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SECOND-HAND EFFECTS OF ALCOHOL CONSUMPTION - Alcohol and society 2015/2016

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SECOND-HAND EFFECTS OF ALCOHOL CONSUMPTION – can we prevent harm to others?
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ALCOHOL AND
SOCIETY
THEME 2015/2016:
SECOND-HAND EFFECTS
OF ALCOHOL CONSUMPTION
Åsa Jinder on growing
up with alcoholism
Alcohol is the fifth
leading cause of death
and disability
Published by IOGT-NTO and the Swedish Society of Medicine in cooperation with Forum Ansvar, 2015
A Swedish language version of this report is also available from IOGT-NTO (www.iogt.se) or the Swedish
Society of Medicine (www.sls.se).
© IOGT-NTO & Swedish Society of Medicine, 2015
Graphic design: Pernilla Förnes Form
URN: urn:nbn:se:iogt-2015-aos-en
SECOND-HAND EFFECTS OF
ALCOHOL CONSUMPTION
– can we prevent harm to others?
| The second-hand harms of alcohol 5
| Second-hand effects of alcohol consumption 6
| “Being trapped by grief is living a half-life” 54
| “Our alcohol norms become our children’s norms” 58
| Alcohol is the fifth leading cause of death and disability 62
| Alcohol and public health in emerging economies 64
| Alcohol industry actions to influence alcohol policy making 68
Foreword
Report
Interview
Interview
Current research
Current research
Current research
THE SECOND-HAND HARMS
OF ALCOHOL
IOGT-NTO and the Swedish Society of Medicine are proud to present, for the third year
in succession, a research report on the theme of alcohol. This year’s theme is the alcohol-
related second-hand harm – a relatively underused concept that refers to the harms to
society and to individuals around those who drink alcohol. The second-hand harm of
alcohol consumption occurs in all areas of society and can involve anything from trac
accidents, through violence and abuse in both personal relationships and the public
space, to children being neglected and a loss of the capacity for work. The aim of this
report is to make available what we know about alcohol-related second-hand harm and to
present the research conducted in this eld.
An international team of six researchers, headed by Harold Holder who is one of the
world’s leading alcohol researchers, meets every year in Gothenburg to discuss and
write articles on a pre-determined theme. The group reviews the international research
conducted in the eld and then draws conclusions and comes up with measures tailored
to Sweden and the other Nordic countries. Previous years’ reports have focused on such
subjects as alcohol and young people, and the eects of low-dose alcohol consumption.
The articles in this report have a wide target group and can be read by anyone with an
interest in public health issues. There is also an English language version of the report
that includes descriptions of methodologies and source references. The English language
version is available on our respective websites.
We hope that you will nd this report absorbing and that it will provide you with valuable
information on the latest ndings in the eld of alcohol-related research.
Johnny Mostacero
Chair,
IOGT-N TO
Kerstin Nilsson
Chair,
The Swedish Society of Medicine
Samuel Uneús
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SECOND-HAND EFFECTS OF ALCOHOL
CONSUMPTION
– can we prevent harm to others?
The second-hand effects of alcohol consumption are pervasive affecting,
in principle, all major parts of society, e.g. fetal alcohol effects, lower
grades in school, injuries, violence and cost for medical care. This report
summarizes current evidence on the harm caused by alcohol to people
other than the drinker and effective ways to reduce it.
By Sven Andréasson1, Tanya Chikritzhs2, Frida Dangardt3, Harold Holder4, Timothy Naimi5 and Tim Stockwell6
1Karolinska Institutet, Department of Public Health Sciences, Stockholm, Sweden
2Curtin University, National Drug Research Institute, Perth, Western Australia
3Sahlgrenska Academy and University Hospital, The Queen Silvia Children´s Hospital—Paediatric Clinical
Physiology, Goteborg, Sweden
4Senior Scientist Emeritus and former Director of Prevention Research Center, Pacic Institute for
Research and Evaluation, Berkeley, CA, USA
5Boston Medical Center, Section on General Internal Medicine, Boston, MA, USA
6Dept of Psychology - Centre for Addictions Research of BC, University of Victoria, BC, Canada
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EXECUTIVE SUMMARY
Alcohol causes signicant harms to many people other than the drinker; in other words it causes
substantial “second-hand” eects.
The second-hand eects of alcohol are a compelling justication for strong public policies on alcohol to
protect the health and well-being of all Swedes.
Until recently, research into the extent and nature of second-hand eects have been limited. This report
describes emerging research and oers recommendations for their prevention.
Alcohol is the 6th leading risk factor globally for preventable death, disease and disability according to the
latest Global Burden of Disease estimate, ahead of high cholesterol and most dietary risk factors.
Alcohol is the leading risk factor globally for persons aged 15-49, ahead of e.g. smoking and high blood
pressure.
No other risk factor in the Global Burden of Disease report involves as many types of disease and injury
as does alcohol, illustrating the toxicity of alcohol to all tissues and organs of the body through a variety of
physiological and psychological mechanisms.
When the second-hand harms are added to the harms to drinkers it has been estimated the total harm
from alcohol is about double that from tobacco, which is currently considered the 2nd leading contribution to
the global burden of disease.
Similarly, the types of second-hand harms caused by alcohol are pervasive and include impacts on
children and families, unintentional injuries and violence, crime, property damage and adverse economic
eects.
Notable examples of second-hand eects of alcohol include motor vehicle crashes and drunk driving,
sexual assault, domestic violence, child maltreatment and neglect, vandalism, and lost productivity.
The proportion of fatal motor vehicle crashes in Sweden where at least one driver had blood alcohol levels
above the legal limit has been 20-25% of dead drivers over the past 8 years.
Survey data suggest 50,000 Swedish households experience nancial problems due to a family member’s
drinking, 30% of Swedish adults have had a negative alcohol-related experience involving a family member
or close associate in the past year, and 10% have had a negative alcohol-related experience involving a
stranger.
In developed nations, more than half the economic costs from alcohol are borne by those other than the
drinker (e.g., are costs borne by government or individuals not generating the costs).
While most second-hand eects from alcohol are caused by drinking to the point of intoxication (i.e.,
binge drinking), most second-hand eects are caused by those who are not themselves alcohol-dependent.
The most eective ways to prevent second-hand eects and costs from alcohol are policies that reduce its
aordability and ease of access; eorts to simply “treat” those with alcohol dependence can only prevent a
small proportion of alcohol’s second-hand eects.
Specic examples of eective alcohol policies that should be strengthened include: increasing the overall
price of alcohol through taxation, introducing minimum pricing which targets the cheapest alcohol, limiting
the number of outlets that can sell alcohol, limiting the hours and/or days of sale for alcohol, and increasing
the age at which persons can purchase or possess alcohol in public. Attention should be paid to restricting
cross-border sales of alcohol which currently weaken the eectiveness of Systembolaget, and Internet sales,
which may pose a future threat.
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INTRODUCTION
While it is clear that alcohol causes a multitude of
medical and social harms to individual drinkers,
this report is a summary of the harms caused by
alcohol to people other than the drinker. A recent
report from Sweden showed that more than 30%
of the population has a person close to them who
drinks alcohol excessively of whom 50% of them felt
adversely aected by this.1
What makes drinking unique in comparison to
other risk factors is that the costs to society from
these second-hand eects are by several estimates
more extensive than the direct costs to the drinkers.
This was found in a recent Swedish parliamentary
inquiry2, and similar conclusions have been
published from other countries, e.g. Scotland3 and
Australia4. Another type of evidence comes from
the ranking of substance-related harm in the UK,
where the harm caused to others from alcohol was
estimated to be almost double that to the user.
“What makes drinking unique in
comparison to other risk factors is
that the costs to society from these
second-hand eects are by several
estimates more extensive than the
direct costs to the drinkers.
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Furthermore, the combined harm to both drinkers
and others from alcohol was estimated to be almost
double the combined harm to smokers and others
from tobacco.5
To a large extent, it has been these indirect eects
that have motivated national legislators to introduce
policies for the reduction of alcohol related harms
in most countries around the world, including
Sweden. This was the main driving force behind the
creation of restrictive alcohol policies in Sweden in
late 19th and early 20th century. In the report from
the Swedish Society of Medicine 1912 “Alkoholen
och samhället” (Alcohol and Society) it was the
social harm caused by alcohol: public drunkenness,
harm to wife and children, poverty and crime6, that
motivated the national policies recommended. The
Swedish Society of Medicine report came to be the
foundation for Swedish alcohol policy from 1920 and
remains inuential in the 21th century.
In 1974, the Swedish parliamentary “Alcohol Policy
Inquiry” noted the absence of research on social
harms, e.g. eects on children or impact on the
economy, while there was reasonable knowledge of
the most serious medical consequences of alcohol.
Nevertheless, the inquiry still saw the social
problems caused by alcohol as more important and
widespread than medical problems. The inquiry
also suggested using total consumption of alcohol in
the population as an overall indicator of problems,
especially noting that the proportion of heavy
consumers tends to increase with increasing per
capita consumption.7
However, it has only been in the last decade that
more attention has been given in the research world
to alcohol’s harms to others. Even in 2001, WHO
Europe published a report on social harms the
introduction was entitled “Social consequences of
alcohol – the forgotten dimension?”.8 Further, the
impressive WHO Global Burden of Disease project
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FROM ALKOHOLEN OCH SAMHÄLLET (ALCOHOL AND SOCIETY), 1912:
“The brutalizing effect of alcohol on the spirit of the home and marriage should be one of it’s most
serious negative consequences. … the daily impressions of the children … the solidarity between
family members suffer, as does the capability to adjust to each other for peace and comfort, self-
control, truthfulness and openness stand back; harsh words, quarrels, hardened and shameless
behaviours … hygienic care neglected … the mother has to leave the home day-time to work to keep
it up. … marriage problems, work capacity … the harm caused by alcohol in this respect cannot be
expressed in figures”
[Svenska läkaresällskapet (1912). Alkoholen och samhället (Alcohol and society): betänkande angående
de samhällsskadliga inflytanden bruket af rusdrycker medför jämte förslag till systematiska åtgärder
för deras bekämpande i Sverige. Stockholm: Isaac Marcus’ boktr.-aktiebolag. (Alcohol and society.
Swedish Society of Medicine, 1912)]
“No other risk factor in the Global
Burden of Disease report impacts
on as many types of disease and
injury as alcohol.
does not include harms to others (medical or social)
from the various risk factors in the estimations, with
the single exception of second-hand smoke. The
estimates of burden of disease attributed to alcohol
therefore capture only part of the consequences of
alcohol consumption in a population.
There are important lessons to be learned from the
tobacco eld, especially the huge policy implications
following research on the eects of second-hand
smoking. While the secondary eects are dierent
in nature; mostly biologically toxic in the case of
tobacco and mostly social or behavioural in the case
of alcohol, they both provide strong arguments for
society to protect non-consuming individuals and
groups.
Alcohol is dierent from other risk factors also in its
multifaceted impact, in the medical domain as well
as in the social. No other risk factor in the Global
Burden of Disease report impacts on as many types
of disease and injury as alcohol, illustrating the
general toxicity of alcohol to all tissues and organs
of the body. Similarly, the list of social harms caused
by alcohol constitute a long catalogue, summarized
in this report. Indeed, it is dicult to nd any part of
society that is not negatively aected by alcohol.
This report provides an updated overview of recent
research on the harm to others from alcohol. While
this emerging literature is still small in comparison
to the medical literature, it nonetheless helps
establish a stronger foundation for alcohol policies.
