Alcoholic beverages have been used in human societies
at least since the beginning of recorded history.
Fermented drinks were prepared and consumed in most
parts of the world before the European colonial
expansion, which changed the cultural position of
alcohol nearly everywhere.1New forms of alcoholic
beverages were introduced, and a product prepared
within the household and community was gradually
transformed into an industrial commodity available at
any time and virtually any place. As part of the
contemporary dynamic of globalisation, this process
continues today in much of the developing world.
Accompanying the near ubiquity of alcoholic
beverages in human history has been a lively
appreciation of the social and health problems caused by
drinking. Whether in Greece, Palestine, or China,
ancient texts speak eloquently about such problems.
Every major world religion has at least some strands that
counsel abstinence from alcoholic beverages. In most
countries where Protestant Christianity was strong,
substantial temperance movements in the 19th century
at first sought individual pledges to abstain and
eventually pressed for national prohibition. When these
movements lost momentum, a new compromise was
reached: alcohol was no longer viewed as a threat to all,
but rather to a small subclass of “alcoholics”, or in
today’s technical terms, people who were alcohol
dependent. It became the task of health professionals,
among others, to cure alcoholism, and the task of
science to discover its basis as a key to treatment and
Scientific attention to alcohol problems has accelerated
during the past 30 years, when substantial advances have
occurred in our understanding of drinking problems as
well as their prevention and treatment. In this review
our discussion of these advances is organised into three
subtopics: the epidemiology of alcohol’s role in health
and illness; the treatment of alcohol use disorders as part
of the public health response; and prevention and policy
research. We do not cover here the substantial advances
in neuroscience and genetic studies in recent years,
since these are reviewed elsewhere2and as yet have little
relevance for public health approaches to alcohol
In our review of the evidence, we have emphasised
both the medical and public health implications of
alcohol use. Whereas
appropriate responses to alcohol problems in health care
settings, they need to be complemented by population-
based public health interventions to address the broad
dimensions of alcohol problems at the level of
communities and nation states.
medical approaches are
Alcohol and health outcomes
It has long been known that alcohol consumption is
responsible for increased illness and death.3Recent
research has contributed
understanding of the relation of drinking to specific
disorders, and has shown that the relation between
alcohol consumption and health outcomes is complex
and multidimensional. Alcohol has been shown to be
causally related to more than 60 different medical
conditions,4 in most but not all cases detrimentally. Not
only volume of consumption, but also patterns of
drinking, especially irregular heavy drinking, have been
shown to determine burden of disease.4–6Table 17,8
summarises the major disease and injury categories,
and provides estimates (discussed below) of the
proportion of the worldwide disability and death
attributable to alcohol within each category.
For most diseases, there is a dose-response relation to
volume of alcohol consumption, with risk of the disease
substantially to our
Lancet2005; 365: 519–30
Centre for Social Research on
Alcohol and Drugs, Stockholm
University, Stockholm, Sweden
(R Room); Department of
Community Medicine and
Health Care, University of
Connecticut School of
Medicine, Farmington, CT, USA
(T Babor); Addiction Research
Institute, Zürich, Switzerland
(JRehm); and Centre for
Addiction and Mental Health,
Toronto, Canada (J Rehm)
www.thelancet.com Vol 365 February 5, 2005 519
Alcohol and public health
Robin Room, Thomas Babor, Jürgen Rehm
Alcoholic beverages, and the problems they engender, have been familiar fixtures in human societies since the
beginning of recorded history. We review advances in alcohol science in terms of three topics: the epidemiology of
alcohol’s role in health and illness; the treatment of alcohol use disorders in a public health perspective; and policy
research and options. Research has contributed substantially to our understanding of the relation of drinking to
specific disorders, and has shown that the relation between alcohol consumption and health outcomes is complex
and multidimensional. Alcohol is causally related to more than 60 different medical conditions. Overall, 4% of the
global burden of disease is attributable to alcohol, which accounts for about as much death and disability globally as
tobacco and hypertension. Treatment research shows that early intervention in primary care is feasible and effective,
and a variety of behavioural and pharmacological interventions are available to treat alcohol dependence. This
evidence suggests that treatment of alcohol-related problems should be incorporated into a public health response to
alcohol problems. Additionally, evidence-based preventive measures are available at both the individual and
population levels, with alcohol taxes, restrictions on alcohol availability, and drinking-driving countermeasures
among the most effective policy options. Despite the scientific advances, alcohol problems continue to present a
major challenge to medicine and public health, in part because population-based public health approaches have been
neglected in favour of approaches oriented to the individual that tend to be more palliative than preventative.
increasing with higher volume. The exceptions are in the
cardiovascular area, especially coronary heart disease
(CHD) and stroke, diabetes mellitus, and injuries, where
other dimensions of consumption than average volume
play a crucial role in determining outcome. We discuss
the relations between alcohol and disease outcome for
three important disease categories (breast cancer, CHD,
and intentional injury) chosen because there have been
recent advances in our knowledge of the association.
