective. Philadelphia: Brunner/Mazel.

Popham, R. E., Schmidt, W., & de Lint, J. (1975). The prevention of alcoholism: Epidemiological studies of the effects of government control measures. British Journal of Addiction to Alcohol and Other Drugs, 70, 125–144.

Puddey, I. B., Rakic, V., Dimmitt, S. B., & Beilin, L. J. (1999). Influence of pattern of drinking on cardiovascular disease and cardiovascular risk factors: A review. Addiction, 94, 649–663.

Raistrick, D. (1999). “Tackling alcohol together” towards a national alcohol policy for the U.K. Alcohol and Alcoholism: International Journal of the Medical Council on Alcoholism, 34, 113–114.

Ramstedt, M. (2001). Alcohol and suicide in 14 European countries. Addiction, 96(Suppl. 1), S59–S75.

Rapuri, P. B., Gallagher, J. C., Balhorn, K. E., & Ryschon, K. L. (2000). Alcohol intake and bone metabolism in elderly women. American Journal of Clinical Nutrition, 72, 1206–1213.

Rehm, J., & Gmel, G. (1999). Patterns of alcohol consumption and social consequences. Results from an 8-year follow-up study in Switzerland. Addiction, 94, 899–912.

Rehm, J., & Gmel, G. (2003). Alcohol consumption and total mortality/morbidity-definitions and methodological implications. Best Practice and Research: Clinical Gastroenterology, 17, 497–505.

Rehm, J., Rehn, N., Room, R., Monteiro, M., Gmel, G., Jernigan, D., et al. (2003). The global distribution of average volume of alcohol consumption and patterns of drinking. European Addiction Research, 9, 147–156.

Rehm, J., Sempos, C. T., & Trevisan, M. (2003). Alcohol and cardiovascular disease: More than one paradox to consider. Average volume of alcohol consumption, patterns of drinking and risk of coronary heart disease: A review. Journal of Cardiovascular Risk, 10, 15–20.

Reynaud, M., Gaudin-Colombel, A. F., & Le Pen, C. (2001). Two methods of estimating health costs linked to alcoholism in France (with a note on social costs). Alcohol and Alcoholism, 36, 89–95.

Reynolds, K., Lewis, B., Nolen, J. D., Kinney, G. L., Sathya, B., & He, J. (2003). Alcohol consumption and risk of stroke: A meta-analysis. Journal of American Medical Association, 289, 579–588.

Rimm, E. B., Williams, P., Fosher, K., Criqui, M., & Stampfer, M. J. (1999). Moderate alcohol intake and lower risk of coronary heart disease: Meta-analysis of effects on lipids and haemostatic factors. British Medical Journal, 319, 1523–1528.

Ross, H. L. (1992). Confronting drunk-driving: Social policy for saving lives. New Haven, CT: Yale University Press.

Rossow, I. (2001). Alcohol and homicide: a cross-cultural comparison of the relationship in 14 European countries. Addiction, 96(Suppl. 1), S77-S92.

Rotondo, S., Di Castelnuovo, A., & de Gaetano, G. (2001). The relationship between wine consumption and cardiovascular risk: From epidemiological evidence to biological plausibility. Italian Heart Journal, 2, 1–8.

Saffer, H. (2002). Alcohol advertising and youth. Journal of Studies on Alcohol, Supplement(14), 173-181.

Saitz, R. F. (1987). The roles of bars and restaurants in preventing alcohol-impaired driving: An evaluation of server intervention. Evaluation and the Health Professions, 10, 5–27.

Sampson, H. W., Gallager, S., Lange, J., Chondra, W., & Hogan, H. A. (1999). Binge drinking and bone metabolism in a young actively growing rat model. Alcoholism: Clinical and Experimental Research, 23, 1228–1231.

Saunders, J. B., & DeBurgh, S. (1999). The distribution of alcohol consumption. In M. Grant & J. Litvak (Eds.), Drinking patterns and their consequences (pp. 129–152). Washington, DC: Taylor & Francis.

