Nat6W2007[1]

559NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 24. 2007 . 6

Nordic Studies on Alcohol and Drugs Contents

Editorial 561

Research reports

Claes Törnqvist Twenty then – today about thirty-five. The meaning of alcohol in a life course perspective _____________________________ 563Anders Bergmark Guidelines and evidence-based practice – a critical appraisal of the Swedish national guidelines for addiction treatment _____________________________________________ 589 Mats Berglund Commentary on the paper by Anders Bergmark __ 600

Mads Uffe Pedersen Evidence-based practice in “the real world” ___ 605

Overview

Pia Mäkelä & Heli Mustonen & Esa Österberg Does beverage type matter? ____________________________________________________ 617

Making use of alcohol and drug research

Introduction ____________________________________________________ 632Robin Room National variations in the use of alcohol and drug research: Notes of an itinerant worker ________________________ 634Matilda Hellman Public use of and communication about alcohol research ________________________________________________________ 641Hildigunnur Ólafsdóttir Reflections on the use of alcohol research ___ 646Katariina Warpenius & Marja Holmila Connecting alcohol research and prevention practice: Lessons learned from PAKKA _ ____________ 652Emilie Rapley The use of alcohol research in Eurocare’s lobbying activities _______________________________________________________ 656

Book reviews

Harald Klingemann & �inda Carter �obellKlingemann & �inda Carter �obell& �inda Carter �obell (eds.) PromotingPromoting self-change from addictive behaviors. Practical implications for policy, prevention, and treatment (by Dorte Hecksher) _____________________ 662Tuukka Tammi Medicalising prohibition: Harm reduction in Finnish and international drug policy (by Harry G. Levine)________ 664

NAT vol. 24, Innehåll/Contents 667

NAT 6/07

560 NORDIC STUDIES ON ALCOHOL AND DRUGS VOL . 24 . 2007 . 6

Nordic Studies on Alcohol and Drugs by STAKES, the National Research and Development Centre for Welfare and Health (Finland), in co-operation with the Nordic Center for Alcohol and Drug Research (NAD). The Journal is supported by the National Institute for Alcohol and Drug Research (SIRUS), (Norway), the Norwegian Wine Monopoly (Vinmonopolet), the Swedish Ministry of Health and Social Affairs, Alkoholpolitisk Kontaktudvalg, the Ministry of Health (Denmark), and Alko Inc. (Finland).

Editorial board

Researcher Astrid �kretting (chair), National Institute for Alcohol and Drug Research SIRUS, OsloPh.D. Hildigunnur Ólafsdóttir, Reykjavík Akademy, Reykjavík, IcelandM.Pol.Sc. Thomas Karlsson, Alcohol and Drug Research Group, STAKES, FinlandAssociate Professor Philip �alander, Department of Humanities and Social Science, University of Kalmar, SwedenM.Soc.Sc. Petra Kouvonen, Nordic Center for Alcohol and Drug Research, Helsinki, FinlandResearch professor Morten Grønbæk Alcohol Research Department, National Institute of Public Health, Copenhagen, Denmark

Editor-in-chief

Kerstin �teniusphone: +358 - (0)9 - 3967 2197

Editors

Johan �andelin Matilda Wrede-Jäntti Ylva �jöblomphone: +358 - (0)9 - 3967 2198

Assistant editors

�eif Vind, Denmark e-post: [email protected] Bye, Norwaye-post: [email protected]

English language revisionMark Phillips

Editorial office

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Telefax E-mail Website

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Editorial

Guidelines for treatment – national ambitions and local implementation

In 2002, the SwedISh natIonal Board of health and

welfare InItIated a project with the aim of establishing guidelines

for the entire addiction treatment system, including both the health care and

social services parts.

The core of this work was the reviews produced within five expert groups,

in which most of the Swedish alcohol and drug treatment researchers were

involved. The reviews started out from the so-called SBU-review by Berg-

lund et al (2003), but some new aspects were covered as well as the latest

research findings. The reviews summarized the literature according to an

evidence grading, where RCT-studies had the highest rank. The five expert

groups summarized the findings on early identification and prevention, as-

sessment instruments and documentation, psychosocial and medical treat-

ment of drug abuse, psychosocial and medical treatment of alcohol abuse

and the treatment of pregnant women. (See Malmström 2007).

After five years of work, in 2007, the guidelines were published by the

National Board of Health and Welfare (Nationella riktlinjer för missbruks-

och beroendveård 2007), with altogether 53 recommendations formulated

by a group of treatment administrators, providers and researchers. During

the autumn of 2007 these guidelines and recommendations have been pre-

sented at a number of regional conferences all over Sweden, attended by

several thousands, mainly staff from the treatment systems. The implemen-

tation efforts have thus begun.

Guidelines for the treatment of alcohol and drug abuse have also recently

been produced in Norway and Finland. Even though there has been an ex-

change of knowledge and methodologies across the borders, there are inter-

esting national differences in working procedures and implementation that

would be worth analyzing. The Swedish way is characterized by an attempt

to include diverging views in the expert groups, to reach consensus, and

to put much effort into a nationwide implementation. But it also includes

training material and a preparation and call for a continuous discussion

(making use of the internet) at local level concerning the implementation.

Following on from a centrally administered, heavy and slow moving policy

KerStIn StenIuS


machinery, a perhaps more exciting confronta-

tion emerges with the reality of treatment.

Hopefully the implementation will be prop-

erly evaluated. The real effect of this ambitious

Swedish project may not be the introduction of

new treatment methods, but the establishment of

new routines as well as changes in the structure

of the treatment system.

In this issue, Anders Bergmark (2007), mem-

ber and chair of one of the expert groups, gives

his critical remarks on the work carried out on

Swedish guidelines and its usefulness, with fur-

ther comments by Mats Berglund, the main au-

thor of the SBU-report.

In another article, Mads Uffe Pedersen (2007)

puts the significance of Evidence Based Practice

(EVP) into perspective, highlighting that EVP

only constitutes a small part of high quality care.

Using Danish data, he sounds out a warning that

therapists can be so blinded by demands to use

the “right” methods, that they will forget what the

client really needs. He also shows that evidence

has to be developed locally, fitting the treatment

setting and the client group of the facility.

The Swedish project report coincides with

what may in the future be regarded as a turning

point in the history of treatment research, when

the hopes put on evidence-based methods (a nec-

essary step) were succeeded by a focus on the

importance of the functioning of the treatment

system or common factors in treatment.

REFERENCES

Berglund, Mats (2007): Commentary on the paper byCommentary on the paper by Anders Bergmark. Nordic Studies on Alcohol and Drugs 24 (6): 600–604

Bergmark, Anders (2007): Guidelines and Evidence Based Practice – a critical appraisal of the Swed-ish national guidelines for addiction treatment. Nordic Studies on Alcohol and Drugs 24 (6): 589–599

Malmström, Ulf (2007): Nationella riktlinjer för missbruks- och bereondevård. Nordisk alkohol- &

narkotikatidskrift 24 (5): 504–509Nationella riktlinjer för missbruks- och bereondevård.

Vägledning för socialstjönsten och hälso- och sjuklvårdens verksamhet för personer med miss-bruks- och bereondeproblem (2007). Lindesberg: Socialstyrelsen

Pedersen, Mads Uffe (2007): Evidence BasedEvidence Based Practice in “The Real World”. Nordic Studies onNordic Studies on Alcohol and Drugs 24 (6): 605–616.

563NORDIC STUDIES ON ALCOHOL AND DRUGS VOL . 24 . 2007 . 6

Research report

A B S T R A C T

C. Törnqvist: Twenty then – today about

thirty-five. The meaning of alcohol in a

life course perspective

AIM

Studying changes between the ages of

20 and 35 in the use of alcohol and its

meaning to the user and the relation of

this to cultural background.

DATA AND METHOD

Qualitative interviews with 42 persons

in Malmö, Sweden, aged approximately

20 years (21 women, 21 men) belonging

to 3 groups, differing in social

characteristics, in their use of alcohol

and the meaning it had for them. 34

of them were interviewed again in a

follow-up study 15–16 years later.

RESULTS AND CONCLUSIONS

At the age of 35, when matters of work,

family and raising of children had

become of central importance, alcohol

no longer had the much more central

role in their lives it had had at the age

of 20, when intoxication had helped

them create a collective illusion of

future success at their goals. Alcohol

still played a role in their lives, however,

helping to support their feelings of

closeness to their partners, of being

good parents and of succeeding in their

work. Drinking, usually involving wine,

was primarily on weekends in a family

setting, the woman typically taking the

initiative here. The continental European

custom of going out occasionally on

weekday evenings to drink beer with job

colleagues had become more frequent.

Aim and point of departure of the studyIn the mid-1980s the present author, together

with Margareta Norell, conducted a qualitative

investigation of the meaning that alcohol has

for persons some twenty years of age (19–22)

in three different social environments in the

Swedish city of Malmö. The study was of both

cultural sociological and social psychological

character. It resulted in two articles (Norell &

Törnqvist 1997; Törnqvist 1999) and a doc-

toral dissertation, Berättelser om ruset. Alko-

holens mening för tjugoåringar (Narratives

on intoxication. The meaning of alcohol for

twenty-year olds) (Norell & Törnqvist 1995).

Those studied in the respective social en-

vironments were 1) young employed persons

whose ideal regarding alcohol was to achieve

a moderate and controlled degree of intoxica-

tion (cf. Ambjörnsson 1988), referred to here

as the employed group, 2) young students who

aimed at achieving a “civilized” level of intox-

ication, referred to as the student group, and

3) young persons with a more pronounced

subcultural style, referred to here as the peo-

ple-in-black group due to their dark attire,

who tended to feel that in becoming intoxi-

ClaeS törnqvISt

Twenty then – today about thirty-five

The meaning of alcohol in a life course perspective

This study was supported by the Swedish National Institute of Public Health and the Swedish Research Council.


Those without a family or a

partner differed somewhat

in their pattern of drinking.

Effects of one’s social

environment at the age of 20

on the use of alcohol and the

meaning it had for one at

the age of 35 were evident.

KEywORDS

Alcohol consumption,

meaning of alcohol, age,

culture, gender, longitudinal

study, life course

perspective, interviews,

qualitative methodology.

cated they “triumphed” over others. The employed group

and the student group were selected to basically represent

the “broad majority” of young people, whereas the people-

in-black group, who had a rather characteristic view of life,

were selected as an example of a subculture of the time that

was readily identifiable in public places. A question we

posed to all of these young people was “How would you like

your life to be in the future, if you were free to choose?”

This was followed by the question “How do you think your

life will be in ten years, say?” The thoughts of the employed

group centred very much on the idea that at that future time

they would have stopped going out to have a good time and

to smoke “hash” and would instead be sitting in front of their

TV set with their spouse and children, and that on weekends

they would drink a little together with their spouse in even-

tempered Swedish style. A typical conception the student

group, in turn, had was that they would continue to develop

a civilized continental European style of drinking charac-

teristic of their having become well established and of the

social status they had gained. The young avantgarde or peo-

ple-in-black group, in contrast, showed a certain ambivalent

reservation toward things, seeming to be afraid of waking up

in their thirties, taking a hard look at themselves in the mir-

ror and taking note of the fact that they were still frequenting

bars and drinking beer, without their dreams for the future

having come true.

About 15 years later we obtained an answer to the question

of how life in general and their alcohol culture had turned

out for them through conducting a follow-up study, inter-

viewing 34 of the original 42 again in the years 2001–2002,

when they were 35–38 years of age. We studied how they

had successively established themselves in various adult

fields of endeavour and the role that alcohol had played in

this – in relation to their work, their living conditions, their

founding of a family and how they spent their free time.

The article aims at illuminating the place that alcohol had

in their adult lives at that point and the meaning it had to

them, as well as how it related to their life situation and life-

style. The basic question of interest was how the conditions

of life these young persons had encountered at the beginning

of adulthood had affected their subsequent life projects as

adults and their associated life course. This question is dealt



with in detail in the book Ny vuxenhet i

ett livsloppsperspektiv (Törnqvist & Norell

2007), in English New Adulthood and Its

Sequel from a Life Course Perspective. The

scope of the present article is limited to

conclusions that could be drawn concern-

ing the meaning of alcohol in a life course

perspective.

Longitudinal studies concerned with

use of alcohol and narcotics are fairly rare

within the Nordic countries, particularly

studies of a qualitative character. Although

a variety of qualitative ethnographic stud-

ies of alcohol culture have been carried out

in the Nordic countries (Alasuutari 1990;

Elmeland 1996; Sulkunen 1983; Norell

& Törnqvist 1995; Pape 1997; Lalander

1998), none of them are longitudinal in

character or take a life course perspective.

The present longitudinal study of the role

of alcohol in the life patterns of adults dif-

fering in the youth cultures to which they

belonged at the onset of adulthood aims at

filling this gap in Nordic alcohol research.

The only other longitudinal study on the

use of alcohol that has been carried out in

the Nordic countries and employs a quali-

tative methodology is Adalbjarnardottir’s

(2002) Icelandic investigation of the effect

of psychosocial maturity on the use of alco-

hol during adolescence. In the Cambridge

Scientific Abstract there is no longitudinal

study of alcohol use at all of ethnographic

or qualitative character listed under the

social science heading.

What does use of a life course perspective

as a basis for interpreting reality mean? It

rejects for one thing the idea derived from

a life cycle perspective of there being defi-

nite “stages” through which people pass

in the course of their lives. In a life cycle

perspective the period of 35 to 40 years

of age has been regarded as a plateau in

the phase of becoming established in life,

through the individual’s level of perform-

ance in most areas concerned with getting

ahead being at the highest point during

that period (Rapoport & Rapoport 1975).

Describing the individual’s advancement

through life in terms of separate stages is

problematical, since cultures differ from

one another in the stages that can be said

to occur and when. In a life course per-

spective, in contrast, social context is re-

garded as an important factor, changes in

society being taken into account. The peri-

ods of time that different stages of life can

be said to encompass have also changed in

the course of history, changes brought on

by the reflexive modernization processes

that various societies have undergone in

recent decades (Giddens 1991; Beck 1994)

being a case in point. As a result of such

changes, people need increasingly to take

measures on their own to deal with the

risks and uncertainty connected with the

breakup and transformation of modern

industrial society and maintain a sense of

personal identity.

The complex relations between suc-

ceeding generations shown in many tran-

sitions that are of an individual or family

membership character can be studied from

a life course perspective (Hareven 2000).

Karl Mannheim’s (1956/1992) definition

of the generation concept contributes to an

understanding of the life course perspec-

tive. In terms of Mannheim’s cultural psy-

chology, a generation – which consists of

individuals who are basically in the same

phase of life – is formed through each hav-

ing grown up under social and historical

conditions that were roughly the same, the

experiences they have in common follow-


566 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 4. 2 0 0 7 . 6

ing them throughout life as a part of their

life course. From a life course perspective,

social background is thus regarded not as

a static background variable but as some-

thing directly linked to historical condi-

tions. Gender is not considered a static

variable either, since the meaning that

gender is assigned is dependent upon both

time and place. A life course perspective

focuses on the direction a person’s life and

individual development takes. Such a per-

spective helps one to understand the com-

plex interaction between the fundamental

factors shaping one’s life. Although his-

torical and social changes strongly affect a

person’s life and the decisions one makes,

such decisions are not based on historical

conditions alone. What may well seem a

sensible level of drinking for someone who

is 25 may not seem a sensible level at all at

the age of 35, age thus being important for

gaining an understanding of the interac-

tion between the different factors affecting

a person’s life. Ethnicity is another such

factor, separate ethnic groups in society

differing in the conditions under which

they live, both material and cultural.

An individual’s pattern of free-time ac-

tivities is generally established early in

adulthood. For men and women alike, the

drinking of alcohol tends to be associated

with free-time activities (Kunz & Graham

1996; Lalander 1998). The alcohol culture

people show varies, however, with both

gender and age and with whether or not a

person has established a family. It can also

readily shift in response to changes in the

course of a person’s life.

Studies from a wide variety of countries

provide a picture of alcohol consumption

by people of different ages fairly similar to

that of people in Sweden (Leifman & Gus-

tafsson 2003). An overview by Fillmore

et al. (1993) of 20 longitudinal studies

from 15 different countries showed there

to be a decrease in alcohol consumption

with increasing age, both for women and

for men. Also, although men tended to

drink more than women, the difference

decreased with age. It was also noted that

the level of alcohol consumption shown in

youthful years tended to set a standard for

how much people drank later in life, those

drinking more than others in their younger

years tending to do so in their later years

as well.

It has been found (Neve et al. 2000) that

when people marry and have children they

generally drink less. This has been shown

to be the case for men in particular, their

drinking habits after marriage tending to

become more like those of women (Kunz

& Graham 1996).

A marked change in alcohol culture in

the Nordic countries during the last few

decades has been that the drinking pat-

terns of women have become increasingly

similar to those of men, women appearing

in greater numbers than earlier in pubs,

bars and the like traditionally frequented

by men (Pape 1997). Drinking habits have

also become more continental European

through a greater consumption of drinks

of lower alcohol content such as beer and

wine, as opposed to strongly alcoholic

drinks (Leifman & Gustafsson 2003). This

“Europeanization” has also meant that

control of the consumption of alcohol has

been shifted more and more to the individ-

ual as opposed to authorities. Alcohol con-

sumption and light intoxication have also

increasingly become a part of everyday life

rather than being viewed as something re-

served primarily for weekend festivities.



A question that can be asked is to what

extent do people with differing lifestyles

generally adopt the ways of a modern con-

tinental European alcohol culture.

During periods of rapid social change,

life courses of certain types can become

more frequent. Phenomena during such

periods concerning the historical context

at the moment, people’s readiness to act,

close ties between persons developing,

and the time schemes needed for certain

actions to take place can link individu-

als in a complex way with social changes

that occur (Elder & Shanahan 1997). In the

modern double-career family, the timing

of things can also be decisive for many job-

related matters important to each and for

the couple’s common project of creating a

happy family situation and doing the best

they can for their children (Frønes 1997).

In line with the reflexive modernization

that has occurred, the individual tends in

a marriage or partnership today to be freed

to a considerable extent in economic, so-

cial and cultural terms from many of the

obligations of a more absolute character

that existed earlier, a marriage or partner-

ship being viewed primarily as a relation-

ship between two persons who love each

other, rather than as a contract anchored

in their relations to their parents and close

relatives or in religion (Beck 1994; Beck &

Beck-Gernsheim 2002; Giddens 1991). In

Sweden the modernization process this

represents has proceeded further than in

any other country in Europe, as can be

seen in the large numbers of divorces and

separations that have occurred. The risk

is thus increasing of families breaking up,

which in turn means the life histories of

larger numbers of persons being coupled

together through the establishment of new

partnerships and marriages thereafter. In

addition, many men and women alike, in

broad segments of society at least, have

expectations or the experience of having

more than one type of job in the course of

their working life, sometimes in combina-

tion with each other, which increases the

complexity of the planning needed within

the framework of the life courses, or the

family histories, of those involved. What

role do alcohol and the intoxication it can

produce play in relations between men

and women today?

In the Nordic countries it is generally

necessary nowadays that the woman in a

family have a job in order for the family to

get by economically. In Sweden the tran-

sition from the woman in a family being

a housewife to her having a job occurred

during the 1960s, which means that those

born in that decade were the first whose

life course involved socialization under

such conditions. Men and women today

thus share the responsibility for support of

their family economically, in addition to

sharing responsibility for care of the chil-

dren and maintenance of the home, at the

same time as caring for children is also the

responsibility of society generally. The for-

mal symmetry created between men and

women in the respects just named may

become unsymmetrical in reality, both in

spatial and in temporal terms, however

(Friberg 1990). Although, as already indi-

cated, one cannot speak of any universal

phases in the life course of people gener-

ally, either temporally or in terms of con-

tent, certain basic characteristics can be

assumed to have applied to the time of life

involved for many of those who took part

in the present investigation. In Sweden to-

day, women as well as men 35–39 years



of age as a group have a very high rate of

employment. Many of them also live in a

marriage or partnership and have at least

one child, although living under such con-

ditions at that age is more common among

women than among men, at the same time

as the proportion of persons who live

alone has increased during the 1990s. The

average age of women at the time of first

giving birth to a child has increased since

the 1960s, its being more common than

earlier for women to give birth to their first

child at the age of 30 or more; also, about a

fifth of the women who are 35 years of age

have not yet given birth to a child (Hoem

& Hoem 1997). A general pattern has been

established of women first being employed

before they go on to establish a family. It

can be asked how women’s postponement

of having children, in a marriage or part-

nership, has affected the alcohol culture

of both men and women, as seen in a life

course perspective. In contrast to how it

was a generation before, it is not at all un-

usual today for the parents of small chil-

dren to be 40 years of age or older. What

are the drinking habits of working parents

who have small children and how is their

use of alcohol related to the situation with

which they are faced?

It would appear indeed, as Beck (1994)

argues, that society is in a state of reflexive

modernization. This speaks for its being

best to behave in a reflexive way both to-

ward oneself and toward “reality” gener-

ally, even if the relativizing of things that

this brings about can lead to a strong feel-

ing of ambivalence. Although the sense of

identity people have appears to be more

fragmented than earlier, this does not im-

ply it has been lost completely in mod-

ern society. Rather, identity seems more

complex and contradictory than earlier,

making it more difficult to achieve a sta-

ble sense of identity as an adult (Kristeva

1990). The type of identity one wishes to

have appears more to be something that

can be “negotiated” through creating a rea-

sonably coherent account, or life history,

of oneself to assign one the meaning that is

aimed at (Giddens 1991). Another aspect

of the individualization process taking

place today is the standardization of cul-

tural patterns which is occurring through

globalization of the media. In Sweden, for

example, continental European preferenc-

es regarding food and drink are becoming

adopted increasingly.

Young people today need at some point to

create an individual identity for themselves

in order to appear socially competent and

deal effectively with the difficulties with

which an adult individual in modern soci-

ety is faced. The “social timetable” of the

life course of people has changed, creation

of an individual identity taking longer than

it did earlier. It can be asked at what point

one actually becomes “grown up” in Swe-

den today and whether everyone becomes

completely adult in a traditional, stable

sense. The conditions people are confront-

ed with in going through different phases

of their development from adolescence to

young adulthood can strongly affect their

life projects as adults and their life course

as it unfolds. One can ask what effects the

experience with alcohol a person has had

late in adolescence and at the outset of for-

mal adulthood has on the person’s relation

to alcohol at the age of about 35 and what

effects, positive or negative, alcohol has on

the creation and maintenance of a modern

sense of identity as an adult individual.



ParticipantsThe young people approximately 20 years

of age of varying background who were in-

terviewed in the earlier investigation were

selected by use of a “snowball” approach

(Burgess 1984). After we had come in con-

tact with and interviewed a person from

one of the three categories and the person

was found to be appropriate as a participant

in terms of the profile the interview gave,

we could use the information and the good

will the interview had generated as a help

in finding further participants belonging to

that category, the process being continued

until three groups of appropriate size had

been collected and interviewed.

In the present investigation, efforts were

made to come in contact with and enlist

the participation of as many as possible of

those interviewed in the earlier investiga-

tion, some 15–16 years before. The same

group designations – those of the employed

group, the student group and the people-

in-black group – are used in reference to

both the earlier and the present investiga-

tion, despite the conditions of life having

changed radically for the members of each

of the three groups since the earlier study

took place – the vast majority of persons

in all three groups now being employed,

those who were once students long since

having completed or dropped out of their

studies, and those once dressed in black

attire no longer being dressed in that way.

What social characteristics did the

members of these three groups show in

the present investigation, conducted when

they were at about the age of 35–38, under

what conditions were they living, what

education had they attained, what occupa-

tion did they have, what family life or pair

relationship(s) had they established, what

had occurred in terms of their having chil-

dren, and what can be said regarding their

use of alcohol and the role it had played

in their lives?

The “employed group” The persons who belonged to the em-

ployed group had grown up in an apart-

ment house area in the Fosie section in the

southern part of Malmö, a section which

at the time had a cultural and socioeco-

nomic profile similar to that of the city of

Malmö as a whole. The cultural and socio-

economic profile of that section of the city

has changed radically since then, persons

of immigrant background and those with

social or economic problems being over-

represented in comparison to the city gen-

erally. A large part of this group had re-

mained in the area through their twenties

and been gainfully employed. The group

consisted originally of 16 persons (8 wom-

en and 8 men). Five of the women could be

interviewed in the follow-up study. Two of

the other three provided brief information

when they were phoned up, whereas the

third could not be reached. Six of the eight

men that belonged to the group could be

interviewed, and we were able to obtain

information by phone from one of the

other two. Half of those in the group as a

whole lived in apartments in the southern

part of the city, and several of the others

lived in private dwellings either in the city

or nearby. Only two of the women, both

living alone with their child(ren), were liv-

ing in the same section of the city as ear-

lier, in fact on the same floor in the same

apartment building as each other. The ma-

jority of the women who were interviewed

in the follow-up investigation were work-

ing in lower- to middle-level positions in



the service, health care and administrative

sectors. The men were working as crafts-

men of various types, the majority having

made successful careers thus far. The level

of education in the group as a whole was

fairly low. It was typical for them to have

completed two years of high school. One

of the women was the only member of the

group who had a college education. Sev-

eral members of the group had been out of

work for limited periods of time.

All but one of the men had a child, the

number of children per family varying be-

tween one and three, two children being

the most usual. The age of the women at

the birth of their first child ranged from

20 to 24 years, which is clearly rather

young as compared with women in Swe-

den generally. The men were somewhat

older than this (median age 27), and also

differed more from one another in age,

when their first child was born. All the

persons in the group as whole with one

child or more had either initially or at

some later time lived with their partner

and child(ren) under family conditions,

although the permanence of this relation-

ship varied. Half of them had separated

from their partner, the typical pattern be-

ing that of the relationship having ended

after a relatively short time. Only two of

the persons had established a family again

after that. The men who at the time they

were separated had a child, and when the

present investigation took place were liv-

ing either as a single person entirely or

separate from someone they were together

with, had their child(ren) living with them

at least part of the time and maintained

daily contact with them. The women who

were separated from their partner, all but

one of them living without a partner, had

their child(ren) living with them under

conditions of shared custody, with the ex-

ception of one of the women, who had the

sole care of her three daughters, each with

a different father, and care of a grandchild

as well.

The “student group” Most of the student group grew up in an

apartment-house area at the edge of the

Hyllie section in the southwestern part of

Malmö, about a kilometre to the northwest

of the Fosie section where the employed

group was living at the time. Living in

the Hyllie was considered, then just as it

is today, to be “finer” in terms of status

than living in Fosie. At the time the earlier

interview took place, the majority of the

student group had left home to live in dor-

mitories or elsewhere in connection with

the start of their studies at the university.

Today, most of those in the group live ei-

ther in Malmö or in some neighbouring

community. Some who have remained in

the Malmö region are living in the western

part of the city, largely in apartment hous-

es, the rest of this group living in commu-

nities not far from Malmö. The three who

left the Malmö region entirely were living

in cities at a considerable distance from

Malmö, in a single-family house in each

case.

The original group consisted of 14 per-

sons (7 women and 7 men). All of the men

and five of the women were interviewed

in this follow-up study. Most of those in

the group had completed a program of

education at the university, the majority of

them having begun their studies directly

after completing high school. Two of the

men, neither of them having completed

their university education, had started a



firm, with success differing. Several of the

women with children were without a full-

time job and had failed to make use of their

university education in the work they did.

The women as a group were engaged in

middle-class jobs of rather differing char-

acter, including esthetically oriented jobs

in designing or in advertizing, work as an

educational consultant, and being a politi-

cian. The men with a university education

were engaged in jobs, likewise of a mid-

dle-class character, as engineers, lawyers

and teachers.

Just as in the employed group, all the

members of this group, except for one of

the men, had children. The number of

children varied between one and three,

two children being the most usual number

for the men and three the most usual

number for the women. The women were

somewhat younger than the men at the

time of the birth of the first child, 25–28,

the median age for the men being 30, the

variation in age also being greater for the

men. The majority of those in the group

had established a family. In three cases,

separation from their partner had later oc-

curred, in each case after a family relation-

ship had been maintained for a period of

about 5 years.

The “people-in-black” group The people-in-black group had lived at the

time of the first interview near the center

of Malmö, though they had grown up at

various locations, both within the city and

outside of it, some of them not far from

where the employed group and the stu-

dent group members had lived at that time.

At around 20 years of age they had been

drawn to the center of the city, where they

found music and a bohemian way of life

and were able to finance their existence to

a large extent by short-time jobs and unem-

ployment compensation. As with the other

two groups, most of them had remained

in the Malmö region. Two of the women

were living in the respective families they

had established in rural areas in southern

Sweden, and two of the men had moved to

other large cities in Sweden. The remain-

ders of the group were living in apartments

near the center of Malmö.

Eleven of the twelve who had been in-

terviewed earlier could be interviewed

again (6 women and 5 men). Three of the

men had acquired a college or university

education and were working within jour-

nalism or law. The remaining two had

pursued ambitions of theirs in the enter-

tainment industry or the media. The ma-

jority of them had had experience with

part-time jobs of various types. All of the

women except one had a college or uni-

versity education and had studied either

cultural or linguistic subjects or psychol-

ogy, or been trained in social work. This

had led for the most part to publicistic or

cultural work or work within the media,

largely of a freelance nature or connected

with specific projects. Both the men and

the women had in common that they be-

gan their higher-education studies decid-

edly later, at 25–30 years of age, than the

student group did.

The group also showed a different pat-

tern than the other two groups in regard

to establishing family life and having chil-

dren. Only two of the men and three of

the women had children. For those who

had children, their age at the birth of the

first or the only child varied considerably,

being 27 and 36, respectively, for the two

men, and 24, 26 and 32, respectively, for



the three women. The two men were each

living in a long-term relationship with

their partner. Of the three men who had

no child, one had had various relation-

ships of short duration, another had been

together with a partner but without living

with her, and the third had had sporadic

relationships. In contrast to the men, all of

the women had established at some time a

genuine family or pair relationship, two of

them since then having separated, one of

them living alone with her child and the

other living as a single person.