These categories are substantial, but not the largest,
contributors to the health harms from drinking. Many of
the results described
epidemiological work, which has some shortcomings
with respect to alcohol: exposure is often poorly
measured, and studies typically have a shortage of
people with patterns of irregular heavy drinking.9
Another recent advance has been in the methods used to
estimate the total effect of alcohol consumption on the
burden of disease.10
are based on medical
While a role for alcohol in breast cancer has been
suspected for some time, the evidence has only recently
become clear. Meta-analyses have shown a linear
increase of risk of breast cancer with increasing average
volume of consumption.11–14Thus, a pooled analysis of
six cohort studies found a significant dose-response
effect, with consumption of 10 g per day of pure alcohol
increasing risk of breast cancer by 9%, and consumption
of 30–60 g per day increasing the risk by 41%.11
oestrogen replacement therapy after menopause
increases risk of breast cancer, and that oestrogen
replacement therapy combined with alcohol use
magnifies the risk.15 Largely driven by the findings in
postmenopausal women using oestrogen replacement
therapy, discussion has focused on the role of oestrogen
and its metabolism as one candidate for a causal
pathway. A role for genetic polymorphisms in the
association between alcohol and breast cancer has also
further indicates that
Coronary heart disease
A comprehensive meta-analysis on average volume of
alcohol consumption and CHD found a J-shaped curve.18
Compared with non-drinking,
consumption of alcohol is associated with lower CHD
incidence and mortality, the lowest risk being found at
20 g per day (fewer than 2 drinks). For higher average
volume of alcohol consumption, the risk relation
reverses18,19 with consumption of more than 70 g per day
associated with greater risk than in abstainers. Several
physiological mechanisms have been suggested to
explain the cardioprotective effect of moderate drinking,
including effects on lipids and haemostatic factors.20,21
However, most of these mechanisms seem to apply only
to people who have a pattern of regular drinking without
heavy drinking occasions.
Several studies confirming the cardioprotective effect
of regular light-to-moderate drinking found an increased
risk for major coronary events in drinkers with an
episodic heavy drinking pattern compared to abstainers,
even when overall volume of drinking was low.22,23In
addition to its effect on CHD, an irregular pattern of
heavy drinking occasions appears to be related to other
types of cardiovascular problems such as stroke or
sudden cardiac death.24,25 This association is consistent
with the increased clotting, lowered threshold for
ventricular fibrillation, and elevation of low density
lipoproteins that occur after heavy drinking.5,26
In summary, a pattern of irregular heavy drinking is
associated with physiological mechanisms that increase
the risk of CHD, sudden cardiac death, and other
cardiovascular outcomes, whereas regular low to
moderate alcohol consumption is associated with
physiological mechanisms linked to favourable cardiac
outcomes.26,27Another drinking pattern that seems to
have a role in the cardioprotective effect is drinking with
meals;28,29such an effect also has plausible physiological
For a specific country, the net effect of alcohol on CHD
will depend on the distribution of drinking patterns in a
society. For most countries, the net effect of alcohol on
CHD is negative, especially in the former Soviet
countries and developing nations with episodic heavy
drinking patterns.30Related to the question of the net
www.thelancet.com Vol 365 February 5, 2005
Mouth and oropharynx cancers
Unipolar depressive disorders
Alcohol use disorders: alcohol
dependence and harmful use
Ischaemic heart disease
Cirrhosis of the liver
Motor vehicle accidents
Sources: references 7 and 8.
Table 1: Major disease and injury conditions related to alcohol and
proportions attributable to alcohol worldwide
effect on CHD in a population at a particular moment is
the question of what happens to rates of CHD when
consumption of alcohol goes up or down. Since alcohol
is typically used in social situations, an individual’s
drinking tends to be influenced by the drinking of those
around them. As the level of drinking in the population
as a whole rises or falls, it is probable that some will gain
from a change in their consumption while others will
lose. The optimum average level of drinking for the
population as a whole is likely to be lower than that for
an individual,31and lower than the prevailing levels of
consumption in western European countries. In recent
time-series studies of the relation between national
alcohol consumption levels and changes in CHD death
rates, Hemström32found no significant relation for
13 western European countries, and a positive relation
(more drinking related to more CHD) for Spain.