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REPORT
SECOND-HAND EFFECTS
ALCOHOL CONSUMPTION PATTERNS AND SECOND-
HAND EFFECTS OF ALCOHOL
Before considering the dierent types of alcohol-
related problems that make up the second-hand
eects of alcohol, it is important to consider how
alcohol consumption patterns are related to those
eects. For second-hand eects consumption to
and beyond the point of impairment, is responsible
for the vast majority of problems and is the key
determinant of harms to others.9 Impairment
refers to blood alcohol concentrations in which
the performance of certain tasks is compromised.
For example, for outcomes such as motor vehicle
crashes impairment may begin at 0.02% BAC,10
even though that is below the level that denes legal
intoxication for operating a motor vehicle in most
countries. However, for outcomes other than motor
vehicle crashes or risks of unintentional injury,
levels leading to impairment are less well dened
and may be variable at the level of the individual. It
should be noted that impairment of driving ability
begins at blood alcohol concentrations well below
those associated with intoxication, which is when
impairment from alcohol is more easily observable
to the drinker or to an observer.11 12
Binge drinking and resulting alcohol impairment
can lead to a variety of transient physiological and
psychological changes that increase the risk of
harm to others including impaired coordination,
delayed reaction time, loss of self-control and
judgement, diminished executive function, and
aggression.13 It is also possible that chronically high
levels of average alcohol consumption may cause
permanent neurological and psychological changes
that could also increase the risks of second-hand
eects. Furthermore, persons with high average
consumption are impaired frequently and/or for
prolonged periods, and tend to consume most of
their alcohol during occasions in which 5 or more
drinks are consumed. Alcohol dependence (i.e.,
alcoholism) is associated with a loss of economic
productivity and other outcomes that may eect
persons other than the drinker.14
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OVERVIEW: THE SCOPE OF SECOND-HAND EFFECTS
OF ALCOHOL
Alcohol causes or contributes to a vast array of
conditions and events which may cause harm
to those other than the drinker.15 These various
conditions and events occur in several domains,
including health care, social institutions, criminal
and legal justice systems, and economics. Outcomes
range from those that are severe (death) to those
that might be considered mildly annoying (a delay
in falling asleep due to local noise from an alcohol-
related disturbance). Some outcomes associated
with harms to others are well-established (e.g.,
alcohol-related motor vehicle crashes, fetal alcohol
spectrum disorder, sexually transmitted disease),
others are growing in appreciation (e.g. HIV/AIDS,
tuberculosis), and others have yet to be appreciated.
Many of the second-hand eects of alcohol are acute
(immediate and near the drinking event), while
others are more chronic in nature (resulting from
drinking over an extended time, sometimes several
years).
Although health conditions can be measured by
mortality and economic outcomes can be measured
in monetary terms, some second-hand eects may
be dicult to quantify. In addition, it is dicult
to aggregate second-hand eects across multiple
domains (e.g., social harms in relation to economic
costs and health outcomes). However, a study from
the United Kingdom developed a composite harms
index using an expert panel and multi-criteria
decision analysis to compare the eects of 20
psychoactive drugs across multiple domains. Among
those drugs, alcohol caused the greatest overall
harm and the greatest ham to others (e.g., alcohol’s
harm to others was three times that for tobacco).
In addition, alcohol was the only substance which
caused a greater harm to others than harm to the
user.16
The evidence for assessing the second-hand eects
of alcohol is primarily based upon epidemiological
studies, i.e. studies of how often eects occur in
dierent groups of people in relation to data on
alcohol consumption from self-reports or mean per
capita consumption. In addition, “direct” evidence
of alcohol involvement may be assessed through
measurement of blood alcohol concentration (e.g.,
alcohol-related motor vehicle crash data) or by self-
report. Nonetheless, it may be dicult to determine
what proportion of a particular outcome would
constitute a second- versus rst-hand eect.
Because of the strong justication for addressing
risk factors or behaviors that eect others,
additional research into the second-hand eects of
alcohol should be a high scientic priority. Despite
the gaps and deciencies in the evidence, in the
following sections we review several areas for which
alcohol’s second-hand eects are important, well
established, and well quantied.
Among the twenty types of drugs,
alcohol caused the greatest overall
harm and the greatest ham to
othe rs .”
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CHILDREN AND FAMILIES
Many people who drink are also parents or have
a central role in a family unit, e.g. grandparents,
siblings, aunties, uncles, legal guardians. Drinking
among Swedish parents is widespread, as it is
among parents in most Western nations. Based on
a national survey in 2007, 380 000 children were
estimated to be living with a parent who drank
above low risk consumption guidelines.17 When
caregiver drinking is heavy, either intermittently
or on a regular basis, the risk of indirect or direct
harm occurring to vulnerable family members is
increased.
Tolerance to negative eects of alcohol misuse on
children and other family members is generally
low in most societies. The inuence of alcohol
consumption, most often male drinking, on the
family was the impetus behind demands for
alcohol control in the 19th and 20th centuries.18 19
In a Swedish National Public Health Institute
survey, while two thirds of respondents felt it was
acceptable to get drunk at home when children were
not present, less than ten per cent considered this
acceptable if children were present.20 Data from
other countries concurs but some also suggest that
although most people express a view that drinking
to intoxication while engaged in a caregiving role
is inappropriate, many adults will nevertheless at
least occasionally become intoxicated while in the
presence of children.21 22 23
Children
There are multiple day-to-day challenges that
children of heavy drinkers may face. Scientic
evidence for impoverished family functioning and ill
eects on the lives of children due to the drinking of
others has arisen from a range of countries.
Swedish data on the educational results from over
600 000 children found that those of parents with
a substance abuse diagnosis were less likely to
complete primary school and among those who
progressed to secondary school, grades were some
20% lower when compared to other children.24
Another Swedish study of more than half a million
children followed until 35 years of age showed that
almost 3% had grown up in a household where
at least one parent was diagnosed with alcohol
abuse. Among these children the risk of developing
a substance use problem was four to seven times
higher and the risk of dying before 35 years was
three times higher than for the group as a whole.
Financial support from social services was four
times more common among these children and
in adulthood they were signicantly more likely
to receive nancial support as a result of chronic
illnesses.25
One in ten Irish adults reported that children for
whom they were parentally responsible experienced
at least one or more harms as a result of someone
else’s drinking, including being left in unsafe
situations, verbal abuse, physical abuse or being a
witness to serious violence in the home. Frequency
of harms to children were highest when adults had
lower socioeconomic status or drank regularly at
risky levels.26
Australian children living in families with at least
“In Sweden, 380 000 children
were estimated to be living with a
parent who drank above low risk
consumption guidelines.
REPORT
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“Increased drinking by parents
is a risk factor for higher levels of
alcohol use by their ospring.
REPORT
one heavy drinking parent are more often exposed
to family arguments, injury, neglect, abuse and
violence. They are more likely to witness verbal
or physical conict, or inappropriate behaviour
and more likely to be verbally abused, left in
unsupervised or unsafe situations, physically hurt or
exposed to domestic violence.27
A U.S. study of parental drinking patterns, alcohol
outlets and child physical abuse found that parents
who drank more frequently at home, parties or
bars used physically abusive parenting practices
more often. The use of greater amounts of alcohol
in association with drinking at bars appeared to
increase risks for corporal punishment with a dose-
response eect.28
A Russian study concluded that the amount of
alcohol consumed by fathers was negatively related
to the amount of time they spent with their children,
i.e. the more alcohol consumed the less hours spent
interacting with their ospring.29
From a young age, children learn about alcohol
from a range of sources including peers, media,
wider society and family members. Initially,
children’s basic knowledge, attitudes, expectations
and intentions are inuenced by their family,
particularly parents.30 Children may observe their
parents drinking, hear their parents talk about
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their own drinking or witness the outcomes. There
is compelling evidence to suggest that increased
drinking by parents is a risk factor for higher levels
of alcohol use by their ospring.31 Children and
youth may initiate drinking by observing their
parents’ drinking behaviors and often adopt the
values and norms of their parents.32 33
It has been repeatedly demonstrated that children
of alcohol dependent parents are more susceptible
to developing alcoholism, other substance use
disorders (tobacco, drug) and psychiatric disorders
(e.g. mood disorders, anxiety disorders, schizoid
personality, problem gambling). There also appear
to be strong but variable gender-related dierences
in risk depending on the diagnosis. The likelihood
of female children developing alcohol dependence
in later life appears to be increased by the presence
of either paternal or maternal alcohol dependence
whereas the risk for boys seems less related to
the presence of alcohol dependent mothers.34
The increased risk of alcohol dependence among
children of alcohol dependent parents is likely
caused by a mix of both genetic transmission and
shared family environment. Rose and Dick (2005)35
suggest that; “… drinking initiation is determined
primarily by environmental inuences, whereas the
establishment of drinking patterns is determined
mostly by genetic factors, which themselves are
subject to moderation by the environment. (pp.
222)
Beyond the family and societal hardships often faced
by children of heavy drinkers, increased risks to the
child’s physical and mental health have also been
documented, many with long term consequences.
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“Increased risks to the child’s
physical and mental health have
also been documented, many with
long term consequences.
REPORT
Children of heavy and dependent drinkers suer
higher risks of; anxiety, depression, adolescent
suicidality, eating disorders, obesity, poorer general
health, hospitalisation, injury, curtailed cognitive
development, Fetal Alcohol Syndrome (FAS) and
Fetal Alcohol Spectrum Disorder (FASD).36 37 38 39 40
41 42 43 44
Of all the substances of abuse, including heroin,
cocaine, and cannabis, alcohol produces by far the
most serious neurobehavioral eects on the fetus.45
Alcohol is a known teratogen and when ingested
by the mother it crosses the placenta in almost
equal concentrations. The potential adverse eects
of exposing human ospring to alcohol during
gestation have received considerable attention in the
research literature and the public realm in recent
decades. Although the precise relationship between
maternal alcohol use and harms to the fetus are
not yet fully understood, particularly in relation
to threshold levels for signicantly increased risk
and timing of exposure, there is no doubt that
alcohol can have irreversible, negative long-term
consequences for the child including birth defects
and neurodevelopmental disorders.46 47
Perhaps the most commonly known of the alcohol-
caused birth defects is Fetal Alcohol Syndrome
(FAS) -- a debilitating condition caused by high
levels of prenatal alcohol exposure resulting in
facial abnormalities (and usually a range of physical
birth defects), impaired growth, abnormal function
and structure of the central nervous system,
ultimately resulting in lifelong arrested cognitive
development.48 Fetal alcohol exposure may result
in a spectrum of more subtle and variable adverse
eects collectively referred to as Fetal Alcohol
Spectrum Disorders (FASD). The impact of FASD on
an individual’s development and potential is lifelong;
aicted individuals suer learning diculties,
disrupted education, elevated rates of mental illness,
substance use problems and criminality.49
Higher levels of alcohol intake by mothers during
pregnancy may also inuence birth weight of the
baby. A systematic review and meta-analyses found
that compared to abstainers, women who drank
more that an average of 1.5 drinks per day had an
increased risk of having preterm and low birth
weight babies.50
Adverse eects on children’s behaviour have
also been reported for low and moderate levels
of alcohol exposure during pregnancy including:
habituation to stimuli, delayed reaction time,
inattention, hyperactivity, learning problems,
attention and impulsivity problems, memory
decits, distractibility and mood disorders.51 Even in
adulthood, individuals who were prenatally exposed
to moderate levels of alcohol have been shown to
exhibit attention problems, executive functioning
decits leading to diculty with problem solving
and functioning in everyday life, increased incidence
of adult antisocial syndrome and higher rates of
alcohol, drug, and nicotine dependence.52 These
ndings suggest that alcohol can aect academic
and social functioning even when prenatal alcohol
exposure occurs at social drinking levels. Such
exposure has been implicated as the most common
cause of mental retardation and the leading
preventable cause of birth defects in the United
States, accounting for signicant educational and
public health expenditures. 53
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“In a study of US couples, alcohol
consumption increased the risk
of intimate partner violence more
than twofold compared to ab-
staining couples.”