Seitz, H. K., Matsuzaki, S., Yokoyama, A., Homann, N., Vakevainen, S., & Wang, X. D. (2001). Alcohol and cancer. Alcoholism: Clinical and Experimental Research, 25(5 Suppl. ISBRA), 137S–143S.

Seitz, H. K., Poschl, G., & Simanowski, U. A. (1998). Alcohol and cancer. In M. Galanter (Ed.), Recent development in alcoholism, Vol. 14 (pp. 67–95). New York: Plenum Press.

Shults, R. A., Elder, R. W., Sleet, D. A., Nichols, J. L., Alao, M. O., Carande-Kulis, V. G., et al. (2001). Reviews of evidence regarding interventions to reduce alcohol-impaired driving. American Journal of Prevention and Medicine, 21(4 Suppl.), 66–88.

Sillanaukee, P., Koivula, T., Jokela, H., Pitkajarvi, T., & Seppa, K. (2000). Alcohol consumption and its relation to lipid-based cardiovascular risk factors among middle-aged women: The role of HDL(3) cholesterol. Atherosclerosis, 152, 503–510.

Sindelar, J. (1998). Social costs of alcohol. Journal of Drug Issues, 28, 763–780.

Singh, H., Masih, B., Satpathy, S. K., Duseja, A., & Chawla, Y. (2001). Financial burden of alcohol abuse in patients with alcoholic liver disease. Trop Gastroenterol, 22, 172.

Single, E. (1996). Harm reduction as an alcohol prevention strategy. Alcohol Health and Research World, 20, 239–243.

Single, E. (1997). Public drinking, problems and prevention measures in twelve countries: Results of the WHO project on public drinking. Contemporary Drug Problems, 24, 425–448.

Single, E., Collins, D., Easton, B., Harwood, H., Lapsley, H., & Maynard, A. (1994). International guidelines for estimating the costs of alcohol abuse. Ontario, Canada: Canadian Centre on Substance Abuse.

Single, E., & Easton, B. (2001, May). Estimating the economic costs of alcohol misuse: Why we should do it even though we shouldn’t pay too much attention to the bottom-line results. Paper presented at the Annual Meeting of the Kettil Bruun Society for Social and Epidemiological Research on Alcohol, Toronto, Canada.

Single, E., & Leino, E. V. (1998). The levels, patterns and consequences of drinking. In M. Grant & J. Litvak (Eds.), Drinking patterns and their consequences (pp. 7–24). Washington, DC: Taylor & Francis.

Smart, R. G., & Mann, R. E. (1995). Treatment, health promotion and alcohol controls and the decrease of alcohol consumption and problems in Ontario: 1975-1993. Alcohol and Alcoholism, 30, 337–343.

Smeets-Goevaers, C. G., Lesusink, G. L., Papapoulos, S. E., Maartens, L. W., Keyzer, J. J., Weerdenburg, J. P., et al. (1998). The prevalence of low bone mineral density in Dutch perimenopausal women: The Eindhoven perimenopausal osteoporosis study. Osteoporosis International, 8, 404–409.

Smith-Warner, S. A., Spiegelman, D., Yaun, S. S., van den Brandt, P. A., Folsom, A. R., Goldbohm, R. A., et al. (1998). Alcohol and breast cancer in women: A pooled analysis of cohort studies. Journal of American Medical Association, 279, 535–540.

Stevens, T., Conwell, D. L., & Zuccaro, G. (2004). Pathogenesis of chronic pancreatitis: an evidence-based review of past theories and recent developments. American Journal of Gastroenterology, 99, 2256–2270.

Stockwell, T., Chikritzhs, T., & Brinkman, S. (2000). Role of social and health statistics in measuring harm from alcohol. Journal of Substance Abuse, 12, 139–154.

Stockwell, T., Hawks, D., Lang, E., & Rydon, P. (1996). Unraveling the preventive paradox for acute alcohol problems. Drug and Alcohol Review, 15, 7–15.