AttritionMost of those interviewed earlier who

failed to participate in this follow-up

study because of our not being able to

contact them or its not being possible to

interview them belonged to the employed

group, there being five persons from that

group who did not take part in the present

study, as opposed to two from the student

group and one from the people-in-black

group. Of the five from that group who

failed to participate, there were two (a man

and a woman) we were unable to reach.

Although we talked by phone with the oth-

er three (a man and two women), this did

not result in an interview. Regarding the

man and the woman we did not succeed

in reaching, the man had not known any of

the others very well and we were unable to

find him, and the woman, said to be living

with a man who was an addict, had moved

from Malmö and we had no means of lo-

cating her either. The man from the group

of three we talked to without getting an in-

terview spoke of a lack of time because of

his work and of other activities he was en-

gaged in. A friend of his warned us of this,

saying that the man was always so heavily

booked up that he doubted we would suc-

ceed in arranging an interview with him.

The two women, in turn, seemed reluctant

to be interviewed and, although they fi-

nally agreed to it, both of them cancelled

later. Insofar as we know, neither of them

had any problems with drugs. Our impres-

sion was that they felt ambivalent about

letting things about themselves be known

to persons whom they thought were linked

in some way with public authorities. For

those belonging to this group generally, a

tendency to be skeptical of public authori-

ties and distrust them could be noted, both

in the initial interview and in this one. The

failure of so many in this group to take part

in the follow-up interview reduces the

confidence, of course, that can be placed

in the interpretations made of what they

reported as a group.

The two persons from the student group

who failed to take part this time were both

women. One could not be located, whereas

the other could not be reached because of

her being in a foreign country at the time.

A factor that could be thought to contrib-

ute to its being only women in this group

who failed to participate could be that the

women in the group related to one another

less closely than the men did. Even though

not all the men in the group were still in

contact with one another, they neverthe-

less knew where all of the others lived,

and the jobs and family relations they had.

Obtaining this information made it possi-

ble to gain contact with all of them quite

readily. It was difficult, however, to reach

some of the woman, due to a lack of such

information.

The only member of the people-in-black

group whom we were unable to interview

was a man who took his life while in his



twenties. This can be seen as suggestive of

the difficulties that can beset the journey

into adult life and of the particularly in-

tensive efforts to achieve and maintain a

sense of identity that this group may have

needed to make.

Methods – interviews and evaluation of themThe data collection method employed

here, that of qualitative research inter-

views (Kvale 1997), was the same as used

in the investigation carried out when the

subjects were about twenty years of age.

A spirit of openness was sought so as to

encourage participants to express them-

selves as they saw fit, though structure

was also sought so as to enable the mat-

ters of concern to be taken up within the

limited time available. Subjects were to

report both on their current life situation

and their journey in arriving there. Various

themes were considered, in current terms

and life course terms alike, one of them

being the role of alcohol, attention being

directed at questions of how drinking typi-

cally took place, both during the week and

on weekends, and how their use of alcohol

at parties and for enjoying themselves had

changed between when they had been 20

and the current time.

The interviews (approximately 1 1/2

to 3 hours in length) were recorded and

transcribed. The text obtained was read

through first in a phenomenologically

closely involved and then in a more dis-

tanced manner (Riœur 1988). In interpret-

ing the material, note was made in partic-

ular of themes that appeared repeatedly,

these being analyzed carefully. The inter-

pretations made were compared with the

results of the study of the meaning alcohol

had for them, which was carried out when

they were about 20. In an article such as

the present one, very limited in length,

emphasis had to be placed on providing

a summary of the results, although it was

also the intention to insofar as possible

provide a bridge between the phenomeno-

logical use of quotations representative

in character and the overall conclusions

drawn concerning the meaning of alcohol

for these persons from a life course per-

spective.

Alcohol in a life course perspectiveWhat had happened in the life course of

the participants regarding their use of al-

cohol and the meaning it had to them be-

tween the ages of about 20 and 35?

“If you compare then with now, it’s

been dramatic in just about every way.

... A transition ... What’s happened in

the different groups in the course of

time is interesting. At the age of 20,

everyone drank a lot. That’s the way it

was. Now so little is drunk in families

with children or by people who live

alone.” (Cecilia from the people-in-

black group)

The most striking change for the par-

ticipants as a whole between the ages of

about 20 and 35, regardless of the group

to which they belonged – as exemplified

by the rather representative quotation just

given – seemed to be that alcohol and in-

toxication had become less meaningful

to them. In our earlier study of the lives

of these persons as 20-year olds (Norell

& Törnqvist 1995) we found that during

intoxication in the company of others of



their age they could create a sort of land

of opportunity, an illusion regarding the

future. Intoxication enabled them to con-

sider collectively how they measured up

to others of their age and to confirm their

having the potential in their future lives as

adults, through the conscientiousness and

resolve they were capable of, to get ahead

in a career and to succeed in life generally.

As 20-year olds their lives were filled both

with tremendous expectations and with

extreme apprehensions. Under the effect

of intoxication, a whole flock of quiver-

ing “I’s” could be transformed into a self-

confident “we”. The process of becoming

intoxicated had a marked element of play.

Those involved in gatherings of this sort

were testing themselves, without danger of

the consequences such testing could have

in the soberness of everyday reality.

No such strong need of intoxication with a

meaning of this sort was evident when these

same groups of persons had become 35.

“‘Aren’t you going to have anything

to drink?’ ‘No thanks’, I say. ‘Are you

driving? Are you pregnant? Are you

religious?’ Those are the things people

think of. Although it seems phony to

explain things like that now, people

still wonder sometimes. My reaction is

to shrug my shoulders and say, ‘There’s

nothing strange about that at all.’

There’s nothing to explain, yet things

have changed now to people asking,

‘What! Don’t you even drink wine? It’s

so nice having wine with your meal’,

which was something you didn’t say

when you were 20. But now there are

lots of people who think I miss out on

what I should be enjoying.” (Kathy

from the people-in-black group)

Although alcohol was assigned lesser

importance than earlier, it was still con-

sidered to be normal enough at the age of

35 for a person to engage in its use, devia-

tion from this calling forth certain aston-

ishment, as illustrated by the quotation

above. Alcohol and certain intoxication

thus continued being viewed as natural in-

gredients in life that members of all three

groups were expected to relate to, alcohol

still having meaning in their lives.

Relational scenarios“On Fridays we tend to have a quiet

evening at home. We want to be by

ourselves or together with the chil-

dren. Carina and I take a nice evening

meal. The children have usually had

supper by then and gone out. We take

a juicy steak or whatever and a glass of

wine. Having wine on Friday evenings

is pretty usual.” (Kenneth, from the

employed group)

In creating their adult lives, people as-

sign increasing importance to the variety

of new areas in which they are involved,

whereas meeting with groups of friends

and acquaintances as they did earlier

tends to no longer have the role it once

had. Their attention is directed to an in-

creasing extent at new relationships, the

family life they have established and their

work. What primarily steers their drinking

then is the life situation they have estab-

lished as adults and their need of feeling

themselves confirmed in that, as opposed

to the search after a sense of cultural iden-

tity they were engaged in as 20-year olds.

When they relax at the end of a week’s

work as 35-year olds, their use of alcohol

depends very much upon whether they



live in a family they have established,

in a pair relationship, as a single parent

with one or more children, or as a single

person. The drinking habits and views to-

ward alcohol of those who live in a family

relationship appear to represent an ideal

and to be the basis for a dominant form of

alcohol culture. Such an alcohol culture,

manifested in the quotation above from a

member of the employed group, was rep-

resented in all three groups, but was most

clearly evident in the student group. The

majority of the members of that group had

established a family and they clearly cher-

ished family ideals.

“We often get together with close

friends on weekends. Either we pre-

pare a meal for them or we do it Dutch

treat, the group coming with their own

food and drink. We start off having a

game of some sort and a grill out back

and take a drink or two. Then we sit

down together with the children, have

a good meal, and drink and spend the

evening then enjoying ourselves.” (Pe-

ter from the student group)

Eating good food and drinking wine in

the security of the family circle or together

with other couples, as exemplified by the

quotation above, appears to have a special

meaning in itself. It helps people confirm

their having succeeded in creating a warm

family relationship for themselves, or liv-

ing together happily with their partner.

Intoxication can make it easy for them to

experience themselves as being both loved

and capable of loving, even if this is not

the case. Things are not always as they ap-

pear on the surface. The relation between

two people may not function as it should,

and whether one of them is truly loved by

the other may be far from clear. Problems

of this sort can be accentuated by the trials

and tribulations of everyday life, by diffi-

culties within the family or in connection

with one’s work, or by both partners being

employed outside the home and being so

taken up by matters concerned with their

career that they have little time and en-

ergy for each other. The breakup of rela-

tionships today is not at all unusual. The

“holy hours” of spending time together on

weekends consuming food and wine to-

gether can serve as a kind of glue, helping

to hold a marriage or partnership together

and keep it intact. The woman appears to

be more of a driving force than the man

in maintaining a family alcohol culture of

this sort. The drinking of wine is some-

thing perhaps more womanly than manly

in character in this phase of life, as the fol-

lowing quotation suggests:

“On Fridays, after being at the pool

for a swimming course, we usually get

home at about seven to seven-thirty or

so and have a cozy evening of it then.

I don’t spare costs at all, not that I

spend a lot on clothing and that sort

of thing, but food and drink are re-

ally important. After I’ve bought some

groceries, we have a quick meal, since

we’ve gotten home so late, and we go

on drinking. At the moment we usu-

ally have wine twice a week.” (Cecilia

from the people-in-black group)

The conditions for family life that Beck

and Beck-Gernsheim (2002) consider to

be typical of reflexive modernism can be

discerned here, those of the man and the

woman each pursuing a career and ex-



periencing a need of self-realization in

connection with it, their likewise taking

responsibility for family life and attempt-

ing to work together to maintain it, a situa-

tion that can lead to conflicts and tensions.

The authors argue that although there is an

ideology of gender equality in joint efforts

to resolve such tensions and conflicts, it

is the woman who assumes the major re-

sponsibility for seeing to it that family life

functions as it should and finding solu-

tions to things. This was also found to be

the case in the present study in connection

with each of the three groups. It is exem-

plified by the quotation above, in which

the woman tells of seeing to it that the two

of them can eat and drink well when the

weekend arrives.

In a study of Swedish people’s alcohol

consumption conducted by Leifman and

Gustafsson (2003) at about the same time

as the present investigation was carried

out, the picture just presented of the wom-

an’s role in a relationship in connection

with the use of alcoholic beverages was

shown to apply very clearly to women at

the age of 35–40. The authors found alco-

hol consumption to be highest for people

in their early twenties and to then decrease

with age until about 30 for men and 35 for

women. For men the level thus reached

tended to remain, whereas for women an

increase occurred on into their early for-

ties. The typical drink for men was found

to be beer of high alcohol content, whereas

for women it was wine. A clear tendency

was evident in both men and women for

a decrease in the consumption of strong

beer as compared with wine to occur with

increasing age. This suggests that within

a family context a certain harmonizing of

the drinking habits of women and those

of men occurs between the ages of about

30 and 40, wine being the alcoholic drink

the two tend to agree upon drinking for the

most part, the woman being the one who

assumes the position of planning and ini-

tiating this.

In the present study it was observed that

from a life course perspective the relative

position of women and men in determin-

ing the consumption of alcoholic drinks

appears to undergo a considerable change,

at the age of 20 men determined very much

themselves the types and amounts of the

alcoholic beverages they consumed, but by

age 35 women having assumed the domi-

nant role within the family in regard to

drinking habits. How is it then with wom-

en or men who are single or who share the

care of a child with a former partner?

“It was one of the weekends she [her

daughter] spent with Kalle [the girl’s

father] and I got to drinking while I was

out enjoying myself. Drinking really

puts me into a good mood. I felt that

after being taken up with things the

whole time for two weeks ’It’s my turn

now to go out and have a good time’.”

(Susan from the employed group)

Quite a number of the participants were

living either as single parents with one

or more children or as single persons.

The life situations of these two types ap-

peared to have left their stamp on the use

of alcohol by these persons and how they

viewed its use, as the quotation above

suggests. As a group, these persons were

more ambivalent in their views on drink-

ing and celebrating than those living in a

family relationship. Single parents living

with their child(ren) tended to express



caution toward the use of alcohol, feeling

that a child should be protected against

the risks that the consumption of alcohol

involves. Thus, they waited to drink until

the child(ren) left the table, or until their

former partner took his/her turn in car-

ing for the child(ren), the latter allowing

them to go out dancing or to meet with

other single persons. In contrast, those

living in a family relationship considered

their drinking of alcohol together with

meals on weekends to provide a positive

atmosphere, both for themselves and for

the child(ren). The restrictions the single

parents placed on drinking in front of their

child(ren) could be thought to represent a

secret longing to go out and meet some-

one. Their drinking together with those

in a similar situation could be interpreted

as their saying, in effect, “Despite our not

having a relationship with anyone, we’re

succeeding well in caring for our children

and protecting them.” Getting together in

this way was most common among the

employed group members.

“I have the good fortune of having lots

of close friends who are very temper-

ate in their drinking. In addition, I

have a small bunch of reasonably close

friends about 35 to 45 who go out and

booze it up a lot. All of them are single

and, like me, have just broken up with

someone. They’ve returned to about

how things were back in their teens

and early twenties through their begin-

ning to live it up again. They’re look-

ing for a new partner and the feeling of

security that goes with it, but the men

aren’t searching as desperately as the

women are, since it’s the women who

want children. Everyone in the group

has just broken up and has really begun

swinging the bottle” (slight changes in

the quotation were made for clarity’s

sake). (Erik from the student group)

The motives for single persons in go-

ing out to drink and have a good time can

depend upon whether they are “eternal

singles” or are persons who have recently

become single due to the breakup of a re-

lationship. One possibility for those of the

latter category, as exemplified in the quo-

tation just given, is that they seek a stable

relationship with someone through going

frequently to places where they can drink

and enjoy themselves with the aim of find-

ing someone. Another possibility is to seek

contact of a more general sort in efforts to

overcome the feeling of being alone that a

separation has brought on, or that the fact

of being single as such creates.

“When you drink now it’s more in the

company of others. You sit and chat

and have some food or snacks. It’s the

sort of thing that didn’t interest you

so much earlier. In the summers you

go and visit friends with a house of

their own where you can have a grill

in the back yard. You sit and drink

pilsner and shoot the breeze. You’re

completely satisfied with that, you get

back home again in good season and

you feel fine the next day.” (Mikael

from the employed group)

For persons who have been single for

an extended period of time and are partly

resigned to this, there are typical patterns

of drinking related directly or indirectly

to their desire to have a partner and to

their not having one. They may empha-



size, as in the quotation above, that they

are on close terms with one or more fami-

lies and have good times and take drinks

with them. They are apologetic in telling

of their visiting dance halls and the like,

as though that were an admission of their

not having established a steady relation-

ship with someone and of their being a

failure in this respect. Some singles, on

the other hand, represented here primarily

by certain members of the people-in-black

group, appear to have ceased going out to

drink in the company of others almost en-

tirely. This can mean their having given

up hope of being able to establish a rela-

tionship with someone.

The drinking on weekends that most of

those who were interviewed engaged in,

which basically represents a normal level

of drinking, can be seen as providing them

a form of relaxation from the stresses to

which they were exposed in everyday life

and as reflecting in some way how they

experienced the life situation in which

they found themselves at the age of 35 or

so concerning, as the case might be, such

matters as their sense of attachment to

their child(ren) and their enjoyment of be-

ing with them, how they managed as sin-

gle persons to provide adequately for their

child(ren), how they succeeded at their job

and at tasks of other sorts with which they

were confronted, how they experienced

their family life and/or their relation to

their partner and, to the extent this ap-

plied, their continued hope of establishing

a family.

Within the framework of reflexive mo-

dernity, in which it is by no means self-

obvious that a family one has established

will be permanent, new patterns of living

and new cultural forms are developed.

According to Beck and Beck-Gernsheim

(2002), one should regard as important

the manner of relating to one another that

people show prior to their forming a re-

lationship, after a relationship has ended

and between successive relationships. The

efforts of single persons and single parents

to find meaning in the use of alcohol can

be viewed within such a context.

Approaches to alcohol bordering on both the new and the oldThe life situation the participants had cre-

ated for themselves by the age of 35, both

in terms of the partner relationships they

had established and the alcohol culture

they had adopted, was found to be colored

by the cultural style characterizing the ap-

proach to drinking and alcoholic festivi-

ties they had shown some 15 years earlier.

Thus, although at the age of about 35 there

were considerable similarities between the

employed group, the student group and

the people-in-black group in their relation

to alcohol, there were also noticeable dif-

ferences. How during periods of intoxica-

tion at the age of 20 participants had dealt

with certain questions central to their lives

appeared to still affect how they viewed

alcohol and intoxication 15 years later.

“I’m quite often in the company of oth-

ers who don’t drink either. I’d never go

with my children ... to a party where I

knew people would be sitting around

drinking. I have no difficulty in being

together with people like that when

I’m alone, but I don’t sit down with

them when I’m with my children,

since I don’t feel that that’s anything

for them. I’m grown up enough to say



’No, I don’t want any, but go ahead

and take some yourself’ and to leave if

things get to be too wild.” (Kicki from

the employed group)

Although nearly all members of the

employed group lived or had lived under

family or family-type conditions, their

manner of speaking about the use of al-

cohol in a family situation differed from

that of members of the student group. This

can be seen in the attention they directed

at the dangers they felt children were sub-

jected to if they were exposed to drinking

by adults, a view the quotation above ex-

emplifies. This was true in particular of

persons who were single and had one or

more children, a situation more frequent in

the employed group than in the other two

groups. These persons tended to consider

it important that they control their impuls-

es (behave properly) and to be fearful of

their being unable to succeed at this. They

conceived themselves as being a threat to

the children at hand through their difficul-

ties in maintaining control of their own

impulses, despite their being proud other-

wise of their ability to take responsibility

and remain disciplined. Their caution in

the use of alcohol in front of children can

be seen as an effort to not let their impul-

sivity have a detrimental effect on those

dependent upon them. One can note, how-

ever, that this defensive approach toward

use of alcohol in front of children was not

always maintained. In situations that ap-

peared completely safe, children were al-

lowed to take part in festivities involving

use of alcohol.

“Both food and drink are served ...

Families with children are often there.

It really livens things up. There are

lots of people like that you can go and

visit. It’s really great. There are friends

of ours like that in Malmö. We take a

taxi when we go there. Night life as it

was before is nothing for us now.” (Ulf

from the student group)

Those in the student group spoke again

and again of their “family”, both concern-

ing everyday things and in connection

with parties, such as in the example just

given. There is a both manifest and con-

scious ideal of everything being in the

best interests of the family. When a person

is 35, it is not enough to simply make it

known that one has established a family if

one wants to give the impression of hav-

ing succeeded with this. In contrast, when

one was 20, it was quite possible, in a state

of intoxication, to create in an illusionary

way the feeling in oneself that one’s goals

for the future of succeeding and of living

in a family that one had created had al-

ready been achieved. There was no realis-

tic conception of what quality of life such

accomplishments might provide one with.

Now at the age of 35, however, the impor-

tance of creating positive bonds within the

family had become evident. In drinking

together with one’s partner on weekends,

one endeavored to experience a sense of

closeness and a confirmation of one’s hav-

ing a happy relationship with each other

and managing things, despite the strains

and stresses of each having a job to hold

down. Alcohol having taken on a role of

this sort shows a process of maturing to

have occurred since one was 20. At that

time, one believed that happiness consist-

ed of having achieved a particular position

in terms of the work one did and the rela-



tions one had. One took no account of what

this actually meant and how one would

feel during the journey there. By this time,

in contrast, one had experience with what

the efforts that were needed meant. One

understood that happiness is not the su-

perficial accomplishment of having work

and having a family but rather the abil-

ity to be happy together in the situation

in which one found oneself. Alcohol had

more the meaning now of its being some-

thing one gathered around and that could

contribute to relationships within the fam-

ily being experienced as functioning well

and being rewarding. Indirectly that also

implied that it was not self-obvious that

family life functioned as one hoped, even

if one might seek, through the extraordi-

nary state that alcohol put one in, a confir-

mation of one’s living up to the ideals of a

“bourgeois family culture”. The difficulties

that a perspective of reflexive modernity in-

volves have to do with one’s living increas-

ingly within a “self-culture” (Beck & Beck-

Gernsheim 2002) in which one needs to

negotiate with one’s partner on the basis of

one’s own individual needs (Giddens 1995)

rather than considering it to be obvious that

one’s family will remain intact.

From this standpoint, one can see there

to be two different regenerative strategies

in connection with the use of alcohol man-

ifest here, members of the employed group

endeavoring through the cautious use of

alcohol to defend the better interests of

their children, members of the student

group, in contrast, defending the practice

of drinking within the family circle. The

tendency, typical of reflexive modernity,

of not regarding the furtherance of family

life as being a self-obvious goal appears

to be more clearly manifest within the

employed group than within the student

group. Various models for living together

– prior to formation of a pair relationship,

as well as after the breakup of a relation-

ship, and between successive relation-

ships – are evident within the employed

group. The uncertainty of having no clear

partner at hand can create a strong identi-

fication with one’s child. This can be seen

perhaps as representing a displacement of

one’s own feeling of needing to be cared

for and one’s desire to be recognized as an

individual. According to this line of rea-

soning, protecting one’s children from al-

cohol can be regarded, in effect, as a way

of protecting oneself.

“Living it up reached more or less a

high point while I was studying. We

often went to taverns and restaurants

or sat at home and drank. I continued

with that until I was about twenty-six

or twenty-seven. Then that dropped

off, but when I moved to Göteborg

I continued on with it in high gear,

my going on with adult studies there

putting me into a kind of second child-

hood. But now ... I just can’t function

right anymore when I have a hangover.

I can’t work properly when I drink

and there’s lots of work I need to do

on weekends, so it’s very seldom that

I drink.” (Johan from the people-in-

black group)

Members of the people-in-black group

sometimes reflected on the role of alco-

hol in dealing with crises, as reflected in

this quotation. In the life course of various

members of that group, alcohol had served

many times as a means of preserving their

sense of self when they felt downtrodden



or attacked and in need of support. The

group’s members had continued drinking

as they had done at the age of 20 for a long-

er period of time than members of the other

groups did, returning to it as well in peri-

ods of crisis and uncertainty. They lived in

the conviction that in order for life to func-

tion properly one had to take oneself as the

starting point. Their regenerative strategy

can be formulated as declaring that if one

feels good one is in a position to give to

others. To the extent they felt established

and secure in the adult arena and fully ac-

cepted there, alcohol had lost its meaning

for them. Although they had needed alco-

hol at one time to create illusions for them

and a feeling of triumph, they no longer

needed it when they had come far enough

to get by fully on their own, their being at a

point then where they had neither become

shining stars nor floundered completely.

They still understood alcohol as being

linked with the overcoming of crises, the

protection of one’s ego strength, and the

ability to create and maintain the form of

adult living one sought in which one got

by on one’s own strength and created one’s

own individuality.

The individualized way about them

and the self-culture that could be noted

in those members of the employed group

who had failed to succeed in maintaining

a relationship with an adult partner, or

had had difficulties in this respect, were

even more clearly established in the peo-

ple-in-black group, the members of which

were reflexively conscious of the fact that

everything can change, at the same time as

they had confidence in their ability to deal

with crises. A consciousness of how they

had used alcohol in their efforts to achieve

an adult sense of identity was part of the

reflexivity they showed toward themselves

and toward others.

One can readily see in the student group

how the middle-class successful-family

ideal that they expressed harmonized with

the meaning that drinking on weekends

had for the pair or family involved. The

dominant alcohol culture this could be

said to represent involved the conception

of a stable pair relationship and a happy

family life. During a period in which there

appears to be an increasing sense of inse-

curity through cultural changes that are

occurring and through the individualiza-

tion in society becoming greater, this can

be regarded as a kind of contradiction,

but also as resisting such tendencies. One

should also not assign undue weight to

present-day individualizing tendencies,

since the dream of a happy life and how it

can be achieved is so strongly anchored in

both an historical and a cultural sense. In

line with this, there is also a highly mod-

ern bourgeois family goal based in part on

a traditional conception of a working-class

culture in which the family is seen as the

hub in a kind of life circle, and in which

the memory of times characterized by a

highly stable and cohesive family situ-

ation is still alive, along with the idea of

one’s being able to get by without needing

to enlist the support of anyone else.

New forms of alcohol culture“I always went out drinking earlier.

I regret having done that so much. It

isn’t particularly much fun ... You

have to stand around in line and wait,

and you end up paying a lot. Every-

body’s drunk. No, it’s a lot better now.

A bunch of us, guys I work with and I,

go out after work one evening a month,



sit around, drink a few beers and talk

about things. It’s much more fun than

being out running around town.” (Rob-

ert from the employed group)

One thing that at the time of the earlier

investigation distinguished members of

the people-in-black group from the em-

ployed group and the student group mem-

bers was the approach taken toward drink-

ing on weekdays. As outsiders of sorts,

one expression of their sense of identity

was to go to taverns weekday evenings to

drink (Norell &Törnqvist 1995; Törnqvist

1999). In contrast to this, in the present

investigation all three groups considered

drinking during the week to be something

one should be cautious about. Members

of the employed group and the student

group regarded it, however, as becoming

increasingly a part of “normal” behavior,

especially when one drank together with

colleagues from one’s job, as exemplified

by the quotation above. Most of the women

and men alike who spoke of doing this were

very much engaged in their work and want-

ed to deepen and maintain close personal

contacts with their colleagues in this way.

There were clear differences between

beer and wine regarding conceptions as-

sociated with drinking them, as well as in

terms of when, under what conditions and

by whom they were most likely to be con-

sumed. Wine was a highly accepted drink

on weekends, whereas beer was regarded

as particularly appropriate for get-togeth-

ers with work colleagues on evenings dur-

ing the week, it also being considered to

be a drink primarily for men. The partici-

pants appeared to associate wine above all

with leisure time, weekends, the more inti-

mate sphere, close personal relationships,

and femininity, and beer with weekdays,

relationships at the place of work, things

one did in public and manliness. Except

for certain special occasions at work when

drinks were normally taken, drinking was

considered to be something that should

only be done during one’s free time.

How had it come about that, whereas

in about the mid-80s it had been typical

for 20-year olds with a “normal” style

of living to feel that drinking during the

week was taboo, matters had changed very

much for many of these persons some 15

years later, at the age of about 35, when

many of them felt that under appropriate

circumstances drinking on weekdays was

quite all right? The fact of their having es-

tablished themselves as members of the

working force could be one explanation of

this. When people are 20 they can be full

of uncertainties regarding the future and

their chances later of obtaining the sort of

work they want. This could have made it

seem dangerous to the participants then

to deviate from the norm of only drinking

on weekends and to have been a sign of

failure, except for members of the people-

in-black group, who sought the opportu-

nity to drink at such times. When some 15

years later all those taking part in the in-

vestigation then knew they had succeeded

all right in living and working in the adult

world, and also knew of there being a cul-

ture in which work colleagues went out

to drink beer with each other during the

week, partly with the aim of strengthen-

ing their feeling of togetherness, they were

ready enough to take advantage of this.

Also, during the 15 years that had passed,

the Skania region of southern Sweden in

which most of them lived, as well as Swe-

den generally, had been increasingly influ-



enced by the drinking habits of central and

southern Europe, where it is an everyday

matter to go out to bars, pubs and restau-

rants to drink beer and wine (Leifman &

Gustafsson 2003). In addition, the par-

ticipation of women in the working force

had increased, which made it increasingly

important to them to strengthen their con-

tacts with their colleagues at work. The

changes that occurred generally were not

limited, however, to drinking connected

with relations at the place of work.

“On weekdays we usually drink just

water and milk. Sometimes, though, I

take a weak beer, and now and then we

drink a glass of wine, although that’s

not the usual thing.” (Peter from the

student group)

It was not unusual, at least in the student

group, as exemplified in the quotation just

given, and the people-in-black group, to

drink wine with meals on evenings dur-

ing the week. To what extent was this also

a sign of Europeanization? In answering

that one needs to take account of the con-

ditions under which the participants were

living and the meaning they assigned to

the drinking of wine. It was primarily pairs

to which members of the student group

and the people-in-black group belonged

who drank wine – their doing so serving

to emphasize the two of them representing

a happy pair. In contrast, for the employed

group members with a partner the risk they

felt there to be of their child(ren) being

influenced in a negative way if they vio-

lated the norm of keeping what they did at

home apart from what they did while out

enjoying themselves tended to restrict very

much their drinking of wine at home. With

this in mind, one can wonder why, for the

student group and people-in-black group

members and their partners, drinking only

on weekends did not suffice for clarifying

their joy at being a pair. One reason for this

can be that drinking at home in that way

was no longer considered taboo and was

also regarded as a sign that one subscribed

to an ever more internationalized way of

thinking and acting. Another reason can be

that the possibilities for showing their af-

fection for each other in this way on week-

ends seemed insufficient, their feeling the

need for this during the week as well.

In attempts to explain this, one can note

that family life appears to be exposed to

strains and stresses to an increasing ex-

tent. In many relationships the two are not

even accustomed to eating supper together

during the week; their parallel lives and

separate jobs and spare-time interests can

make it appear impractical for them to at-

tempt to do so in a routine way. The free-

time interests of the child(ren) can also

lead to the one or the other parent driving

to where sports activities take place and

possibly taking part in activities there as

well, likewise making it difficult for the

two to get together at home on weekday

evenings.

All of this illustrates the difficulties

there are today for couples 35 years of age

or thereabouts to live together in a manner

supportive of what would otherwise be

their ready access to the intimacies of eve-

ryday life in their living together. Deep-

ening their everyday contacts with each

other by eating and drinking wine together

can enhance their feeling of closeness and

be supportive of their relationship, where

family relationships today are exposed to

so many forces that tend to disrupt them.



ConclusionsThose who participated in the study ap-

pear today to be living a reasonably well-

anchored existence, after having been able

to test themselves against the realities of

everyday life and see how things went in

terms of both their expectations and their

apprehensions regarding life as an adult.