Divorce and domestic violence
Many studies have shown an association between
the divorce rate and heavy alcohol consumption,
and a few well-designed studies have demonstrated
a signicantly increased risk of divorce among
married heavy drinkers.55 An aggregate level study
based on U.S. divorce data from 1934 to 1987
demonstrated that for every one litre increase
in per capita alcohol consumption, the divorce
rate increased by about 20%.56 A more recent
longitudinal study also based on U.S. data found
that couples with one heavy drinker were more
likely to divorce than couples who both abstained or
where both were heavy drinkers.57 However, a study
of Russian couples indicated higher risk of divorce
where both husband and wife were heavy drinkers.58
Some studies have attempted to gauge the impact of
family member drinking on other members of the
household by surveying representative samples of
a population. A 2005 nation-wide Swedish survey
reported that 2% of respondents stated they were
sharing a household with someone who had a
drinking problem. These respondents had a lower
quality of life-score than those without anybody
close with a drinking problem. Areas most aected
included general health, pain and discomfort,
energy and fatigue, working capacity and sex.59 An
Australian study found that 17% of people surveyed
were negatively aected by a family member’s
drinking, half of whom were aected “a lot”. Twenty-
eight per cent named a partner or ex-partner, 14% a
parent, 19% a child, 20% a sibling and 17% another
relative as the person whose drinking had most
aected them. Being emotionally hurt or neglected
(66%) was the most common harm reported,
followed by having a social occasion negatively
eect them (65%) and being involved in a serious
ar g u ment (63%). 60
A review of 60 studies on the association between
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alcohol use and marital functioning concluded that
spousal alcoholism is maladaptive, and that heavy
and problematic alcohol use is associated with
lower levels of marital satisfaction, higher levels
of maladaptive marital interaction patterns, and
in particular, higher levels of marital violence.61
A meta-analysis of 50 studies focused on alcohol
and intimate partner violence, found a small to
moderately sized association between alcohol
use/alcohol disorder and male-to-female partner
violence. The association between alcohol and
aggression was strongest among those with more
severe alcohol-related problems.62 Risk of violence
also appears to vary depending on the combination
of drinking habits of intimate partners. In a study
of US couples, alcohol consumption increased the
risk of intimate partner violence more than twofold
compared to abstaining couples. The risk increased
when both partners were moderate drinkers and
when both were frequent drinkers. The risk tripled
for couples where the partners had large dierences
in drinking habits, e.g. one with frequent heavy
drinking and the other with infrequent drinking.63
Many assaults occurring in private settings where
the perpetrator is male and the victim female are
of a sexual nature. It has been estimated that as
many as 75% of sexual assaults involve prior alcohol
consumption by the perpetrator, the victim, or
both.64
Aggregate studies of changes to alcohol policy and
alcohol availability have also demonstrated eects
on intimate partner violence. One recent review
of 10 outlet density studies concluded that higher
densities of alcohol outlets were associated with
higher rates of intimate partner violence.65 Relatively
few studies have examined impacts of changes to
trading hours on intimate partner violence, however,
there are some examples from Australia which show
that restricting trading hours in communities with
high levels of alcohol-related problems reduces the
number of injured females presenting to hospital
or women seeking refuge at women’s shelters.66 The
evidence for eects of price changes on intimate
partner violence is also limited although some
analysts have estimated that for the US population,
a 1% increase in the price of alcohol lead to a 5%
decrease in intimate partner violence towards
women.67
Household finances
Financial strain and depletion of household
resources are challenges frequently reported by
families aected by the alcohol misuse of a member.
For the Swedish population it has been estimated
that as many as 50 000 families (0.7%) have less
money available to the household as a direct result
of a member’s drinking.69 About 7% of the U.S.
population have experienced nancial trouble due to
someone else’s drinking70 and in Ireland about 4.5%
have had money problems71. In Italy, researchers
investigated whether consumption of alcoholic
beverages had an eect on the distribution of
resources among household members and found that
a high level of alcohol consumption of one household
member signicantly aected the allocation of
household resources among the others. Specically,
there was evidence of a ‘passive drinking’ eect
where non-moderate drinking by males generated a
quasi-external eect on spouses via unfair allocation
of resources.72
Few studies have attempted to estimate the
magnitude of nancial loss to the household. An
Australian survey asked household members who
were directly aected by another family member’s
drinking to quantify both the number of occasions
when money was not available for household
expenses and the average amount of money that was
unavailable as a result of the drinker’s behaviour.
About 30% reported having less money as a direct
result of the family member’s drinking with the
amount ranging from about $10 to $10 000 on an
average of eight occasions a year.73
“Non-moderate drinking by males
generated a quasi-external eect
on spouses via unfair allocation of
resources.
REPORT
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World Health Organization (WHO) review of
intimate partner violence
A review by the World Health Organization (WHO) noted that studies of intimate partner violence routinely identify
recent alcohol consumption by perpetrators. Estimates varied between countries. In the U.S, and in England and
Wales, victims believed their partners to have been drinking prior to a physical assault in 55% and 32% of cases
respectively. Perpetrators in one Canadian community had consumed alcohol in 43% of cases. In Australia, 36%
of intimate partner homicide offenders were under the influence of alcohol at the time of the incident, while in
Russia, 10.5% of such offenders were intoxicated. In South Africa, 65% of women who experienced spousal abuse
within the past 12 months reported that their partner always or sometimes used alcohol before the assault.
1960S SWEDISH NATURAL EXPERIMENT
WITH STRONG BEER
The effects of alcohol availability on prenatal
alcohol exposure among young mothers and
subsequent long-term consequences were
demonstrated by a 1960s Swedish natural
experiment where strong beer (max 5.6% alcohol
by volume) was trialled for sale in grocery stores
instead of monopoly stores in two counties
for eight months. The trial was planned to run
from November 1967 until the end of 1968 but
was ended prematurely in July 1968 due to a
sharp increase in alcohol consumption in the
experimental regions, particularly among youths.
During the first six months of 1968, per capita
consumption of strong beer increased ten-fold in
the experimental region. Since the age limit for
strong beer in grocery stores was only 16 years
of age compared to 21 years in the monopoly
stores, youth access to alcohol increased
markedly during the trial months. It was later
shown that children born to mothers under 21
years in the trial areas and pregnant during the
experiment had fewer years of schooling, lower
high school and college graduation rates, lower
levels of employment, lower income and a higher
welfare dependency rate than did children born
to young mothers outside of the trial areas.54
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HARMS BEYOND THE FAMILY:
UNINTENTIONAL AND INTENTIONAL
INJURIES AND MORTALITY
The risk of harm associated with drinking extends
beyond the family into the local environment
including driving, public drinking, and crime
where violence and intentional injury and death are
occurring outside of the home.
Drink Driving
Alcohol use by a driver of any motor vehicle has
been widely recognized as contributing to an
increase in accidents, injuries, and deaths. Since
operating a motor vehicle is a complex task with
many challenges to judgment, reex and skills,
drinking alcohol, even with only one drink, can
impair the ability of the driver to appropriately and
safely operate the vehicle. Thus the risk of a motor
vehicle crash increases when a driver has been
drinking, even allowing for speed, road conditions
and weather, as well as other vehicles. Alcohol-
involved crashes are of considerable risk not only to
the impaired driver but to passengers of that vehicle,
drivers and passengers of other vehicles, as well as
pedestrians.
It is well established that the risk of alcohol
involvement in crashes is highest for young adults
thus, injuries associated with alcohol-related crashes
are at highest risk of being caused by the alcohol
consumption of others, particularly for the 15-19
year age group. Evidence suggests that among
children (under 18 years old) who are injured in
alcohol-related crashes, most are passengers in a
vehicle where their own drivers were drinking.74
Over 14% of motor vehicle crash deaths involving
children have been linked to the drinking of
others.75 Studies in the United States found that
over 60% of crashes in which at least one child was
killed involved a drinking driver who was actually
transporting these children.76 77 In practice, the more
a driver is alcohol-impaired, the less likely that a
child passenger will be protected by a seat belt or
child carrier equipment.78 These studies conrm
the signicant contribution which drinkers make
to trac-associated harm to others as well as to the
individual drinker.
In Sweden, the number of crashes in 2006-2009,
resulting in road death or severe injuries, were
11,035 of which 11% were denitely conrmed as
alcohol-related. However, up to 20% of the accidents
did not have this information recorded.79 Over the
last 8 years, the proportion of fatal motor vehicle
crashes where the driver had blood alcohol levels
above the legal limit has been stable at 20-25%
of dead drivers. In 2013, of 102 drivers who died
in crashes, 19 had blood alcohol levels above the
legal limit. In the same year, of the 260 persons
that died in road accidents in Sweden, 49 died in
an alcohol related accident.80 The relative risk of
being killed in a car crash given a specic blood
alcohol concentration (BAC) has been estimated
to be 12 times that for a sober driver in the lowest
concentration interval, 0.02–0.04% BAC, and rises
considerably with increased alcohol concentration
to almost 1,300 times that for a sober driver for the
interval 0.22–0.24% BAC.81
In both Norway and Sweden, per capita alcohol
consumption has been found to be highly associated
with rates of arrests for driving while intoxicated
(DWI).82 This association has been conrmed even
allowing for the density of automobiles on the
roadway.83
In the United States, a time series analysis of
fatal accidents between 1950 and 2002 found
that changes in per capita alcohol consumption
REPORT
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23
accounted for a large part of fatal motor vehicle
crashes for both men and women.84 This is
conrmed by a review of ve studies with direct
measurement of BAC in fatal motor vehicle crashes.
These studies provided evidence of a dose-response
relationship between BAC and risk of fatal injury
such that for every 0.02% increase in BAC the injury
risk increased by 74%.85 Another study found that
about 14% of all motor vehicle crash fatalities were
considered victims of impaired driver crashes using
United States data.86 More recently, signicant
reductions in both violent and impaired driving
oences in British Colombia, Canada were found to
be associated with increases in minimum alcohol
prices.87
In New Zealand, a study found that in a ve-year
period (2003–2007), more than 40% of injuries
resulting from alcohol-related crashes were for
people who were not themselves drinking,88 and
a recent study in Australia found that road deaths
from another’s drinking were more than three and
a half times as common as deaths from violence
attributable to another’s drinking. For both deaths
from violence and pedestrian deaths, there were
twice as many male as female deaths, while there
were over three times as many male as female deaths
among non-pedestrian trac deaths.
Injuries and Violence
Injuries caused by the behavior of others, most
often associated with violence, can involve persons
who have been drinking, both as perpetrators and
as victims. Thus drinking may increase the risk of
harm when either or both (or many) participants
have been drinking. Specically, to determine the
connection of drinking to violence in the general
population, two approaches have been undertaken.
One approach is to analyze the relationship over
time between overall level of alcohol consumption
“For every 0.02% increase in BAC
the injury risk increased by 74%.”