Intentional injury (violence)
Alcohol is consistently associated with violent crime,33
although the relation might not always be causal.34
Experimental research suggests that alcohol causes
aggression under certain circumstances, and meta-
analyses suggest a small to moderate effect size of about
in the overall relation between alcohol
consumption and aggression; the effect size measure
can be interpreted as a correlation here.36Alcohol alters
brain receptors and neurotransmitters, and several
pharmacological effects of alcohol are likely to increase
the probability of aggressive behaviour. First, alcohol
seems to have an effect on the serotonin and
?-aminobutyric acid (GABA) brain receptors similar to
that produced by some benzodiazepines.37
subjective experience of this effect might be reduced fear
and anxiety about the social, physical, or legal
consequences of one’s actions,38resulting in increased
risk-taking and aggressive behaviour in some drinkers.
Findings linking alcohol, GABA receptors, and
aggression in animals add to the evidence for this causal
pathway.39Alcohol also affects cognitive functioning,40
leading to impaired problem solving in conflict
and overly emotional responses or
Cultural differences have also become apparent in the
strength of the relation between alcohol consumption
and violence,43,44mediated by patterns of drinking and by
cultural expectations about behaviour while drinking.
Thus, time-series analyses of the relation of changes in
level of drinking to changes in homicide rates have
found a gradient from the south to the north among
western European nations, with an extra litre per capita
of ethanol raising the homicide rate by more than twice
as much in northern Europe as in southern Europe.45
The experience of Russia during the anti-alcohol
campaign of 1985–88, in the late period of the Soviet
Union, suggests that changes in alcohol consumption
are even more dramatic in their effects there than in
northern Europe: in a period when alcohol consumption
(including unrecorded alcohol) is estimated to have
dropped by 25%, the rate of male victims of homicide
dropped by 40%.46These findings imply that there is not
a single relative risk relating average level of alcohol
consumption to homicide everywhere; rather, the
relative risk will depend on the patterns of drinking and
of behaviour associated with drinking in a particular
society. In the new estimates in connection with the
WHO’s Global Burden of Disease project, the relative
risk for alcohol’s role in violence and in injuries in
general varies among countries and subregions
according to differences in their patterns of drinking.8
Alcohol and global burden of disease
Table 27,47summarises indicators of alcohol use in major
regions of the world.8Two kinds of information are
needed to estimate variations in the global burden of
disease attributable to alcohol: the average volume of
alcohol consumption, and the predominant patterns of
drinking. Average volume of alcohol consumption can
www.thelancet.com Vol 365 February 5, 2005 521
Very high or high mortality;
Very high or high mortality;
Low mortality emerging
Very low mortality
EMR-D, SEAR-D (Islamic middle east
and Indian subcontinent)
AFR-D, AFR-E, AMR-D (poorest
countries in Africa and America)
AMR-B, EMR-B, SEAR-B, WPR-B (better-off
developing countries in America, Asia, Pacific)
0·411·47 1·88 15·0%12·272·9
3·11 2·825·9342·8%14·21 2·8
3·791·44 5·2351·0% 10·532·4
AMR A, EUR A, WPR A (North America,
western Europe, Japan, Australasia)
9·62 1·2810·90 77·8%14·00 1·5
Former socialist: low mortality EUR B, EUR C (eastern Europe and central Asia)
Calculations based on reference 8. *Regional subgroupings defined by WHO47on basis of mortality levels (A=very low child and very low adult mortality; B=low child and low adult mortality; C=low child and high adult mortality;
D=high child and high adult mortality; E=very high child and very high adult mortality). †Litres of pure alcohol per resident aged 15 and older per year. ‡Indicator of hazard per litre of alcohol consumed, composed of several
indicators of heavy drinking occasions plus frequency of drinking with meals (reverse scored) and in public places (1=least detrimental; 4=most detrimental).
Table 2: Economic development status and alcohol consumption variables
be derived from country-specific estimates of per capita
consumption and survey information. Both recorded
and unrecorded consumption should be taken into
account to arrive at a realistic estimate of total
consumption, because in many regions of the world the
larger part of the production, sales, and consumption is
not recorded (table 2).8Patterns of drinking are shown in
terms of a country-specific hazardous drinking score.8
The score is an indicator of the hazard per litre of alcohol
consumed, and is composed of several indicators of
heavy drinking occasions plus the frequency of drinking
in public places and not drinking with meals.8It was
used in conjunction with the volume of drinking in
assessing the alcohol burden from CHD and injuries in
the following burden estimates.
Table 3 shows alcohol-related burden based on both
average volume of consumption and patterns of
drinking. Globally, the effect of alcohol varies greatly by
region, from 1·3% of the burden of disease in the
poorest developing countries with low consumption to
12·1% in formerly socialist countries. Overall, 4·0% of
the global burden of disease is attributable to alcohol
(table 3). Thus, alcohol accounts for about as much of
the burden of disease globally as tobacco (4·1%), and is
surpassed only by the burdens caused by underweight
(9·5%), unsafe sex (6·3%), and high blood pressure
In interpreting these global figures, it should be taken
into account that they are based on several
assumptions8—most importantly, that patterns of
drinking are homogeneous within a country and that the
risk relations between exposure and chronic disease
(excepting CHD) do not differ by region.