At the age of 35, they were living less in

the future and more in the present than

they had done at the age of 20, when they

had been much concerned about how

their lives would develop, regarding re-

lations with others, founding of a family

and becoming established occupationally

or professionally. They now saw what

their efforts had resulted in. Regardless of

which of the three groups they belonged

to, the vast majority appeared to be basi-

cally satisfied with life and what they

had achieved thus far. Even if life had not

reached up to their highest expectations, it

had hardly become what they had some-

times been fearful of. Although a certain

degree of disillusionment is unavoidable,

one comes to gradually experience how

one can deal effectively with the demands

placed upon one as an adult.

At the age of 35, those in the three groups

no longer felt the strong need they had ear-

lier of support by others of their own age

in creating illusions that they could take

control of things and assume responsibili-

ties adequately (the employed group), real-

ize their ambitions of establishing a family

(the student group) or have the willpower

needed to make their dreams become reali-

ty (the people-in-black group). This had re-

quired their taking responsibility for their

lives on a daily and hourly basis, keeping

their goals in mind, and managing to get

by on their own in situations far from easy

to deal with. Their now having developed

an adult identity and having managed to

get by all right in so doing, intoxication of

the sort they had experienced at the age of

20 had been drained of much of its mean-

ing. They no longer had the same need as

before of being able to “live it up” with the

help of alcohol.

Establishing an intimate relationship

with someone, having a child and starting

a new job all typically lead to a change in

a person’s pattern of alcohol consumption.

One no longer needs to go on with one’s

hopes and expectations alone when one

knows that, having become an actor on the

adult stage one can establish and maintain

relationships effectively with other adult

individuals, hold down a job and have

the feeling of doing something creative or

worthwhile. A state of “generativeness”,

as it has been called (Erikson 2000), devel-

ops – the person being able to care deeply

for someone, establish a relationship with

that person, have children and guide a new

generation toward adulthood. Whereas as

a 20-year old one is taken up with ques-

tions of how one can get by, as a 35-year

old one is less preoccupied with concep-

tions regarding oneself as such and more

oriented to what one wants to be involved

in and take responsibility for. “We are that

which we love” (Erikson ibid., p. 118), be it

our children, relationships with others or

our work. Such a view of life is not one of

there being natural laws in terms of which

people all do basically the same thing at

some particular age. Rather, it is the idea

that what one does is a function both of

the historical and cultural situation one is

in and of where one is located in one’s in-

dividual life course (Berman 1995; Kotre

1984). In the present context one can note



there being clear differences between the

employed group, the student group and

the people-in-black group at both the indi-

vidual and the cultural level.

Alongside all of this, one can also note

that many people make use of alcohol reg-

ularly, also in their adult lives, one reason

for this being that there is no absolute se-

curity in what one does, however strong

one’s identification may be with goals one

is pursuing and the relationships one has.

There is a continual search for identity,

asking oneself who one is and how life as

a whole functions, with a need of positive

reinforcement. Alcohol can serve as a cat-

alyzer, one that facilitates such reinforce-

ment. For the employed group such rein-

forcement can be the feeling that one is

caring for one’s children properly, for the

student group the feeling that one’s fam-

ily life is functioning as it should, and for

the people-in-black group the belief that

one is functioning well and that one has

something genuine to offer. The idea that

one’s life situation is as one would like

can be reinforced by the search for mean-

ing that the use of alcohol involves. The

question can be of how one functions as

a partner, as a single parent with one or

more children, or as a single person. This

life situation as one experiences it does

not reflect some mechanical identification

of a cultural character one has with be-

ing a person of the sort found within the

employed group, the student group or the

people-in-black group, even if rather many

of the employed group members are single

persons with a child or children, many of

the student group members are living in

a stable relationship with a partner, and

many of the people-in-black group mem-

bers are single.

It appears as though a form of alcohol

culture emphasizing one’s living together

happily with one’s partner and in the fam-

ily constellation one has established is a

dominant one, its being regarded by a great

many people as the ideal for how they

want or would wish to live. Yet achieving

this has its costs. In a world that appears to

be becoming increasingly individualized,

a successful relationship between two per-

sons requires the ability both to negotiate

and to make adjustments where needed

(Giddens 1991). Taking alcoholic drinks

during the evening on weekends can be

seen as often representing a highly impor-

tant element in efforts to maintain the feel-

ing of two people loving each other and

having a happy family life. It is important

to note that it is the woman who tends to

assume the more dominant role than the

man in this scenario. Whereas at 20 it was

thoughts regarding the future that seemed

most important, at 35 what is seen as most

important is to have a happy family life.

This latter ideal is one so powerful that

Beck and Beck-Gernsheim (2002) would

place it on a par with religion. In an in-

creasingly individualized world, a truly

meaningful life would seem to be found

in closeness to one’s partner and one’s

children. The role that alcohol can play

in helping people to feel that they have

succeeded at this should not be underes-

timated.

The reinforcement of a feeling of this

sort tends to be concentrated above all to

weekends. At the same time, one can note

a clear tendency for other, more every-

day forms of drinking to take place with

increasing frequency, forms coupled in

particular with drinking habits in central

and southern Europe. It is becoming more



and more common, for example, for cou-

ples and families generally to occasionally

combine eating with the drinking of wine.

It is not at all unusual either for people to

go out and drink beer together with their

colleagues after work occasionally. Drink-

ing beer with one’s colleagues in a public

place also symbolizes one’s ability to func-

tion well both in one’s work and in a pub-

lic place. As women are coming to play an

increasingly strong role in public life, there

is also an acceleration of individualization

that one can note, men and women living

and working together generally to perhaps

a greater extent than at any previous time

in history (Castells 2000).

Translation: Robert Goldsmith

Claes Törnqvist, university lecturer in psychologydepartment of Psychologylund universityBox 213 222 00 lund, Swedene-mail: [email protected]


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Research report

A B S T R A C T

IntroductionEvidence-based practice 1 (EBP) has been advo-

cated since the beginning of the 1990s and is

today, at least within the western hemisphere,

an established doctrine in many professional

fields. This holds true also for addiction treat-

ment. One important example of this develop-

ment is the production of practice guidelines.

In the following an analysis and discussion of

the recently published (February 2007) Swed-

ish national guidelines for addiction treatment

will be presented. These guidelines cover

almost 200 pages and deal with several top-

ics. The focus here will be on what arguably

constitute the most important issues: psycho-

social and pharmacological interventions for

alcohol and drug problems. The analysis aims

to deal with several dimensions of the guide-

lines: a) The quality of the guidelines in terms

of scientific underpinning, b) The usefulness

of the guidelines, i.e. to what extent it is pos-

sible to use the guidelines in actual practice,

c) How the guidelines were produced (time-

aspects, involvement of experts and the role

of the National Board of Health and Welfare

as the responsible organisation), d) To what

extent the guidelines have been developed

with reference to and from a discussion of

the rivalry between the earlier manifestation

anderS BergmarK

Guidelines and evidence-based practice

A critical appraisal of the Swedish national guidelines for addiction treatment

A. Bergmark: Guidelines and evidence-

based practice – a critical appraisal of the

Swedish national guidelines for addiction

treatment

Evidence-based practice (EBP) has

been advocated since the beginning of

the 1990s and is today, at least within

the western hemisphere, an established

doctrine in many professional fields. This

holds true also for addiction treatment.

Over time EBP has come to signify a

more general orientation to a scientifically

secured knowledgebase and by this partly

obscuring the fact there exists different

and to some extent contradictory opinions

on how EBP should be implemented. The

paper aims at an analysis of the newly

published Swedish national guidelines

for addiction treatment. The analysis

addresses several dimensions of the

guidelines: a) The quality of the guidelines

in terms of their scientific underpinning.

b) The usefulness of the guidelines, i.e.

to what extent it is possible to use the

guidelines in actual practice. c) How the

guidelines were produced (time-aspects,

involvement of experts and the role of

the National Board of Health and welfare

as the responsible organisation). d) To

what extent the guidelines have been

developed with reference to and from

discussion of some of the major scientific

controversies related to the EBP issue.

KEywORDS

Guidelines, evidence-based practice,

psychosocial interventions.


of EBP, where the individual practitioner

is responsible for critically appraising the

evidence, and the production of “expert

guidelines” and e) Have some of the major

scientific controversies related to the EBP

issue (as the Dodo bird verdict and the re-

searcher allegiance effect) been taken into

consideration?

Although only one “case” is analysed in

the following, it can be argued that some

of the aspects discussed have a bearing on

a more general level concerning the pro-

duction and usefulness of practice guide-

lines. At the same time the analysis can

be described as a product of an “insider

perspective”, since the present writer par-

ticipated in some of the preparatory work

for the guidelines. 2 Even though such an

involvement can be regarded as a serious

complication with respect to the objectiv-

ity of the analysis (increasing the probabil-

ity for a partisan or an overly critical anal-

ysis), it can also be regarded as an asset

in the sense that some important informa-

tion, not accessible in the actual text, con-

cerning the process of developing them is

known to the present writer.

The guidelines are published by the

Swedish National Board of Health and

Welfare (NBHW) but have no legal status

and are thus not mandatory for practition-

ers to follow. But at the same time it is

claimed that the guidelines will be used

as a document of reference in the surveil-

lance of treatment agencies, which is a

major responsibility for the NBHW, and

in this respect it can be said to constitute

a document with – at least in theory – a

regulative power over treatment practice

(Socialstyrelsen 2007, 29).

An important source for the guidelines

is the comprehensive review on evidence-

based treatment for alcohol and drug prob-

lems published by the SBU (2001; revised

English version, Berglund et al. 2003). But,

as will be pointed out in the following, it

is unclear to what extent the relation be-

tween the two documents is based purely

on authority (i.e. the fact that both the SBU

and NBHW are state agencies) and whether

or not the guidelines represent an uncriti-

cal reproduction of the SBU’s review.

Are the guidelines evidence-based?Although the concept of evidence by no

means has a self-evident meaning, it can

nevertheless be claimed that evidence, as

a minimum requirement, should be char-

acterised by transparency, both in terms

of systematic and articulated procedures

as well as a complete display of the refer-

ences to the studies that have been used in

order to establish evidence. In both these

respects the guidelines discussed here are

seriously flawed. The actual recommenda-

tions in the text are based on narrative re-

views produced by groups of experts, but

these reviews are not present in the text

(they can, however, be reached through the

homepage of NBHW). But the correspond-

ence between the reviews of the experts

and the recommendations is often very

weak. In the summary of the expert report

on psychosocial interventions for drug

problems, the coordinators of the group

write: “The situation concerning misuse of

opiates is contradictory. On the one hand

the SBU-study identifies some positive

results; on the other hand other reviews

and meta-analyses reach different conclu-

sions” (Socialstyrelsen 2007, 146; author’s

translation). Given that the guidelines are

claimed to be based on the expert reports



it is unclear on what the following recom-

mendations for drug misuse are based on:

On the highest level of evidence (1, in a ev-

idence-hierarchy consisting of four levels)

five different interventions are identified;

Cognitive behavioural therapy with focus

on the misuse; Brief intervention/Moti-

vational Interviewing; CRA-treatment;

Dynamic therapy; Family therapy with a

focus on misuse and dependency. Further-

more it is claimed, also on the “highest

level of evidence”, that common factors

for the interventions identified as effective

are: a clear structure; a focus on misuse

and dependency; clear definitions of the

interventions; and that the interventions

are manual based (Socialstyrelsen 2007,

52–53). For anyone that reads the expert

report on treatment for drug problems it

becomes quite clear that none of these rec-

ommendations has unambiguous support

in the report. Instead, it seems like the

source of these recommendations is the

SBU-study from 2001. This might be seen

as reasonable, but since the lack of empiri-

cal support for these general characteristics

of the interventions designated as effective

is also valid for the SBU-study, the oppo-

site is the case. Neither is there any pres-

ence of the criticism directed towards the

SBU-study (se e.g. Bergmark 2001; Mäkelä

2001; Poikolainen 2002; Thorsen 2001).

When it comes to the second basic

component for achieving transparency

the guidelines are extremely underdevel-

oped. As already mentioned, no parts of

the experts’ narrative reviews are present

in the text, but beyond this, there is also

an almost complete absence of references

altogether. The reader has no possibilities

to see the sources (with the exception of

the SBU-study) for the recommendations

that are put forward, and with that, no

real opportunity to disagree or critically

evaluate the scientific basis of the recom-

mendations. In this respect the guidelines

are clear-cut examples of the type of docu-

ments which is heavily criticized by pro-

ponents for the type of EBP put forward

by Sackett and colleagues (Sackett et. al

2000).

The lack of references is also striking

in relation to other attempts to establish

which interventions can be considered to

represent “best practice”. Notwithstanding

that the Cochrane Collaboration (which

can be considered to be the most prestig-

ious EBP organisation) has produced sev-

eral reviews that come to radically differ-

ent conclusions than those presented in

the guidelines, this is not mentioned or

commented on in any way (this is, e.g.,

true for psychosocial interventions for

opiate problems, with or without substitu-

tion treatment, and for treatment with nal-

trexone for alcohol problems; see Amato et

al. 2004; Mayet et al. 2004; Srisurupanont

& Jarusuraisin 2004).

The lack of references is also conspicu-

ous in the parts of the guidelines that deal

with conceptual issues. In connection with

a discussion on the definition of “treat-

ment”, and the introduction of another

version of the concept, there are no refer-

ences to previous attempts on the subject.

This stands out not only as a violation of

institutionalised standards concerning sci-

entific writing, but also as something even

worse, given the fact that a substantial part

of the suggested definition has previously

been put forward by others.



Can the guidelines be used in practice?The legitimacy for the production of

guidelines is, by and large, founded on

the assumption that they will improve

practice in the sense that practitioners

will use them to make informed clinical

decisions. This idea is in turn dependent

on a number of circumstances if it is to be

realised, i.e. if some prerequisites are not

fulfilled the usefulness of guidelines is put

in question.

A major problem with many guidelines

concerning non-medical interventions

is that they are poorly operationalised

(Wambach et al. 1999), and hence more or

less difficult to use as a point of reference

for actual clinical practice. They tend to

lack specificity in the sense that recom-

mendations are articulated in an equivocal

or global fashion that provides little or un-

clear information. This problem is clearly

present in the guidelines in focus here: The

interventions listed for alcohol problems

are the same as for drug treatment (stated

in the section above), but three more in-

terventions are added; twelve-step pro-

grammes; interactional therapy and moti-

vational treatment. But the mere listing of

eight different interventions, only nomi-

nally defined, does not provide a strong

knowledgebase for the decisions of prac-

titioners. The only supplemental guidance

to the labels of the interventions is the

assertion that a common ground for all of

the recommended interventions is a clear

structure; a focus on misuse and depend-

ency; clear definitions of the interventions

and that they are manual-based. It seems

somewhat contradictory that a guideline

text which gives no substantial definitions

whatsoever of the interventions it recom-

mends underlines that any effective inter-

vention has to be clearly defined. Beside

this, no evidence (i.e. studies or reviews)

for the general characteristics of the inter-

ventions that are designated as effective

are provided, neither in the guideline text

nor in the SBU-study.

The next problem connected with the

actual use of the guidelines is on what ba-

sis should – e.g. in the case of a specific

individual seeking treatment for alcohol

problems – the practitioner choose one in-

tervention before the other. One possible

rationale for such a decision could be spec-

ifications of the suitability/effectiveness of

the recommended interventions concern-

ing different types of alcohol problems.

But no such specifications can be found in

the text: On the contrary, it is clearly stated

that no such specifications are made: “One

question that is not explicitly dealt with in

the guidelines below is for which groups

or where (specific organisational settings,

author’s brackets) the recommendations

shall be valid” (Socialstyrelsen 2007, 42;

author’s translation).

In the section of the guidelines that deals

with the knowledge-base for psychosocial

interventions for alcohol problems it is

claimed that “Several specific psychoso-

cial treatment interventions have positive

effects... Specific methods show better ef-

fects than unspecific” (Op. Cit., 207) The

term “specific psychosocial treatment” is

defined as an intervention that is based on

a specific or systematic method or tech-

nique. 3 If we, for the time being, leave

the possible objections to this definition

aside, and take a closer look at some of the

underlying material (i.e. the expert report

that deals with psychosocial interventions

for alcohol problems) for the state of affairs



concerning specific interventions, yet an-

other problem arises. In the expert report

the issue of specific interventions is elabo-

rated in the following way “No specific

intervention is more effective than any

other” (Socialstyrelsen 2007, 203). Since

this conclusion is also present in the SBU-

study and the text of the guidelines explic-

itly states that conclusions from the SBU

on psychosocial interventions for alcohol

problems remain unaltered by adding the

new studies and reviews scrutinized by

the expert group, there can be little doubt

that the conclusion identifying a lack of

differences in outcome concerning differ-

ent types of specific interventions can be

considered as a part of the guidelines text.

Given that, how can it be explained that

only eight interventions are recommend-

ed? Obviously much more than eight psy-

chosocial interventions can be identified

as “specific” by using the definition pro-

vided by the guidelines. It can be claimed

that the guidelines should have – if an am-

bition of consistency is cherished – recom-

mended any specific intervention instead

of the eight that actually are provided in

the text.

The production of the guidelines In almost every aspect the guidelines stand

out as characterized by the fact that the

work was organised within the NBHW.

The work with planning and substanti-

ating the guidelines started with a series

of seminars during the year 2000, but the

final product was not finished until Feb-

ruary 2007. The substantial time span be-

tween initiating and publishing the guide-

lines could be interpreted as a sign of the

seriousness and ambition to provide qual-

ity, but is more likely to be an effect of the

fact that NBHW is a central bureaucracy

which has a “natural” tendency of involv-

ing a large number of individuals and or-

ganisations. All in all 57 individuals have

been directly involved in producing the

guidelines; 14 in a “project group” mainly

consisting of administrators from NBHW;

15 in a “reference group” with a mix of

experts and representatives for different

authorities and interest groups; 28 experts

in the 5 expert groups. To a large extent

the choice of external participants seems

to have been governed by a sort of “demo-

cratic” principle; there is a wide range of

representatives from different authorities

and interest groups, and an equal share of

experts from social science and medicine.

Both the size of the group and the profes-

sional rivalry between social and medical

scientist are likely to have contributed to

the long time span.

The time aspect can be considered as

a factor of major importance; the fact that

much of the work in the expert groups was

done in the 2002 and 2003 but the actual

guidelines was published first in 2007

puts a strain on the relation between the

recommendations and the knowledge-

base as it appears today. In the guidelines

one can, e.g., see an emphasis on the ben-

efits of combining naltrexone or acamp-

rosate with psychosocial interventions.

This conclusion can be regarded as highly

questionable in light of the results from

the major study in that specific area, i.e.

the COMBINE study (Anton et al. 2006).

A major difference can be identified

between the expressions of the EBP idea

in countries with a strong “welfare state”

tradition, as Sweden, and countries with

weaker inclination in that direction, as



e.g. the US. The Swedish NBHW guide-

lines lack in many respects local competi-

tion (the presence of the review from the

SBU is no real problem since it is by and

large accommodated within the guide-

lines). This is true both in a formal sense

(materialised through specific agreements

between the two authorities) as well as

in the actual conclusions that are put for-

ward. In the US, a substantial number of

problems seem to emanate from the fact

that a large amount of agencies (state and

federal), professional organisations, and

interest groups have ambitions to articu-

late guidelines and thereby delimit good

practice from bad. This rivalry between

different producers of practice advice

seems to bring along a more heightened

awareness of the problems connected with

practice guidelines and the general organi-

sation of the EBP project. Gambrill (2006,

342) writes that many conceptions of EBP

“could be described as business as usual,

for example, continuation of unrigorous

research concerning practice claims, in-

flated claims of effectiveness, lack of at-

tention to ethical concerns such as involv-

ing clients as informed participants, and

neglect of application barriers” (p. 342).

The enlightened practitioner or guidelines – rival conceptions of EBPOver time EBP has come to signify a more

general orientation to a scientifically se-

cured knowledgebase and by this partly

obscuring the fact that there exists differ-

ent and to some extent contradictory opin-

ions on how EBP should be implemented.

With a certain amount of simplification it

is possible to describe the actual use (or

perhaps better, the ideas of how to practice

EBP) of EBP with reference to two basic

models of the same. The first and more

original one is built around the individual

practitioner’s active scanning of the scien-

tific literature in line with the following

scheme: a) formulating clinical questions;

b) searching for the best evidence; c) criti-

cally appraising this evidence; d) applying

this evidence to patients, and; e) evaluat-

ing the impact of this application” (Upshur

& Tracy 2004, 198).

This scheme for the use of EBP is to a

large extent built on the idea of a rational

procedure that generates what could be

called an “enlightened practitioner”. The

major criticism against this version of EBP

has been directed towards its lack of real-

ism in the sense that it is not used in prac-

tice (and that it is extremely demanding to

actually use). In the case of medical doc-

tors it has been observed that they general-

ly do not perform the critical appraisal of

the evidence by themselves, but rather rely

on pre-appraised literature, i.e. evidence

evaluated by others (Guyatt et al. 2000).

This has brought on the distinction be-

tween evidence users and evidence-based

practitioners, where the former, which

seem to constitute a substantial major-

ity, do not live up to the five points listed

above. This generates yet another problem;

which criteria should an evidence user ap-

ply in order to identify which evidence

that can be considered to be the “best”

(i.e. best practice)? The most common re-

sponse to this problem has been the use

of an “evidence hierarchy”. Unfortunately

this does not solve the problem since there

is no consensus concerning how such hi-

erarchies should be constructed. Upshur

and Tracy (op. cit.) identifies seven sugges-

tions for such evidence hierarchies within



the medical field, which they characterise

as highly divergent and non-commen-

surable. The same dilemma is identified

by Petrosino (2003, 184) concerning the

“standards of evidence” for school-based

drug prevention: “Each of the seven efforts

used a different approach to identifying

standards for evidence and evidence for

standards”.

The second basic model for the use of

EBP can to a certain extent be regarded as a

re-active alternative to the model outlined

above. Instead of an independent, critical-

ly appraising practitioner this model puts

emphasis on the necessity of guidelines.

Rosen et. al. (2003, 209) clearly position

themselves behind this model when dis-

cussing how EBP should be used within

the field of social work: ”Rather than con-

tinue to place unrealistic expectations for

the use of research on practitioners, social

work and its researcher should assume re-

sponsibility and increase efforts to devise

decision-making aids for practitioners”.

This suggestion is materialised by Rosen

et al. through their identification of guide-

lines as the most important component for

the implementation of EBP. But this model

has also received criticism; as is the case

with the first model, guidelines also suffer

from the weakness that they generally are

not used by practitioners (Howard & Jen-

son 1999; Bergmark & Lundström 2002).

To the extent that guidelines de facto are

used, critics have pointed out that the

top-down structure in guidelines might

de-professionalize those who make use

of them in the sense that they are reduced

to executors of a given set of procedures,

leaving little or no room for concerns of

the individual client or patient.

Although the rivalry between the two

models outlined above has gained consid-

erable attention in the international litera-

ture (see e.g. Gambrill 2006; Rosen et al.

2003; Upshur & Tracy 2004), the NBHW

guidelines contain no comments whatso-

ever on this subject. Instead it seems like-

ly, as pointed out above, that the guide-

lines will be used in order to put pressure

on practitioners to use the interventions

that are designated as effective. This will

mainly be achieved by the surveillance

that NBHW has to perform of treatment

agencies, i.e. the use of non-listed inter-

ventions might lead to criticism and pre-

scriptions from the NBHW.

Major methodological considerations? The Dodo bird and researcher allegianceDuring the last 30 years the Dodo bird’s

verdict – i.e. the general equivalence of

outcomes from different modalities of psy-

chotherapy – has developed into a major

controversy between the “common fac-

tor” position and the “medical model”

(with an emphasis on specific ingredients)

of psychotherapy. In the book “The great

Psychotherapy Debate” Wampold (2001)

delivers massive empirical support for the

common factor position by systemically

analysing the empirical evidence concern-

ing psychotherapy outcome.

A cornerstone in his analysis is the ne-

cessity to separate absolute efficacy from

relative efficacy. While absolute efficacy

can be established by comparing the out-

come from a given treatment intervention

and comparing it to the outcome for a non-

treatment control group, relative efficacy

requires a comparison between two (or

more) treatment interventions. Absolute

efficacy has been established for psycho-



therapy in many studies (Wampold op.

cit., 58) but cannot be used to disprove the

Dodo bird effect; if the treatment interven-

tion is efficacious it cannot be established

if the effect is due to common or specific in-

gredients. Proof of relative efficacy, on the

other hand, would constitute evidence of

the presence of specific ingredients, since

the difference in outcome between differ-

ent treatment interventions implies effects

that are related to specific ingredients.

However, the most elaborated studies have

not yet been able to establish the presence

of significant differences between different

modalities of psychotherapy (Luborsky et

al. 2002). Furthermore, in a meta-analysis

of component studies of psychotherapy,

i.e. studies designed to identify the spe-

cificity of a given psychotherapeutic in-

gredient4, Wampold and Ahn (2001) have

shown that there is no evidence that the

specific ingredients of psychotherapy are

producing or contributing to the benefits

of psychotherapy.

A central consequence of these findings

is that it is of fundamental importance

– if we want to be able to organise the evi-

dence of treatment outcome in a rational

fashion – to pay attention to the difference

between comparisons of two alternatives

of bona fide treatments and comparisons

between a bona fide treatment and what

is commonly referred to as standard treat-

ment (or alternatives in the same line).

In the addiction field, Finney (2000) has

expressed serious doubt about whether

treatment outcome reviews can become

meaningful without the adoption of a

“truly standardised” bona fide comparison

treatment (he suggests that MET should be

adapted as such a comparison standard).

The discussions of the Dodo bird verdict

can also be said to include (as an aspects

that has evolved during the controversy

over the Dodo bird effect) the problem con-

nected to “researcher allegiance”. The re-

searcher’s allegiance effect refers to the ex-

tent to which the researcher believes that

any of the involved treatments in a given

trial is efficacious. This effect has turned

out to be of substantial importance; Lubor-

sky et al. (1999, 103) write: “The results of

both past analyses and of the present one

imply that the researchers allegiance tends

to be strongly associated with the differ-

ential outcomes of the treatments. For the

present study each of the three allegiance

measures are significantly associated with

the effect size of the treatments compared,

and the combination of the allegiance

measures shows a very large association

with treatment outcomes (r=.85!)”. It is

easy to agree with Messer and Wampold

when they write: “How odd it is, then, that

we continue to examine the effects of dif-

ferent treatments (accounting for less than

1% of the variance) when a factor such as

the allegiance of the researcher accounts

for nearly 70% of the variance” (Messer &

Wampold 2002, 23).

None of these important methodologi-

cal considerations or their consequences

for the EBP project are discussed in the

guidelines or in the SBU-study. On the

contrary, as pointed out above, there is an

explicit adherence to the fact that “no spe-

cific treatment is more effective than any

other”, but no comments whatsoever can

be found concerning the consequences of

this empirical finding. The conclusion fits

like the hand in the glove with the Dodo

bird verdict, but no awareness of, or atten-

tion to, this fact can be found in the guide-

lines.



Final remarksThis paper has aimed to critically review

the Swedish national guidelines for addic-

tion treatment. Most readers will probably

have few doubts about the present writer's

overall impression of the guidelines; I find

them to be seriously flawed in terms of sci-

entific rigour and quality, and I predict that

very few practitioners will be able to make

use of them to make informed clinical de-

cisions. However, this critique should not

be seen as a general critique of the efforts

to build a scientifically solid knowledge-

base for addiction treatment (it is hard to

conceive any rational argument in favour

of an unscientific approach), but rather as

an emphasis on the fact that the difficul-

ties associated with such efforts are often

underestimated or ignored. To some extent

such an approach can be seen as an obsta-

cle for the general development of the field

at hand. Should we just continue on the

same old track with reference to a legitima-

cy based on the hope that future research

in the end will actually be able to identify

the specific and efficacious ingredients of

addiction treatment interventions? If we

do find it necessary to deal with the diffi-

culties that are involved, it also has conse-

quences for our relation to the EBP move-

ment. The hunt for a manualised “best

practice” will cease to be the only mean-

ingful objective, and we must find new

strategies for improving treatment through

research. If nothing else we should at least

discuss what might be ahead of us.

Be that as it may, by and large EBP still

– at least in the fields characterised by psy-

chosocial interventions – has the character

of a project; a normative projection of the

hopes invested in the future, a legitimacy

of what potentially rather than what actu-

ally has been achieved. The Swedish na-

tional guidelines for addiction treatment

cannot be acknowledged as a product of

scientific progress or a useful document

for practice, but even so, it is not unlikely

that a similar document will appear in an-

other seven years.

Anders Bergmark, professor addiction research group department of social work Stockholm universitysveavägen 160, Se-106 91 Stockholme-mail: [email protected]

NOTES

1) Evidence-based practice (EBP) is here used as fully congruent with the term evidence-based medicine (EBM).

2) I acted as one (of two) coordinators for the expert group reporting on the knowledge-base concerning psychosocial interventions for drug misuse.

3) The opposite goes for unspecific interven- The opposite goes for unspecific interven-tions, i.e. interventions not based on a spe-cific or systematic methods or techniques (se Socialstyrelsen, 2007, p. 34).

4) Component studies comes in two major Component studies comes in two major forms; dismantling designs and additative designs where the former involves the com-parison between treatment A and treatment A without a given specific ingredient of treatment A. In the additative design treat-ment A is compared with treatment A with the addition of a specific ingredient which is believed to effecacious.



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600 NORDIC STUDIES ON ALCOHOL AND DRUGS VOL. 24. 2007 . 6

I have been invited by the Editor to comment on the paper by

Anders Bergmark. We were both involved in the work with

the Swedish national guidelines for addiction treatment. I was

a member of the reference group and I made no contributions to

the expert literature reviews or conclusions. However, I was able

to comment on the different reports from the experts and also on

the first versions of the final reports written by the project group.

I also attended meetings of the expert group working with drug

use disorders, with Anders Bergmark as coordinator. Previously

I was chairman of the Swedish SBU group on alcohol and drug

problems. Bergmark was not a member of this group. My posi-

tion as professor of addiction psychiatry also involves treating

patients regularly, unlike Bergmark.