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“Swedish homicide rate has been
signicantly associated with sales
of spirits with an attributable frac-
tion of about 50%.
and the population level of violence. For Sweden, a
statistically signicant relationship between assaults
rate and a combined measure of on-site outlet sales
of beer and spirits with an attributable fraction of
about 40% has been found. In addition, Swedish
homicide rate has been signicantly associated with
sales of spirits with an attributable fraction of about
50%.89 Previous cross-sectional and trend studies
have shown associations between levels of spirits
and beer consumption and levels of dierent forms
of criminal violence in Sweden.90
Similar associations have been found in other
countries. In Australia, for every one-litre
increase in per capita alcohol consumption there
was an 8% increase in male and a 6% increase
in female homicide rates, mainly related to beer
consumption.91 In a time series analysis of annual
alcohol consumption and homicide rates for two
groups of countries, one with more hazardous
drinking patterns (Russia and Belarus) and one
with somewhat less hazardous patterns (Bulgaria,
Hungary, Poland, and former Czechoslovakia),
annual changes in alcohol consumption were
positively and signicantly associated with homicide
rates for both groups of countries, however, the
associations were stronger among the countries
with a more detrimental drinking pattern.92 In the
European context, beer consumption per capita
-- a useful indicator of alcohol consumption among
young people -- is strongly correlated to levels
of assaults/ threat of harm. In a global estimate,
alcohol consumption was associated with self-
reported assault rates93, and a recent meta-analysis
reported strong associations with violence.94
Using changes in alcohol taxes across U.S. states, a
study also found that an increase in alcohol taxes
and its estimated impact on drinking was related to
a reduction in rates of violent and property crime.95
Alcohol is known to be associated with criminal
violence both in the domestic and public domain and
national levels of violence are particularly associated
with beer consumption. Although consumption
of alcohol is not an absolutely (100%) necessary
or sucient cause of violent crime, its excessive
use is known to lessen behavioural control and
to contribute to violent behaviour among young
males in specic cultural settings.96 97 98 In the
U.S., a longitudinal study of adolescents found a
strong positive relationship between self-reported
alcohol consumption, the commission of crimes, and
criminal victimization for both genders.99
In the European context beer consumption is
positively related to national wealth. In relation to
this, a statistically signicant correlation was found
between levels of auence and violent crime among
European countries. In the current era alcohol
abuse in Europe is no longer, as in the 19th century,
predominantly associated with extreme poverty and
related social problems; alcohol-related violence can
be identied as more contemporarily associated with
modern auence.100
A second and independent approach to study
the relationship between drinking and violence
is to determine if either victims or perpetrators
were drinking. In a WHO study from emergency
departments across 14 countries, victims’ estimates
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25
“In Australia with a total of 182
interpersonal violent deaths in
2005, 42% were estimated to be
attributable to another person’s
drinking.
of whether the perpetrator had been drinking
ranged from 14% up to 73% of victims.101 102 A recent
study from Sweden found that 62% of perpetrators
of assaults were intoxicated while 39% of the victims
were intoxicated.103
One study showed that across the world alcohol
consumption was associated with self-reported
assault rates.104 In the specic case of alcohol,
researchers have consistently noted that alcohol use
by the perpetrator or victim immediately preceded
many violent events.10 5 106 107 In addition, other
studies have found drinking to precede at least half
of all violent events.108 109 In fact, drinking more than
ve drinks per occasion increases the likelihood
that the drinker will be involved in violence, either
as perpetrator or a victim.110 More than any other
group, young adults are likely to have been drinking
prior to being either a perpetrator or victim of
fatal or nonfatal violence.111 112 Alcohol use by both
attacker and victim is common in incidents of rape,
assault, robbery with injury, and family violence.113
114 115 116 In addition, Roizen117 reports that in nearly
40 studies of violent oenders, and an equal
number of studies of victims of violence, alcohol
involvement was found in about 50% of the cases.118
Death from violence includes victims of homicide or
manslaughter, whether in public or in private places.
In Australia with a total of 182 interpersonal violent
deaths in 2005, 42% (77 deaths) were estimated to
be attributable to another person’s drinking, and a
total of 1,802 potential years of life were estimated
to be lost (PYLLs).119
In New Zealand a recent study found that almost
7% of men and 3% of women reported having been
physically assaulted in the previous year, with 44%
of these people having suered more than one
assault including sexual assault. In more than half
of all physical as well as sexual assaults, victims
reported the perpetrator to have been drinking.120
There exists a question of whether the level of
drinking by a victim, either in the moment or as a
general pattern, inuences the self-report estimate
of whether one’s perpetrator was also drinking.
In an Irish study, the self-report of perpetrator
drinking by the victim was examined to determine
if this was associated with the victim’s own drinking
pattern. For assault victims, there was a higher
likelihood of reporting perpetrator drinking
with more frequent episodes of risky drinking
by the victim. For example, of those who were
non-drinkers, 5% reported experiencing assault as a
result of someone else’s drinking, and of those who
did not drink in a risky way, the proportion was 6%.
This proportion increased to 10% for infrequent
risky drinkers and rose to 17% for those engaged
in risky drinking at least once a week. There were
no apparent signicant dierences for money
problems or property vandalised when examined
by drinking pattern.121 While one interpretation of
these ndings is that the victim’s drinking pattern
can bias the self-report of whether the perpetrator
had been drinking, an alternate interpretation is
that the victim’s drinking pattern can be associated
with entering settings and situations where drinking
exists and thus increases one’s personal risk of a
drinking-related assault.
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CRIME IN GENERAL AND PROPERTY DAMAGE AS
WELL AS SOCIETAL COSTS
While drinking is associated with increased risk
of harm to others, it has also been associated with
crime in general but especially property crimes
including theft, robbery and burglary as well as
property damage. Pernanen et al (2002) estimated
the proportions of dierent crime categories that
are likely caused by alcohol based on a survey of
Canadian prison inmates. They estimated that
approximately 28% of violent crimes, 11% of robbery
and theft, and 35% of other criminal code oences
were committed under the inuence of alcohol.122
Within the EU, levels of car vandalism and property
damage have also been found to be related to levels
of beer consumption.123
One report, reviewing research on the relationship
between price changes and crime, found that
U.S. and UK studies in general supported an
inverse relationship such that price increases
were associated with reductions in most crime
outcomes.124 While the report found variable
results of studies in Scandinavian countries,
studies on recent tax reductions concluded that tax
reductions led to increases in overall crime levels. In
non-Scandinavian and modeling studies, decreases
in tax/price were associated with an increase
in overall crime, violent crime, and drunk and
disorderly behaviour.
Specically the report found:
Overall crime: The evidence was mainly from
Overall crime: Taxation decreases were associated
with increased overall crime rates, and taxation
increases with decreased rates of crime.
Criminal damage: The evidence was mainly
from several modeling studies of how tax and price
increases would be related to reductions in criminal
damage oences. Only one older observational
study was located, with ndings consistent with the
modeling studies.
Specic policies: A large majority of modeling
studies from both the United Kingdom and
internationally estimated that increased alcohol
taxes, minimum alcohol prices or restrictions on
discounting would be associated with a reduction
in alcohol-related crime. The evaluation evidence
relates only to taxation or naturally occurring price
changes.125
Cost to society for crime in general is associated
with enforcement, medical care, adjudication,
employment disruption and personal or property
losses with the nancial repercussions borne by
the total population, not specically by individual
drinkers. For example, one study estimated the total
economic costs of alcohol abuse in Canada to be
$14.6 billion Canadian dollars of which $3.1 billion
was attributable to police, court and prison costs
associated with crime.126 A study of England and
Wales estimated alcohol-related crime costs and how
these would be reduced by dierent alcohol pricing
policies; they estimated a cost saving of 231 million
English pounds by introducing a minimum price of
45 pence per 8 grams of ethanol.127
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ALCOHOL-RELATED COSTS AND
ADVERSE ECONOMIC EFFECTS
Losses in economic productivity and costs to the
workplace caused by drinking or increases in
alcohol-related costs to society constitute second-
hand eects of alcohol consumption. These
economic costs extend far beyond any nancial
impacts directly on the individual drinker and are
ultimately paid for by the broader community. Thus,
economic considerations are increasingly important
for policymakers, nationally and globally.
Estimates of Total Societal Costs
Estimates of world-wide alcohol-related costs have
been based upon extending individual national costs
tentatively to a global scale. Studies have suggested
a range of estimates, that is, 1.3 to 3.3% of total
health costs, 6.4 to 14.4% of total public order and
safety costs as well as 0.3 to 1.4 per thousand of
gross domestic product (GDP) for criminal damage
costs, 1.0 to 1.7 per thousand of GDP for drink-
driving costs, and 2.7 to 10.9 per thousand of GDP
for work-place costs (absenteeism, unemployment
and premature mortality). On a global level, this
suggests costs of $210 to 665 billion USD in 2002.128
Another review estimated that the economic burden
of alcohol across 12 selected countries studied varied
between 0.45 and 5.44% of GDP.129
In Sweden, the societal cost of alcohol consumption
in 2002, as well as the eects on health and quality
of life, is estimated at 20.3 billion Swedish kronor
(SEK) with the gross cost (counting only detrimental
eects) at 29.4 billon (0.9 and 1.3% of GDP). The
estimation includes direct costs, indirect costs and
intangible costs. Relevant cost-of-illness methods
are applied using the human capital method
and prevalence-based estimates, as suggested in
existing international guidelines, allowing cautious
comparison with prior studies. Alcohol consumption
is estimated to cause a net loss of 121,800 (Quality
Adjusted Life Years-- QALYs). The results are within
the range found in prior studies, although at the low
end.130
The cost of alcohol abuse to Sweden in 2008 was
estimated at SEK 49.3 billion. 131
In France, the use of alcohol, tobacco and illicit
drugs cost more than 200 billion francs (French
Francs or FF) in 1997, representing 3 714 FF per
capita or 2.7% of the gross domestic product (GDP).
Alcohol is the drug estimated to cause the greatest
costs in France, i.e. 115 420.91 million FF (1.42%
of GDP or 20 230 M USD) or an expenditure per
capita of 1966 FF in 1997. The greatest share of
the social cost of alcohol comes from the loss of
productivity, due to premature death, morbidity, and
imprisonment, representing more than half of the
estimated costs of all drugs to society.132
In Australia, a recent estimate for heavy drinking
concluded that the annual cost to others was in
excess of 13 billion Australian dollars (AUD) in
out-of-pocket costs and lost wages or productivity in
2005. Hospital and child protection costs to society
due to another’s drinking sum to a further AUD
765 million. In addition, there were large intangible
costs, estimated at a minimum of AUD 6 billion.133
In the US, total alcohol-related costs were estimated
to exceed those for smoking, with more than half
accruing to people other than the drinker. The
estimated economic cost of excessive drinking was
$223.5 billion (U.S. dollars) in 2006 (72.2% from
lost productivity, 11.0% from healthcare costs,
9.4% from criminal justice costs, and 7.5% from
other eects) or approximately $1.90 per alcoholic
drink. On a per capita basis, individual cost is
approximately USD 746 per person, most of which is
attributable to binge drinking.134
In Scotland, alcohol misuse imposes a substantial
burden on Scottish society, approximately
costing £1,071 million (British Pounds) per year
REPORT
“The benet-to-cost ratio of a
substance abuse employee assis-
tance program was estimated to
be 26:1, i.e., for each 1 US dollar
expended, 26 dollars were saved.
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Alcohol is the drug estimated to
cause the greatest costs in France
115 420.91 million FF
The cost of alcohol abuse to Sweden in 2008
was estimated at
SEK 49.3 billion
In the US, total alcohol-related
costs were estimated to exceed
those for smoking
The global cost of alcohol-related
absenteeism in the year 2002 was
estimated to be between
$3065
billion (USD)
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“High-risk drinkers were up to
22 times more likely to be absent
from work compared to low-risk
drinkers.