The role of alcohol use disorders (ICD categories of
alcohol dependence and harmful use) within the burden
of disease also varies by region. Globally, about a third of
the alcohol-attributable burden of disease is accounted
for by alcohol-use disorders, ranging from less than 20%
in Africa and the formerly socialist countries to more
than half of the alcohol-related burden of disease in
high-income countries with very low mortality (western
Europe, North America, Japan, Australia). As attention
turns increasingly to prevention and management of
alcohol problems across the globe, it is therefore
important to look beyond the frame of alcohol
dependence, which has tended to dominate the concerns
of alcohol-related research over the past decades.
Implications for policy and practice
Recent years have brought substantial advances in our
understanding of the risk relations of alcohol
consumption and specific disorders. The contraindi-
cations of heavy drinking occasions now include not
only the well-recognised risk of accidental injuries but
also such consequences as heart failure. The popularly
believed connection between drinking and violence has
now received substantial scientific support. This
connection, and more broadly the connection with traffic
accidents and other injuries, means that alcohol
consumption can cause substantial harm to the health of
others besides the drinker. There are a number of
medical grounds for health workers to strongly
discourage heavy drinking even on holidays or
weekends. The findings for breast cancer imply that
advice about moderate drinking should emphasise that
almost no pattern of drinking is entirely risk-free, and
that consumers should be aware that a range of health
risks should be balanced against benefits they might
derive from drinking.
Studies such as the Global Burden of Disease project
have greatly enhanced the opportunity for quantitative
comparisons between nations of drinking practices and
problems. The comparisons themselves become
arguments for new policies. That British, Danish, and
www.thelancet.com Vol 365 February 5, 2005
Developing countries Developed countriesWorld
Very high or high mortality; Very high or high mortality; Low mortality
lowest consumption low consumption
(Islamic middle east and (poorest countries in
Indian subcontinent) Africa and America)
Very low mortality
(North America, western
Europe, Japan, Australasia)
Former socialist: low
mortality (eastern Europe
and central Asia)
countries in America, Asia,
Neuropsychiatric conditions in total
Only alcohol use disorders (also part
of neuro-psychiatric disorders)
Other non-communicable diseases
Total alcohol related burden in DALYs
Total burden of disease in DALYs
Proportion of total disease burden
that is alcohol related (%)
Data in thousands of disability adjusted life years (DALYs) unless otherwise stated.
Table 3: Economic development status and alcohol-associated burden of disease
Irish 15-year-olds, for instance, considerably exceed
those of the same age elsewhere in Europe in the
proportion who have been drunk three or more times in
the past 30 days48can serve as a wake-up call for action.
The Global Burden of Disease analyses have underlined
that, although the health problems from drinking can be
familiar and often even taken for granted in many
societies, they are very substantial in magnitude,
accounting on a net basis (subtracting protective effects)
for 6·8% of the total burden of disease in developed
societies such as in western Europe. In making policy,
social problems from drinking—for instance, the effect
on family life—must be taken into account on top of the
health problems measured in the burden of disease
analyses. There is thus a strong justification for the
health professions stepping up their health advocacy
with respect to policies to reduce rates of alcohol
Treatment of alcohol-use disorders
When a diagnosis indicates that an individual has a
mental or behavioural disorder related to alcohol use,
several important clinical decisions must be made about
the type, setting, and intensity of the intervention.
Among heavy drinkers without evidence of severe
alcohol dependence, an intervention in primary care
aimed at the reduction of drinking to moderate levels of
consumption may suffice. By contrast, chronically
alcohol-dependent people and other drinkers with high
levels of alcohol consumption are likely to have a range
of associated disabilities that also need attention. The
goals of treatment for such cases typically include
complete abstinence from alcohol, management of acute
medical and psychiatric conditions, assistance with
occupational, interpersonal, and housing needs, and
promotion of long-term recovery. The presence of
complicating medical (eg, acute pancreatitis, bleeding
oesophageal varices) or psychiatric conditions (eg,
psychosis, suicidal intent) is an important determinant
of whether rehabilitation is initiated in an inpatient or an
outpatient setting. Other considerations are the current
living circumstances and social support network of the
person with alcohol problems. The focus of this section
is the clinical management of mental and behavioural
disorders due to the use of alcohol, with special
emphasis on the ICD-10 categories of harmful use
(F10·1) and alcohol dependence syndrome (F10·2).49
Approaches to management
A range of interventions have been developed to deal
with alcohol-related problems.50,51These treatments can
be divided into three general categories: brief
intervention; specialised treatment programmes; and
mutual help groups. The figure52provides a schematic
diagram of current approaches to clinical management,
starting with the results of a common screening test
designed to differentiate among different levels of risk
and severity. In such an approach, persons who score in
the low positive range (8–15) on the Alcohol Use
Disorders Identification Test (AUDIT)53,54should receive
a brief intervention based on their risk for the
consequences of acute alcohol intoxication and the
possibility of developing alcohol dependence. Those
scoring in the intermediate range (16–19) need a brief
intervention and regular monitoring, including referral
for a more formal diagnostic assessment if heavy
drinking and related problems continue. Those scoring
in the high range (20–40) should receive a diagnostic
assessment and, depending on the severity of physical
dependence, detoxification and other treatments.