I agree with Bergmark that the preparation of the Swedish

Guidelines is of considerable general interest to the theme of

evidence-based practice. In Sweden as well as in other Nordic

countries social science has had a strong impact on alcohol pol-

icy through the work of many brilliant researchers such as Kettil

Bruun and Ole Jörgen Skog. Swedish medical research in the

alcohol field has also had a long tradition, with Magnus Huss

and Leonard Goldberg as prominent scientists. Robin Room was

director of SoRAD at Stockholm University during the last dec-

ade and has had major influence on the development of Swed-

ish alcohol policy in recent years.

While research in social science and medicine has a long tra-

dition in Scandinavia, research into intervention and treatment

using randomised controlled trials, RCTs, did not begin until

the 1980s. Important Swedish studies have concerned the ef-

fects of short intervention for risky alcohol consumption and

methadone treatment for heroin addiction. RCT studies became

matS Berglund

Commentary on the paper by Anders Bergmark

Commentary


common in the 1990s in Swedish clinical

research and had a strong influence on the

development of evidence-based medicine.

SBU is a state agency responsible for

evaluation of medical technology includ-

ing treatment of mental disorders. The

Swedish SBU report on treatment for al-

cohol and drug problems was based on

systematic reviews/meta-analyses of RCT

studies. The Swedish version was pub-

lished in 2001 and a revised English ver-

sion in 2003.

The National Board of Health and Wel-

fare (NBHW) consists of two large divi-

sions, one for medical disorders (includ-

ing psychiatry and disorders with both

psychiatric and substance use diagnoses)

and one for social issues (including treat-

ment of both alcohol and drug disorders).

The latter division was responsible for

producing the guidelines.

Leading Swedish social scientists felt

that the SBU report was seriously biased

towards a medical perspective, and this

strongly influenced the organisation when

the Swedish Guidelines were produced. In

order to balance the influence from medi-

cal scientists, social researchers were well-

represented in the organisation.

The project group was responsible for

formulating the guidelines, which were

based on the experts’ opinions as well

as those of the members of the reference

group. The plan was to also include writ-

ten statements from the expert groups in

the guidelines. The project group, of which

the chairman was a social scientist, was to

resolve differences between opinions of

the experts. Five different expert groups

were appointed, each of them co-chaired

by one social and one medical scientist.

The medical scientist was not permitted

to have been a member of the SBU group

(one exception was made).

When preparing the Guidelines, the ex-

pert groups could use all published sys-

tematic reviews. In addition criticism of

the conclusions of the SBU report was fa-

cilitated by the exclusion of previous SBU

members from expert chairs.

The efforts to reduce or eliminate the

presumed medical bias in the SBU report

while transforming systematic reviews

into guidelines were clearly not success-

ful. The conclusions were very similar.

Bergmark himself argues that “it is unclear

... whether or not the guidelines repre-

sent an uncritical reproduction of SBU’s

review”. He suggests that the similarities

could be based “purely on authority (i.e.

the fact that both SBU and NBHW are state

agencies)”.

But what did all the experts do during

the years 2000–2007? They certainly had

a lot of time to correct the presumed bias

of the SBU report in their summaries of

available systematic reviews. Bergmark

suggests that the wrong experts were in-

volved. “To a large extent the choice of

external participants seems to have been

governed by a sort of ‘democratic princi-

ples’ ... and an equal share of experts from

social science and medicine”. He himself

was one of them. Another possibility could

be that the SBU conclusions were robust

enough to withstand criticisms from the

experts in describing state-of-the-art treat-

ment for alcohol and drug problems.

Bergmark criticises the lack of transpar-

ency of the report, i.e. that the expert opin-

ions are only available on the Web and not

in the report itself. I agree with this opin-

ion. However, when reading these Web-

based papers, it is obvious that some of

Commentary to Bergmark


them would have required considerable

improvement if they were to be published

in the report. These authors have had many

years to do so and I understand the deci-

sion to write a summary report. But it is

nevertheless a weakness of the guidelines.

Bergmark expresses the opinion that the

previous critical papers of the SBU report

should be discussed in the guidelines. I do

not understand why. The SBU report is a

systematic review. The NBHW publica-

tion is guidelines. In addition these papers

have been carefully answered by the SBU

authors and published in the same jour-

nals as the critical papers. The SBU group

has also revised its work in view of the

earlier criticism, and this was published

in English in 2003.

Bergmark is critical of the poor cor-

respondence between the coordinator’s

report and the final recommendations

regarding psychosocial interventions for

drug problems. But he does not mention

that the experts in the group had different

opinions and that a new systematic review

was produced in order to resolve differ-

ences of opinion. When this did not re-

solve the disagreement, the project group

had to take the final decision according to

the predefined rules.

This type of disagreement certainly de-

layed the production of the guidelines. In

fact the Swedish Medical Products Agen-

cy initiated a new systematic review that

included meta-analyses and recommen-

dations regarding medication for alcohol

dependence. This report was produced

and published before the publication of

the guidelines (www.lakemedelsverket.se

2007) and the results were available to the

project group before the guidelines were

published. The report included the COM-

BINE study and the Swedish recommen-

dation concerning the combined treatment

with acamprosate and naltrexone.

Similarly, guidelines for agonist treat-

ment for opioid dependence were pub-

lished separately while the guidelines

were being produced. Consequently, the

medical scientists continued to update

the literature during this period. Perhaps,

therefore, the delay may have been caused

more by the rivalry between Bergmark and

NBHW than between social and medical

scientists.

The present guidelines contain many

other weaknesses, some which are criti-

cised by Bergmark. As I see it, what is

important about this long journey in pro-

ducing these guidelines is that it was pos-

sible to produce them at all. To be able to

integrate medical and social concepts and

results into one single guideline report is

an important success for the project group

and for all the experts who have contrib-

uted to the guidelines. Bergmark stresses

US examples of successful cooperation be-

tween medical and social scientists. I sug-

gest that this was also the case in the work

on the Swedish guidelines.

The NBHW plans to revise the guidelines

in one or two years. This is positive. The

scale of the work to integrate the overall

area of alcohol and drug prevention and

treatment into one guideline report inevita-

bly involves a lot of weaknesses. Revision

involves much less work than the original

work. Ideally the expert reports should be

published in such a revision but some of

them have to be considerably improved

before such publication is possible.

I personally have presented the guide-

lines to users in one of the local meetings

and the attendance rate and the interest



was very high. For me it is obvious that

the people working with clients/patients

with substance use disorders welcome the

guidelines. Similar experience has been

reported from others who have presented

the guidelines in other places in Sweden.

At the NBHW website it is reported that

all local presentations of the report were

over-booked and that over 6,000 people at-

tended the presentations. This is definitely

a success story that contradicts Bergmark’s

view that it was a major failure. Hope-

fully the guidelines could, in the future,

contribute to better understanding and co-

operation between the medical and social

systems in prevention and treatment of al-

cohol and drug use problems.

Mats Berglund, professorClinical alcohol research universitetssjukhuset maS, Ingång 108 Se-205 02 malmöe-mail: [email protected]



Research report

A B S T R A C T

M.U. Pedersen: Evidence-based practice

in “the real world”

The term evidence-based practice

(EBP) has developed into a mantra not

just within the medical area of treatment,

but within the psychosocial realm of

treatment as well. Today, decision-

makers and funding authorities are

increasingly demanding that psychosocial

treatment should be evidence-based

and that the different types of treatment

facilities should attempt to adapt to

this, inter alia by providing offers that

are reputed to be evidence-based. In

this article, EBP is viewed under a

slightly different perspective than the

one usually used when discussing

it. It is claimed that evidence-based

counselling and therapeutic methods

only account for a small part of the

strategies that are relevant for treating

clients with substance and/or alcohol

misuse. In the first part of the article,

EBP is defined and placed in relation

to evidence-based counselling/therapy

(EBC/T). In the article’s second part,

the relevance of – not least – EBC/T in

the “real world” is discussed. The real

world is defined as, among other things,

“what clients receive, not what they are

offered” and “what clients need, not what

the system needs”. This is illustrated by

discussing two Danish research projects

that demonstrate, inter alia, that what is

received does not have much in common

with what is offered.

KEywORDS: Substance misuse,

treatment, evidence-based paractice,

counselling, therapy, organisation.

How to define evidence-based psychosocial practice (EBP)When reading different guidelines and various

critical surveys of guidelines for treatment,

you could almost be led to believe that a treat-

ment facility can establish an EBP by using

treatment methods such as cognitive-behav-

ioural therapy (Carroll et al. 1994; Azrin et al.

1994; Kelley et al. 2002; Winters et al. 2002),

motivational interviewing (Dunn et al. 2001;

Secades-Villa et al. 2004), contingency manage-

ment (Higgins et al. 1994; Griffith et al. 2000),

methadone treatment (Carroll et al. 2001; Car-

roll & Onken 2005), 12-step counselling (Sique-

land & Crits-Christoph 1999; Stoffel & Moyers

2004; Weiss et al. 2005), multisystemic treat-

ment (Curtis et al. 2004), familiy therapy (Stan-

ton & Shadish 1997), and others.

The above-mentioned methods, only to be

seen as examples, have proven themselves su-

perior to standard support in randomised con-

trolled trials (RCTs) and, if they are to be truly

superior, in meta-analyses of RCTs (see the

evidence hierarchy, Phillips et al. 1998). This

is not how EBP will be defined for the pur-

poses of this article. Thus a distinction must

be made between on the one hand EBP, which

can be linked to general guidelines for good

treatment, and on the other hand evidence-

based counselling/therapy (EBC/T), which

madS uffe PederSen

Evidence-based practice in “the real world”


covers the specific type of special inter-

vention methods that are nearly always

referred to when RCT and meta-analyses

are involved (including the methods men-

tioned above).

Below are examples of 20 pointers ex-

tracted from the NIDA Principles of Drug

Addiction Treatment and the NDARC

Guidelines for Alcohol Treatment (NDARC

2005). These are merely examples of

“strong advice”. Advice like this will be

linked to EBP in what follows, which does

not include medical advice.

1. No single treatment is appropriate for

all individuals (NIDA).

2. Treatment needs to be readily available

(NIDA).

3. Effective treatment attends to multiple

needs of the individual, not just his or

her drug use (NIDA).

4. Screening for high-risk consump-

tion should be widely implemented

(NDARC).

5. Assessment for more intensive inter-

vention should be conducted in a semi-

structured, narrative style (NDARC).

6. Assessment should lead to a clear,

mutually acceptable treatment plan

(NDARC).

7. The treatment and services plan must

be assessed continually and modified as

necessary to ensure that the plan meets

the person's changing needs (NIDA).

8. Remaining in treatment for an adequate

period of time is critical for treatment

effectiveness (NIDA) and the intensity

of interventions should vary; with cli-

ents with more severe problems receiv-

ing more intensive treatments (patient

matching) (NDARC).

9. When possible, clients should be offered

a choice of intervention (NDARC).

10. Decisions about treatment setting

should be based on the clients’ treat-

ment goals, preferences, severity of de-

pendence, the presence of co-morbid

disorders, cognitive and social func-

tioning and relapse history (includ-

ing other specific target group such as

adolescents, gender and indigenous

patients) (NDARC).

11. Addicted or drug-abusing individu-

als with coexisting mental disorders

should have both disorders treated in

an integrated way.

12. Counselling (individual and/or group)

and other behavioural therapies are crit-

ical components of effective treatment

for addiction. (Approaches to Drug Ad-

diction Treatment section discusses de-

tails of different treatment components

to accomplish these goals.) (NIDA and

NDARC = Psychosocial Interventions.)

13. An organised approach to treatment

is most effective supported by careful

case and progress notes (NDARC).

14. Psychosocial relapse prevention strate-

gies are recommended for use with all

moderate to severely alcohol depend-

ent patients (NDARC).

15. Treatment does not need to be volun-

tary to be effective (NIDA).

16. Possible drug use during treatment must

be monitored continuously (NIDA).

17. Treatment programs should provide as-

sessment for HIV/AIDS, hepatitis B and

C, tuberculosis and other infectious dis-

eases, and counselling to help patients

modify or change behaviours that place

themselves or others at risk of infection

(NIDA).

18. Recovery from drug addiction can be

a long-term process and frequently re-

quires multiple episodes of treatment



(NIDA).

19. Extended care: Attention should be giv-

en to the clients’ retention in treatment

and social support networks (NDARC)

20. Extended care: Aftercare should be

structured and assertive, with follow-

up of missed appointments (NDARC).

Behind each of these items there usually

lie a number of deliberations, possibili-

ties and strategies which can be brought to

use in order to meet the overall objectives

of the guidelines. EBC/T is placed under

item 12. From the link http://www.nida.

nih.gov/PODAT/PODAT10.html you can

reach an itemised roster of which methods

are recommended and can be considered as

EBC/T. 1

It may be discussed whether the above

guidelines are even exhaustive for estab-

lishing good treatment (we shall return to

this), but it is probably beyond discussion

that EBC/T only constitutes a minor part

of the strategies linked to treatment efforts.

This brings us to the closest we get to an

officially recognised definition of EBP –

below are 5 excerpts from Sackett and his

colleagues’ understanding of EBP (seen as

a synonym of evidence-based medicine).2

Evidence-based medicine is the con-

scientious, explicit, and judicious use

of current best evidence in making de-

cisions about the care of individual pa-

tients. The practice of evidence-based

medicine means integrating individual

clinical expertise with the best avail-

able external clinical evidence from

systematic research.

By individual clinical expertise we

mean the proficiency and judgment

that individual clinicians acquire

through clinical experience and clini-

cal practice. Increased expertise is re-

flected in many ways, but especially in

more effective and efficient diagnosis

and in the more thoughtful identifica-

tion and compassionate use of indi-

vidual patients' predicaments, rights,

and preferences in making clinical de-

cisions about their care.

By best available external clinical

evidence we mean clinically relevant

research, often from the basic sciences

of medicine, but especially from pa-

tient centred clinical research into the

accuracy and precision of diagnostic

tests (including the clinical examina-

tion), the power of prognostic markers,

and the efficacy and safety of thera-

peutic, rehabilitative, and preventive

regimens.

Clinicians who fear top-down

cookbooks will find the advocates of

evidence-based medicine joining them

at the barricades. Some fear that evi-

dence-based medicine will be hijacked

by purchasers and managers to cut the

costs of health care. This would not

only be a misuse of evidence-based

medicine but suggests a fundamen-

tal misunderstanding of its financial

consequences. Doctors practising evi-

dence-based medicine will identify

and apply the most efficacious inter-

ventions to maximise the quality and

quantity of life for individual patients;

this may raise rather than lower the

cost of their care.

Evidence-based medicine is not re-

stricted to randomised trials and meta-

analyses. It involves tracking down the

best external evidence with which to

answer our clinical questions.



As is clear from the excerpts from Sack-

ett et al., it would be a misunderstanding to

reduce EBP to being tantamount to EBC/T.

It is also a misunderstanding to focus ex-

clusively on RCT/meta-analyses, just as it

would be completely erroneous to exclude

professional and individual judgment.

In the following section, it will be dem-

onstrated that while EBC/T is a lesser

component of EBP, EBP is again a lesser

part of what will henceforth be defined as

EBT (evidence-based treatment). And not

only that – EBC/T is also but a very small

part of the practice that is viable in the real

world of misuse treatment.

How to define “the real world”The definition of reality for the purposes

of this article is very simple. It goes as fol-

lows:

“The real world” is what the clients get,

not what they are offered.

“The real world” is what the clients

need, not what the system needs.

“The real world” is much more than

EBP.


receive, not what they are offered

In the following, the results from a nation-

wide study of misuse treatment in Den-

mark will be used as the empirical basis

(Pedersen & Nielsen 2007; see http://www.

crf-au.dk/0020.asp). Case reports from 443

representatively selected drug misusers

enrolled in treatment from July 1, 2005 to

July 1, 2006 were analysed. Representa-

tivity was assessed by checking the study

group against the Danish national register

for drug misusers enrolled in treatment.

The study group only deviated negligibly

from register information regarding gender,

•

•

•

age and which offers were made to clients.

Some of the results of the study were:

example 1. Intensity

First, 70% of all drug misusers admitted

to Danish outpatient treatment received 3

counselling sessions or less during the first

three months of treatment (after they were

referred to a treatment facility). But of

course, all were offered more treatment.

Second, In Denmark it is mandated by

law that opiate users in methadone treat-

ment must be offered psychosocial treat-

ment, but 80% of all methadone users

receive 3 or less counselling sessions dur-

ing the first three months in methadone

treatment. But they are, of course, offered

counselling.

Third, Usually these counselling ses-

sions involve the prescription of medicine

or a kind of “here and now” fire-fighting

which should be defined as an attempt to

solve or reduce a tangible “here and now”

problem.

Of course these (fire-fighting) counsel-

ling sessions are very often extremely im-

portant and very often reduce the client’s

“here and now” problems, but they are not

what we usually mean by evidence-based

methods. More predominantly, they tend

to be experience-based, focusing on solv-

ing urgent, hands-on problems. It seems

we have to accept that what we usually

mean by EBC/T is currently not relevant

for about 70% of clients admitted to Dan-

ish outpatient treatment (and 80% of the

methadone users).

Fourth, 20 to 30% of drug misusers in

outpatient treatment completed treatment

as planned. Conclusion: No compliance

was reached with 70 to 80% of the cli-

ents.



Signs would seem to indicate that we

are facing an enormous compliance prob-

lem within substance abuse treatment.

EBC/T conceivably plays a larger role in

countries where drug misusers enrolled in

treatment make up a smaller and highly

motivated (and selected) part of the drug

misuser population (possibly more finan-

cially well-off, as well) than in places

(like the Nordic countries) where different

forms of treatment guarantees mean that

the treatment population is much more

variegated and perhaps – as a consequence

– comprised by drug misusers with a high

severity index in a physical, psychological

as well as a social sense. Maybe one of the

most important benefits of physician-pre-

scribed heroin lies in the resulting higher

degree of compliance achieved with pa-

tients.

example 2. methods

Another problem lies in the fact that what

treatment facilities advertise as offers for

clients may not necessarily be what cli-

ents actually receive. Thus in post-millen-

nial Denmark it has almost been de rigeur

to offer Cognitive-Behavioural Therapy

(CBT), family therapy and couples thera-

py. 47 residential institutions were asked

a) which methods they offered clients;

and b) which methods they were trained/

educated in using. “Trained” was defined

as involving a diploma proving that the

counsellor had received at least one year

of training in that particular counselling/

therapeutic method, including at least 15

whole days of training and supervision.

20 residential institutions advertised that

they employed CBT, but only 12 facilities

had a minimum of one counsellor trained

for at least one year in this method (as

defined above). Similarly, 20 facilities of-

fered couples therapy but only 11 facilities

had counsellors actually trained in couple

therapy; and finally 18 facilities proffered

to offer family therapy, while only 13 had

an employee actually trained in this. On

top op this, couples therapy and fam-

ily therapy were often vaguely defined.

One hypothesis here is that management

at these residential institutions is under

strong pressure from referring authorities

to employ what they consider to be EBC/T.

While EBP – which also includes proper

screening and assessment; different match-

ing strategies; an individual service plan;

focusing on multiple needs, etc. – did not

appear to play any major role in considera-

tions concerning the treatments’ outcome.

In conclusion, clients very often do not

actually receive what they are offered and

a sizeable group either receive no psycho-

social support or a very limited amount

of such support, predominantly hinging

upon disbursing medicine or solving ur-

gent and specific “here and now” prob-

lems. Yet treatment systems are not what

should be criticised for this. Rather, it may

be the widespread rhetoric (which cen-

tres almost exclusively on EBC/T) and a

skewed research focus (too little attention

paid to, say, fire-fighting and strategies to

increase compliance and thus increase

show-ups).


need, not what the system needs

One problem often discussed with re-

gard to EBC/T is its top-down nature. If a

method that has proved effective in RCTs

does not prove effective on a client, it must

be the client that is the problem – not the

method (see Sackett et al. 1996). In the fol-



lowing, there will be examples of a) that a

large group of substance misusers receiv-

ing offers from methods that purport to be

evidence-based do not in effect fare very

well in treatment; the question being what

was actually offered to those who did not

benefit from the EBC/T offerings; did they

simply have to take what they could get?

– and b) that it is apparently very locally

determined who in fact benefits from the

offered EBC/Ts. The examples build on the

Danish Registration and Information Sys-

tem3 (DanRIS, see English version: http://

www.danris.dk/default_en.asp).

example 1. methods versus needs

565 women enrolled at 23 residential in-

stitutions participated in the project. This

group was representative of women en-

rolled in drug-free residential treatment

in 2004 to 2005 and partially responded to

queries outlined by the European Addic-

tion Severity Index (all 30-days questions

and other selected questions). The pur-

pose was to identify groups of women that

could from their enrolment be categorised

as being at high risk of early drop-out. Us-

ing cluster analysis, the 5 groups below

were singled out (regarding method and

elaboration, see Pedersen 2007).

All 23 treatment centres were either

different Therapeutic Communities (hier-

archical TCs or democratic TCs), 12-step

treatment facilities, or social educational

programmes. They offered the whole range

of cognitive therapy, behaviour therapy

and/or 12-step counselling.

The table clearly shows that from groups

1, 2 and 3, only 4%, 21% and 40%, re-

spectively, went through with treatment

as planned. In other words, right from the

start it is possible, based on a EuropASI in-

terview immediately prior to treatment, to

single out several groups of women with a

high probability of dropping out of treat-

ment. Staffers working at the treatment

facilities were asked what they would

do about the group of women who were

clearly not benefiting from treatment. Sub-

sequently, they were asked about the pos-

sibility of implementing different strate-

gies for those women in risk of early drop-

out. Some of them said it was not possible

because it would sabotage the programme;

others said they lacked the resources for

undertaking this kind of individualised

focusing on needs; while a third group of

facilities concluded that they had to do

something about it – but they really did

not know what. In other words, there was

such a fixation on the established method

that there was no vision of a more need-

oriented approach. In yet other words, the

external and general guidelines have be-

come emphatically determining for treat-

ment. The system has colonised the “real

world”, so to speak.

example 2. general versus local evidence

Just as different EBC/Ts do not function

equally well on all clients, all methods for

pinpointing groups at risk do not function

equally well at all treatment facilities. As

Completion ofScore n Programme

group 1 >=0<2 21 4%

group 2 >=2<6 117 29%

group 3 >=6<10 197 40%

group 4 >=10<14 180 52%

group 5 >=14 50 64%

Table 1. 565 women from 23 treatment centres divided into 5 groups on the basis of a prediction score (see ibid)



shown in Table 2, it is possible – using que-

ries from EuropASI – to single out groups

at risk, but this scale clearly worked better

at some treatment facilities than others. In

Table 2, the 23 treatment facilities are di-

vided into facilities where the prediction

scale did not work (n=12), and facilities

where it did (n=11).

It does not make much sense to apply the

prediction scale to the 12 facilities on the

left, while the scale becomes all the more

relevant regarding the 11 facilities listed

to the right. The reason why the predic-

tion scale did not work at the 12 facilities

could not be explained by different clients

or different courses (same age, same sever-

ity score and same percentage completing

treatment). Moreover, it could not be ex-

plained by the treatment programme; the

mean age of the counsellors was the same,

and the distribution by gender (staff) was

the same. More pertinently, it was also

found that the counsellors from the 11 fa-

cilities where the prediction scale worked

more often than the counsellors from the

12 facilities where the prediction scale did

not work could furnish proof of having

received some kind of psychotherapeutic

training (could produce a diploma). This

was the only identifiable, significant dif-

ference between the two categories of

treatment facilities (Pedersen 2007), a fact

that will be dealt with in the following

section.

Differently put, a great many drug mis-

users do not benefit from treatment meth-

ods otherwise defined as EBC/T and at the

same time, the same assessment tools can-

not be meaningfully applied to all facili-

ties. So two things are required: a) that the

clients’ needs are put above the counsel-

ling or the therapeutic method and b) to

develop local evidence (i.e. local tools for

identifying groups at risk).

The “real world” is much more than

EBP

As has already been made clear, EBP

amounts to much more than just EBC/T. In

the following, it will be demonstrated that

furthermore, EBP is again but a small part

of EBT (evidence-based treatment). This is

illustrated by the Table below.

Evidence-based treatment (EBT) consists

of three different types of practice: Experi-

ence Based

Practice, evidence-based practice and

organisational-based practice, respec-

tively. By experience-based practice, is

meant a specific practice with a specific

client. Experience-based practice is very

often seriously underestimated. Being

Table 2. PPC1 applicability to the two categories of residential institutions

1) PPC = Prediction Programme Completion

Completion of programme

PPC19 does not work 12 treatment centres n

PPC19 works11 treatment centres n

group 1 20% 5 0% 16

group 2 42% 53 19% 64

group 3 40% 84 40% 113

group 4 41% 80 60% 100

group 5 45% 45 77% 30

41% 242 43% 323



good at telling about edifying examples, is

often seen by researchers as being rather

boring because these examples cannot be

understood as evidence-based in the way

this term is usually used. Nevertheless it

is through experience-based practice that

psychosocial EBP becomes implemented.

There can be no EBP without experience-

based practice. Most people will probably

acknowledge this as a fact of life, yet this

type of practice generally finds little room

in discussions concerning good practice.

Organisational-based practice involves

conditions concerning the entire organi-

sation which have implications for client

treatment. You could say that the entire

question hinges upon a sort of local pol-

icy-making where leaders, counsellors

and other decision-makers to a higher or

lesser degree negotiate towards reach-

ing decisions regarding treatment. This

also includes negotiations with decision-

makers outside the organisation (e.g. heads

of government agencies and decision-mak-

ers from other focus areas including the

health care system in general, the prison

and probation service, etc.) These nego-

tiations also involve which options the or-

ganisation makes available to clients, etc.

This is where the take in practice enters

the picture. This concept refers to the ex-

tent to which the organisation seeks out,

discovers and implements different recip-

ies (methods, strategies, controlling mech-

anisms; see Røvik 1998: 14f). Also, by

decoupling practice, is meant which strat-

egies the organisation adopts in order to

keep different recipies distinct from each

other so that a possible discrepancy be-

tween recipies does not lead to insoluble

conflicts (say, treatment with physician-

prescribed heroin within a facility also

offering drug-free treatment). Self-evalu-

ation practice refers to which strategies

the organisation employs for evaluating

its own practice. If there is no self-evalu-

Table 3. Evidence-based treatment

Experience basedpractice

Evidence-basedpractice

Organisational based practice

Description Local, specific, internal experi-ence with: – Social work/treatment in general– the target group and relevant other target groups– establishing trust, working alliance, compliance– Planning, coordination of specific client courses in a specific local context– Communication about specific cases– Communication in general– etc.

Integrating, external, research-based guidelines and methods

Guidelines

methods (eBC/t)

Local policy-making– management– decision-making– negotiation – Coordination, planning – take in practice– decoupling practice– Self-evaluation practice – etc.

Objectiveto increase communicative competencies

to increase research-based technological competencies

to increase organisational competencies

Strategy training education organisational development

Perspective local general Context

Clients this client groups of clients the client context



ation, bad strategies, wrong decisions, etc.

will go unchanged, perhaps leading to out-

and-out treatment errors for years on end.

Under the heading organisational-based

competencies also comes a practice born

of negotiations and decisions concerning

working conditions, resources, salary con-

ditions, ethics, etc., which may all be of

great significance for treatment of the cli-

ents involved.

On the whole, EBT is not something

you can calibrate. It is like a big kettle into

which you toss a plethora of ingredients

such as experience, communication skills,

training, techniques, guidelines, policy,

decision-making, take in practice, working

environment, resources, compliance and

much more. All this is stirred together and

sometimes it all suddenly congeals into a

greater whole – and sometimes it does not.

Obviously, what comes out of this boiling

stew is not happenstance. There is a cer-

tain likelihood that if the stew consists of

the right ingredients, it will also taste good.

But it does not take more than one wrong

spice added, too little or too much heat

under the kettle, a little too sloppy pre-

paratory work, etc. before the whole thing

tastes really bad – regardless of whether

you are applying Cognitive-Behavioural

Therapy or some other EBC/T. So you may

rely on a certain degree of probability, but

even though the ingredients are known,

the resulting stew will never be the same

every time.

Precisely the fact that it is not random

what you use as ingredients in the stew is

what justifies qualitative as well as quanti-

tative treatment research. For this reason,

the arguments put forward in this article

should by no means be seen as a rejection

of EBP. Yet research should also to a far

higher degree involve ingredients from ex-

perience-based and organisational-based

practice in its efforts to describe what con-

stitutes good practice.

DiscussionAbove, a distinction has been made be-

tween EBT (evidence-based treatment),

EBP (evidence-based practice) and EBC/T

(evidence-based counselling/therapy). The

attention focused on EBC/T in recent years,

often misplaced, sometimes seems to have

done more harm than good. Often, it has

contributed towards creating a top-down

regime, which is not what Sackett et al.

intended with evidence-based practice

(which they call evidence-based medicine).

In Bergmark’s article (in this volume), the

Swedish guidelines are criticised for lack-

ing quality. But the question of quality is

perhaps the least of all the problems. There

are far greater problems at issue.

The first problem lies in the total fixation

on EBC/T instead of EBP and EBT. As has

been made clear, the question of whether

to employ cognitive-behavioural therapy,

Motivational Interviewing, etc. has lesser

significance for EBP. Likewise, RCTs and

meta-analyses will definitely not solve all

the problems we are facing today. In the

bigger picture, EBC/T will probably not

make that great a difference. Thus some-

thing would seem to indicate that the ef-

fect of drug and alcohol misuse treatment

has not generally improved during the

course of the last 30 years (see Prendergast

2000). Nonetheless we have in that same

period been given a number of EBC/Ts and

different guidelines for good treatment

(Pedersen 2005). The lack of improvement

in drug and alcohol misuse treatment may

be attributable to several conditions which



only makes it more imperative that we

widen our focus. This is not to say that we

can be indifferent to this type of research.

Thus EBC/T can be a very important ingre-

dient in the stew. Not only concerning the

effect of treatment, but also with regard to

communication between employees in the

organisation.