REPORT
at 2000/2001 prices. Nine percent of this is due
to National Health Services Scotland (NHS)
expenditure, 8% to social work services resource use,
25% to resource use by the criminal justice system,
38% due to wider economic costs and 20% due to
human costs. In terms of the statutory agencies,
alcohol misuse imposes the greatest burden on the
criminal justice system followed by NHS Scotland
and social work services.135
While several dierent approaches for estimating the
eects of alcohol consumption on loss of productivity
in the work place have been utilized, based on a
meta-analysis of national cost studies the global cost
of alcohol-related absenteeism was estimated to be
between $30-65billion (USD) in the year 2002.136
Other Workplace Related Consequences from Drinking
In addition to overall costs, both drinking at work
and drinking patterns of workers can produce
work disruptions, lower productivity and increase
absences including paid sick leave.
An Australian study of 13 582 workers found that
more than 40% of the work-force consumed alcohol
at high-risk levels at least occasionally and high-
risk drinkers were up to 22 times more likely to be
absent from work compared to low-risk drinkers.
Alcohol-related absenteeism was not restricted to
the relatively small proportion of chronic heavy
drinkers, but predominantly involved the much
larger number of non-dependent drinkers who
occasionally drank at high-risk levels.137
There are also studies that demonstrate how
employee assistance programs can potentially save
employer costs associated with injuries, productivity
loss, and absenteeism. For example, a study of a U.S.
transportation company estimated the benet-to-
cost ratio of a substance abuse employee assistance
program to be 26:1 , i.e., for each 1 US dollar
expended, 26 dollars were saved.138
A Swedish study on the relation between per
capita alcohol consumption and sickness absence
for the period 1935 to 2002 found that a one litre
increase in total consumption was associated with
a 13% increase in sickness absence among men.
For women the corresponding increase was 6% but
was not statistically signicant.139 A similar study
from Norway using time series analysis (1957-2001)
among manual employees found that a one litre
increase in total alcohol consumption was associated
with a 13% increase in sickness absence among men,
but was not linked to female work absence.140 Yet ,
other studies have demonstrated signicant eects
of alcohol consumption on sickness absence and
disability pensions for both men and women.141 142 143
A study conducted at 114 work sites of seven
corporations showed an almost linear relationship
between increasing average consumption and a
summary measure of job performance, nding the
strongest associations between consumption and
getting to work late, leaving early and doing less
work, and only a weak association with missing
days of work. Although moderate-heavy and heavy
drinkers reported more work performance problems
than very light, light, or moderate drinkers, the
lower-level-drinking employees, since they were
more plentiful, accounted for a larger proportion of
work performance problems than did the heavier
drinking group.144
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Total, %
Total, corresponding
number of persons in
Sweden 2013, 17-84
years of age Women, % Men, %
Have persons nearby that drink too much 30,3 2 300 000 33,5 27, 2
Negatively affected by persons nearby 14,6 1 100 000 18,7 10,5
Much affected 3,3 250 000 4,7 1,9
A little affected 10,7 800 000 13,1 8,3
Been hurt or neglected 11,2 840 000 14,9 7,5
Negative impact in a social situation 9,0 680 000 11,1 6,9
Someone failed or not fulfilled something 7,1 540 000 8,8 5,3
Ceased meeting someone 3,7 280 000 4,4 3,1
Someone taken money or valuables 0,8 60 000 0,9 0,7
Exposed to violence 0,6 45 000 0,9 0,3
Forced to sex 0,5 38 000 0,7 0,3
Someone in the household not carried out their part of work in the household 1,6 120 000 2,3 0,8
Avoided friends or family on account of being ashamed of the drinking of someone in the
household 1,1 83 000 1,6 0,7
Having less money on account of the drinking of someone in the household 0,7 53 000 1,0 0,5
Been forced to leave home on account of the drinking of someone in the household 0,5 38 000 0,7 0,3
Negative consequences of other persons drinking, Sweden 2013.*
* Respondents 17 to 84 years of age, experienced consequences during last 12 months.
Reference: Ramstedt M, Sundin E, Landberg J, Raninen J. (2014). ANDT-bruket och dess negativa konsekvenser i den svenska befolkningen 2013 (The use of
alcohol, narcotics, doping and tobacco (ANDT) in the Swedish population 2013). STADs rapportserie, rapport nr 55. Stockholm: STAD
Total, %
Total, corresponding
number of persons in
Sweden 2013, 17-84
years of age Women, % Men, %
Been afraid in a public place 20,1 1 500 000 25,4 14,9
Kept awake at night 16,5 1 200 000 17,3 15,7
Been offended 14,0 1 100 000 15,8 12,2
Been assailed or troubled in a public place 13,2 1 000 000 14,8 11,7
Been assailed or troubled in private social situation 7,9 600 000 8,8 6,9
Clothes or other belongings ruined 4,4 330 000 4,4 4,3
Physically hurt 2,1 160 000 1,9 2,4
Seven negative consequences from an intoxicated person (known or unknown), Sweden 2013*
* Respondents 17 to 84 years of age, experienced consequences during last 12 months.
Reference: Ramstedt M, Sundin E, Landberg J, Raninen J. (2014). ANDT-bruket och dess negativa konsekvenser i den svenska befolkningen 2013 (The use of
alcohol, narcotics, doping and tobacco (ANDT) in the Swedish population 2013). STADs rapportserie, rapport nr 55. Stockholm: STAD
RESEARCH REPORT 2015/2016
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WHAT TO DO TO PREVENT SECOND-
HAND EFFECTS OF ALCOHOL
THE ACCEPTABILITY OF RESTRICTIONS ON ALCOHOL’S
AVAILABILITY AND AFFORDABILITY IN THE NORDIC
COUNTRIES
There is now a large research literature containing
high-quality studies from many countries to inform
the development of eective policies to reduce
hazardous patterns of drinking and related harms,
both to drinkers and nondrinkers.145 146 147 Studies
from Sweden and the Nordic countries generally are
well represented in this literature and contribute to
evidence that restrictions on both the availability
and aordability are eective strategies to reduce
consumption and related harms.148 Given that the
majority of the Swedish adult population consumes
alcohol at least occasionally such restrictions require
tolerance and understanding from citizens that they
serve the greater good for society as a whole.
Public opinion surveys in Sweden and Nordic
countries generally conrm that the majority of
the population supports such measures and sees
them as an important means to protect vulnerable
members of the community while beneting society
at large. Public support for restrictive policies to
reduce alcohol-related harm has even increased in
recent years in Scandinavia, as shown by surveys
in both Norway and Finland.149 ,150 Furthermore, a
2014 Swedish national survey from the University
of Gothenburg asked whether the positive
consequences of alcohol outweigh the negative, for
the respondent personally and for society more
generally. While respondents viewed alcohol’s
eects on themselves personally as more positive
than negative, these perceptions were reversed
for society as a whole: 75% felt that the negative
consequences of alcohol dominated for society
and only 9% held the opposite view. In an analysis
of the public support for alcohol policies, such as
raised alcohol taxes, elimination of the alcohol retail
monopoly and more restrictive licensing rules for
serving alcohol at restaurants, the view of alcohol as
a societal problem was the most important. The view
of alcohol as a personal problem was also important
for the support of restrictive policies but to a lesser
extent. The authors concluded that the Swedish
public make entirely dierent assessments of the
“Public support for restrictive
policies to reduce alcohol-related
harm has even increased in recent
years in Scandinavia.
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consequences of alcohol consumption for themselves
personally than for society. The respondents
seem to be prepared to put up with economic and
practical inconveniences to prevent problems that
aect others than themselves, which is probably
an important explanation of the longstanding
support of relatively restrictive alcohol policies
in Sweden.151 It seems reasonable that to accept
or support restrictive political measures, alcohol
should be seen as a problem, which is supported
by several studies, including a survey from Canada
nding that respondents who had experienced harm
from others drinking or had been concerned about
another’s drinking problems were more likely to
support restrictive alcohol policy measures.152 A
Finnish study was conducted on public attitudes
to a major strike in the monopoly stores in 1973.
While respondents were mostly indierent as to
how it aected them personally, most saw it as
favourable for their own family and society as a
whole. In fact, during the 5-week strike, total alcohol
consumption was estimated to have reduced by more
than 30%, with substantial reductions in arrests for
drunkenness, cases of assault and battery, as well as
drunk driving and reported crime rates.153
These studies provide an important background for
alcohol policies. The policies described in this report
all have evidence for reducing harms to others. The
challenge to governments is that they all involve
restrictions of some kind. Political leaders normally
would be hesitant to impose regulations that reduce
individual liberties, fearing losing votes. Counter to
this, the historic tradition in Sweden has been quite
positive to alcohol restrictions. In the only popular
referendum on this issue in 1922, the side favouring
total prohibition was narrowly defeated by a two
per cent margin, 51-49. The winning side instead
developed an extensive regulatory system, with
rationing of alcohol at its core, as well as monopolies
on virtually all aspects of the alcohol trade, e.g.,
monopolies on production, distribution and retail
of alcohol. High taxes on alcohol were introduced
to counter the rapid increase in drinking which
occurred when the rationing system was abandoned
in 1955. Advertising was later banned.
In keeping with a gradual shift in popular opinion,
some elements of the Swedish system have
become less restrictive over the past 30-40 years.
Membership in the European Union 1995 forced
an acceleration of this process and a resulting
increase in per capita consumption and related
harms.154 155In the past decade however public
support for some restrictive policies has again risen,
as demonstrated by the study from the University
of Gothenburg.156 Here, a gradual increase in the
support for Systembolaget’s retail monopoly was
observed, showing that a majority of Swedes now
support the monopoly. Also, support for high taxes
on alcohol has increased and those favouring alcohol
tax reductions are now a minority.
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EVIDENCE ON SPECIFIC POLICIES
THAT AFFECT HARMS TO OTHERS
There are strong reasons to suppose that policies
aimed at reducing population consumption and
harms to drinkers will also be eective for reducing
alcohol’s harm to others. Firstly, there is direct
evidence linking these same policy measures to
second-hand harms e.g. pricing strategies that
reduce violence and impaired driving.157 Second ly,
it is well demonstrated that hazardous drinking
patterns are related to the total consumption
of alcohol158 and that a great proportion of total
population consumption of alcohol is consumed
outside low-risk drinking guidelines.159 It follows
that strategies capable of reducing the total
consumption of alcohol will also reduce hazardous
patterns of drinking which in turn will mean a
reduction in secondhand eects or harms to others.
These relationships are illustrated in Figure 1 below
and are discussed in relation to specic evidence-
based alcohol policy measures in the next section.
Maintaining high alcohol prices
Comprehensive international reviews conrm that
price increases reduce population level
alcohol consumption160 161 162 and
also consumption for heavy or
problem drinkers.163 Taxes are
one method of increasing prices
and it is known that, in general,
increases in alcohol taxes are
almost invariably passed on to
the consumer164 . In a monopoly
situation such as in Sweden,
there can also be direct controls on
alcohol prices by regulation. Swedish
research has shown that, for example, price
increases in the cheapest segment of the market
result in the greatest reductions of consumption.165
This market segment includes a large proportion of
heavy drinkers.166 167 Recent evidence conrms that
increasing prices in the cheapest market segment
(“oor” or “minimum” prices) can signicantly
reduce consumption of high strength beverages168,
impaired driving and violent crime169, alcohol-
related hospital admissions170 and deaths171. These
latter studies include outcomes involving harm to
others such as alcohol-related road crashes and
assaults. On the basis of a comprehensive review of
all high quality published studies, Wagenaar and
colleagues concluded that a 100% increase in alcohol
excise taxes in the US would lead to trac crash
deaths being reduced by 11%, sexually transmitted
disease by 6%, violence by 2%, and crime by 1.2%.172
Maintaining high alcohol prices and taxes with
regular adjustments for ination (for overall and
oor prices) and pricing on alcohol content173 are
highly eective strategies to reduce harm to others
from alcohol consumption in Sweden.