Brief interventions are intended to provide prophylactic
treatment before or soon after the onset of alcohol-
related problems. They are typically designed to motivate
high-risk drinkers to
consumption, rather than promote total abstinence.
They are often simple enough to be delivered by primary
care practitioners and are especially appropriate for
patients whose hazardous drinking meets ICD-10
criteria for harmful use rather than dependence. During
the past two decades, several randomised controlled
trials have been done to assess the efficacy of brief
interventions. The cumulative evidence55–58shows that
clinically significant effects on drinking behaviour and
related problems can follow from brief interventions.
Nevertheless, the results have not always been
moderate their alcohol
www.thelancet.com Vol 365 February 5, 2005 523
AUDIT score <8 AUDIT score 8–15AUDIT score 16–19 AUDIT score 20–40
Brief interventionBrief intervention
and severity of
is absent or mild
is moderate or severe
Management in psychiatrist's
office or referral to outpatient
or inpatient rehabilitation
Aftercare including mutual help
Figure: Algorithm for identification and management of harmful drinking and alcohol dependence
Adapted from reference 52.
consistent across studies,58and the feasibility of routine
screening in primary-care
questioned.59Moreover, there is little evidence that these
interventions are beneficial for alcohol-dependent
settings has been
Specialised treatment refers to interventions directed at
the management of alcohol withdrawal, the prevention
of relapse to alcohol dependence and the social and
psychological rehabilitation of the problem drinker.
Specialised treatment services
programmatic or setting components (eg, detoxification
facilities, inpatient residential programmes, outpatient
clinics) and therapeutic approaches (eg, the twelve steps
of Alcoholics Anonymous, relapse prevention).
consist of both
Management of alcohol withdrawal
An important initial intervention for many alcohol-
dependent patients is the management of alcohol
withdrawal to relieve discomfort, prevent medical com-
plications, and prepare the patient for rehabilitation.
Non-pharmacological or social detoxification consists of
frequent reassurance, personal attention, monitoring of
vital signs, and general nursing care;61–63this is most
appropriate for patients in mild-to-moderate withdrawal.
Pharmacological detoxification, typically done in an
inpatient setting, is indicated for serious medical or
surgical illness, and for individuals with a past history of
adverse withdrawal reactions or with current evidence of
delirium tremens. The benzodiazepines are preferred
for the treatment of alcohol withdrawal because of their
favourable side-effect profile.61
Alcohol rehabilitation has typically been provided in a
residential setting lasting for periods of a month or
more. Residential settings include hospital-based
rehabilitation programmes, freestanding units, and
psychiatric units. Because of increasing cost concerns,
outpatient management has recently become the
dominant setting in many countries. Treatment
outcomes64–66tend to be similar regardless of setting, but
residential treatment may be indicated for patients who
are highly resistant to treatment, have few financial
resources, come from environments that present a high
risk of relapse, and have more serious, coexisting
medical or psychiatric conditions.67
Therapeutic approaches most often employed in both
residential and outpatient
behaviour therapy, motivational enhancement, Twelve
Step Facilitation, family therapy, and pharmacotherapy.
Behavioural treatments, which focus on the teaching
of relapse prevention skills and the development of
more appropriate cognitive strategies, have been found
confrontational and family therapies.64Several large
studies have indicated that Twelve Step Facilitation,
which is designed to introduce patients to the principles
of Alcoholics Anonymous,
Enhancement Therapy, which is designed to increase
the drinker’s motivation for abstinence, are as effective
as cognitive and behavioural therapies.68–70Although
patients with certain characteristics (eg, severe
dependence, high levels of anger, social networks that
support drinking) respond marginally better to certain
types of therapy (eg, Twelve Step Facilitation,
motivational enhancement, cognitive behavioural,
respectively),70,71the research findings do not suggest
that matching to therapeutic modality substantially
improves treatment outcomes beyond the effect of
receiving any intervention.