The second problem is that often there

is only scant interest as to what the clients

actually receive and whether the EBC/Ts

that are so highly visible in today’s dis-

cussion are at all relevant to the majority

of drug misusers enrolled in treatment.

This article would argue that these EBC/Ts

play a lesser role for the vast majority of

clients in Danish drug abuse treatment.

The significant majority of drug misusers

enrolled in outpatient misuse treatment

would never make it to completion in a

long-term EBC/T programme. This is not

to say that some of the elements in these

methods could not be efficacious in estab-

lishing compliance, fire-fighting, etc. But

this is something we actually know far too

little about.

The third problem is that the wealth of

discussion about EBC/T and EBP seems to

have completely obscured any discussion

about experience or organisational-based

practice. This has led to a lack of focus

on policy-making, management, decision-

making, education, working conditions,

communication, compliance, etc. When

resources are lacking there may even be an

interest in not ensuring too much compli-

ance.

So it is definitely not merely a question

of research quality. It is at least as much

a question of proper focus. It is therefore

urgent that we start focusing on the real

world of drug and alcohol misuse treat-

ment, including a) evidence-based practice

as a whole; b) experience-based practice;

c) organisational-based practise, d) what it

is that clients are actually receiving; and

e) what they actually need. This should

not be misunderstood. EBP is indeed of

the highest importance. Absence of EBP is

like lasagna without pasta. EBC/Ts are the

spices which can make a difference, but

they should not be overestimated.

Mads Uffe Pedersen, head of the centerCentre for alcohol and drug researchnobelparken Building 1453, 3.Jens Chr. Skou's vej 3dK-8000 aarhus Ce-mail: [email protected]

NOTES

1) From the link above, only regarding drug misuse. In the NDARC Guidelines, EBC/Ts are placed under the heading of “Psychoso-cial Interventions”.

2) See Sackett & Rosenberg 1995 and Sachet et al. 1996. Sackett’s and colleagues are pione-ers in establishing what they call evidence-based medicine; their definition has served

as the foundation for later understandings of EBP (see Webb 2001).

3) Any residential institution treating drug misusers in Denmark is under obligation to submit necessary data to DanRIS if they are to have clients referred paid for by public agencies.



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A B S T R A C T

IntroductionThere is a long-standing interest in Finland

in the relative harm associated with beer and

wine consumption, on the one hand, and spir-

its consumption, on the other. The interest has

been visible both in the scientific literature and

in practical alcohol policy. In the first research

programme issued by the Finnish Foundation

for Alcohol Studies for 1951–1957, described

by Kettil Bruun as “scientists’ response to the

pleas for help from alcohol policy makers”

(Bruun 1957, 199), one of the major contribu-

tions was The Effects of Distilled and Brewed

Beverages by Martti Takala, Toivo A. Pihkanen

and Touko Markkanen. The differential effects

of mild and strong beverages were also ad-

dressed in the 1950s by Pekka Kuusi (The Liq-

uor Question and Alcohol sales Experiment in

Rural Finland), when he assessed the impacts

of the beer and wine outlets that were opened

in rural areas on an experimental basis (Kuusi

1952; Kuusi 1957). Kuusi concluded in The

Liquor Question: “If alcohol policy is judged

on the original and only sensible criterion in

this field, i.e. against the extent of harmful ef-

fects, then we can only conclude that our al-

cohol policy makes a fundamental mistake in

favouring strong alcoholic beverages.” (Kuusi

1952, 350, our translation).

An account of the differential treatment of

spirits and milder alcoholic beverages in prac-

PIa mäKelä helI muStonen eSa öSterBerg

Does beverage type matter?

P. Mäkelä & H. Mustonen & E. Österberg:


The purpose of this article is to review

the associations of different beverage

types with different types of harm and

discuss their likely causes. The key

issue is whether alcohol policy can

influence the occurrence of harms by

affecting consumers’ beverage choices.

This is dependent on the following

questions addressed in this article:

1) Does beverage choice affect alcohol-

related harm if quantity of alcohol is

equal?

2) Does beverage choice impact the

quantity of alcohol consumed?

3) Can beverage choice influence the

nature of the drinking situation and

thereby quantities and harm?

The literature review did not reveal

great differences between different

beverages with regard to harm if

equal amounts are drunk, although

it seems that spirits are somewhat

more closely associated with alcohol

poisonings and aggressive behaviour.

Our results showed that spirits have

a prominent role in Finnish binge

drinking: the proportion of spirits

consumed increases in direct proportion

to the amounts of alcohol consumed

on individual drinking occasions. we

conclude that it would be unwise to

encourage consumers to favour spirits.

Currently, the difference in taxes on

spirits and mild alcoholic beverages in

Finland is larger than the corresponding

difference in harm per litre of ethyl

Overview


tical alcohol policy is provided in the 75th anniversary his-

tory of the Finnish State Alcohol Monopoly (Alko) by Martti

Häikiö, who describes the 1959–1968 period as a beer and

wine favouring era (Häikiö 2007, 159). As late as 1978, Alko

defended its alcohol policy by arguing that “the level of acute

alcohol-related harm tends to decrease in direct proportion

to the alcohol content of the beverage consumed” (Alkon teh-

tävä ja toimintalinja 1978, our translation).

The 1980s and 1990s saw a waning of interest in Finland

in the relative harmfulness of different beverage types. How-

ever the most recent Finnish overview of the differential ef-

fects of alcoholic beverages dates from this same period, i.e.

the early 1990s. Its emphasis was twofold: it addressed the

differential effects of the same quantities of alcohol depend-

ing on beverage type and as a new contribution it presented

empirical results on the true strength at which different bev-

erages were consumed (Simpura et al. 1993; 1996).

In recent years there has been a revived interest in these

questions, particularly in the context of the optimal taxation

of alcoholic beverages. In this review we are interested in the

associations of different types of alcoholic beverages with

different types of harm. We will discuss whether these dif-

ferent associations are likely to reflect a causal relationship,

or whether the most probable explanation lies in other fac-

tors that possibly affect both the choice of beverage and the

consequent harms.

Choice of beverage in its context

Apart from the fact that they all contain ethyl alcohol, al-

coholic beverages differ quite widely from one another in

their other properties, including their strength, taste and the

impressions and images they invoke. It follows that differ-

ent beverages do not lend themselves in the same way to

satisfying consumers’ multiple needs. The question we need

to ask, then, is how the intended use of alcoholic beverages,

drinking situations and individual preferences influence the

choice of beverage, the amount of alcohol consumed and

consequent harms (Figure 1). It is clear that the single most

important factor with regard to the occurrence of violence,

accidents and other types of harm associated with individual

drinking occasions is the quantity of alcohol consumed. The

quantities consumed on a single drinking occasion tend to


alcohol. However, an equal

rate of taxes would make

spirits much cheaper per

litre of ethyl alcohol than

other beverages. Based on

our review, this situation

would in all probability lead

to an increase in alcohol-

related harm.


vary sharply depending on the purpose

of drinking (e.g. to wash down a meal or

to get drunk), and that in turn is associ-

ated with the choice of beverage type.

That choice can be steered and influenced

by means of alcohol policy, say by adjust-

ing beverage-specific excise duties, but the

key issue is whether by manipulating the

choice of beverage type it is possible to in-

fluence the level of alcohol-related harm. If

the association between the choice of bev-

erage type and the prevalence of harm is

due solely to individual variation in needs

and preferences and to differences in the

intended uses of alcohol, then manipula-

tion of people’s choices of beverage type

by means of taxation will have no effect on

the level of harms and is therefore unjusti-

fied. After all, if heavy taxes are levied on

spirits, people can still get drunk on e.g.

medium-strength beer or wine. From an

alcohol policy point of view, therefore, the

interest lies in whether the effects indicat-

ed by the broken lines in Figure 1 actually

exist, i.e.

1) whether the choice of beverage type is

directly connected to alcohol-related

harm if the quantity of absolute alcohol

consumed and the nature and purpose

of the drinking situation is standard-

ized, e.g. in an experimental setting;

2) whether the choice of beverage type has

a direct impact on the quantity of abso-

lute alcohol consumed; in other words,

do people drink larger quantities of

spirits than wine or beer, for instance,

Figure 1. Impact of beverage type on harms

Supply– Prices– availability– alternatives

Individual properties– Sex, age, socio-economic status

Alcohol policy

Purpose of drinking– thirst, with a meal, social lubricant, intoxicant+ Nature of drinking situation

Choice of beverage type– Beer, wine, spirits– Beverages within beverage type

Amount of alcohol consumed– on a single drinking occasion– In the longer term

Harmful effects– diseases associated with long-term use, accidents, violence, public disturbance etc.

1 to 3 relate to the numbered questions set out in the introduction.

1

2

3

Demand– needs and preferences



when they are used for the same pur-

pose, e.g. as an intoxicating substance

or as a social lubricant; and

3) can the choice of beverage type influ-

ence the purpose or nature of the drink-

ing situation, and thereby the quantities

consumed and the level of consequent

harm?

There is as yet no conclusive scientific

evidence on these various effects. In this

article we will be using both existing and

new research evidence to analyse the pos-

sible effects that are at play in the relation-

ship between beverage types and alcohol-

related harm. First, based on the existing

literature, we aim to establish what is cur-

rently known about the effects of consum-

ing the same quantities of alcohol in the

form of different alcoholic beverages by re-

viewing epidemiological and experimental

studies in which the quantity of alcohol

consumption is controlled. We then look

at new research results on the associations

between beverage type and quantities of

alcohol consumed. Our main emphasis

and contribution, however, is the discus-

sion at the end of the paper, where we ad-

dress and interpret the existing research

knowledge and the new results in the light

of the three questions listed above.

Differences in the harmful effects of different beverage types when the quantity of alcohol consumed is the sameWe begin by reviewing the research evi-

dence on the possible differences in the

harmful effects of different types of alco-

holic beverage, assuming that the quantity

of absolute alcohol consumed is the same.

Some experimental studies have been re-

ported, which are able to control exter-

nal factors confounding the relationship.

However the evidence from these studies

is not particularly persuasive with regard

to the harm caused by long-term drinking,

and they have also attracted criticism be-

cause of the difficulty of generalizing to

real life situations where matters are com-

plicated by a whole array of intervening

factors. On the other hand, there are also

epidemiological studies on the prevalence

of different types of harm in people who

prefer different types of beverages. In these

studies the quantity of alcohol consump-

tion is typically standardized by means of

statistical models. There is a particularly

large body of research on the question of

whether different types of beverage have

a different effect on coronary heart disease

(CHD). We begin with this line of work be-

cause it also provides a good illustration

of the limitations of the epidemiological

research evidence.

Most of the recent reviews on the associ-

ations between alcohol and CHD conclude

that moderate drinkers are at a lower risk,

and furthermore that this association re-

flects a causal relationship (e.g. Rehm et

al. 2003). However, the size of the impact

varies by age and gender, and drinking

habits have a bearing on the level of risk:

binge drinking has no protective effect, but

in fact it can increase the risk of CHD.

There has been much interest in the ques-

tion of whether a certain type of drink has

a greater protective effect than others. Re-

view articles have suggested that the pro-

tective effect is mainly attributable to ethyl

alcohol rather than any other substance

in alcohol (Rimm et al. 1996). However,

in a review from 2003 Grønbæk, present-

ing also potential biological mechanisms,

defends the possibility that wine-drinking



may afford additional protection beyond the

beneficial effects of ethyl alcohol.

There is an abundance of epidemio-

logical studies on the effects of different

beverage types on CHD or mortality in

general. Some suggest that beer, others

that wine and others still that spirits have

a greater protective effect than other bev-

erages, although the reports in favour of

wine seem to be somewhat more numer-

ous than the reports favouring other bever-

ages (Rimm et al. 1996; Grønbaek 2003).

However, it seems that the better health

of wine drinkers mainly has to do with

their better health habits and their better

social background. For instance, it has

been reported that wine drinkers smoke

and drink less than others, that they have

a healthier diet, and that they come from

a better social background (Barefoot et

al. 2002; Mortensen et al. 2001). Indeed,

Mortensen and colleagues (2001, p. 1844)

conclude that “wine drinking is a general

indicator of optimal social, cognitive, and

personality development in Denmark”.

A study in California showed that when

certain key health habits and education

were controlled for, wine drinkers’ 30 per

cent lowered risk of hospitalization for

CHD was reduced to 10 per cent. In other

words, the better health of wine drinkers

is explained not so much by the character-

istics of wine, but by the characteristics of

the people who prefer wine.

It is quite difficult then to draw a clear

and coherent picture of the differential

health effects – benefits or drawbacks – of

different beverage types based on the epi-

demiological research evidence: the con-

founding effects of other factors are just too

great and it is very hard, if not impossible

to control for them altogether. In short, the

results of individual epidemiological stud-

ies on the differential effects of different

beverages types cannot be trusted. Such

results have been published on the effects

of different beverages on e.g. liver cirrho-

sis, different cancers and gout. Earlier re-

views have concluded that strong alcoholic

beverages show a closer association than

other beverage types with oesophagal can-

cer (Longnecker 1995), but a recent review

by Boffetta and Hashibe (2006) observes

that the research evidence on the differen-

tial effects of different beverage types on

cancers of the mouth and upper digestive

tract is contradictory and that alcohol it-

self is probably the main causative agent.

In Finland, Poikolainen et al. (2002)

studied the day-to-day variation in the re-

tail sale of alcoholic beverages and in fa-

tal alcohol poisonings in 1983–1999. The

results showed that the number of deaths

from alcohol poisonings correlated more

closely with sales of spirits than with total

alcohol sales, suggesting that in Finland

spirits account for more fatal alcohol poi-

sonings than other alcoholic beverages.

In other words, although it is possible to

drink beer and wine in large enough quan-

tities to die of alcohol poisoning, this is

more likely to happen with spirits.

When the effects of the same quantities

of alcohol are considered from the point

of view of accidents and violence, the

key concern is whether different bever-

ages cause different kinds of behaviour

changes. Experimental studies show that

undiluted spirits, when consumed on an

empty stomach, induce a faster rise in

blood alcohol content and a higher maxi-

mum level of blood alcohol content than

ingestion of the same amount of absolute

alcohol in beer (e.g. Takala et al. 1957). On



the other hand, the opposite result is ob-

tained when alcohol is consumed in con-

nection with or immediately after a meal:

beer induces a higher maximum of blood

alcohol content (Roine et al. 1993). Ac-

cording to the psychological observations

in the study by Takala and colleagues, the

consumption of spirits was more likely to

prompt aggressive behaviour and uncon-

trolled behavioural reactions. Beer, on

the other hand, was more closely associ-

ated with difficulties of perception and

inappropriate responses to stimuli. Other

studies using experimental designs, some

in laboratory environments and others in

more natural settings, have also reported a

closer association for spirits than for beer

with both verbal and physical aggressive-

ness (Boyatzis 1974; Pihl et al. 1984; Mur-

doch and Pihl 1988), although this may be

based more on the anticipated effects of a

certain type of beverage than on the bever-

age’s actual physical properties (Pihl et al.

1984).

All in all it can be concluded that by far

the single most important factor with re-

spect to alcohol-related harm is the quanti-

ty of ethyl alcohol consumed at one sitting

and in the longer term. The choice of bev-

erage type has only marginal significance

on top of this effect. However, it seems

that the volume of spirits consumpiton is

a more crucial factor than consumption of

other alcoholic beverages with respect to

fatal alcohol poisonings, and there is quite

persuasive evidence that spirits have a

greater effect on aggressive behaviour than

beer and wine. As for CHD, the scientific

verdict is still out on whether wine has a

greater protective effect than other alco-

holic beverages, and on whether spirits are

more likely to cause certain cancers.

Are certain beverage types liable to be consumed in larger quantities than others?If we had concluded above that beverage

type has no effect at all on alcohol-related

harm when the quantity of ethyl alcohol

consumed is the same, would that auto-

matically have meant that tax or other ma-

nipulation of the choice of beverage type

can have no effect on the related harms?

Things are not quite as simple and straight-

forward as that: real life is not a laboratory

where people who drink different types

of beverages are served exactly the same

amount of alcohol. Another important

consideration from an alcohol policy point

of view is whether the choice of beverage

type influences the quantities consumed

if individual preferences and the purpose

and nature of the drinking situation are

the same (broken line arrow 2 in Figure 1).

We move on now to review the research

results on how beverage type is associated

with heavy consumption and binge drink-

ing. The research design does not allow

us to control for individual preferences or

the nature of the drinking situation, so the

following description of the associations

between beverage type and heavy con-

sumption are not necessarily indicative

of causal effects. We revert to the alcohol

policy implications of our observations in

the Discussion.

What do heavy consumers drink?

It is often assumed that heavy drinkers

seize every opportunity to ingest alcohol,

regardless of whether it is available in the

form of spirits or milder alcoholic bever-

ages, and thus that they consume large

quantities of all types of beverages. On the

other hand the public perception at least



in Finland often associates heavy con-

sumption above all with spirits. We have

analysed the results of the 2006 Alcohol

and Drug Study (Mustonen et al. 2007)

and compared the breakdown of different

demographic groups’ annual consumption

between beer, wine and spirits in 100 per

cent alcohol. For our analysis of heavy

consumption, we focused on the top 10,

5 and 1 per cent of alcohol consumers. In

these groups of heavy consumers, spirits

accounted for around one-fifth of total con-

sumption (Table 1). Among all consumers,

spirits accounted for 17 per cent of total

annual consumption, among others than

heavy consumers (using the 10 per cent

definition) the figure was 16 per cent. Ac-

cording to these questionnaire data, then,

spirits account for a slightly larger propor-

tion of total consumption among heavy

consumers than they do in the total popu-

lation.

What do people drink on heavy

drinking occasions?

In the Drinking Habits Survey in 2000 (Met-

so et al. 2002; Mustonen et al. 2001), data

was collected on the quantities of different

beverages consumed on the respondents’

most recent drinking occasions. These

data allow us to review choices of bever-

age type on heavy drinking occasions.

Beer accounted for around 60 per cent

of the total consumption of pure alcohol

on all reported drinking occasions, while

wine and spirits accounted for around 20

per cent each (Table 2). On heavy drinking

occasions the share of beer was otherwise

the same as on other drinking occasions,

but in the heaviest binge drinking episodes

the proportion of beer consumption was

somewhat lower. The proportion of spir-

its, on the other hand, varied systematical-

ly according to the quantities consumed:

the heavier the binge drinking episode, the

greater the proportion of spirits. This result

applied to both men and women (results

not shown in the table). In other words the

results of the Drinking Habits Survey in-

dicate that spirits had a prominent role in

Finnish binge drinking in 2000.

The limits used in this analysis for

heavy drinking at one sitting (7, 13, 20 and

27 servings), describe heavy binge drink-

ing, but it should be pointed out that the

drinking of even as high number of drinks

as 20 is not extremely rare among Finn-

ish men. For example, in the 2006 Alco-

hol and Drug Study, 21 per cent of men

and 4 per cent of women reported at least

one annual occasion when they consumed

more than 18 servings. In the age group

20–34, the figures were 36 and 5 per cent,

respectively.

Who drink mild alcoholic beverages

and who drink spirits?

According to the 2006 Alcohol and Drug

Study, women consumed 90 per cent and

men 80 per cent of their alcohol intake

during the past year in the form of wine

or milder beverages (Figure 2). Within the

category of mild alcoholic beverages, the

Beer, Wine SpiritsCider

all users 63 20 17

heavy users (10%) 66 15 19

heavy users (5%) 63 15 22

heavy users (1%) 63 15 21

Source: alcohol and drug Study 2006 (Stakes)

Table 1. Percentage breakdown of heavy users’ annual consumption by beverage type



preferences between men and women dif-

fer more clearly. While men consume more

than half of their annual absolute alcohol

intake in beer and less than 10 per cent in

cider, women consume more or less equal

amounts of beer and cider. Among women,

wine accounts for a much larger propor-

tion of total alcohol consumption than

among men.

In younger age groups both men and

women prefer to drink mild alcoholic

beverages, beer and cider (Figure 3). In

the age group 15–29 these beverages ac-

count for more than three-quarters (79%)

of men’s total alcohol consumption and

for almost three-quarters (70%) of wom-

en’s consumption. Among women, wine

consumption increases with age particu-

larly at the expense of cider, but also at the

expense of spirits. Among men, the pro-

portion of both wine and spirits consump-

tion increases with age, particularly at the

expense of beer but to some extent at the

expense of cider.

The popularity of wine in older age

groups may have to do not only with ac-

quired tastes but also with wealth. Espe-

cially among women but also among men,

wine-drinking increases significantly with

rising income. Among women in the high-

est income bracket, wine accounts for 46

per cent of total alcohol consumption,

whereas the proportion among women in

the lowest income bracket is around 20

per cent. The corresponding proportions

for men are 17 and 9 per cent.

Discussion Beverage types and harms in real life

The real-life observation that the use of

different types of alcoholic beverages is as-

sociated with different amounts of harm is

explained, on the one hand, by the physi-

cal properties of alcoholic beverages and

the social and cultural rules that govern al-

cohol use (Mäkelä 1983); and on the other

hand by the availability of different bever-

ages, as regulated by alcohol taxation and

other alcohol policy measures. These fac-

tors are crucial in explaining for instance

why a different type of beverage is more

closely associated with harm in one country

or at one point in time than in another

country or at another point of time.

number of drinking occasions

Percentage share of beverage type

Beer wine Spirits

Share of 100% alcohol consumed on all drinking occasions

6 383 59 21 20

less than 10 cl consumed at one sitting (less than 7servings)

5 010 59 24 17

more than 10 cl consumed at one sitting (7+ servings)

1 373 61 10 29


399 60 6 34


120 51 4 45


45 42 4 54

Source: drinking habits Survey 2000 (Stakes)

Table 2. Percentage breakdown by beverage type of total alcohol consumption on all drinking occasions and on binge drinking occasions.



Different beverages are chosen and used

by different people and on different kinds

of occasions on account of their different

properties. Alcoholic beverages can be

used at least to quench a thirst, to wash

down a meal, to get drunk, as a social lubri-

cant or as medication. Different alcoholic

beverages are differently suited to meeting

these needs: for instance, a beer is much

better suited as a thirst-quencher after sau-

na than a glass of red wine or whiskey. The

ability of alcoholic beverages to satisfy peo-

ple’s needs is dependent not only on their

physical properties, but also on different

customs and norms as well as the cultural

determinants associated with alcohol. For

instance, it is hard to imagine a wedding

reception where people would toast with

mugs of beer or vodka rather than flutes of

champagne. Having said that, advertisers

and promoters are certainly pushing hard

to extend and expand the range of situa-

tions where different types of beverages

would have cultural approval.

All in all the differences in how alco-

holic beverages are suited to different pur-

poses and the de facto differences in their

uses are not perhaps as great as one might

be inclined to assume at first glance. One

noteworthy factor here is that the proper-

ties of beverages vary quite markedly even

within each beverage category. People in

Finland can travel across to Estonia and

legally buy a bottle of vodka with 80 per

cent alcohol by volume, and they can walk

down to the corner shop and get a bottle

of ready-to-drink Gin Long Drink with

1.2 per cent alcohol by volume. The alco-

hol content of beers sold in Finland has

ranged from 0 to 16 per cent, and grocery

stores and supermarkets carry wines that

contain less than 4.7 per cent alcohol by

volume.

Furthermore, alcoholic beverages are

not always consumed in the form they

come from the bottle, but various mixers

are often added to change their original

taste, colour and aroma before consump-

tion. According to Simpura et al. (1993;

1996), on one half of all Finnish drinking

occasions in 1992, spirits were diluted to

strengths comparable to wine or milder.

Alcohol policy influences our choices of

beverage in various ways, through taxation

and mechanisms to control the availability

of alcohol. A good example of the impact of

50–69

30–49

15–29

All

0 20 40 60 80 100

Beer Cider Wine Spirits

50–69

30–49

15–29

All

0 20 40 60 80 100

MEN

WOMEN

%

%

Source: Alcohol and Drug Study 2006 (Stakes)

Figure 2. Percentage breakdown of annual alcohol consumption by beverage type in male and female age groups in 2006



alcohol policy is provided by the exemp-

tion of fortified wines from ration cards in

1952 (see Häikiö 2007, 135). In 1951, al-

cohol consumed in the form of wine ac-

counted for 5.6 per cent of total alcohol

consumption in Finland, and the propor-

tion of people arrested under the influence

that had drunk wine was 3.5 per cent.

Two years later, the corresponding pro-

portions were 19.9 and 36.8 per cent (Oy

Alkoholiliike Ab 1952 and 1954). In 1951,

the number of wine drinkers arrested per

1,000 litres of alcohol consumed in wine

was less than 10, by 1953 this climbed to

almost 30. The corresponding numbers of

arrested spirits drinkers per 1,000 litres of

alcohol consumed in spirits were 14 and

12, so on this basis someone could argue

that in 1953 (but not in 1951) wine was

clearly more harmful than spirits. How-

ever, the properties of these beverages had

not changed at all from 1951 to 1953, but

because of the change in the relative avail-

ability of alcohol, a large proportion of

binge drinking had shifted from spirits to

fortified wines.

A similar shift was observed in the early

1960s when the price of spirits and forti-

fied wines increased at the same time as

the prices of wine were reduced. This

again led to an increase in the number of

drunken arrests due to wine drinking rela-

tive to the volume of alcohol consumed as

wine (Häikiö 2007, 44; Ahlström & Öster-

berg 1981, 54), probably as a result of the

increased use of wine as an intoxicating

substance.

Can alcohol policy influence alcohol-

related harm through beverage type?

There is no doubt then that it is possible

by means of alcohol policy to influence

people’s choices of beverage type, but the

crucial issue is whether this has any effect

on the occurrence of alcohol-related harm:

it is primarily through this effect that any

tax or other policy interventions favouring

or disfavouring different beverage types

can be legitimized. As far as harms are

concerned the single most important fac-

tor is unquestionably the quantity of al-

cohol consumed at one sitting as well as

in the longer term, but what we want to

establish here is whether the type of bev-

erage consumed can have an independent

effect on the amount of alcohol-related

harms. Based on the review above, there

remain many unanswered questions about

the possible differential effects of different

beverage types. However, there are indi-

cations that spirits may have somewhat

more adverse effects than milder alcoholic

beverages. This does not mean to suggest

that we underestimate the harmful effects

of beer consumption, for instance: beer ac-

counts for almost one-half of all the alco-

hol sold in Finland, so it clearly has to be

responsible for a large part of a wide range

of alcohol-related harms. Below, we move

on to discuss the three key alcohol policy

questions that were raised at the beginning

of our paper.

1) Is the choice of beverage type directly

connected to harm if the amount of ab-

solute alcohol consumed and the nature

and purpose of the drinking situation are

standardized, say in an experimental set-

ting?

Our literature review showed no large or

consistent differences between different

beverage types with regard to the harm

they caused. We did, however, see some

minor differences and potential indica-

tions of differences. It seems that spirits



are more closely associated than other

beverage types with alcohol poisonings

and aggressive behaviour. Via aggressive

behaviour, spirits may therefore also be

a somewhat more important cause of vio-

lence. It has been hypothesized that wine

drinking might offer a greater protective ef-

fect against CHD and that spirits are a more

important cause of certain cancers, but the

evidence remains inconclusive and con-

tradictory.

2) Does the choice of beverage type have

a direct effect on the amounts of absolute

alcohol consumed?

Our results showed that spirits have a very

prominent role in Finnish binge drinking:

the proportion of spirits consumed increas-

es in direct proportion to the amounts con-

sumed on individual drinking occasions.

Beer is also consumed in large quantities

on binge drinking occasions, but a system-

atic correlation is only seen for spirits. In

other words, beer is widely consumed on

different kinds of drinking occasions, but

spirits are “needed” in order to get really

drunk. As was pointed out earlier, this as-

sociation is explained not just by the causal

effect of the choice of beverage type: even

in the hypothetical situation where spir-

its would be efficiently prohibited, these

heavy drinking occasions would not be

transformed into moderate drinking ocas-

sions, but some other alcoholic beverage

would be chosen to fulfil the same purpose

of getting drunk.

On the other hand, even in instances

where the intention of getting drunk has

preceded the choice of spirits, we may ask

which factors have driven that beverage

choice. Compared to undiluted spirits, me-

dium-strength beer drinkers need to con-

sume eight times the amount of liquid in

order to reach the same level of ethyl alco-

hol intake. Even wine contains about three

times the amount of liquid per one centi-

litre of ethyl alcohol compared to spirits.

The easiest way to consume large quanti-

ties of alcohol, to carry it around and to

drink it unnoticed is thus to consume it in

the form of spirits. Spirits provide a faster,

more effective and more dependable way

of getting drunk. Conversely, the state of

drunkenness achieved when consuming

milder beverages might often end up at a

less intensive level. With spirits, there is

also a greater chance than with milder bev-

erages that people drink more than they

intended, and consequently that they get

more drunk. Even though there is no firm

scientific evidence that people are inclined

to drink more spirits than milder alcoholic

beverages while others factors (such as the

purpose of drinking) remain constant, the

practical experience strongly suggests this

is the case. It is hardly a coincidence that

one of the A-Clinic Foundation’s top tips

on how to cut down on drinking on its

dedicated website says: “Switch to mild-

er beverages, dilute your drinks” (http://

www.paihdelinkki.fi/juomisen-hallinta/

vahentamisen-vinkkeja).

It is worth repeating here that the

strengths at which different beverages

are consumed differ much less than the

strengths at which they are sold in the bot-

tle (Simpura et al. 1993; 1996): spirits are

often diluted, and on half of all drinking

occasions they are consumed at strengths

comparable to wine or milder. However

the same source indicates that there is

marked variation in the strengths at which

alcohol is consumed and that on up to 40

per cent of all drinking occasions on which

spirits are consumed, they are drunk at an



alcohol content of 25 per cent by volume

or higher.

3) Can the choice of beverage type influ-

ence the purpose of drinking or the nature

of the drinking situation and thereby the

quantities consumed and the level of con-

sequent harm?

There is no question that price regulation

can act to change drinking habits by mak-

ing certain types of drinking situations

more common. In a purely hypothetical

example, the removal of all taxes on wine

would undoubtedly increase the consump-

tion of wine with meals. However the crea-

tion of new drinking situations does not

contribute to harm reduction. Whether it is

possible to reduce binge drinking by steer-

ing people’s choices of beverage type is the

important question.