High age limits for the purchase or possession
of alcohol
Laws to increase the age limits for the purchase or
possession of alcohol have a very strong evidence
base demonstrating that they eectively reduce any
alcohol consumption and binge drinking among
youth.174 This suggests that age limits are eective
at reducing the second-hand eects
of alcohol consumption because:
most consumption by youth is in
the form of binge drinking175;
those who drink and binge
drink at younger ages are
more likely to binge drink as
adults17 6; most alcohol-related
problems among youth are
acute in nature and are associated
with second-hand eects (e.g.,
injuries, sexual violence, unintended
pregnancy). In addition, there is direct evidence that
the adoption of laws increasing age limits are related
to decreases in motor vehicle crashes, homicide and
vandalism. 177 178
körkort sverige
s
“Swedish research has shown that,
for example, price increases in the
cheapest segment of the market
result in the greatest reductions of
consumption.
REPORT
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TOTAL POPULATION CONSUMPTION
OUTLET DENSITY
PRICINGADVERTISING CONTROLS SALES HOURS
ACUTE IMPAIRMENT CHRONIC EXPOSURE
AGE RESTRICTION
DRINKERS: INJURIES, POISONING
Harm to others:
Violence
Road trauma
Crime
Absenteeism
KONSUMENTER: ALLVARLIGA SJUKDOMAR
Harm to others:
Parental neglect
Children’s physical/mental health
Modelling for children
Fetal effects
Household finances
ECONOMIC COSTS TO SOCIETY:
Productivity
Policing
Health care and social services
HIGH RISK CONSUMPTION
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Safety & health Society Children & families Fetal effects
Road crashes
Pedestrian injuries
Assault
Sexual violence
Homicide
Workplace injuries
Fires
Infectious diseases e.g. AIDS/
HIV, hepatitis, TB and sexually
transmitted diseases
Healthcare costs
Policing costs
Court costs
Prison costs
Lost productivity
Property damage, vandalism
Public nuisance
Intimidation, other forms of
social disruption
Impaired health for children of
problem drinkers
Parental neglect
Poor school grades
Future mental health and
substance use problems
Domestic violence, including
child abuse
Financial problems
Divorce
Fetal alcohol spectrum disorder
(FASD), including fetal alcohol
syndrome (FAS)
Low birthweight
Epigenetic effects on future
social, physical and cognitive
development
The wide scope of alcohol’s second-hand effects across multiple domains
REPORT
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39
Limits on the number of outlets selling alcohol
There is a well-established association between
“densities” of liquor outlets in a population and rates
of alcohol consumption and harm179 , though some
have questioned whether this is causal180. Evidence
of a causal relationship is suggested by longitudinal
analyses nding that increases in outlet density tend
to precede increases in alcohol consumption181 and
also studies of sudden changes in outlet densities.
British Columbia in Canada experienced a 40%
increase the density of privately owned liquor
stores between 2002 and 2006 that was unequally
distributed across a large geographic area. Studies of
the local area eects of this rapid increase conrmed
increased per capita alcohol consumption182 , alcohol-
related deaths183 and hospital admissions184 in
areas with the largest increases in outlet density.
It is thought that both increased convenience and
cheaper alcohol driven down by competition drive
the relationship between outlet density and alcohol
consumption185. There is also recent evidence that
increased density drives alcohol prices downwards,
likely through increasing local competition.186
Again, harm outcomes used in these studies
include signicant harms to others such as violence
(physical and sexual) and other types of trauma. It
can be concluded that reductions in outlet density
will tend to drive down overall consumption,
hazardous drinking patterns and hence all varieties
of harm to others. Furthermore, maintaining
controls over outlet density, for example through a
government-owned liquor monopoly, will similarly
help prevent increases in total consumption,
hazardous drinking patterns and harms to others.
Limits on the hours and days of sale
Limits on hours of sale or limits on days of sale
are one of a generally eective group of policies
intended to reduce the physical availability of
alcohol.187 Although limits on hours of sale are
related to reduced per capita consumption, limits
on hours of trade are typically applied late at night
or early in the morning. At these times, a larger
proportion of the drinks sold are intended for
immediate consumption, often by those who are
already intoxicated. Limits on hours of sale may be
applied to o-site outlets (e.g., liquor stores, super
markets), on-site outlets (bars, restaurants), or both.
As would be expected, more hours of restriction
are more eective than fewer; a systematic review
by the U.S. Centers for Disease
Control and Prevention concluded
that restrictions on hours
of sale were more likely to
reduce excessive alcohol
consumption and related
harms when changes were
greater than 2 hours.188
Another comprehensive
review189 found that when
the highest quality studies are
considered, signicant reductions
in harm were associated with changes of even
just one hour. Since that review, two further high
quality studies conrmed that even reductions of
a single hour in bar trading hours are associated
with signicant reductions in violent incidents, one
study being from Australia190 and the other from
Scandinavia191 .
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Impaired driving laws and their enforcement
Like other economically developed countries,
Sweden has extensive controls to deter alcohol
impaired driving. There are three key aspects of
these controls, (a) the legal limit of Blood Alcohol
Concentration (BAC) of the driver such that beyond
a certain level, the driver is considered to be
drunk or impaired for legal purposes, (b) visible
enforcement of the legal limit by stopping drivers
and checking the breath of the driver for alcohol,
and (c) the sanctions or punishment of drivers with
BACs exceeding the legal limit. All three controls
have been used in Sweden to limit drinking and
driving crashes in Sweden.192
Eective strategies for reducing alcohol-
related trac crashes world-wide
include increased and highly visible
law enforcement, e.g., sobriety
checkpoints and random breath
testing, and the level of legal
blood alcohol concentration
at which a driver is considered
legally drunk or impaired.193 194
The evidence is mixed concerning
severe sanctions or punishments
for conviction for drinking and driving.
In cases when these strategies are shown to have
eects, they appear to decay over time which
suggests that severe sanctions may lose their
eectiveness unless accompanied by renewed
enforcement or media eorts.195 It is clear that the
degree of certainty and the swiftness with which
penalties are imposed are more powerful deterrents
for impaired driving than severity of penalties
alone.196 A recent Canadian study eliminated
criminal sanctions for impaired driving at low BACs
and replaced these with more certain and immediate
sanctions i.e. immediate vehicle impoundment
and a small ne.197 Alcohol related fatalities were
estimated to decline by over 40% following the new
law.
Server training
Alcohol consumption in bars and restaurants is
associated with serious problems in communities
worldwide, primarily in the form of violent assaults
and trac crashes. Responsible Beverage Service
(RBS) programs aim to reduce these problems,
primarily by reducing over-serving and service
to under-aged drinkers. RBS programs involve
management developing responsible serving policies
and allowing their sta to be trained to implement
these. To be eective, RBS programs need to
combine such training with eective enforcement of
laws regarding service to intoxicated and under-age
customers.
In Sweden RBS programs were initially developed by
the STAD project in Stockholm, where studies found
signicant reductions in police reported assaults
in the intervention area compared to the control
§
REPORT
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41
area.198 In the national dissemination of the STAD
program, signicant eects were also found, albeit
with smaller eects than in the initial Stockholm
project, likely reecting less consistent program
implementation.199
The potential of RBS programs to reduce road
crashes was demonstrated in the US state of Oregon.
Statistically signicant reductions in single-vehicle
nighttime trac crashes were found following the
implementation of the compulsory server-training
policy.200 RBS programs have subsequently been
incorporated in many community-based eorts
to reduce alcohol impaired driving. A systematic
review of the eectiveness of multi-component
community-based programs that included RBS
training, alcohol availability restrictions, sobriety
checkpoints, public education and media advocacy,
provided strong evidence that these programs are
eective in reducing alcohol-related crashes.201
Marketing restrictions
The liquor industry invests billions of dollars
every year on the advertising and promotion of its
many products. Marketing strategies employed
by the industry are strategic, sophisticated, and
multifaceted and use a range of media. Media
include traditional forms such as television, radio,
print, and billboards but with rapidly increasing
use of broader and often more tailored marketing
techniques via digital (e.g. brand web sites, mobile
phone apps, internet games) and social media (e.g.
Facebook), branding (e.g. clothing), point of sale
promotions (e.g. 2 for 1 deals) and sponsorships (e.g.
people and events). It is often argued by the liquor
industry that the purpose of alcohol advertising is
not to encourage drinking or increase the number
of new drinkers but to encourage customers to
switch brands and/or maintain brand loyalty i.e. the
advertiser gains market share while its competitors
lose market share.202 Nevertheless, whether intended
or otherwise, a great deal of industry marketing
activity, if not most, reaches the attention
of youth and the under-aged203
204 where it has an inuence on
attitudes and behavior.205 At
least two systematic reviews
have concluded that there is
a strong association between
adolescent exposure to alcohol
advertising and the likelihood
of initiating or increasing alcohol
use.206 207 Of particular note, Smith
and Foxcroft point to three longitudinal
studies which demonstrated a temporal relationship
between exposure and drinking and a dose-
response relationship between level of exposure and
frequency of drinking. General population exposure
and the exposure of young people to alcohol
marketing can be reduced by eective independent
government regulation with eectively enforced
limits on placement, timing, quantity and content
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!
REPORT
of advertisements. The US Surgeon General, the US
National Research Council and Institute of Medicine,
and Canada’s Alcohol Strategy all recommend
limiting exposure to alcohol advertising.208 209 210
As children and young people are potentially most
at risk of being inuenced by liquor marketing
and advertising and repeatedly implicated in our
understanding of alcohol-related harms to others,
it is reasonable to assume that curtailing industry
marketing practices will reduce second-hand impacts
of alcohol consumption in society.
Screening, brief intervention and referral (SBIRT)- brief
interventions
Randomized controlled trials conducted in several
countries, including Sweden, have conrmed that
screening of patients attending health centers or
hospitals and delivering brief interventions to those
identied as early-stage problem drinkers (lasting
typically 5 to 15 minutes) by trained healthcare
providers (e.g. GPs, community nurses) can result
in signicantly reduced consumption. 211 Recent
systematic reviews of the large international
literature on this topic conrm that SBIRT in health
care settings eectively reduces alcohol use and
related harms, particularly with less severe alcohol
use disorders. 212 213 214 215 SBIRT is eective for men,
women216, adolescents and adults217. It has been
estimated that a 70% uptake of SBIRT by GPs would
result in $1.6 billion of savings annually in Canadian
health, crime and productivity costs. 218 Uptake
by GPs and health care providers has, however,
mostly been quite low but literature is emerging on
strategies which are more eective at increasing
uptake.219 It can be concluded that SBIRT could
be one contributing component to an overarching
strategy to reduce hazardous drinking patterns and
related harms to others.
Health messaging on alcohol containers - warning labels
The WHO Global Alcohol Strategy calls for the
broad dissemination of information on
alcohol-related harms as part of a
comprehensive strategy.220 Although
in isolation there is limited evidence
for eective behaviour change from
alcohol labeling, US alcohol labelling
raised awareness of health risks,
increased conversations about these
and was associated with less impaired
driving.221 222 223 Health messaging can
address limited awareness of the link
between alcohol use and serious diseases such
as cancer.224 One study of the US alcohol warning
label indicated that awareness of the message
regarding drinking during pregnancy was associated
with reduced consumption by pregnant mothers225.