be more effective than insight-oriented,
Although the benzodiazepines have played a key role in
the treatment of alcohol withdrawal, and disulfiram, an
alcohol-sensitising drug, has been in clinical use since
the 1940s, pharmacotherapy has not yet had a
demonstrable impact on
dependence. During the past decade, however,
medications have begun to play a more important part
both in the treatment of co-morbid psychiatric disorders
in alcoholics and in the rehabilitation of alcohol
Alcohol-sensitising drugs such as disulfiram and
calcium carbimide cause an unpleasant reaction when
combined with alcohol, due to raised concentrations of
acetaldehyde. Despite its durability in the alcohol
problems pharmacopoeia, the few placebo-controlled
studies that have been done have shown that the drug is
ineffective because of poor medication compliance.76
However, a variety of approaches to enhancing voluntary
compliance with disulfiram therapy have been
employed.77,78These include the use of incentives,
contracting with the patient and a partner to promote the
patient’s taking disulfiram, providing additional
information to the patient, behavioural training, social
support, and depot formulations.
Another class of drugs is designed to directly reduce
alcohol consumption. Consistent with neurobiological
research implicating neurotransmitter systems in the
control of alcohol consumption,2medications to treat
excessive drinking have increasingly focused on agents
that have selective effects on endogenous opioids,
serotonin, and catecholamines, especially dopamine.
Opioid antagonists, such as naltrexone, have been
shown to reduce the rate of relapse to heavy drinking79,80
but the effects tend to be fairly small.75,81–85Factors such
as poor medication compliance, severe alcohol
dependence, and the
psychotherapy might therefore determine whether the
medication is effective.
treatment of alcohol
choice of concomitant
www.thelancet.com Vol 365 February 5, 2005
Another focus of interest on medications to treat
alcohol dependence has been the indoleamine
neurotransmitter, serotonin. Placebo-controlled trials
have generally shown no overall advantage in drinking
perhaps because these drugs are
differentially effective with different types of individuals,
such as those with a family history of alcohol problems.88
Acamprosate, an aminoacid derivative, affects neuro-
transmission of both GABA and excitatory aminoacid
(glutamate). Multicentre studies in Belgium, the
Netherlands, and Luxembourg,89Austria,90Germany,91
and Italy,92,93have shown substantial advantages of
acamprosate compared with placebo. Despite at least
one negative study in the UK94(which showed no
significant effect on consumption, but some psycho-
logical effects), studies with more than 4000 patients
have provided consistent evidence of the efficacy of
acamprosate in alcohol dependence rehabilitation.75,95In
view of the benign side-effect profile, and a 13% overall
improvement in 12-month continuous abstinence
rates,95the drug seems to hold substantial value for the
treatment of alcohol dependence.
Mutual help organisations, aftercare, and maintenance
Although mutual help societies composed of recovering
alcoholics are not regarded as a formal treatment, they
are often used as a substitute, an alternative and an
adjunct to treatment.96Mutual help groups, such as
those based on the Twelve Steps of Alcoholics
Anonymous, have proliferated throughout the world.97,98
Published research lending support to the effectiveness
of Alcoholics Anonymous is limited.99Attendance at the
programme is associated with long-term abstinence,100–102
but the type of motivated person that persists with
Alcoholics Anonymous might do just as well with other
forms of supportive therapy. Results of several large-
scale, well-designed studies68,70,103suggest that Alcoholics
Anonymous can have an incremental effect when
combined with formal treatment, and attendance at the
group alone might be better than no intervention.
Evidence also suggests that Alcoholics Anonymous is
especially effective in people whose social network
includes large numbers of heavy drinkers.68,71
Implications for policy and practice
During the past 25 years, substantial progress has been
made in the scientific study of the treatment of alcohol
problems. The following conclusions appear warranted
at this time: (1) individuals who obtain help for a
drinking problem, especially in a timely manner, have
better outcomes than those who do not receive help, but
the type of help they receive (eg, self-help or formal
treatment) makes little difference in long-term
outcomes;104(2) the intensity and duration of treatment
are not associated with pronounced improvements in
outcome, (3) medically-based inpatient treatment,
although more costly, is not demonstrably more effective
than non-medical residential or outpatient treatment;
and (4) little evidence exists that any one psychotherapy
or pharmacological approach is best. Although several
studies have shown that patients experience substantial
improvement during the year after treatment for alcohol
problems, results of follow-up studies over a longer
period100,105showed that treatment had little effect on
long-term outcome. More long-term investigations are
needed to assess the effects of different kinds of
treatment on the course of alcohol dependence.
Additional research is also needed to clarify both the
prognostic relevance of patient-related variables,
including co-morbid psychiatric disorders, and their
interaction with different kinds of treatment. The verdict
is, at best, a “guarded affirmative”106to the question of
whether increased provision of treatment has an effect
in lowering the rate of alcohol problems in the
population. Provision of such treatment is an imperative
for a humane society, but it is not in itself a sufficient
policy for reducing rates of alcohol problems.