Stockwell, T., Lang, E., & Rydon, P. (1993). High risk drinking settings: The association of serving and promotional practices with harmful drinking. Addiction, 88, 1519-1526.

Strandberg, A. Y., Strandberg, T. E., Salomaa, V. V., Pitkala, K., & Miettinen, T. A. (2004). Alcohol consumption, 29-y total mortality, and quality of life in men in old age. American Journal of Clinical Nutrition, 80, 1366–1371.

Strategy in Focus & The Henley Centre for Forecasting. (1991). New report on competition between alcoholic drinks. Brussels, Belgium: European Commission.

Stratton, K., Howe, C., & Battaglia, F. (1996). Fetal alcohol syndrome: diagnosis, epidemiology, prevention, and treatment. Washington, DC: National Academy Press.

Thomas, V. S., & Rockwood, K. J. (2001). Alcohol abuse, cognitive impairment, and mortality among older people. Journal of the American Geriatric Society, 49, 415–420.

Trevisan, M., Ram, M., Hovey, K., Russell, M., Freudenheim, J., Muti, P., et al. (2001). Alcohol drinking patterns and myocardial infarction. American Journal of Epidemiology, 153, S97.

Trevisan, M., Schisterman, E., Mennotti, A., Farchi, G., & Conti, S. (2001). Drinking pattern and mortality: The Italian risk factor and life expectancy pooling project. Annals of Epidemiology, 11, 312–319.

Truelsen, T., Thudium, D., & Gronbaek, M. (2002). Amount and type of alcohol and risk of dementia: The Copenhagen City Heart Study. Neurology, 59, 1313–1319.

UK Ministry of Health. (1995). Sensible drinking: A report of an interdepartmental working group, December 1995. Wetherby, U.K.: Department of Health.

Vachon, C. M., Cerhan, J. R., Vierkant, R. A., & Sellers, T. A. (2001). Investigation of an interaction of alcohol intake and family history on breast cancer risk in the Minnesota Breast Cancer Family Study. Cancer, 92, 240–248.

Wagenaar, A. C., Murray, D. M., & Toomey, T. L. (2000). Communities mobilizing for change on alcohol (CMCA): Effects of a randomized trial on arrests and traffic crashes. Addiction, 95, 209–217.

Walsh, C. R., Larson, M. G., Evans, J. C., Djousse, L., Ellison, R. C., Vasan, R. S., et al. (2002). Alcohol consumption and risk for congestive heart failure in the Framingham Heart Study. Annals Internal Medicine, 136, 181–191.

Wannamethee, S. G., Camargo, C. A., Jr., Manson, J. E., Willett, W. C., & Rimm, E. B. (2003). Alcohol drinking patterns and risk of type 2 diabetes mellitus among younger women. Archives of Internal Medicine, 163, 1329–1336.

Whelan, G. (2003). Alcohol: A much neglected risk factor in elderly mental disorders. Current Opinion in Psychiatry, 16, 609–614.

Williams, F. M., Cherkas, L. F., Spector, T. D., & MacGregor, A. J. (2005). The effect of moderate alcohol consumption on bone mineral density: A study of female twins. Annals of the Rheumatic Diseases, 64, 309–310.

World Health Organization (WHO). (2004). Global status report on alcohol. Geneva, Switzerland: Author.

Xie, X., Rehm, J., Single, E., Robson, L., & Paul, J. (1998). The economic costs of alcohol abuse in Ontario. Pharmacological Research, 37, 241–249.

Zador, P. L. (1991). Alcohol-related relative risk of fatal driver injuries in relation to driver age and sex. Journal of Studies on Alcohol, 52, 302–310.

Zuccala, G., Onder, G., Pedone, C., Cesari, M., Landi, F., Bernabei, R., et al. (2001). Dose-related impact of alcohol consumption on cognitive function in advanced age: Results of a multicenter survey. Alcoholism: Clinical and Experimental Research, 25, 1743–1748.