Giesbrecht has argued for a re-conceptualisation
of the role of education around alcohol from direct
behaviour change to creating more informed public
RESEARCH REPORT 2015/2016
43
debate to favour the introduction of other evidence-
based policies.226 One advantage of container
labelling is that messages are more likely to be
recalled by those who drink the most i.e. one of
the key target audiences.227 228 229 Alcohol container
labelling may have some limited direct impacts on
drinking behaviours leading to harm to others (e.g.
impaired driving, drinking during pregnancy) and
may create an environment favouring informed
public debate and support for evidence-based
policies.
Maintenance of alcohol monopolies
A state monopoly on alcohol retail provides an
opportunity to exercise stronger control on a
number of factors that contribute to alcohol sales,
consumption and harm, including controls on the
number of outlets, hours of sale, enforcement of
drinking age laws, marketing and pricing. A number
of studies have examined the eects of monopolies,
usually the eects of abandoning retail monopolies
and shifting sales to grocery and other stores. The
general conclusion from these studies is that alcohol
consumption increases with privatization.230 In
the latest study of the Swedish retail monopoly,
Systembolaget, total alcohol consumption was
projected to increase by 37.4% if alcohol was sold in
grocery stores.231 The study also estimated the eects
of increasing consumption on a number of harms.
These were mostly harms to drinkers, but assaults
were also estimated to increase by 24%.”
One important function of retail monopolies is to
reduce the availability of alcohol to young people.
Increased drinking among young people can be
associated with unplanned pregnancies and more
children with fetal alcohol impairments. This was
illustrated by the 1967-1968 policy experiment
described above involving strong beer (5.6 % alcohol
by volume) being sold in grocery stores instead of
monopoly stores in two counties in western Sweden.
The experiment was ended prematurely in July 1968
due to a sharp increase in alcohol consumption in
the experimental counties, particularly among youth
and a range of other social problems experienced by
children of mothers who were pregnant during the
experiment.232
Another important consequence of increased
drinking among young people is increased trac
crashes. In a study comparing states in the US with
a retail monopoly over spirits or wine and spirits, an
average of 14.5% fewer high school students reported
drinking alcohol in the past 30 days and 16.7% fewer
reported binge drinking in the past 30 days than
high school students in non-monopoly states. Lower
consumption rates in monopoly states, in turn,
were associated with a 9.3% lower alcohol-impaired
driving death rate under age 21 in monopoly states
versus non-monopoly states.233
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SUMMARY AND CONCLUSIONS
This report summarizes current evidence on
the harm caused by alcohol to people other than
the drinker. It reviews the dierent aspects and
magnitudes of the problem, and eective ways to
reduce it. In contrast to other risk factors, alcohol
consumption leads to more harm to others than to
the drinker. Without the benet of modern scientic
methods, this has been recognized for well over a
century and has led most countries in the world
to adopt legislation to limit alcohol’s harm. Until
recently most alcohol research has been focused
on individual drinkers, with research devoted to
indirect and social eects mostly neglected. In
the last two decades however, there has been an
increased interest in this eld, with the publication
of a number of new research reports.
A striking feature of this literature is the vastness
of the secondary eects, aecting, in principle, all
major parts of society, from fetal alcohol eects to
supporter violence at football matches. In this regard
the secondary eects of alcohol are similar to the
biological eects, where the toxic eects of alcohol
cause harm to virtually all tissues and organs of the
human body. These pervasive social eects can all
be traced to physiological and psychological eects
of alcohol on human behavior. Indeed, one study of
expert opinion suggested that when second-hand
consequences are considered, the burden of harm
from alcohol is about double that from tobacco.
Heavy drinking occasions are the key determinant
of harms to others. Because of the well-established
relationship between average per capita
consumption and binge drinking, interventions that
reduce per capita consumption can be expected to
reduce second-hand eects. As reviewed above,
there are also studies demonstrating how such
policies (e.g. pricing and availability restrictions)
directly reduce harms to others such as from
violence or road crashes. It should be understood
that most instances of heavy sessional drinking
occur among people who otherwise are moderate
drinkers. Even if their individual risk is small, most
problems in a population would come from this
group. This is a strong argument for alcohol policies
that eect the whole population, foremost policies
that reduce the economic and physical availability of
alcohol.
This review of second-hand effects included four main
domains:
Children and families
The inuence of alcohol consumption, most often
male drinking, on the family was one of the driving
forces behind demands for alcohol control in the
19th and early 20th century.
Unintentional and intentional injuries and
mortality
The risk of harm associated with drinking extends
beyond the family into the local environment
including driving, public drinking, and violent
crime.
Crime, property damage and societal costs
Rates of violent crime, theft, robbery and burglary
and vandalism are aected by levels of drinking in
the community.
Adverse economic eects
Losses in economic productivity or increases in
alcohol-related costs to society constitute second-
hand eects of alcohol consumption. The global
costs of alcohol have been estimated to 210-665
billion USD in 2002.
REPORT
RESEARCH REPORT 2015/2016
45
What then can be done to reduce alcohol related harm
to others?
There is good evidence that a number of policies are
eective in reducing drinking that is harmful both to
drinkers as well as to others. These include:
Increased alcohol prices
Increased age limits for the purchase or
possession of alcohol
Limiting the number of outlets selling alcohol
Limits on the hours and days of sale
State run alcohol retail monopolies
Impaired driving laws
Server training
Marketing restrictions
Screening, brief intervention and referral to
Treatment (SBIRT)
Warning labels
Historically, Swedes have held quite positive attitudes
towards alcohol restrictions, supporting extensive,
public health motivated alcohol policies. Some of
this support was eroded when Sweden joined the
European Union 1995. In the last decade however
public support for restrictive policies has again
risen. A large majority in Sweden now supports
Systembolaget’s retail monopoly. Also, the support
for high taxes on alcohol has increased, where those
favoring reduced taxes now are a minority. These
shifts in popular opinion should be viewed against
the background of increasing concerns about the
negative societal eects of alcohol.
CONCLUSIONS
While support for restrictive policies on alcohol in Sweden has long been driven by concern about the
second-hand eects of alcohol, scientic study of second-hand eects has only recently been a priority.
Swedes are currently mostly prepared to put up with economic and practical inconveniences of restrictive
policies to prevent alcohol’s harm to others though till recently this has been more “received wisdom”
or perception. The evidence reviewed in this report conrms the substantial nature of alcohol’s harms
to others and adds further weight to the need for retaining and strengthening eective alcohol policies.
Attention should be paid in particular to placing greater restrictions on cross-border and internet alcohol
sales so as not to further undermine the role and eectiveness of Systembolaget and greater restrictions on
alcohol promotions across all media.
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47
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Apr;42(4):418-27.
231. Norström T, Miller T, Holder H,
Osterberg E, Ramstedt M, Rossow
I, Stockwell T. (2010). Potential
consequences of replacing a retail
alcohol monopoly with a private
licence system: results from Sweden.
Addiction. 2010 Dec;105(12):2113-9
232. Nilsson, P. (2008). “Does a Pint a Day
Aect Your Child’s Pay? The Eec t of
Prenata l Alcohol Exposure on Adult
Outcomes.” Cemmap Working Paper
No. CWP22/08, Institute for Fisca l
Studies, London.
233. Miller T, Snowden C, Birckmayer J,
Hendrie D. (2006). Retail alcohol
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APPENDIX
A NOTE ON METHODS USED TO ORGANIZE THIS
REPORT AND SELECT CITED PUBLICATIONS
This report is based on a narrative review drawing
on existing systematic and comprehensive reviews
published in peer-reviewed journals, major
international (e.g. WHO, UN, World Bank) and
government reports, plus Sweden-specic data on
prevalence of relevant harms. The topic of harm
to others or second-hand eects is a very broad
area of concern as the types of harm to “others”
spring from a great number of sources. A total of 52
types of harm to others were identied during the
preparatory work for the report, spanning 12 wide
domains (e.g. road safety, crime, parenting, fetal
and infant development, absenteeism and societal
economic costs). The literature searches conducted
to identify these materials were exhaustive. The
topic of harms to others from alcohol use has only
been a major focus of research in the past 10 years
and we are condent we have identied the major
works relevant for consideration.
Narrative reviews are appropriate for cross-
cutting reports that aim to synthesize ndings and
generate conclusions from multiple areas of related
research. Of note, it was not feasible to conduct
multiple systematic reviews on each of these areas.
Furthermore, scientic papers for each of these
outcomes typically focus on the entire outcome,
rather than those outcomes that aect those other
than the drinker him or herself.
The main scholarly database searched for peer
reviewed articles was PubMed. Google Scholar
was also employed to identify potentially relevant
government reports. The search terms were created
from 30 of the 52 categories of types of harm to
others identied as priority areas. For each type of
harm, up to 200 (if available) of the most recently
added items were examined for relevance and
potential inclusion. Reviews and quantitative studies
of broad relevance to the topic of alcohol’s harm to
others were selected. A total of 445 relevant articles/
books/reports were initially identied which were
circulated and discussed by the team to further
narrow the list down to 167 most relevant articles.
The research team was also able to identify from
their own collections and knowledge a further 25
items for inclusion.
The process for synthesising material involved the
preparation of an organised summary draft covering
the major identied areas of harm to others, listing
the relevant ndings from the identied studies.
This rst draft was circulated to team members as a
basis for preparing the shorter summary consensus
report. This was prepared through an intensive
four-day meeting in which topics were discussed
by the group, drafts of individual sections created,
edited and debated until there was consensus on the
nal document. Our aim was to clearly summarize
and synthesise available evidence and make this
both accessible and relevant to a Swedish audience
of non-specialists.
This kind of narrative, expert review is important
as a means of providing a large overview of a rapidly
emerging and potentially controversial eld. We are
a group of independent scientists, but we worked
hard to achieve a consensus in the interpretation
of the available data on the chosen topic. We did
exercise judgement in our selection of the material
and in our weighting of the dierent types of studies
and evidence.
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“BEING TRAPPED BY GRIEF IS LIVING
A HALF-LIFE
Åsa Jinder’s childhood memories are tinged with sorrow, but her life
today is enriched by experiences that have given her a strength of will, and
brought success and wisdom. With an alcoholic mother, she was forced
to build up her own secure foundation and she refuses to see herself as a
victim.
TEXT: CAROLINE FISCHER, PHOTO: ANNA LEDIN WIRÉN
Åsa Jinder’s summer talks on the P1 radio channel
grab your attention from the moment she begins
to talk. She talks of a time when, early one autumn
morning, when the seasonal chill demanded a woolly
hat, a warm coat and boots, the 3 year old Åsa took
her tricycle and left her home and its insecurity,
barefoot and dressed in a thin nightdress. She sat in
a sandbox and shivered until a neighbour saw her,
picked her up, and carried her home.
Over a coee in the Stockholm suburb of
Midsommarkransen, Åsa reminisces about the
recurring rough times at home with an alcoholic
mother, about when she took an Alsatian dog that
was tied up outside a grocery store because she
wanted some company when she went to the lake for
a swim. The dog bit her, so there was no swim that
day…
“The older I get and the more distance I have to my
childhood, the more the images that come to mind.
When I see that little 3 year old in the cold, I want to
shout,” What on earth is that child doing out here at
this time of the morning and why isn’t she dressed?!”