Policy research and options
Published evidence on prevention programmes and
policies for reducing alcohol-related problems has been
substantially strengthened in recent years. Studies in the
field now include well-designed experimental trials not
only of programmes aimed at individuals, but also of
community-oriented approaches107and even of national
policies.108Unfortunately, the cultural coverage of the
research is somewhat restricted: policy and prevention
research tends to be particularly strong for English-
speaking and northern European societies,109whereas
often only case-study information is available for
developing societies and
Policymakers in societies where published work is
strong, however, now have a substantial knowledge base
on what works, under what circumstances, for whom,
and how well. The general principles based on these
findings are also applicable in other countries, but the
implementation needs to be adapted to the specific
Education and public information: popular but
The first recourse in case of public concern about rates
of alcohol problems in a society is usually to enhance
school-based education and public information
campaigns. However, research findings suggest that
these measures are not likely to be effective. Much
work has been published on assessments of school-
based alcohol education, which is increasingly
technically sophisticated.110In general, this evidence
suggests that, although knowledge can be increased,
and expressed attitudes may be changed, affecting
drinking behaviour through school programmes is a
very difficult task.111School-based efforts to influence
individuals not to drink or to drink less have generally
www.thelancet.com Vol 365 February 5, 2005 525
failed to show lasting effects.112Efforts to affect the
collective social climate of students in terms of
drinking have shown more promise, but programmes
tend not to show a measurable effect after 3 years,112
and claims of success with university students are now
Experience with public information campaigns is also
largely negative.111Unless governments are willing to
proceed with intensive counter-advertising campaigns,
which the alcohol industry will interpret as a frontal
attack, the most promising path forward for public
information campaigns in the alcohol field is rather in
terms of building support for implementing proven
Controlling price and availability: effective but out of
There is no doubt that consumption of alcoholic
beverages, like consumption of other commodities, is
responsive to price. For instance, price elasticities in the
UK have been estimated as –0·48 for beer consumed on-
premises, –1·03 for packaged beer, –0·75 for wine, and
–1·31 for spirits.115This means that a change in taxes
that raised the prices of alcoholic beverages across the
board by 10%, for instance, would be expected to
diminish on-premise beer consumption by 4·8% and
spirits consumption by 13·1%. Substantial evidence
exists that heavy drinkers are, like other drinkers,
affected by taxes and prices of alcoholic beverages.116,117In
accord with this finding, tax increases have been shown
to affect rates of cirrhosis mortality, drink-driving
deaths, and violent crime, to name a few outcomes.118–120
Putting together the price-elasticity estimates and
analyses of UK alcohol-related mortality data,121we can
estimate that a 10% rise in British alcohol prices would
produce a drop in cirrhosis mortality of 7·0% in men
and 8·3% in women, and a fall of 28·8% in men and
37·4% in women in deaths from explicitly alcohol-
involved causes (alcohol dependence, poisoning, etc).
Although price elasticities vary between societies, as do
the sizes of effects of changes in consumption on
mortality, raising the price of alcoholic beverages is an
effective way to reduce rates of alcohol-related problems
Besides price, other controls on the availability of
alcoholic beverages have been shown to affect levels of
drinking and rates of alcohol-related problems.
Ironically, much of this evidence has become available
through studies of what happens when controls are
removed or weakened.109As the strict controls imposed
in many places as an alternative to prohibition in the
early 20th century were progressively weakened after
1950, levels of consumption and rates of alcohol-related
problems rose substantially.122Drinking and alcohol-
related problems can be affected by restriction of the
hours and days of alcohol purchasing108,123–125and of the
numbers and types of alcohol outlets.111,126
As a partial exception to the general trend toward
loosening controls on alcohol sales, in the past 25 years
the minimum legal age for purchasing or drinking
alcohol has been raised in the USA and some other
countries. Strong evidence exists that raising the
drinking age diminishes both alcohol consumption and
traffic casualties for the affected ages.107
Reducing alcohol-related vehicle casualties
Rates of alcohol-related casualties have been reduced in
many countries by a combination of counter-measures,
such as the adoption in much of the world of “per-se
laws” forbidding driving above a stated blood-alcohol
concentration, and the subsequent lowering of the
accepted level.111,127Britain and Ireland, in which the
accepted blood-alcohol concentration is 0·08%, have
lagged behind most of the rest of Europe in this. Even a
further reduction from the general European standard of
0·05% to the current level in Sweden of 0·02% has had a
further substantial effect on drink-driving fatalities.128
The effectiveness of such laws is, to a substantial
extent, dependent on the perceived probability of being
caught driving at greater than the allowed level. There is
clear evidence that sustained police attention to drink-
driving has an effect in lowering the number of alcohol-
related casualties.127Routine use of sobriety checkpoints,
where people whom police judge to have been drinking
are asked to take a breath-test, has some effect; an
Australian study showed a 15% reduction in fatal
accidents.129 Several analyses of Australian experience,
however, have shown that a sustained programme of
publicised and random breath-testing, in which
motorists passing a check-point are chosen randomly to
take a breath-test, to be significantly more effective than
sobriety checkpoints. In some Australian states,
motorists are stopped for random breath-testing about
0·6 times a year, on average.111 Sobriety checkpoints and
random-breath testing have also shown similar
reductions in alcohol-related casualties in other
jurisdictions, most notably in the USA.127
Graduated licensing measures, with a blood-alcohol
limit of zero for young or new drivers, have also been
shown to reduce drink-driving, crashes, and injuries for
those affected.111,127Taken together, drink-driving counter-
measures have clearly demonstrated effectiveness in
reducing alcohol-related traffic injury, but have not been
as fully or widely applied as they could have been.