The prime motive behind the 1960s

policy of favouring mild alcoholic bever-

ages was to encourage a change in drink-

ing habits and purposes of drinking: to

discourage binge drinking, to lower the

amounts drunk, and to reduce alcohol-re-

lated harm. However, the lesson of history

is that, at least in the short term, it was un-

fruitful to try and reduce binge drinking by

favouring mild beverages. Since the 1960s

alcohol has become a more integral part of

everyday life and social interaction, but

binge drinking has not decreased; quite

the contrary. The policy that favoured mild

alcoholic beverages lowered the threshold

to start drinking for new groups of users

such as women, among whom both binge

drinking and alcohol-related harm have

increased more sharply in recent decades

than among men (Tigerstedt 2004).

However, it is quite possible that in the

longer term this policy of favouring mild

beverages has had a greater impact than is

generally thought. It is interesting to spec-

ulate on alternative historical scenarios.

Let us imagine that overall alcohol con-

sumption in Finland today is at its current

level, but there has never been a conscious

policy to favour beer and wine, and that

therefore spirits accounted for almost 70

per cent of consumption as it did 50 years

ago, rather than for under 30 per cent as it

does today. Who believes that there would

not be more alcohol-related harm than we

have today?

There is in fact much debate on this very

issue in Russia today, where consumption

levels are extremely high and the number

of alcohol poisonings is even higher than in

Finland. Researchers there are convinced

that a milder policy line and a large-scale

shift from vodka to beer consumption

would reduce the amount of alcohol-relat-

ed harm. Western alcohol researchers who

have seen the consequences of the policy

line favouring mild alcoholic beverages

in the Nordic countries – the increase in

total consumption and in harm – have not

argued against such a shift towards milder

alcoholic beverages as a way of reducing

alcohol-related harm.

In conclusion then, there is no compel-

ling scientific evidence that spirits are

much more harmful than milder alcoholic

beverages. However, based on the argu-

ments presented above, we feel it is rea-

sonable to claim that the risks involved in

drinking spirits are to some extent greater

than those involved in drinking milder

beverages and it would therefore be un-

wise to encourage consumers to favour

spirits. There is a group of people, particu-

larly heavy consumers, who calculate and

minimize the cost of obtaining ethyl alco-

hol and for whom alcohol is first and fore-



most an intoxicating substance. Especially

for this group of people, it would undoubt-

edly be safer if spirits were not the cheap-

est source of ethyl alcohol.

The lesson of the previous Finnish anal-

ysis of different types of alcoholic bever-

ages (Simpura et al. 1993) has sometimes

been interpreted to be that, from a harm

point of view, beverage type is irrelevant

and that the only thing that matters is the

amount of alcohol consumed. Nonethe-

less, Simpura and colleagues conclude

that “the policy of favouring mild bever-

ages and the underlying thinking that fa-

vours softer drinking habits is a sensible

alcohol policy objective” (ibid., 420), with

which we agree. The main message of the

article by Simpura et al., as we interpret it,

was that beverage type is not as significant

a factor as was believed at the time. The

times have changed, and today it seems

we have been drifting towards the other

extreme again: there are some arguments

around which suggest that beverage type

has no significance at all. Our message is

that beverage type is likely to have some

significance.

Some health economists take the view

that the only acceptable tax policy is one

where the differences in taxes levied on al-

coholic beverages are proportionate to the

external harm they cause (see e.g. Cnossen

2007). If spirits cause only modestly more

harm than milder alcoholic beverages, the

tax levied per litre of ethyl alcohol should,

according to this thinking, be only slightly

higher for spirits than for milder alcoholic

beverages. In 2007, the tax on spirits in

Finland was 28.25€ per litre of 100 per

cent alcohol, on intermediate products

23.56€ (calculated for wine at 18 per cent

abv), on wine 19.27€ (wine at 11 per cent

abv) and on beer 19.45€. So the question

could arise: why are taxes on spirits not

reduced – or taxes on beer and wine not

put up to at least nearly the same level

as those for spirits – if the differences in

related harm per one litre of 100 per cent

alcohol are not that large? In our view, this

line of thinking is not justified, for as far

as public health and social harm are con-

cerned the key issue is the price at which

different alcoholic beverages are retailed,

not the amount of tax that is levied on

them. Since the costs of manufacturing,

packaging and transporting spirits are sig-

nificantly lower per litre of ethyl alcohol

than the corresponding costs for milder

alcoholic beverages, an equal rate of taxes

would make spirits much cheaper per li-

tre of ethyl alcohol than other beverages.

Based on our review above, this situation

would in all probability lead to an increase

in alcohol-related harm.

Translation: David Kivinen

Pia Mäkelä, senior researcher alcohol and drug research groupStaKeS – national research and development Centre for welfare and healthPoB 220, fIn-00531 helsinkie-mail: [email protected] Mustonen, senior researcher alcohol and drug research groupStaKeSPoB 220, fIn-00531 helsinkie-mail: [email protected] Österberg, senior researcher alcohol and drug research groupStaKeSPoB 220, fIn-00531 helsinkie-mail: [email protected]



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Making use of research

“Making use of alcohol and drug research: picking the best bits from the smorgasbord?” was the theme for the mini-seminar hosted by the Nordic Centre for Alcohol and Drug Research (NAD) at the annual NorDAN con-ference in Reykjavik on October 13th 2007. Alcohol and drug research is experiencing a changing environment, with increasing ideo-logical conflicts, and where research has less of an automatic authority than one or two generations ago. New, and sometimes high-ly valuable knowledge cannot be claimed as solely a product of and in the control of scientific peers. For example, the so-called third sector is establishing partly new re-lations to research, maybe most clearly so in the “post-corporative” Norden. A more problematic phenomenon is the alcohol in-dustry's increasingly active and inventive involvement in the financing and use of re-search. One of the leading ideas behind the Reyjkavik meeting was that researchers and representatives from the third sector would be able to exchange views on the roles, mo-tives and limitations of different actors in the use of alcohol and drug research, based on their own experiences.

In the following five commentaries, con-tributors of the workshop discuss the matter from different aspects. Robin Room describes his experiences from four countries where he has worked as researcher and research administrator: the US, Canada, Sweden and Australia. He outlines the four different po-litical cultures and regimes, with their dif-

ferent relations between science and policy and different ways of dealing with alcohol and drug problems. True to his calling, Room presents a research programme: One way of gaining knowledge of the dynamics and dif-ferences would be to analyze how important research innovations, such as the “total con-sumption theory”, have been received and implemented within various national frame-works, with different actors and policy-re-search structures.

Matilda Hellman, one of the organisers of the seminar in Iceland, reflects upon the use of alcohol research, in part from a science communication point of view. The espe-cially close relation between (alcohol) pol-icy and research in the Nordic countries, in combination with a strong presence of vol-untary organisations, may have resulted in a non-hierarchical and socially responsible kind of research, but it may also have created a strong culture of cautiousness and consen-sus, where politicians and the research com-munity are expected to talk with one voice. The present more diversified scene may seem threatening from a consensus perspective.

Hildigunnur Ólafsdóttir discusses dif-ferent uses of research. The demand for an evidence base and the “technocratization” of research is to some extent a consequence of the diminishing role of the alcohol ques-tion and of increasing steering of public re-search money. Alcohol and drug research has further challenges in the shape of com-municating across disciplinary boundaries

Making use of alcohol and drug research: An introduction


and with professionals in the fields of treat-ment, education and policy making, and in the shrinking role of relevant voluntary organisations. In political decision-making, research can perhaps be more important on an international than national level, Ólafs-dóttir suggests. In small countries good con-tacts with the media may be more important in influencing decision-making than direct contacts with politicians. To summarize, the author suggest that researchers, if they want to influence society, must make themselves much more aware of the experiences, values and interests of the different consumers of research.

Katariina Warpenius and Marja Holmila describe their experiences from a localised alcohol prevention project, PAKKA, in four towns in Finland. As an example of the role of researchers in projects aimed at an evi-dence-based policy, PAKKA is illustrative. The authors argue for active contacts be-tween researchers, politicians and the media if the aim is to achieve changes and a lasting implementation of new policies.

Finally, Emilie Rapley from Eurocare de-scribes the challenges in using research from the point of view of an umbrella third-sec-tor organization that aims at promoting the prevention of alcohol-related harm on a European level. The organization in general

seeks three types of research findings, she states: figures, best practices and future chal-lenges. But the unfortunate reality is that the evidence is often fragmented, different ver-sions of facts are presented, and evidence is not always comparable, or even policy relevant. (In fact, Rapley defends the rights of researchers to be politically “useless”.) Finally, the industry is actively using “evi-dence” to argue its cause and to gain a posi-tion in the EU political process. As a conclu-sion, Rapley notes that the relation between research and organisations lobbying for public health measures in the alcohol field is embedded in a complicated web “where evidence, stakeholders, political decision-making and public opinion are interrelated”. The causal links between advocacy success and any particular factors may often be dif-ficult to identify. She ends by presenting the example of the homelessness researchers in Europe, who have organised themselves so as to improve their understanding of the problem of homelessness and to develop ef-fective politics. Can this be a model for alco-hol (and drug) researchers?

This collection of commentaries will hope-fully lead to further debate about the relation between research and research consumers in the Nordic countries and Europe.

The editors



I have been a social researcher on alcohol, and sometimes also on drugs and gam-

bling, in five countries. This is an account of my own experience in four of those countries with the relation between social research and the world of policy. (Norway is excluded, since I worked there for only six months.) In all of those countries, I was working on research which could be seen as relevant to policy: studies of patterns of use and problems in the general population, and to some extent also policy impact studies. Let me start with some notes on the experi-ence in each country, before moving on to some comparisons, reflecting on my experi-ence.

Experiences as an itinerant scholar

Berkeley, California, USA, 1963–1991I started as a research assistant on the Cali-fornia Drinking Practices Study in 1963, and moved up through the ranks of what even-tually became the Alcohol Research Group to be its director from 1977 until 1991. In all that time, I can remember testifying in government hearings a total of twice. I was the only person to testify to a California state government agency in favour of Governor Jerry Brown’s inspired but doomed idea of combining the state alcohol licensing and control agency with the state alcohol prob-lems treatment agency. And I testified once,

along with biological researchers, at a Senate hearing in Washington basically in support of more money for alcohol research. Besides that, one California state senator took an in-terest in the field for a while, and met with us several times. Otherwise there was little contact with politicians or the political proc-ess.

We did have some influence on policy. But it tended to be by influencing civil servants or through intermediaries. The head of the California state agency (Loran Archer) came to us as he started to think beyond building a treatment system as the limits of alcohol policy (see Room & Sheffield 1976). Like-wise, a group of us served as mentors to the Prevention Division of the National Institute on Alcoholism and Alcohol Abuse (NIAAA) as it moved in the same direction. The in-coming head of NIAAA (Ernest Noble) came out to visit us, since he had read and been persuaded by the “purple book” produced by Kettil Bruun and colleagues (Bruun et al. 1975). Our work and thinking also played a role when the National Academy of Sciences produced a 1981 report on Alcohol and Pub-lic Policy (Moore and Gerstein 1981).

In the early days, we were mostly left alone by the media. If they came by, the only question of interest to them was “How many alcoholics are there in the United States?” By the late 1970s, the alternative community newspapers were beginning to pick up on a

roBIn room

Notes of an itinerant worker

Revised from a presentation at a Nordic Centre for Alcohol and Drug Research workshop on “The use of alcohol and drug research”, Reykjavik, Iceland, 13 October, 2007. Thanks to Norman Giesbrecht for his comments.

National variations in the use of alcohol and drug research


change in the wind on thinking about alco-hol—what has been called the “new public health” approach—and later that gradually made its way into the mainstream press. Nongovernmental organizations mostly had their own policy agenda, not much attuned to research findings. That began to change with the rise of Mothers Against Drunk Driv-ing (MADD), which did its homework on data which was relevant to its aims. Alcohol industry interests sniffed around a few times, but showed no serious interest in funding social research, and gradually settled into an antagonistic relationship to the “new public health” orientation. Very late in the game, the state alcohol monopoly systems began to realize that researchers had something to of-fer them in their struggle to survive.

In the U.S., the prestige and the media and political attention went to biomedical research, and to a lesser extent to clinical re-search. Occasionally, social scientists were called into play, as in the moves to decrimi-nalize public drunkenness in the late 1960s and 1970s, but basically the policy concep-tion of alcohol problems was in terms of alcoholism and the solutions were seen as coming in the indefinite future from bio-medical advances.

Toronto, Ontario, Canada 1991–1998In Toronto, I was the Vice-President for Re-search in a large provincial agency, the Ad-diction Research Foundation (ARF), with re-search, treatment, training and community program functions. I testified maybe 10 times in all at parliamentary or city council hear-ings at various levels—nationally, in Ontario and in British Columbia. We had regular meetings and some collaboration with the Ontario alcohol monopoly. I had moved into a political system which, more than in the U.S., saw social research as relevant to the alcohol and drug policy process, and into a tradition at ARF of offering “Best advice” documents to the policy process whether or not they were asked for.

Relations with the alcohol industry were less polarized in Canada than in the U.S. On

the other hand, the Toronto media were quite hostile to ARF, particularly on alcohol is-sues. The media and political environments were very “wet”, and the reporters could not imagine that we were right in reporting that alcohol policy attitudes in the general popu-lation of Ontarians were considerably “dry-er” than those of their friends. On the other hand, the public health community, includ-ing various Boards of Health, had considera-ble influence in alcohol policy, and success-fully opposed the provincial government’s proposed privatization of alcohol retailing in Ontario in 1995.

Nongovernmental organizations were often in fact supported with government funds, so that “community meetings” often turned out to be between employees of dif-ferent quasi-governmental organizations. Policy decisions were more consensual than in the U.S., and changes were rarely abrupt. During the 1990s, the federal government was in retreat in the alcohol and drug field and in terms of its general funding of health research, so policy was mostly made at the provincial level, and there were efforts to make up for the absence of a national pres-ence by interprovincial activities (Anony-mous 2007).

Stockholm, Sweden 1999–2006In Stockholm, I directed the new Centre for Social Research on Alcohol and Drugs at Stockholm University. The first week I ar-rived, I testified on alcohol policy matters to a committee of the parliament, with all 15 members in attendance. While the contacts thereafter tended to be less formal, our Cen-tre was regularly involved in contributing evidence or analyses to the policy process, to parliament, to the ministry and to various authorities (myndigheter), and in a network of contacts and discussions with civil servants. The Swedish tradition of commissioning of-ficial investigations and then inviting formal submissions commenting on the investiga-tion’s report ensured that relevant researchers were involved in the policy process.

Alcohol matters are generally more news-



worthy in Sweden than in North America, and I was often involved in our regular contacts with the press, despite my lack of spoken Swedish. The media was generally well informed, and press relations were gen-erally respectful. After the appointment of a national drugs coordinator in 2002, attitudes on illicit drugs relaxed a little in Sweden, opening up the possibility for that area, too, to become more evidence-based.

Until now, at least, the alcohol industry has played much less of a role in politics in Sweden than in politics in North America. We had polite contacts, but not much more. We had more regular contacts with temper-ance movement organizations, which retain some presence in Sweden (indeed their membership is rising); they were among our main points of contact with civil society.

Melbourne, Victoria, Australia 2006–2007In Melbourne, I am director of a small alco-small alco-hol policy research centre within a multi-function agency (treatment, help lines, train-ing, research), as well as a professor at the University of Melbourne. My position was funded by the state government as a signal of increased interest in alcohol policy; the requirement that three policy papers be pre-pared for the department each year ensures regular contact with the civil service. I had testified to Victorian state parliamentary committees several times before coming to Melbourne, but since coming to Melbourne contacts have been primarily through infor-mal meetings with legislative staff and civil servants, and by my appointment to state and federal advisory committees.

Generally, governmental interest in the evidence basis for policy is as strong as in the Nordic countries. But the alcohol industry is much stronger, and wary of public health researchers, and these attitudes carry over also to the state liquor licensing agency. The media is interested, and often well informed. An increasing number of nongovernmental agencies (often government-funded, at least in part) are interested in alcohol issues, and

looking for partnerships with the research world. My unexpected appointment as board President of the coordinating body for alco-hol and drug service agencies in Australia is a sign of this readiness to involve research-ers in the world beyond the academy.

�ome comparisons Each polity has its own style in terms

of the relation between social science and policyIn the U.S., the style is more hands off. Most research is funded though specific-topic research funding agencies—the NIAAA, in the case of alcohol. This ensures that there is earmarked money for alcohol research—without this, in all four countries alcohol research tends to lose out, because of the topic’s location at the periphery of academic disciplines. But, as Lorraine Midanik (2006) has charted, there has been a long-term drift towards an increasing biomedical domi-nance of what receives research funding. Social research is generally insulated from the political process, though occasionally the facts or the findings of some study are seen as politically shocking, and the insula-tion breaks down. At least directly and in the short run, social science research has little influence on policy.

In Canada, at least during my years there, research programs continued from old mo-mentum. New research was viewed as an optional extra in an era when governments had been cutting their research commit-ments. Despite ARF’s best efforts at dis-semination and implementation in Ontario, policies with regard to specifics of access to alcohol, e.g., hours and days of alcohol sales, real price, and control of smuggling, overall policies seemed not much influenced by re-search. Exceptions to this were the area of drink-driving, and the area of alcohol con-trol, where research had provided some sup-port for the maintenance of the provincial alcohol monopolies.

Sweden, with its strong commitment to so-cial engineering, is to some extent the social scientist’s utopia. In the alcohol policy are-



na, alcohol research tended to be a relatively conservative force, providing an evidence base to defend Swedish alcohol control poli-cies from the free-market pressures from the European Union (e.g., Norström 2002). In the drugs area, there had been an era of a strong drug-free ideology in which social research-ers in the field were suspect and marginal-ized, and little research was commissioned. This was transformed by the drugs coordina-tor’s commitment to collecting an evidence base for policy, which meant that a plethora of small studies were carried out after 2002, in a considerably changed political climate for such research.

Australia’s traditions of alcohol and drug research are largely a product of the last 20 years. Researchers’ main influence on policy has probably been through a dense network of advisory committees. Researchers and professionals have consistently insisted on the importance of alcohol, compared to drugs, to the political world. The message was unpalatable to the federal government in power between 1996 and 2007, but even abolishing one advisory system and erect-ing another (Fitzgerald 2005) did not really get the federal politicians the answers they wanted. Civil servants and parliamentary staff are quite committed to developing and using an evidence base for policies, although in an area like alcohol policy, where substan-tial economic interests are at stake, actual policy change tends to be at a glacial pace.

Each polity has its own style of defining and handling alcohol and drug problemsIn the U.S., the political framing of alcohol problems is as “alcoholism”, and of drug problems as a “recurring brain disease”. This biomedicalization of the problem definition has effects on research priorities, generally assigning a marginal role to social research. But the framing has rather little effect on the actual handling of alcohol and drug prob-lems. The lead social agency in handling drug problems, and increasingly also alco-hol problems, is the criminal court system.

A high proportion of those coming to treat-ment, in treatment modalities generally more social than medical, are there under pressure from the courts, often formalized in such in-stitutions as Drug Courts. Alcohol and drug treatment agencies generally turn as much of a blind eye as possible to the coercive auspices of their client flow, since this does not fit the idealized therapeutic model of the treatment trials and textbooks. The practical focus of the U.S. treatment system is thus on social and criminal problems, but there is a strong disjunction between this and the elab-orate research effort, which tends to focus on brain pathways and the search for anti- addiction medications.

The Canadian framing is mixed. The dis-ease model is present as part of the policy frame, but less rigidly defined than in the U.S. In the great U.S. battles of the 1980s over whether “controlled drinking” was a legitimate aim of alcohol treatment (Sobell & Sobell 1995), Canada provided a welcom-ing and less ideologically rigid refuge. The criminal courts have less of a gate keeping function on treatment than in the U.S., so the treatment is generally less often coerced. As in the U.S., treatment methods are generally nonmedical, except for opiate maintenance therapy. In the research world, influenced by the U.S. (and the possibility of U.S. funding), there is a creeping biologization, but social and policy research appears to have held its own and even advanced, for instance in Brit-ish Columbia.

Sweden has long differed from the Eng-lish-speaking world and from much of Eu-rope in defining alcohol problems primarily in terms of social welfare and workforce participation. Despite the advent of opiate maintenance therapy, which requires some medical input, two-thirds of Swedish treat-ment is still provided by the social welfare system, and only one-third by the health sys-tem. Sweden has kept a system of civil com-mitment of heavy alcohol and drug users to treatment, mostly abandoned in Anglophone countries. But the system is small (about 1000 cases a year)—much smaller than the



diversion from criminal courts in the U.S. or the U.K. While there is some biologization of research, the traditions of social, crimino-logical and policy research have remained strong with respect to alcohol. Although the social rejection of illicit drugs remains strong, the panic has faded, enabling a re-surgence of social and criminological drug research.

Australia’s framing of alcohol and drug problems, like Canada’s, might be described as mixed. In the modern era, the emergence of alcohol and drug research as a field came in the wake of public concerns over the rise of illicit drug use. The main framing has been in terms of public health and “harm reduc-tion”, with public health-oriented doctors providing the main conceptual matrix. The conservative political reaction against this framing redefined it somewhat, but did not succeed in dislodging it. Given this history, present-day arguments on alcohol policy, as it comes to the fore, are often framed in terms of comparisons with illicit drugs. Though funded through decentralized and often quixotic paths, social and policy research on alcohol and drugs have built up quite strong traditions in Australia, and the media and policy worlds show interest in the results of such research.

Normal science and paradigm shiftsFunding and support for research is almost always provided within the terms of the dominant paradigm or framing of the nature of the problem and of suitable solutions for it. Using Thomas Kuhn’s (1962) term in The Structure of Scientific Revolutions, research support is thus provided for “normal sci-ence”, research projects that operate within a given framing of the research problems. What the policy process looks for from so-cial science is reports on such matters as the monitoring and analysis of behavioural trends, scoping and monitoring the size of problems, the identification of new and worrying trends, intelligence on hidden behaviours, and studying the effectiveness and cost-effectiveness of particular ways of

handling problems or particular policy in-terventions. All such studies can easily be justified within the bounds of a particular policy framing.

What this model of the relation between science and policy does not allow for is the possibility of “abnormal science”, in Kuhn’s terminology—that research may question relationships taken for granted in the domi-nant paradigm, or may bring to the fore is-sues which do not fit within it. Research and researchers may then play an important role in the construction and institutionaliza-tion of a new paradigm. Or, in practically- oriented fields such as ours, the impulse for paradigm change may come from outside the research community.

A start on comparing national experiences with paradigm shiftsIn the context of alcohol research and poli-cy, we may identify the “new public health” approach—known in Sweden as the “total consumption model”—as such a paradigm change. Elements of the new approach came to the fore in Finland after 1969, as research-ers grappled with the rise in consumption and alcohol-related problems following an increase in alcohol availability which was supposed to tame Finnish drinking (Tiger-stedt 1999). The Swedish experience with the rise in youth consumption and problems when “medium beer” was introduced also provided empirical background for a shift. Meanwhile, Canadian researchers recog-nized the relation between changes in price, in levels of consumption and in rates of cirr-hosis deaths, pointing to the total level of alcohol consumption in a population as an important policy concern (Room 1991). U.S. researchers found that drinking problems in the general population were widely spread but much more diffuse than in treatment populations, which suggested that providing treatment was at most a limited response to rates of alcohol problems in a society.

As these elements came together (for in-stance in the “purple book”, Bruun et al. 1975), their first and strongest influence was



in the Nordic countries. In part this reflected a closer connection between social science researchers and the policy process, and in part probably a specific structure of poten-tial political influences—that Nordic tem-perance movements retained some strength in the 1970s, and that the alcohol production interests were relatively politically weak. In the Canadian context, research agendas were relatively insulated from political pressures, and it was recognized relatively early that the new framing provided a defense for the state’s strong control of the alcohol market, notably through the provincial alcohol mo-nopolies. On the other hand, the policy in-fluence of the new paradigm has weakened in recent years; the provincial government retailers have shown little interest in con-trolling overall consumption, and instead have focused on alcohol promotion, market-ing and increasing sales from one year to the next.

In the U.S., the new paradigm advanced in the face of strong opposition, particularly from the alcohol industries, who forced out two directors of NIAAA in succession pri-marily because they had picked up the para-digm. As one of the directors put it, looking back, he “had no choice … but to be in con-frontation: research was leading and we had no choice but to move” (Room 1983).

Meanwhile, in Australia the new para-digm had little initial traction. A leading social alcohol researcher, Margaret Sargent (1979), to some extent picked up on the paradigm, but she was in the process of be-ing pushed by more mainstream sociologists out of research work. Australian attention to the model came in eventually in the specific context of alcohol problems among Aborigi-nal populations in remote areas and country towns, and has gradually taken hold also with respect to the wider society. One reason for the relatively late adoption of the model in Aus-tralia was that substantial investment in alco-hol research has also come relatively late.

Paradigm shifts do not always come di-rectly from research into the policy world.

When I arrived in Sweden in 1999, there was a strong political consensus against the “harm reduction” paradigm shift in illicit drugs which had taken root in many other countries. Swedish illicit drug research-ers—primarily criminologists—who had been part of these international currents of thinking were marginalized from the policy process and indeed held at arms-length from it. As Lenke and Olsson (2002) put it, drug “researchers and other drug policy experts were ... placed in an intellectual quarantine”. Given the commitment of Swedish public life to take account of research findings in setting policy, the political solution had been to commission very little social drug research; a study which is not done cannot upset a political consensus. The advent of the drugs coordinator in 2002, and his com-mitment to increasing the knowledge base for Swedish drug policy, played a substan-tial role in breaking up this stalemate, and putting Swedish drug policy on the more usual Swedish path of evidence-based social engineering. In this case, the impulse for a change which might be seen as amounting to a paradigm shift came from the political side rather than the research side.

Science is international—even most of social science, though it must take account of social and cultural particularities. Para-digm shifts in science thus are also usually international. But studying and comparing whether and how and when a shift takes root in a particular society is illuminating in many ways. In particular, it offers a good way to compare national practices and tradi-tions in the relations between social science and policymaking.

Robin Room, Ph.d.School of Population health, university of melbourne, australia;aer Centre for alcohol Policy research, turning Point alcohol & drug Centre, fitzroy, victoria, australia;Centre for Social research on alcohol & drugs, Stockholm university, Sweden



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Bruun, K. & Edwards, G. & Lumio, M. & Mäkelä, K. & Pan, L. & Popham, R.E. & Room, R. & Schmidt, W. & Skog, O.-J. & Sulkunen, P. & Österberg, E. (1975): Alcohol Control Policies in Public Health Perspective. Helsinki: Finnish Foundation for Alcohol Studies, Vol. 25

Fitzgerald, J. (2005): The Australian National Council on Drugs (ANCD) and governance in the Australian drug policy arena. Contempo-rary Drug Problems 32: 259–293

Kuhn, T. (1962): The Structure of Scientific Revo-lutions. Chicago: University of Chicago Press

Lenke, L. & Olsson, B. (2002): Swedish drug po-licy in the twenty-first century: a policy model going astray. Annals of the American Associa-tion of Political and Social Science 582: 64–79

Midanik, L. (2006): The Biomedicalization of Al-cohol Studies: Ideological Shifts and Institutio-nal Challenges. Edison, NJ: Aldine Transaction

Moore, M. & Gerstein, D.R. (eds.) (1981): Alcohol and Public Policy: Beyond the Shadow of Pro-hibition. Washington, DC: National Academy Press

Norström, T. (ed.) (2002): Alcohol in Postwar Europe: Consumption, Drinking Patterns, Consequences and Policy Responses in 15 European Countries. Stockholm: National Insti-tute of Public Health and Almqvist & Wiksell International

Room, R. (1983): Former NIAAA directors look back: policymakers on the role of research. Drinking and Drug Practices Surveyor 19: 38–42

Room, R. (1991): Social science research and alcohol policy making. In: Paul Roman (ed.): Alcohol: The Development of Sociological Per-spectives on Use and Abuse, pp. 311–335. New Brunswick: Rutgers Center of Alcohol Studies

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Tigerstedt, C. (1999): Alcohol policy, public health and Kettil Bruun. Contemporary Drug Problems 26 (2): 209–235.



Drinking three or more alcoholic drinks per week may reduce the risk of devel-

oping rheumatoid arthritis (RA). This was a result from a large scale study from Karolins-ka Institutet presented in June 2007 (Källberg et al. 2007). In the study, greater amounts of reported alcohol consumption was associat-ed with even lower risks of developing RA. However, in the initial media coverage, the researchers responsible for the study empha-sized that they by no means were encourag-ing excessive alcohol consumption.

The Swedish temperance movement IOGT-NTO quickly reacted to the reporting with a press release (IOGT-NTO 2007) re-minding the general public about the harms caused by alcohol. The press release referred to and cited the scientific EU-report “Alco-hol in Europe” (Anderson & Baumberg 2006) pointing out that the risks of getting ill gen-erally increase directly in proportion to the amount of alcohol consumed.

In this fragmentary description of the course of events, we come across some in-teresting aspects on the different actors and arenas for public use of and communication on alcohol research findings. At least the fol-lowing arenas were involved: the research community, in which the results were pre-sented in the first place (at the 2007 annual meeting of the European League Against Rheumatism, EULAR), the media, which picked up in various ways on the research results and reported on them, and some rep-resentatives of the voluntary organisations, who saw their responsibility in weighing up the reports from the researchers by referring to another kind of knowledge on the risks involved with consumption of alcohol. In this paper I will mainly discuss the role of

the social alcohol research. My main aim is to discuss aspects of how (Nordic) alcohol research is used in the public space in which science meets the public.