Children are always the losers with substance abuse
Åsa Jinder learned quickly to be happy with the
situation, not to expect anything to change, and to
avoid dreaming about how things could be dierent.
“I always had this internal dialogue that said I
preferred to be happy, without necessarily being
constantly happy. I’ve always been kind and
forgiving with myself. I’ve armed my strengths
and known that there is another life, a better life –
one that I can create.”
In a room full of people, Åsa can always tell the
people with similar experiences to hers.
“I don’t really know how, but many of those who’ve
grown up with substance abuse radiate some sort of
feeling of betrayal and loneliness, of strength and
social competence.
The main common denominator amongst adult
children is precisely that – a sense of betrayal and
a lack of trust. The feeling of having come second to
alcohol. In Åsa’s case, the lack of trust meant that
she always wanted to do everything herself, wanted
everything to be on her terms. She ran her projects
with an iron st and no one in her team was allowed
to work independently.
“I was bolshie and unnecessarily decisive, acting as
if other people were trying to take something away
from me. I never considered that they were trying
to give me something. It was very much as though
something had been excised from me so that I found
it hard to handle situations that should really have
been about collaboration and compromise.”
On the plus side, Åsa’s experiences have given her
clear vision and the ability to complete a course of
action, once she’s decided on it. She compares herself
with her daughter, Josene, Little Jinder, who also
very single-mindedly goes her own way but who
has a core sense of security that gives her a natural
“It’s hard, receiving no conrma-
tion when you’re growing up, not
learning that you’re worthwhile,
not having any foundation of love.
It forces you to build your own
ground on which to stand.
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ability to work with others. Nowadays, Åsa has
learned to slacken the reins a little and to see what
happens when she allows other people to participate
in the decision-making process.
Seeing substance abuse as a disease
After the publication of her collection of poems
entitled “Bli min mamma igen” [Be my mother
again], Åsa began giving public talks about her
experiences and about people’s preconceptions about
adult children. She also spent a lot of time thinking
about all those people who stop drinking and how
they manage. And about why not everyone can do
this.
“In those days, I just couldn’t see alcoholism as
a disease: I saw it as a choice and I was heavily
criticised for that viewpoint. Nowadays, I have a
greater understanding of the fact that some people
come to life with that rst drink. It’s chemical.”
She wonders how things would have worked out if
she’d been shy and withdrawn. Would it maybe have
been easier for her to be trapped by addiction, too?
“I’ve never been addicted to alcohol, but that’s
nothing to brag about because I know just how easy
it is to lose yourself in the bottle. It doesn’t have to
be about depression or about developing alcoholism
because you’ve been drinking heavily for a long
ti me.”
Åsa didn’t have a real relationship with her mother
during her childhood, but she did have one with her
father, Curt Einar, who lent her a typewriter and
bought her her rst Swedish hurdy-gurdy.
All I felt from that non-existent relationship with
my mother was betrayal, and that overshadowed
everything else. I saw her as the biggest problem in
my life.” This lack of a mother-daughter relationship
reared its head when Åsa saw her female friends and
their mothers, and felt the lack of someone to talk
to and ask questions. And when Åsa had her own
children, her mother, Astrid, wanted to get involved
and be a grandmother. And Åsa let her do it.
“She was good at being a grandmother and it was a
huge help to me, seeing my mother in a new light,
as a person. It looked so lovely – we were playing
with my son in the park and so many people were
charmed by her.”
Alcohol is a sensitive subject
Talking about alcohol is still more or less a taboo
subject, precisely because alcohol has such a
given role in all types of social get-togethers. The
inability to handle alcohol is seen as shameful. And
questioning the self-evident place that alcohol has
in society also arouses strong feelings. Åsa explains
this by saying that people quite simply want to be
able to enjoy a drink in peace.
“For many people, alcohol is their comfort blanket.
It calms them down and shuts down uncomfortable
feelings. Alcohol makes people feel positive, and
that’s the problem. It’s not until you’re hooked that
it’s regarded as a problem.”
Some years ago, Åsa and her husband, Jonas Otter,
attended a show put on by eighth graders for their
parents. The children had produced a play about
young people who drank, and once it was over, there
was a general discussion.
“It was very clear just how uncomfortable a subject
this was for many of the adults there. When I
mentioned that I don’t drink alcohol when my
children are out because I want to be able to pick
them up if necessary, one of the mothers exclaimed,
‘So when am I supposed to drink my wine, then?!’”
Moving on
For Åsa, it’s been important not to get trapped in
a sense of grief over having been betrayed, and
she does not want to be a victim. She wouldn’t
change her experiences though, because it is these
experiences that have made her who she is today.
She sees the fact that she can handle so much by
herself as a gift that came from something that was
initially so wrong.
As a child, you’re a victim and have no right to
choose, but once you’ve reached a certain age, it’s
“Nowadays, I have a greater
understanding of the fact that some
people come to life with that rst
drink. It’s chemical.
“She was good at being a grand-
mother and it was a huge help to
me, seeing my mother in a new
light, as a person.
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time to take responsibility for your life and realise
that a dierent way is possible.”
Children from dysfunctional families fail to acquire
certain fundamental abilities. Åsa says that she
has had to learn to love herself and other people as
an adult, and that she had to learn how to put up
Christmas decorations.
The feeling of being an outsider has never bothered
her.
“I’ve grown as a person by being conrmed in my
dierence, on the path I’ve chosen for myself.”
Åsa has no time for the idea of nding oneself and
completing oneself.
“If you face up to your problems, have the courage
to recognise them, you can move on in life, but
constantly telling ourselves that we can make
ourselves into nished products only leads to
unhappiness. We are so complex and we are
constantly developing. We’re nished products when
we die.”
About Åsa
In 1979, she became Sweden’s youngest
“National Folk Musician” on the Swedish
hurdy-gurdy.
She also works as a composer, producer,
lyricist, author and public speaker.
She has won the Eurovision Song Contest
with the Norwegian entry, “Nocturne: Secret
Garden”.
In the same year, she co-wrote the lyrics of the
World Cup song for Sweden’s women’s football
team.
“Av längtan till dig” was the Song of the Year
on the “Svensktoppen” record chart.
Åsa has been awarded gold and platinum
records and has won three Grammys.
She has toured the world and played at the
Nobel Prize Banquet.
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“OUR ALCOHOL NORMS BECOME OUR
CHILDREN’S NORMS”
Here in Sweden, we have a strong alcohol norm, whereby alcoholic
drinks have more of a given place in numerous contexts than alcohol-free
ones nowadays. The continental habits that we are so keen to adopt are
nowadays being combined with the more traditionally Nordic romance
with spirits. Louise Hallin, a psychotherapist specialising in children,
says that the constant presence of alcohol in the lives of children has
consequences that follow these children into adult life.
TEXT: CAROLINE FISCHER. PHOTO: JOHNÉR BILDBY, ANNA LEDIN WIRÉN
Louise Hallin, a psychotherapist and midwife,
doesn’t mince her words when it comes to alcohol
consumption by parents of small children in
Sweden, and she is very concerned about the
development of the alcohol norm. She talks about
a social dependence that ensures alcohol is present
in the majority of contexts. Opinion surveys
commissioned from YouGov by the insurance
company, If, show that 23% of parents think that it is
OK to drink to intoxication in front of their children.
“When did someone last invite you round for a
coee? The constant presence of alcohol obviously
aects our children, and all this normalisation
of alcohol consumption normalises it for the
children, too. I’m worried that we’re going to see a
signicantly worse harm scenario in the generation
that is growing up now. We are taking a massive risk
with this social habituation.”
Alcohol steals the mental bond with the parent
Louise only used to ask parents about their alcohol
consumption if she saw signs that something wasn’t
quite right. Nowadays, she raises the issue at all of
her therapeutic sessions with parents.
“Many parents are unaware that their consumption
aects their children, so they’re quite happy to give
“I’m worried that we’re going to
see a signicantly worse harm
scenario in the generation that is
growing up now.
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me the uncensored details of how much they drink
during the course of a week. They see it as normal.
When I tell them about the eects that alcohol
consumption has on their children, it comes as quite
a surprise to them, so I let them go home and think
about it before their defence mechanisms kick in.”
According to Louise, the vast majority of these
parents come back and want to know more about
it, and when it comes to those parents who opt not
to continue with their therapy after the discussion,
Louise can only hope that she has planted a seed
that will get them thinking.
She believes that adults’ consumption of alcohol in
front of children gives rise to unease and insecurity
in the children that escalates in line with the amount
of alcohol consumed. Because even when a small
amount of alcohol has been consumed, some of the
mental bond with their parents disappears, and this
makes the child feel uncomfortable.
And even if both parents are not drinking, it’s
common for one of the parents to try and convince
the child that the fact that Mummy or Daddy is
drunk isn’t a problem, that everything’s perfectly
normal because this is a party, and that everything
will be back to normal tomorrow. This is of little help
to the child, according to Louise, and simply gives
rise to confusion because what the parent is saying
clashes with what the child is feeling. “Children
simply don’t just go up to their parent and say, ‘I
don’t like it when you’re strange like this.’ They
expect parents to stay the same at all times,” says
Louise.
Co-dependent children perform less well at school
When alcohol consumption becomes alcohol abuse,
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the consequences are obviously worse. 380,000
children in Sweden are living with a parent with
risky levels of alcohol consumption, according
to a nationwide survey from 2007. And Swedish
data gathered from over 600,000 children show
that children whose parents have been diagnosed
as substance abusers were more likely to leave
compulsory school without the grades necessary for
upper secondary education.
“Children who live with substance abuse carry a
burden of worry inside them – and that takes away
their focus from their studies. Plus keeping a secret
like that demands a lot of energy. The alcohol abuse
is a massive source of shame for them and the
majority of children become co-dependent, never
speaking about what life is like at home. It becomes
all-consuming, leaving them very little time for their
own, personal development and their opportunities
for simply being kids and acting their age are very
limited.
Louise also says that children’s imaginations are
inhibited by the constant tension and that many of
the children who live with substance abusers have
psychosomatic problems.
“In these families, it’s usually the oldest children
who take responsibility for their parents, their
siblings, their pets and their home, and this, coupled
with never knowing what things will be like when
they come home from school, has a massively
inhibitory eect on their development. Children
of substance abusers become hyperaware of their
surroundings, they listen for footsteps and for how
they sound when their substance abusing mother or
father comes home.”
In the longer term, people who have grown up
with substance abuse in their home are less well-
equipped to handle setbacks later in life.
“If these children go through some kind of crisis,
once they have grown into adulthood, they’re
often hit by a whole avalanche of emotions and
experiences that make the crises so much worse.
Their self-image is poor, as is their self-awareness,
and they often put themselves in situations where
they’re trying to save someone else.”
Signs of substance abuse in the family
There are a number of signs that outsiders can look
out for in children of substance abusers – so-called
“adult children”:
“They’re often worried and scared. Girls are more
likely to become introverted than boys, and are more
likely to go in for self-harm and self-destructive
behaviour, whereas boys tend to display aggressive,
outward-orientated behaviours. They can develop
tics, such as scratching themselves, hair pulling,
and being immeasurably sad when something goes
wrong.” Louise says that these children are also
more likely to be absent from kindergarten and
school, and that there may be signs of neglect at
home, e.g. the children are not wearing winter boots
when the temperature falls.
Louises tips till föräldrar
Don’t drink alcohol in the presence of your
children. Think about whether it’s really a good
idea to put out a bottle of wine for your babysitter.
Make it clear to your children that they are
allowed no alcohol whatsoever until they are 18
years old. This makes crossing that boundary
something out of the ordina