Although evaluative studies are scarce, increasing
attention is also being paid to strategies for reducing
alcohol-related casualties in other vehicular environ-
ments—eg, recreational boating.130,131
Reducing violence and casualties around public drinking
Injuries, whether intentional or unintentional, account
for a very substantial fraction of the burden of harm
from drinking. For instance, 29% of the alcohol-
attributable deaths in the UK are related to injuries.132 In
www.thelancet.com Vol 365 February 5, 2005
recent years, prevention strategies have focused on
drinking in public places, primarily pubs or taverns and
restaurants. These strategies have a particular relevance
for cultures with strong traditions of pub drinking, such
as Britain and Ireland (70% of the beer consumed in
Britain in 1998 was consumed in pubs).133The strategies
are predicated on a licensing system and enforcement
mechanisms for on-premise serving of alcohol, so that
the pub or restaurant manager or owner can be held
responsible for house policies and their implementation.
One such strategy has been the enforcement of
responsible service training and policies denying alcohol
service to those who are already intoxicated or underage.
Assessments have generally shown that training in itself
has little effect on behaviour of servers. However, clear
positive effects have been noted on indicators such as
rates of customer intoxication when server training and
policies are backed up by active enforcement,134,135
including evidence of reduced drink-driving casualties136
and violence.137A related strategy with promising results
is to combine server training with training of pub staff as
a means of reducing violence in and around the
In the USA, and to a lesser extent in Canada and
Australia, civil liability law has increasingly been used to
enforce responsible serving, by holding the serving
establishment partly liable for damage caused by a
customer who is underage or drunk when served.
Goodliffe139has argued that this strategy is also
potentially available in the UK. Assessments lend
support to the effectiveness of the server’s civil liability
for damages in reducing rates of traffic fatalities and
What unites these strategies is their focus on holding
the alcohol seller responsible for staying within legal
parameters in the on-premise drinking situation. On the
other hand, current approaches in the UK tend to focus
attention on the drinker, through such mechanisms as
Pubwatch schemes for sharing information on
troublesome drinkers and exclusion orders to ban such
people from pubs.142Only perceptions, rather than
formal assessments, of the UK approach are available.143
But the general rule in such situations is that it is easier
and more effective for the state to influence licensed
occupational behaviour than it is to influence the
behaviour of private customers.144
Building effective alcohol policies
A stark discrepancy exists between research findings
about the effectiveness of alcohol control measures and
the policy options considered by most governments. In
many places, the interests of the alcohol industry have
effectively exercised a veto over policies, making sure
that the main emphasis is on ineffective strategies such
as education. A case in point is the recent Alcohol Harm
Reduction Strategy for England, which emphasises co-
operation with the alcohol industry and eschews
effective strategies.145The tendency has often been to
treat alcoholic beverages more and more as an ordinary
commodity, overlooking the very serious health and
social problems related to alcohol consumption. In the
context of the European Union, national controls such as
relatively high taxes are increasingly undercut by large
traveller’s allowances for imports for personal use.111
There has been a growing contrast between the
treatment of alcohol in trade agreements and disputes as
an ordinary commodity and the more restrictive
treatment of such other commodities as tobacco and
pharmaceuticals, which also entail public health risks.
In a globalising world of common markets and trade
agreements, alcohol policy is thus no longer only a
national or subnational matter. To reverse the trend, a
new international agreement on alcohol control, along
the lines of the Framework Convention on Tobacco
Control, is needed.111
At the national and subnational levels, responsibility
for the alcohol market and for the various social and
health problems from drinking is typically split among
several government departments, and often between
different levels of government. The crucial need, from a
public health perspective, is for a regular means of co-
ordination whereby prevention of alcohol-related
problems is taken fully into account in policy decisions
about alcohol controls and other regulation of the
market for alcoholic beverages.
Conflict of interest statement
We declare that we have no conflict of interest.
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