The special research-policy relationshipThere are some basic characteristics of the public space in which the Nordic societal problems related to alcohol use are framed and defined. One of these characteristics is the relatively close interaction between research and policy. According to Olsson, Ólafsdóttir and Room (2002) this relation-ship was gradually developed in the decades after 1950, in line with a belief in science and progress as well as in social science re-search as a tool for policy making. Alcohol policies started to be seen as part of the wel-fare policy, and knowledge acquired by sci-entific methods as a necessary element in the planning of the welfare state. Social alcohol research has played a significant role in the Nordic alcohol policy field when it comes to monitoring social developments on a popu-lation level, analyzing and describing drink-ing patterns and examining characteristics and impacts of different policy tools. The role that this kind of research has played in the Nordic countries could be viewed in the light of theories of what is called “mode 2 knowledge production”, where knowledge is generated “in the context of application” (see Gibbons et al. 1994; Nowotny et al. 2001). In societies where mode 2 knowledge produc-tion prevails, conditions are established in which not only science speaks to society, but society can 'speak back' to science, resulting in more open systems of knowledge produc-tion. The ideal mode 2 science is transdisci-

matIlda hellman

Public use of and communication about alcohol research


plinary, heterogeneous, it works in varying networks; it is flexible, non-hierarchical and characteristically it carries a social respon-sibility. There is a close interaction of many actors throughout the process of knowledge production which is therefore considered more socially accountable.

Apart from the special relationship be-tween science and policy, the Nordic alcohol policy field has also been characterized by a strong presence of social movements, espe-cially in Norway and in Sweden, and by a lively public alcohol policy debate. Research has been highly contextualized and the com-munication between science and the public active.

Good examples of highly contextualized social alcohol research tasks are projects like the Swedish STAD-project, which tests and evaluates methods for preventing alcohol and drug problems (like responsible serv-ing-methods), and the Finnish community-based PAKKA project (see Warpenius & Hol-mila 2007).

In line with the theories on a mode 2 science we should consider research pro-grammes designed to meet specific socially mandated objectives (as e.g. “wars on can-cer”) as less integrated or contextualised re-search projects. Priorities are here pre-iden-tified within a structural framework and financial resources are earmarked. A strong hypothesis is that the level of contextualisa-tion depends on who is the orderer or the initiator of the research tasks, and on what kind of networks and support systems the research process depend.

The different economic and administra-tive structures of the knowledge producing institutions may have driven the alcohol re-search into different directions in the differ-ent Nordic countries. In order to get a picture of how the structures and financing of the research centres affect the tasks of the main social alcohol and drug research centres in the Nordic Countries, NAD has carried out an investigation that will result in a report to be presented in the spring 2008.

The translator, the assistantNordic social alcohol research is contextu-alised and negotiated in different more or less publicly visible processes that involves a variety of forces and actors: the scientific community, policy making on different lev-els, the third sector, the industry and the me-dia. Even though interaction between policy, research and the third sector has been close in this field, many circumstances seem to indicate that some third sector actors would like a more effective alcohol research com-munication to support their own agenda.

The traditional, canonical account of the communicative relationship between sci-ence and society (see Bucchi 1998) starts out with the idea that the scientific enterprise has become much too specialized and com-plicated to be understood by the general pub-lic. Therefore, a form of mediation is needed in order to make scientific achievements more suitable and accessible to the public. The mediation requires the intervention of a new professional figure, a third person who wants to “bridge the gap between scientists and the non-scientific audience” (Bucchi 1998). This mediator is often described as an interpreter, a translator, who is reformulat-ing scientific discourse in simpler words.

As the RA-example illustrated, third sec-tor organizations often work naturally as translators of science, when they make use of and emphasize such results that support their own interests. Eurocare, a European al-liance of voluntary and non-governmental organisations concerned with the European Union’s influence on alcohol policy, is dis-cussing the use of research in its own activi-ties, and ponder a more structured solution for continuous use of alcohol research find-ings. In her discussion paper, Emilie Rapley (2007) glances at a model with a researcher-based observatory developed by FEANTSA, the European Federation of National Organi-sations Working with the Homeless. The Observatory is composed of a network of researchers across Europe, carrying out tran-snational research relevant to FEANTSA’s policy agenda. Another example of an ex-



tended need for research-based knowledge by third sector players is the Finnish Blue Ribbon Organisation, which from 2007 has expanded its own research and investigative activities.

It is too early to draw any empirical con-clusions of the policy effects of these research ambitions, but the initiatives per se tell us something. Firstly, the organisations want to shrink the gap between science production and the users of science (e.g. themselves). Secondly, the initiative introduces a partly new role for the researcher. The researcher becomes a mediator and an assistant but po-tentially also an activist.

Researchers doing science translationThe communication of science to the public is in Bucchi's canonical account reduced to a mere matter of linguistic competence. The researcher employing this role is translating the science language into a lay and practical discourse. When interviewed by the media, for example, the alcohol researcher makes some choices about the role to play, but is of course unable to fully control his/her role in the final reporting format.

The role of the researcher in the public arena has been discussed e.g. by Väliverro-nen (1996) in his study on the publicity of environmental problems in Finnish media. Based on the findings in his material Väli-verronen groups the tasks of the researcher in the public sphere into five categories: the popularisationist, the interpreter, the participant, the manager and the critic. The popularisationist's role is telling about the new research results, the interpreter's is to comment on different phenomena and prob-lems, the participant's role is to demand po-litical action and to warn about threats, the manager's role is to describe the use of tax money for research and market the research and finally, the critic's role is to interpret and comment on research.

Reporting on alcohol policy in the Nordic press and on the Internet have, at least be-tween 2005–2007, when I have followed it

on a daily basis, presented three clear tasks for the alcohol researcher: 1) to present the overall picture of the developments of alco-hol consumption and drinking patterns, 2) to comment on alcohol use, patterns, practices and damage developments and 3) to com-ment – and often to take a stand – on differ-ent alcohol policy tools and decisions. The roles connected to these tasks are mainly the popularisationist's, the interpreter's and the critic's. As an underlying (weaker) discourse one can read into it the role of the participant that wants e.g. to guide the public into un-derstanding the value of a restrictive alcohol policy.

Only on rare occasions does the researcher intentionally step out of these roles and ac-tively take part in the debate on his/her own initiative. One good example of such a breach is when in 2004 the researchers Jessica Palm, Sharon Rödner and Kalle Tryggvesson from SoRAD, Stockholm University, commented on the national Swedish Alcohol Commit-tee's campaign on pregnancy and alcohol in a debate article in the daily paper Dagens Ny-heter. They found that the campaign was ex-aggerating the risks of low alcohol consump-tion during pregnancy, pointing out that there was no sustainable scientific evidence to support the abstention arguments in the campaign. The campaign was, according to the writers, rather putting unnecessary pres-sure on pregnant women. The researchers broke with their own peers' expected public role, but they also broke with the unanimous voice of policy and research, considered so important for the argumentation behind a restrictive alcohol policy. Whereas the role/ function of the researchers involved in the FEANTSA’s Observatory and the Blue Rib-bon would mainly be attached to a specific (or overall) policy agenda, the function of the publicly participating researchers in this foetal alcohol syndrome case can be viewed as quite different and more active. The inde-pendent and deviant (from the point of view of expected consensus) view of Palm and colleagues on this aspect of a national alco-hol policy and its argumentation was criti-



cised by other researchers and politicians, who referred to the difficulties involved in the use of science for argumentation in this particular alcohol policy matter – the sensi-tive question of the health of pregnant wom-en and unborn children.

In a comment to the discussion, one of the participants, Kalle Tryggvesson, asks wheth-er the article in Dagens Nyheter could have had any influence on the amount of state support that SoRAD later received from the Ministry of Health and Social Affairs (Trygg-vesson, 2007). How much will alcohol re-search be bridled and obliged to support the official or hegemonic policy positions?

The economic dependence on State fund-ing has also been considered by others to af-fect the tasks of research and its focus (Fjær 2006). I want to suggest that – perhaps even to a larger degree – it also affects and forms the public role of the alcohol researcher and to what extent he/she is able to express standpoints in the public arena. Consensus among the experts (researchers, interests groups, civil servants etc.) is generally con-sidered important in this field.

ConclusionsCommunicating science is a difficult task that involves some delicate positioning be-tween the culture that science operates with-in and the format in which the message is mediated to the public. In the aims of the Si-monyi Professorship in public understand-ing of science at Oxford University we find the following description of the scientist as the communicator:

The task of communicating science to the layman is not a simple one. In par-ticular it is imperative for the post holder to avoid oversimplifying ideas, and pre-senting exaggerated claims. The limits of current scientific knowledge should always be made clear to the public. Once done so, however, there is also a role for presenting speculative ideas, which can convey to non-scientists some of the ex-citement of doing true science. (Aims of the Simonyi Professorship)

Even though much of the alcohol research carried out today cannot unreservedly be used for arguing in favour of any particular standpoint or any particular question, it is used on a daily basis by representatives of NGOs, politicians, civil servants and journal-ists in value-based arguments. It is important for the research community to study and to discuss new roles of research(ers) in society, both in relation to state interests as well as the third sector (not to mention the relation-ship to the industry’s interests as a huge task on its own). Is research to be solely a tool for developing a restrictive alcohol policy? Is the researcher to be a translator of science for political goals, or an expert to comment on developments, or is he/she e.g. to take a more independent role and initiate public discus-sion? Or maybe all of the above? However we feel about this question, there is no doubt that looking into the functions and the roles given to and taken by the researcher can offer us insights into the rationales of this particu-lar knowledge producing field.

It is difficult to say how the claimed spe-cial relationship between alcohol research and alcohol policy in the Nordic countries influences the communicative interactions between science and the public, but one could at least assume that a more applica-tion-oriented research would perhaps draw the public's and the media's attention. The alcohol researchers – especially the ones that carry on research on alcohol consump-tion trends and harms at the population level – are indeed visible in the Nordic media cov-erage. However, as the research has strong roots in the state context, it perhaps makes researchers on occasions more reluctant to step out of the commenting expert role to be-come an initiator and a driving force in the public debate.

The role of scientific expertise changes as expertise becomes socially distributed. There seems to be a growing need for an evidence base to be used by the third sector in this field. This need can be seen in the light of the industry´s expanding involve-ment in alcohol policy questions following



the developments at the European level, but it can also be viewed as a shortage in the sci-ence communication between the research community and the people that need the research in their everyday work. When it comes to the use of research, most caution is often (understandably) practiced by the research community itself.

Matilda Hellman, project coordinatornordic Centre for alcohol and drug research (nad) annegatan 29 a 23fIn-00100 helsingfors, finlande-mail: [email protected]

REFERENCES

“Aims of the Simonyi Professorship” [Ref. 1.11.2007. Online: http://www.simonyi.ox.ac.uk/aims/index.shtml]

Anderson, P. & Baumberg, B. (2006): Alcohol in Europe. A public health perspective. A report for the European Commission. [Online: http://ec.europa.eu/health-eu/doc/alcoholineu_con-tent_en.pdf]

Bucchi, M. (1998): Science and the media. Al-ternative routes in scientific communication. Routledge: London and New York

Fjær, S. (2006): Den flerfaglige rusmiddelforsk-ningen i Norden – utfordringen til det nordiske forskerfellesskapet. Nordisk alkohol- och narkotikatidskrift 23 (2–3): 178–182

IOGT-NTO (2007): Alkohol bakom fler än 60 sjukdomar. (Alcohol behind more than 60 diseases). [Internet press release by IOGT-NTO dated 18.06.2007. Ref. 1.11.2007. Online: http://www.iogt.se/templates/NewsPageSmall ___13952.aspx]

Källberg, H. & Padyukov, L. & Klareskog, L. & Alfredsson, L. (2007): Ethanol consumption is

associated with decreased risks for developing RA – Results from the Swedish EIRA study. Ann Rheum Dis 66 (Suppl II): 92. Presented at the 2007 annual meeting of the European Lea-gue Against Rheumatism (EULAR), Barcelona, Spain, June 13–16, 2007

Nowotny, H. & Scott, P. & Gibbons M. (2001): Rethinking Science. Knowledge and the Public in an Age of Uncertainty. Cambridge: Polity Press

Tryggvesson, K. (2007): Comments on the alcohol and pregnancy debate by e-mail, November 2007

Väliverronen, E. (1996): Ympäristöuhkan anato-mia. Tiede, mediat ja metsän sairaskertomus. (The anatomy of environmental threats. Sci-ence, media and the case record of the forest). Tampere: Vastapaino

Warpenius, K. & Holmila, M. (2007): Connecting alcohol research and prevention practice: Les-sons learned form PAKKA. Nordic Studies on Alcohol and Drugs 24 (6): 652–655.



Research as an idea has almost the same status as prevention; it is widely praised

and supported. However, if researchers want their results to have an impact, there is no plain sailing from alcohol research to how it is used. In the following, some influential complications related to the position of alco-hol research in society will be pointed out. Furthermore, aspects on the communication between the research field and selected areas of society will be shortly discussed.

Expectations of researchThe relevance of alcohol studies is a matter of continuous discussion as research may provide material for policy decisions. Kettil Bruun was of the opinion that research led to the production of arguments rather than logical conclusions (Room 1986, see http://www.arg.org/kbs/room-on-bruun.html). In line with this view, scientific knowledge can be a valuable instrument of the current debate on social affairs, but democratic deci-sions are best taken on the basis of values.

Best knowledgeIn recent years we have seen increasing de-mand for evaluations of various programs and policies. Some even talk about an evalu-ation industry. Increased interest in evi-dence-based knowledge probably indicates a demand for so-called “best knowledge”, the best we know now, presuming that we will gain more knowledge and better understand-ing at some time in the future. Claiming that “more studies are needed” can, therefore, have the consequences that policy changes are not taken or postponed.

Sometimes, new challenges cannot be met without new knowledge, and research can provide answers to problems. But research may have an even more important task by providing new ways of thinking about old issues. Science is equally often about tearing down old knowledge as building up new.

Most researchers want their studies to be useful. To turn research results into practice is, however, no easy task and the relationship between research and policy has never been simple. Svanaug Fjær (2006) recently initi-ated a debate on the relationship between al-cohol research and the public administration in this journal. She raised the questions how a critical and creative knowledge produc-tion could evolve when the research com-munity is so dependent on the State, and the research field is so ideologically loaded. For a lively debate in society and for democracy it is problematic if the relationship between alcohol research and political power is too close, leaving little space for points of views that are alternative to those of the power cen-tre.

Large societal questions and researchIn an article that Pekka Sulkunen (2007) calls “Re-inventing the Social Contract” he examines how sociology has changed from being a study of societies to become a study of practices. In his analysis, within the con-temporary society of contracts, partnerships, projects, plans and voluntary commitments the State is no longer regarded as having a superior role or being a centre of integra-tion, but rather one among several actors in a rhizome-like network. In this society, the

Reflections on the use of alcohol research

hIldIgunnur ÓlafSdÓttIr


media is interested in lifestyle issues and the moralities involved, the State organs are interested in the impact of their own ac-tions. Researchers are asked to evaluate, to identify best practices, to measure outcomes and efficiency. Neither politics nor research is dealing with large societal questions such as the alcohol question; instead we have segmented problems defined by specialized expertise. It will have consequences for how alcohol research is used in society, if the re-search is trapped in this narrow and techno-cratic frame.

Per Ole Träskman (2007) has described the prerequisites for the Golden Age of Nordic criminal policy as a period when continuity of the policy was important, and comparative research and collaboration between the Nor-dic countries had priority. He has explained the decline of the Golden Age through pres-sure from the EU and the international com-munity for the Nordic countries to conform to other countries’ harsher criminal policies. This pressure has moved law-makers from using Nordic research as a basis for deci-sions. The idea of zero tolerance for criminal offences has been introduced to the Nordic societies. In Iceland, a harsher drug policy has cleared the way for heavier sentences for other offences, particularly sexual offences. Like in the other Nordic countries, crimino-logical research has had very little influence on criminal policy (Ólafsdóttir & Bragadóttir 2006).

Different from the criminal policy field, the rising interest in women’s issues on the international political level is assumed to have brought benefits for women’s issues in the Nordic countries. International women’s year in 1975, the UN decade for Women, and World Conferences on Women above all served to initiate steps in Iceland towards in-creasing knowledge, intensifying demands for equal rights, and making women more visible and active (Ástgeirsdóttir 2006). The women’s movement has been relatively suc-cessful in gaining the attention of new gen-erations by introducing new issues that have had support among the grass-root. Specific

research centers for women’s and gender studies have proved to be very important for continuity of research and the relationship between research, grass-root and policy.

Widespread public attention for envi-ronmental threats and climate change has been obtained by activities from the scien-tific community as well as by environmen-tal groups and concerned politicians. In this whole process, research was for some time disputed but its role both for chang-ing attitudes and for policy decisions is now considered to be of the utmost importance. Climate change and its consequences have become an issue on the international politi-cal agenda, but there are also examples that they are affecting individual lifestyles.

Can alcohol researchers draw any conclu-sions from the comparison of the relation-ship between research and society as in the fields of humanitarian criminal policy, environmental concerns and women’s is-sues? Researchers in these fields are strug-gling with the same problems as alcohol re-searchers in finding a way to communicate with society. However, research related to a broader framed issue such as women’s is-sues and environmental concerns is more likely to have an impact than an issue such as humanitarian criminal policy, which is often seen as only referring to a segment of society. A strong relationship between the respective researchers and the various en-vironmental groups and womens’movement has sometimes pressed the State to make use of research. Alcohol research today lacks this strong connection to movements.

The alcohol research community and societyIn a segmented society researchers will nev-ertheless interact with numerous agents. Re-search questions and results can be dissemi-nated to the general research community, other professionals, public administration, politicians, mass media, the alcohol market, interest groups and civil society.



Researchers and other professionalsEven if scientific work is usually a lonely work, at some stages, research is carried out in dialogue with other scientists. Re-search ideas are discussed; interpretations and conclusions are disputed or accepted by colleagues. Most advances in research are developed through dialogues, so other researchers’ responses are extremely impor-tant.

Alcohol research did not use to have a high esteem compared to many other re-search fields. It was well known that the stig-ma attached to the problem drinker spilled over to the clinicians working in the alco-hol treatment field. Those devoting their life to studying problematic drinking were not considered to be good examples of academic success. This is no longer the case, probably thanks to prominent and productive alcohol researchers.

Despite this rise in academic status, it is often difficult for alcohol researchers to reach out to researchers in other subject fields or special disciplines. Alcohol re-search has certain special obstacles, such as being multidisciplinary. Loyalty usually leads most academics to rely more on and refer more frequently to research carried out within the mother discipline than mak-ing use of contributions across disciplinary boundaries.

Communication with others than those directly involved in research may involve sharing knowledge with addiction profes-sionals, other health care experts, and coun-selors, specially trained persons working in the field of prevention and education, social workers and the police. In a recent yearly report for the Center of Addiction Medi-cine it is stated that the conceptual basis for the services is first and foremost scien-tific research in health sciences, psycho-logy and social sciences (http://www.saa.is/Files/Skra_0022712.pdf). This ideal may in practice not be so easily reached because of the above-mentioned barriers between disciplines and because research evidence may contradict clinical practices. The lack

of evidence of good results from alcohol education in schools in Babor et al.’s (2003) book: Alcohol: No Ordinary Commodity has for instance been hard to swallow for many working in the alcohol prevention field who thought they were doing a good job (see also Craplet 2007; Rise 2007; Odejide 2007; Damberg 2007).

Public administration and politiciansIt has been pointed out that government of-ficials are eager consumers of research and that they encourage research. But they ask for answers to problems as seen by them-selves whereas research may offer answers to other questions. How public administra-tion in the Nordic countries makes use of re-search is not very well documented. It may be assumed that the degree of use of research is higher in countries with well-established national research centers such as SIRUS in Norway and STAKES in Finland, than in countries with more decentralized alcohol research.

In international politics, research has been proven to be an important vehicle regarding the global burden of diseases. Research may be the heaviest weighing argument when nations bind themselves to international conventions that may restrain national eco-nomic interests. Unpopular policy decisions are more likely to be accepted by the gen-eral public if they can be scientifically sup-ported. At home, politicians are inclined to follow the national mood and they are under pressure from interest groups. According to Icelandic alcohol law, local government representatives have more power in alcohol policy than they are probably aware of. On the local level, pressure from local interest groups may carry more weight than research evidence.

Mass mediaContact with the media has often been very problematic for researchers and populariza-tion of science has always been questioned by the academic community. At present there seems to be an increasing pressure to



publish in peer reviewed journals whereas reporting to the public is not rewarded in the university environment.

In Icelandic society, the mass media is relatively easily accessible for researchers. A submitted article published in a newspaper or an interview with a scientist is more like-ly to reach a larger readership than a paper published in a peer reviewed journal. This may be a good way to reach politicians who watch the mass media very carefully and use it to promote their causes. Many journalists have some knowledge of social sciences and have a role in agenda-setting by framing the issue. The selection of researchers as com-mentators on results or changes in policy can be a powerful tool to steer the public discourse.

Scientific breakthroughs in alcohol re-search are rare. Room and Midanik (2005) note how in the USA, results from robust so-cial science studies get little attention com-pared to biomedical research, the latter of which is often based upon very small clini-cal samples and animal studies. The general public receives much of its information from the mass media, but even if the mass media can have tremendous short-term effects, it often has very little long-term effect. The public memory seems to be short.

Alcohol market Groups involved in for-profit alcohol produc-tion and sales are known to be key players in policy debates. Representatives for alcohol production and marketing may praise inde-pendent research when it is convenient, but are otherwise very selective in how they re-act to alcohol research relevant to their field. In cross-national alcohol policy discussions, representatives of the alcohol industry have been found to bring different views than government officials and non-governmental organizations proposing measures for im-pact, for which scientific evidence is rather weak, and opposing regulations for which the scientific evidence for impact is rather strong (Anderson & Baumberg 2006). In the Nordic countries, there seems to be a greater

distance between researchers and the alco-holic beverage industry and services than is the case in many other European countries. Alcohol studies funded directly by the alco-hol beverage industry have been rare in the Nordic countries.

Interest groups and consumersSome of the associations which traditionally aimed for temperance are nowadays con-cerned with reducing alcohol use and argue for creating alcohol-free zones in society. These pressure groups promote their cause by providing information in order to influ-ence policy. Some of them may even initiate particular research projects, but more often they are consumers of research.

With consumerism being a penetrating characteristic of society it is not unexpect-ed that the most important interest groups relate directly to consumption. In the Ice-landic context such interest groups may be classified in two different branches: consum-ers of alcoholic beverages, and consumers of public services offered for those experienc-ing harms from alcohol.

The so-called consumers of beverages are a floating group usually represented by those concerned with the high prices and low availability of alcohol.

Consumer of services are for instance par-ents’ groups, which offer support for parents and their substance-using children. They of-ten take on the role of campaigning for better services. In Iceland, the far largest interest group in the alcohol field is SÁÁ, with 8000 members. Many of the members are people in recovery or family members of people in recovery. Originally, the purpose of the asso-ciation was to fight for better treatment and services for alcoholics, and today its major activities are running the Center of Addic-tion Medicine, the main treatment center for addiction. Interest groups in Iceland have a strong victimological approach which may partly explain why personal experience rather than research evidence has been more central in campaigning for improved serv-ices.



Popular conceptionsIcelandic society like many small societies likes to think about itself as a very special case. Acting rather than discussing is con-sidered to characterize society. In line with the general image of society many Iceland-ers think that Icelandic drinking habits are extraordinary. It is also a recurring theme in the discourse that the Icelandic alcohol policy is a failure. University students are sometimes surprised when they learn that it is not the heavy drinking pattern but prohi-bition of beer for most of the 20th century, a large alcoholism treatment system, and high numbers of AA meetings that distinguish the position of alcohol in Iceland. Comparative studies such as ESPAD and GENACIS have been valuable in bringing knowledge that is contrary to what is presumed. Old stereo-types seem to be long-lasting in the general population.

What is the conclusion? The use of alcohol research will always be a complicated matter and difficult to predict. This is both related to the nature of science,

and to the various types of recipients and us-ers. Research follows its own rules; science is slow and not always available when most needed. Scientific results will be presented when there is no demand for them. Besides, knowledge is unstable, not all is known and knowledge can be questioned.

Another complication is that potential recipients of research are not waiting with empty baskets to be filled by news from the research community. They have their own experiences, interests, and values which can all be legitimate. If we are aware of these complications, alcohol researchers may increase their opportunity of a better com-munication with society. In addition to in-creasing the demand for relevant and critical alcohol research in professional practice and in politics, the research community can add to the cultural capital of our fellow citizens.

Hildigunnur Ólafsdóttir, Ph.d.reykjavik academyhringbraut 121107 reykjavik, Icelande-mail: [email protected]

REFERENCES

Anderson, P. & Baumberg, B. (2006): Stakeholders’ views of alcohol policy. Nordic Studies on Alcohol and Drugs 23 (6): 393–414

Ástgeirsdóttir, K. (2006): “Þar sem völdin eru, þar eru konurnar ekki”. Kvennaráðstefnur og kven-naáratugur Sameinuðu þjóðanna og áhrif þeirra á Íslandi 1975–2005. Saga, XLIV, 2: 7–49

Babor, T.F. & Caetano, R. & Casswell, S. & Ed-wards, G. & Giesbrecht, N. & Graham, K. & Grube, J. & Gruenewald, P.J. & Hill, L. & Holder, H.D. & Homel, R. & Österberg, E. & Rehm, J. & Room, R. & Rossow, I. (2003): Alcohol: No Ordinary Commodity: Research and Public Policy. Oxford: Oxford University Press

Craplet, M. (2007): Prevention of alcohol – and tobacco-related harms. Education or control – must we choose? Nordic Studies on Alcohol and Drugs 24 (3): 299–319

Damberg, R. (2007): Education should give posi-tive alternatives and focus on adults! Nordic Studies on Alcohol and Drugs 24 (3): 328–329

Fjær, S. ( 2006): Den flerfaglige rusmiddelforsk-ningen i Norden – utfordringer til det nordiske forskerfellesskapet. Nordisk Alkohol- & Narko-tikatidskrift 23 (2–3):178–182

Odejide, O. (2007): Political will is necessary to a comprehensive prevention approach. Nordic Studies on Alcohol and Drugs 24 (3): 324–327

Ólafsdóttir, H. & Bragadóttir, R. (2006): Crime and criminal policy in Icelannd: Criminology on the margins of Europe. European Journal of Criminology 3 (2): 221–253

Rise, J. (2007): Prevention of alcohol – and tobacco-related harms. Education or control – must we choose? Nordic Studies on Alcohol and Drugs 24 (3): 320–323



Room, R. & Midanik, L. (2005): Contribution of social science to the alcohol field in an era of biomedicalization. Social Science & Medicine 60 (5): 1107–1116

Sulkunen, P. (2007): Re-inventing the Social Cont-ract. Acta Sociologica 50 (3): 325–333

Träskman, P.O. (2007): Var finns forsete? Nordisk Tidsskrift for Kriminalvidenskab 94 (2):127–142.

wEB PAGES

Room, R. (1986): Kettil Bruun, 1924–1985: An Ap-preciation. [Online: http://www.arg.org/kbs/room-on-bruun.html]

[Online: http://www.saa.is/Files/Skra_0022712.pdf].



PAKKA: Active partners and mixed interventionsThe Local Alcohol Policy Project (PAKKA) was carried out between 2004 and 2007 in two Finnish regions comprised of several municipalities. The project has had three main goals: 1) to promote responsible bev-erage service in restaurants, with the idea of decreasing related acute alcohol harms, 2) to increase age-limit control (18 years in Finland) and 3) to develop a model for sus-tainable prevention at the local level. In the project, researchers and state-level experts from STAKES (National Research and Devel-opment Centre for Welfare and Health) have been active partners with the community organisers in planning and implementing interventions.

Recent reviews on the effectiveness of alcohol political interventions recommend that local communities combine commu-nity mobilisation with restrictive alcohol policies. The PAKKA project has relied on a mixed-intervention strategy that attempts to change the social and economic environ-ments related to risky and underage drink-ing. The interventions have included evi-dence-based practices, such as enforcement of the law forbidding alcohol sales to under-age and intoxicated persons and responsible beverage service training for shops and bars, but also supportive strategies like media advocacy, alcohol-free events for youth and drama-based educational programs for par-ents. In other words: To gain maximum util-ity different approaches were combined in a co-ordinated manner.

Research interest – to study what works and why?The research interest in this project is to retest existing interventions which, on the basis of previous studies, are (considered to be the) most effective. We used a quasi-experimental research design to determine whether the interventions have achieved their goal, and how it was done. Pre- and post-intervention data have been collected in two intervention regions and in the two matched comparison regions for process and outcome evaluation.

As in most public health trials, the role of the researchers in the PAKKA-project has been to design interventions, supervise the implementation and conduct the process and outcome evaluations. The evaluatorsʼ active participation in the project imple-mentation has been necessary because the research interest is in creating a controlled test situation. In an experimental design it becomes important to control not only the research setting, but also the content of the intervention. Consequently there has been sustained pressure to achieve high scientific research standards in a real-world situation and simultaneously to respond to local proc-esses and needs.

A top-down, researcher-designed project Originally the PAKKA project was a part of the National Programme for combating al-cohol and drug related problems. Since the initiative for local action came from the na-tional government the project can be classi-fied as “top-down”. To ensure the scientific

Connecting alcohol research and prevention practice: Lessons learned from PAKKA

KatarI Ina warPenIuS marJa holmIla


relevance of the interventions, the action plan, which stressed the methods affecting the availability of alcohol, was developed in co-operation between the STAKES team of researchers, local co-ordinators and their networks. Thus, the PAKKA project could be characterized as a researcher-designed project.

When the planning process began, some efforts were needed to convince the local prevention workers to adopt a science-based, policy-oriented strategy. Education and in-formation measures had previously been used frequently in the two project towns, but as we know, the impact of education on the proportion of alcohol problems is limited. During the planning, the researchers there-fore reminded the local action groups that political control measures, such as effective law enforcement and clear sanctions, are crucial for achieving effects. They stressed that educational measures have a value in raising awareness of certain problems, and advocating for policy changes, but have a very modest effect on the actual prevalence of alcohol-related problems.

Active expert involvement and immediate feedbackTo test the effectiveness and feasibility of an availability-oriented local alcohol pol-icy it was important to influence the local actors to actually carry out this type of in-tervention. Thus an active involvement by researchers was chosen already in the im-plementation phase. Training and assistance were provided by the STAKES expert team in order to support local prevention efforts. The two intervention regions could develop local approaches to implementation that were acceptable in their situation, as long as the basic design was maintained.

