Alcohol: No Ordinary Commodity. Research and Public Policy. By T. F. Babor, R. Caetano, S. Casswell, G. Edwards, N. Giesbrecht, K. Graham, J. Grube, P. Gruenewald, L. Hill, H. Holder, R. Homel, E. Osterberg, J. Rehm, R. Room and I. Rossow. Oxford University Press. £29.50. 290 pgs. ISBN 019 263261 2

Abstract

Since 1977, the World Health Organisation has sponsored publications which give updated accounts of recommended policies to prevent and treat alcohol problems. The current volume is the fourth in the series. Its multiplicity of authors illustrates its generous embrace of issues, which the text places into four disciplines: social, population, behavioural and medical. Basically, the publication offers a critical account of the assumptions and resultant approaches that have been favoured. A brief historical narrative, starting from the sixth century bc, moves to an extended description of the strategies employed since 1990 and studies evaluating their usefulness. The authors keep at the forefront throughout the book the need to prevent research evidence in a manner acceptable for official decisions and public discussion. The debated strategies are chosen to affect the drinking practices of three groups: the general population, high-risk drinkers and persons whose consumption has already led to medical or social problems. Ten measures are recommended for efficacy and low cost. They are alcohol taxation, increase in age limit for legal purchase of alcohol, state monopoly of alcohol sales, reduced hours or days of sale, few places that sell alcohol on or off their premises, enforced regulations for licenses to sell alcohol, breath testing of drivers, low blood alcohol concentration for driving, restricted licenses for novice drivers and brief interventions for hazardous drinkers. The authors' belief that their options would be acceptable across cultural and international boundaries is clearly right in most of the strategies, but not necessarily for government monopolies or fewer days of sale. Their general view of treatment is interesting. Intervention, irrespective of its nature, produces a significant reduction in drinking and its dangers. Alcoholics who obtain help (the considered sources include Alcoholics Anonymous) are distinctly more likely to improve than others. Alcohol education, as in schools or by warning labels, enhances knowledge and attitudes although drinking practices are not altered. Similar ineffectiveness applies to curbs on alcohol advertising, particularly due to opposition or circumvention by the alcohol industry. The book reports that the criminal justice and other social costs of alcohol outweigh the health expenditure. Defining the burden as years lost through disability or death places alcohol as the third most prominent cause of disease in developed countries, surpassed only by tobacco and hypertension. Neuropsychiatric conditions produce the largest health strain from alcohol, followed by accidental and intentional injuries. Alcoholic cirrhosis exerts a smaller impact on health but the authors cite studies in three countries, which report an inverse relationship between falling cirrhosis rates and the development of services for excessive drinking. The book extends beyond national alcohol policies to enfold an international agenda. Its fundamental message warns that both state and multistate discussions and agreements view alcohol as a commodity like other goods and largely ignore its dangers. Developed countries in particular have weakened longstanding alcohol controls, notably by allowing inflation to erode taxes and by extending hours of sale. An exception that is noted is the European Alcohol Action Plan, initially proposed in 1992 for 33 nations within the WHO European region. The policy aims generally to lower the overall consumption of alcohol and to reduce specific damages entailed amongst high-risk drinkers. Although many of the targeted states have now formulated relevant strategies with appropriate laws, the active implementation of the European Plan is patchy. Perhaps its main benefit to date is rendering the dangers of alcohol more obvious to legislation. Who would benefit from reading the book? The foremost are politicians; but they do not peruse books. Neither do their senior officials. Fortunately the latter rely, intermittently or continuously, on well-informed advisors. Several are amongst the authors. Mentors of national policies will find in the text a wealth of recommendations, each described concisely, in terms of what should be done and what should not be done. The general public will also encounter fresh perspectives. Finally, researchers will receive indications about studies which need replication in other cultures, or that suggest investigations to improve present strategies.