A special feature of the PAKKA project was that pre-intervention research findings were immediately shared with the local actors already during the implementation process. Research feedback enabled joint researcher–community assessments of the utility of the work and helped to identify

the problems needing attention. There was a strong interest in scientific input when test-ing the intervention’s orientation.

Especially important for the local actors was concrete feedback in the form of data on intermediate outcomes (i.e. outcomes that reflect the intermediate situation between the preventive intervention and longer-term goals like alcohol-related harm reduction). For example, dummy purchases were carried out in order to test the serving of alcohol to intoxicated patrons and under-age drinkers. This data could be presented immediately to local workers and discussed at the local staff meetings. Such information aided local actors in management, decision-making and process steering.

Moreover, the results gave a neutral de-scription of the local situations (problems) in bars and retail stores and perhaps helped to overcome some of the contradictory in-terests between alcohol markets and control policy.

Ensure ownership through media strategies and political lobbying The alcohol research literature reflects the considerable importance placed on the role of community involvement and ownership of interventions. Far-reaching participation can increase potential effectiveness but more importantly it may increase the likelihood of institutionalization of the adopted strate-gies.

One of the important goals for the PAKKA project was to examine the possibilities of the institutionalization of those forms of action that have been shown to be effective. One step in this was to create a dialogue with the community leaders and the key actors. As we know, alcohol issues are linked to many conflicting interests, and local decision-mak-ers may not want to get involved with these, unless it is shown that an agreement can be achieved (on at least some issues).

Through media strategies and political lobbying, the project sought to create pos-sibilities for sustainable structures for al-cohol prevention. As the implementation



proceeded, research results were utilized in media advocacy and community mobilisa-tion in order to gain public understanding and support for prevention practices. The project co-ordinators were encouraged to distribute research findings to the media. For example, the results from surveys on public opinion showed that there was a very high community support for the policy-based al-cohol interventions such as age-limit control and sanctions.

Exaggerated expectations on the political usefulness of research In practice it was not easy to find the nec-essary resources for long-term institution-alisation. Some of the local authorities who participated in the project had unrealistic expectations. They were hoping to achieve objective knowledge on the cost-effective-ness of the interventions already at a very early phase of the project. From the research-ersʼ point of view this was an impossible demand: The results simply were not there yet.

Unique communities – copying implementations is difficultIn community-based action the interven-tion is hardly ever exactly transferable to another locality—each community has it own traditions and ways of working. The PAKKA project wanted to gain information on what kinds of circumstances produced the achieved impact: One action could lead to another and be effective, but only if it took place in the right kind of circumstances. When analysing the community context one needs to know about the essential features of the community’s inner mechanisms, like its traditions, cultural characteristics and power structures. This understanding can assist other regions with implementing poli-cies based on research.

Effects of researchers’ involvement in projects?When researchers are involved in the imple-mentation—as well as in the evaluation—of

a project, there is a worry that the scientific objectivity may be lost. It is argued that re-searchers cannot make reliable assessments, because they are also stakeholders, desiring the project to be a success. One way of easing this problem is to have several researchers in the team and have some division of labour between them. Also, if the researchers fol-low the scientific rules of data gathering, analyses and reporting, purely subjective conclusions will become too visible to pass scientific scrutiny.

It is also likely that the presence of the re-searchers and their attention influences the prevention project—either for the better or for the worse. When this happens, evalua-tors do not learn how the intervention would work in normal conditions without research-er involvement. One should, however, not exaggerate the effect researchers can have. They remain outsiders, and they can only have a passing influence in the generally quite strong localities with their own ways of handling things. In any case, the research interest is a true factor in demonstration projects, and has to be discussed and ana-lysed as such.

Conclusions: Researchers’ active participation is neededOn the basis of lessons learned from PAKKA the project’s researchers are hopeful that lo-cal communities can be encouraged to pre-vent alcohol-related problems by increasing enforcement of law in combination with training, community mobilization and influ-encing public opinion.

However, the methodologies of the posi-tivist research paradigm have been recog-nized as difficult if not impossible to em-ploy. In order to carry out a “proper” experi-ment, researchers should attempt to control for such phenomena as selection and self- presentation of participants, competition, community history, limitation of interven-tions and other threats to validity. Of course one can argue that it makes little sense to insist on “evidence-based research” in the sense of well-controlled experiments since



it is not feasible in most research settings. But if the researchers carefully follow the scientific rules about data gathering, analysis and transparency there is an increased pos-sibility to reach reliable results—and to be protected against biased conclusions.

All in all: As long as researchers decide to be non-participating observers in com-munity projects, the genuine connection of alcohol research and prevention practice will be an impossible dream. Aiming for empirical evidence is essential for research, but we think it is equally important to inter-pret existing evidence and results with the prevention workers. The dialogue requires

common goals and sticking to the research setting, but also flexibility and compromise —in one word: social skills.

Katariina Warpenius, special researcher alcohol and drug research groupStaKeS – national research and development Centre for welfare and healthPoB 220, fIn-00531 helsinki, finlande-mail: [email protected] Marja Holmila, senior researcheralcohol and drug research groupStaKeS PoB 220, fIn-00531 helsinki, finlande-mail: [email protected]



Picking the best bits from the smorgasbord?Matilda Hellman likened the use of alco-hol and drugs research in policy-making to “picking the best bits from the smorgasbord” in the background paper to the seminar. The understanding being that a large amount of this research can be used by different inter-ested parties, NGOs, politicians, journalists or civil servants, and that the “research form a smorgasbord, from which anyone can pick the pieces that suit them” (Hellman 2007). The objective of this discussion is to provide a practical overview of the use of alcohol re-search in Eurocare’s (the European Alcohol Policy Alliance) lobbying activities in Brus-sels. The realities and difficulties of using re-search in a cross-sectoral, multifaceted and relatively emotive and politically sensitive arena can be more appropriately likened to the “subtle art of selecting the appropriate dishes and displaying them in such a way as to awaken (and satisfy) the appetite of the guests”.

Having firstly defined a conceptual frame-work for the discussion, a brief overview of the work of Eurocare will follow, sketching out the difficulties faced with regards to: research (the fragmented nature of the evi-dence on alcohol, rarely the sole driver of policy change, and often political) policy makers (engaged in balancing interests and reaching compromises with varying degrees of political will with regards to alcohol) and the alcohol industry (a legitimate stakehold-er putting forward its own evidence to suit commercial interests).

The use of alcohol research in lobbying: A question of framing?Striving for an ideal of “evidence-based policy” has become paramount in a number of areas of social policy1. In many of these fields, there arises the twin problem of a lack of knowledge and thorough understand-ing of the problem at hand (despite growing bodies of evidence), coupled with a press-ing need to implement adequate policies to resolve them. Given the ubiquity of alcohol use in society (and amongst many research-ers and policymakers, though not all lobby-ists), “the alcohol issue” can all too easily be observed through a purely sociological or anthropological lens. Roizen and Fill-more (2000) accurately expose this parallel between research “for its own sake” and the need for “remedies”, suggesting “our field is under constant pressure, of course, to ad-dress itself to pragmatic ends—to the mini-mization of alcohol problem, our ostensible master problem”. In this sense, policy impli-cations are expected to be inextricable from the evidence. In these fields, “research” in the form of a disinterested quest for knowl-edge, carried out in the aim of enlightening society on socio-cultural norms, behaviours and attitudes, can seem almost irrelevant, and perhaps extravagant from the point of the advocate, who may consider the nature of the problem calls for research with more “valuable” and “useful” conclusions.

The World Health Organisation (WHO 2007) emphasizes that “rational policy mak-ing on alcohol requires a consideration of the nature of the evidence, how the evidence may be used, and the ways in which policy

emIlIe raPley

The use of alcohol research in Eurocare’s lobbying activities


decision-making actually occurs—the mul-tidimensional nature of the responses and their dynamic interactions”. Critiques of the evidence-based policy model suggest it is flawed by a misconception of the proc-esses at play, and that in fact “decisions are less about projected consequences and more about process and legitimation. Politics is about shaping interpretations and express-ing preferences” (Young et al. 2002). This twin nexus of process and legitimation may appear to be somewhat obscure in our role as advocates, but nevertheless makes it all the more fascinating and challenging in our day-to-day work.

Eurocare: Who we are and what we doEurocare, is an alliance of around 50 volun-tary and non-governmental organizations across Europe created in 1990, working on the prevention and reduction of alcohol-re-lated harm2. One of the main goals is to pro-mote the prevention of alcohol-related harm in European Union decision-making; this is achieved by monitoring all EU level policy initiatives, and carrying out advocacy cam-paigns directed at the European Commis-sion (EC) and the European Parliament (EP) to ensure that alcohol issues are included in relevant policy discussions. The catalyst of our work in recent years (and the concrete result of fifteen years of lobbying) has been the “EU Strategy to Support Member States in Reducing Alcohol Related Harm”, pub-lished by the Directorate General for Health and Consumer Protection (DG Sanco) of the European Commission in October 20063. A cornerstone of this strategy is the recently launched Alcohol and Health Forum, a multistakeholder platform bringing together the industry and well as NGOs4 pledging to commit to concrete actions to reducing alco-hol-related harm. The cross-sectoral nature of alcohol policy includes the Television Without Frontiers Directive (concerned with young people’s exposure to alcohol advertis-ing), Minimum Excise Duties (a report from the EP proposed to scrap these in order to

avoid cross border trade and smuggling), and Labeling (the EC is to present a draft Direc-tive on labeling at the end of the year).

For Eurocare, lobbying on alcohol presents several difficulties: first the EU has limited competence to legislate in the domain of public health5. DG Sanco’s Alcohol Strat-egy is thus useful for advocacy in Member States; at EU level, it has allowed alcohol to secure a place on the political agenda, de-spite being weakened by the influence of the Commission’s more powerful “big brothers” (DG Trade, DG Market, DG Agriculture, etc.) (Ulstein 2006). Second, at European level, the aim of reducing alcohol-related harm is competing against other strong public health discourses for example in the field of tobacco, nutrition and physical activity, the latter exemplified in the EU Platform for Diet, Physical Activity and Health on which the Alcohol and Health Forum is modeled. Roizen and Fillmore (2000) articulate this from the researchers’ perspective, but it is also true for advocates that “our consum-erist or dangerous-commodity orientation to alcohol (…) obliges us to compete in a public-health-information-offering market place already crowded with health warnings of many kinds”. The specificities of alco-hol serve to further complicate the picture; parallels with tobacco or junk food are ob-vious: indisputable public health burdens; links with social inequalities, and of course, powerful industries. What sets alcohol apart though, is the highly problematic, misunder-stood and misused evidence on the “benefits of alcohol consumption”; like it or not, the “ambiguous molecule” alcohol forms an in-tegral part of most cultures across Europe, “causing deaths while saving lives, inflicting pain while producing pleasure” (Baumberg 2006).

“Evidence shows that …”The WHO (2007) states that “all policies and actions to improve public health need a firm knowledge base (…); research and evidence are among a society’s most valuable and im-portant tools for laying the foundation of



better strategies to improve public health”. Evidently though, the interaction between research and policy is complex, and does not form a linear relationship of influence. The “enlightenment model” (Young et al. 2002) where “research is often addressed not to the problem itself but to the context in which that decision will be taken, providing a frame for thinking about it” is a useful one, as it proposes a more realistic “evidence-informed policy” approach (ibid.). Weiss (1977) suggests that in this model “the ma-jor effects of research on policy may be the gradual sedimentation of insights, theories, concepts and ways of looking at the world”.

With this in mind, the actual data Euro-care most commonly requires can broadly be categorised under three loose headings. The first is “Figures”, and can include in-formation such as levels of consumption across Europe; the second concerns “Best Practice”, and the third concerns “Chal-lenges ahead” such as “Why has alcohol consumption increased in some countries?” or, “What is the role of national governments in tackling these issues?”. The recently pub-lished Alcohol in Europe report (heralded “The Bible”) provides many of the answers to these questions; as well as being a robust scientific report, it is also an invaluable ad-vocacy tool, which includes policy recom-mendations (Anderson & Baumberg 2005). The report was commissioned to form the basis of the Commission’s strategy, and in itself represents an excellent case study of how the industry plays the “evidence game” (Baumberg & Anderson 2007; Anderson & Baumberg 2006).

However, in trying to use this data we are often confronted by two problems. A first, overarching concern is the fragmented nature of the evidence in the alcohol field, where seemingly many voices compete (Young et al. 2002). Indeed journalists, “social com-mentators”, think tanks or research institutes all affect and influence public opinion to a certain degrees, and may serve to entrench stereotypes, which then risk appearing more “truthful” than the evidence itself. In terms

of scientific research, an obvious difficulty is that of keeping abreast of all new evidence in a field spanning a variety of disciplines.

A second concern, intrinsically linked to the first, is that not all existing data on alcohol is useable by advocates: not all evi-dence is conclusive (answering only a set of questions it addresses); not all evidence is comparable (both within Member States and across Europe); and not all evidence is pol-icy relevant. In other words, although some evidence may be worthwhile in furthering our knowledge of society’s relationship with alcohol, it does not propose any “remedies”. And nor should it; after all, academia is a highly competitive arena, in which observ-ers battle to gain recognition for their con-tributions to their understanding of society, through the production of knowledge. Cra-plet (2007), Chairman of Eurocare, notes that “referring to the research community as ‘somewhat politically naïve’ is not an attack, but rather a compliment to [his] friends in the field”. Researchers should be reassured that it is at times exasperating for advocates to attempt to “neatly package” research findings, thus ironing out subtleties and nuances of rich and multilayered data, and almost always frustrating to be expected to provide “silver bullets” and panaceas for politicians.

“Evidence-based” arguments for “opinion-based” decision makersPoliticians are engaged in the complex proc-ess of creating interfaces between policy ar-eas, balancing interests and brokering com-promises; in this sense “the policy-making process has the basic aim of reconciling interests in order to negotiate consensus, not implement truth” (Weiss 1977). From a pessimistic perspective, this is perhaps best encapsulated in Keyne’s view that “there is nothing a Government hates more than to be well informed, for it makes the process of arriving at decisions more complicated and more difficult” (in Solesbury 2001). The role of European policy makers is further com-plicated by the need to maneuver within



the competence they are granted to balance national interests (for example, the wine growing regions) with the requirements of an ever expanding, and primarily economic European Union.

Further, it is no secret that politicians, despite their lack of expertise, have en-trenched ideas and opinions about alcohol and alcohol policy. Advocates are constantly exposed to biased, partial views of the evi-dence: “Red wine is good for you” or “We don’t binge drink in Italy as they do in the Nordic countries”. Views on policy also re-flect a certain take on the evidence: “Alcohol should not be demonised, it is an important part of our cultural heritage”, “We have to respect the principle of subsidiarity, as cul-tural differences mean we cannot implement blanket policies”. Marmot (2004) suggests that “government’s willingness to act may shape their view of the science”; when it comes to alcohol, the reality may be “policy based evidence” rather than “evidence based policy” (ibid.).

The alcohol industry: no ordinary stakeholderThe alcohol industry is undeniably a rival voice in the political process of “weighing up the evidence”; a strong economic asset, with increasingly visible corporate social responsibility policies, the industry repre-sents a valid stakeholder. Alcohol produc-ers unite under “legitimate fronts” through social aspects (SA) organisations6, such as the International Centre for Alcohol Policies (ICAP) or the European Forum For Respon-sible Drinking (EFRD), both of which are participating in the Commission’s Alcohol and Health Forum. Under these banners, research, policy analysis and of course, lob-bying are carried out: in fact, it has not been uncommon to find such groups walking the same corridors of power as ourselves.

To the layperson, the “research” and “pol-icy analysis” (e.g.: ICAP Blue Book)7 carried out by these organisations may appear meth-odologically sound, and conclusive, and the (simplistic) models as comprehensive and

logical. For example, that “patterns of drink-ing are the best way to understand the place of alcohol in society”; that “targeted inter-ventions are most sensitive to cultural differ-ences”, and that “partnerships offer the best opportunities to develop policies”. Funnily enough “Drinking in Context: Patterns, In-terventions and Partnerships”, an ICAP col-laborative publication (Stimson et al. 2006) was recently publicised at a lunch meeting held in the European Parliament, hosted by German MEP Renate Sommer. Staff from the Eurocare Secretariat attended this lunch; the event was reminiscent of the spirit of the film “Thank You For Smoking”8; a sequel named “Thank You For Drinking” should be consid-ered, and would be highly entertaining.

This example highlights the tensions in-volved in the political process, and how ap-parently sound and legitimate evidence can be put forward by the industry, in order to counter what is regarded by the public health community as “legitimate” evidence. When the Institute of Alcohol Studies published the Alcohol in Europe report, the British Beer and Pub Association (also participating in the Alcohol and Health Forum) attempted to undermine its scientific objectivity by “denouncing” vested interests, namely, links to temperance; they likened this to “vegetar-ians writing a report about the benefits of eat-ing meat”. The EFRD’s view (in Baumberg & Anderson 2007) was that those advocating a stronger EU alcohol strategy “had a biased view of the evidence base”.

It is precisely through the use of “evi-dence” and their engagement in research, policy analysis and lobbying (activities mir-roring our own work) that the industry tries to secure a place at the policy table, which may be potentially difficult for the public health community to fight off. The WHO (2007) stresses the “importance of the par-ticipation of civil society organisations with-out the conflict of interests in alcohol policy development, as a counter influence to the vested trade interests, which might other-wise dominate political decision making”.



Concluding thoughts This brief overview will have hopefully served to shed some light on the difficulties involved in using alcohol research in lobby-ing at European level, as well as highlighted the organic nature of the processes, where “evidence”, “stakeholders”, “political deci-sion making” and “public opinion” are inter-related, forming a vast and complicated web, from which it is often difficult to untangle the strands. Given the fragile and precarious nature of “evidence” as well as its potential for ambiguous interpretation in this process (what Baumberg and Anderson describe as the “evidence game”), it is often impossible to attribute any advocacy success in Brussels to any particular “factor”. France’s manda-tory pictorial labelling of alcohol beverages targeted at pregnant women is a perfect example of this. The legislation came into force last year, but the process started with a lawyer, Benoit Titran, defending a group of mothers of children born with FAS (Foetal Alcohol Syndrome) and taking alcohol pro-ducers to court. Using a European Directive on Product Safety9 as legal basis, he argued that alcohol should be treated as an “ordi-nary commodity” and producers had a re-sponsibility of warning pregnant women of the dangers of alcohol consumption. Gradu-ally gaining political support, this eventu-ally snowballed into the current legislation. While Titran was a lawyer in the north of France, he became aware of the problem of FAS from his father, a paediatrician who had conducted research within his hospital in the same region. It is, however, impossible to untangle the interlinked roles of evidence, existing legislation, political support, resil-ience and personal conviction.

The WHO (2007) concludes that “to con-tribute constructively to the policy debate,

the scientific community needs to frame policy relevant research questions in time for the data to be available when needed, to have carried out high quality research and to have interpreted and disseminated the data in ways that are relevant to the policy de-bate”. FEANTSA, the European Federation of National Organisations Working with the Homeless, based in Brussels, has developed an interesting model with a view to recon-ciling these tensions; the European Observa-tory on Homelessness, was set up over ten years ago, under the premise that “a good un-derstanding of the problem of homelessness is the key to developing effective policies”10. The Observatory is “composed of a network of researchers across Europe, carrying out transnational research relevant to Feantsa’s European Policy priorities” (my emphasis). It is emphasised that “the close co-operation between academic researchers and NGOs is not always easy, but has been very useful for the quality and added value of FEANTSA’s work”. It may seem that motivations and priorities within the arena of alcohol policy are incompatible: the competitive and pres-tigious field of academia, the sensitive and thorny political realm, and the cut-throat commercial world of the alcohol industry. There is a continuous need to reflect on strategies and to rethink the ways in which we, as advocates, engage with the research, and consider the most effective means of advocating, with credibility and weight, the implementation of evidence-based alcohol policies.

Emilie Rapley, Policy and Public affairs officereurocare eu liaison office, rue des Confédérés 96-98, 1000 Brussels, Belgium e-mail: [email protected]



NOTES

1) See Young et al. (2002), Packwood (2002).2) For more information, see http://www.euro-

care.org/abu/what.html 3) “An EU strategy to support Member States in“An EU strategy to support Member States in

reducing alcohol related harm”, COM (2006) 625 final. [Online: http://ec.europa.eu/health/[Online: http://ec.europa.eu/health/ph_determinants/life_style/alcohol/alcohol_com_en.htm].

4) Including Eurocare and eight of its members. 5) Competence for public health is left to Member

States, although Article 152 of the Treaty states the EU’s obligation to ensure a high level of human health protection in the definition and implementation of all Community policies and activities.

6) For a more detailed discussion, see Anderson, P. (2003): The Beverage Alcohol Industry’s Social Aspects Organisations: A Public Health Warning. Eurocare Paper.

7) ICAP Blue Book: Practical Guides to Alcohol Policy and Prevention Approaches. [Online:[Online: http://www.icap.org/Publication/ICAPBlue-Book/tabid/148/Default.aspx]

8) This 2005 Jason Reitman film is a satire of a lob-byist defending the tobacco industry yet trying to remain a role model for his 12-year-old son.

9) DIRECTIVE 2001/95/EC of the European Parlia-DIRECTIVE 2001/95/EC of the European Parlia-ment and of the Council of 3 December 2001 on general product safety. See also “ConsumerSee also “Consumer protection, Labels and warnings” (Conference Presentation), Eurocare Bridging the Gap Conference, Helsinki November 2006. [Online:[Online: http://btg.health.fi/?i=107586].

10) Feantsa European Observatory on Homeless-ness. [Online: http://www.feantsa.org/code/en/[Online: http://www.feantsa.org/code/en/pg.asp?Page=23].

REFERENCES

Anderson, P. & Baumberg, B. (2005): Alcohol in Europe: A Public Health Perspective. London: Institute of Alcohol Studies

Anderson, P. & Baumberg, B. (2006): Stake-holders’ views of alcohol policy. NordicNordic Studies on Alcohol and Drugs 6 (English Suppl.): 393–413

Baumberg, B. & Anderson, P. (2007): The European Strategy on Alcohol: A Landmark and a Lesson. Alcohol and Alcoholism 42 (1): 1–2

Craplet, M. (2007): Prevention of alcohol-and-tobacco-related harms: Education or Control- Must We Choose? Nordic Studies on Alcohol and Drugs 24 (English Suppl.): 299–319

Marmot, M. (2004): Evidence Based Policy or Policy Based Evidence? British Medical Journal 328: 1–2

Packwood, A. (2002): Evidence Based Policy: Rhetoric and Reality. Social Policy and Society 1 (3): 262–271

Roizen, R. & Fillmore, K. (2000): The Coming Crisis in Alcohol Social Science. Nordic Studies on Alcohol and Drugs 17 (English Suppl.): 91–104

Solesbury, W. (2001): Evidence Based Policy: Whence it Came and Where it’s Going (working paper). ESRC Centre for Evidence Based Policy and Practice

Stimson, G. & Grant, M. & Choquet, M. & Garrison, P. (2006): Drinking in Context: Patterns, Interventions, and Partnerships. London: Routledge

Ulstein, A. (2006): No Ordinary Partner. Nordic Studies on Alcohol and Drugs 6 (English Suppl.): 499–508

Weiss, C. (1977): Research for Policy’s Sake: The Enlightenment of Social Research. Policy Analysis 3 (4): 531–545

World Health Organisation (2007): Second Re-port of the Expert Committee on Problems Relating to Alcohol Consumption, Geneva

Young, K. & Ashby, D. & Boaz, A. & Grayson, L. (2002): Social Science and the Evidence-based Policy Movement. Social Policy and Society 1 (3): 215–224.


662 NORDIC STUDIES ON ALCOHOL AND DRUGS VOL . 24. 2007 . 6

The third wave of research on self-changeKlingemann, Harald �� Carter Sobell, Linda �eds��Harald �� Carter Sobell, Linda �eds�� 2007��: Promoting self-change from addictive behaviors. Practical implications for policy, prevention, and treatment. new york: Springer, 260 p.

Through 11 well-written chapters the edi-tors Klingemann and Sobell have deliv-

ered a comprehensive book on the subject of self-change. Researchers from USA, Canada, and Europe are represented as authors and contribute with results from current research projects, methodological and conceptual re-views, and historical accounts of this area of research. According to this publication, the field of research on self-change suffers from conceptual and methodological inconsisten-cies, such as diverse conceptualisations of treatment and intervention, or variations of time in recovery among research samples. The term self-change is used throughout the book to describe the process of: ‘change in a persons substance use in the absence of formal treatment or help’ (chapter 1). Other concepts, such as spontaneous remission, denoting a process of sudden and unexpect-ed change without a designable reason, are omitted in the text. Despite Sobell’s initial exclusion of the use of other terms to des-ignate the process of self-change, concepts such as: untreated remission, natural re-covery, and spontaneous recovery, slip their way into different chapters of the book. This may reflect the rather different types of be-haviour change presented in the book; from self-change of alcohol and drug addiction to desistance of crime (chapter 6.4) or recovery from problem gambling (chapter 6.3) as well as the aforementioned methodological in-consistencies.

The book serves three purposes. First of all, it provides a historical, conceptual and research-oriented presentation of the field of self-change, and alcohol and drug addiction; secondly, through five chapters, self-change is described in a broader context; and thirdly, it provides a number of chapters on the use of the knowledge of self-change in policy, prevention and treatment. The final chapter of the book provides information directed towards the actual process of self-change from addictive behaviour, and contains lists of assessment instruments to promote self-change and assess problem severity, as well as relevant websites grouped country-wise.

As a phenomenon, ‘self-change’ has been subject to both research and discussion dur-ing the last 30 to 40 years. Research on the subject has, from time to time, been able to elicit an almost denying response among both professionals and the general public (chapter 1; Chiauzzi & Liljegren 1993). But how can we, according to this book, under-stand self-change? One answer could be: In different ways, depending on e.g. the sub-stance of interest and the specific socio-cul-tural setting. According to chapter 10, the use of a specific drug might in one socio-cultural setting elicit the characterisation of deviant behaviour; while in another context it might not be perceived particularly devi-ant or socially unacceptable. In Western so-cieties, the cessation of smoking tobacco is commonly thought to be obtained through a process of self-change, whereas the cessation of alcohol and drug abuse is rarely perceived within the realm of a self-change process. The endpoint of change from addictive be-haviour may well vary in different cultural settings. In some societies an accepted goal might be moderation of intake of the spe-cific drug. In other cultural settings the only acceptable goal of a (self-)change process would be a complete cessation of intake of the drug. In general, the book provides the reader with varied knowledge and well- researched arguments on the subject of ‘self-change’. Self-change is described in relation to very different types of behaviour, such as

Bookreviews


eating disorders and stuttering. In line with this, a chapter on self-change from differ-ent affective disorders, could have been rel-evant as well. Comparing self-change from social phobia with self-change from addic-tion, research indicates some similarities of individual predictors of recovery (e.g. being employed and presenting less psychopatho-logical symptoms when tested) (Vriends et al. 2007).

If one objective of the book is to argue that self-change from addiction is neither sponta-neous nor unexplainable, but is to be regard-ed as a rather common process influenced by intrinsic and extrinsic factors (e.g. personal, interpersonal and social), then the objective is met. As one would believe from the title of the book ‘Promoting self-change...’ a dis-tinct objective is to draw attention to possi-ble consequences for treatment and preven-tion from this line of research. The relatively high prevalence rates of self-change from different addictive behaviours might actu-ate the continuous study of both the barriers to treatment and the ways in which people actually change. Throughout the book, ques-tions such as “What triggers the process of change?” and “When is the change process initiated?” are pointed out as central themes for further research.

The first, the second, and maybe a third wave?In the second chapter of the book a histori-cal line of research on self-change is pre-sented as consisting of at least two waves. The first wave comprises more methodologi-cally loose and imprecise studies, and states self-change from addiction as a separate phenomenon, as well as outlining pertinent themes for further research. The knowledge on self-change, derived from these studies, was primarily side effects of research stud-ies focusing on other subjects (e.g. general population studies on addictive behaviour, or the effect of treatment intervention). In spite of this, it served to undermine common beliefs on addiction: such as the perception of ‘addiction as an irreversible condition’, or

‘recovery can only be reached through treat-ment’.

The second wave of research on self-change encompasses studies focusing specif-ically on the exploration and assessment of the phenomenon and its prevalence. These studies are primarily based on standardised procedures applying both quantitative and/or qualitative methods.

If we assume the second wave is still in motion, a central question might be what the third wave of research on self-change is going to bring. Could it be, as suggested in chapter 7, to provide a model for change, which encompasses those who manage to change addictive behaviour on their own? Or will it be a more proactive wave, in terms of ‘popularizing’ the notion of self-change, to obtain a public acceptance of process as being common, and the phenomenon as widespread? Maybe the book itself can be perceived as part of a third wave in terms of researchers creating an overview of the field, and communicating: major findings; similarities to other fields of research; and directions for policy, treatment, and preven-tion. A central objective of this third wave is then to make sure knowledge on self-change is available, not just to other researchers through peer-reviewed journals, but also to people influencing politics and treatment, as well as to the people making changes of their own addictive behaviour.

Dorte Hecksher, PhdCentre for alcohol and drug researchBygning 1453, Jens Chr. Skous vej 3 8000 Århus C, denmark e-mail: [email protected]

REFERENCES

Chiauzzi, E.J. & Liljegren, S. (1993): Taboo topics in addiction treatment. Journal of Substance Abuse Treatment 10: 3003–3316

Vriends, N. & Becker, E.S. & Meyer, A. & Williams, S.L. & Lutz, R. & Margraf, J. (2007): Recovery from social phobia in the community and its predictors: Data from a longitudinal epidemiological study. Journal of Anxiety Disorders, 21 (3): 320–337.


The new dual-track drug policy paradigm – an important and original findingTuukka Tammimedicalising prohibition: harm reduction in finnish and international drug policy. helsinki: Stakes, 2007, 151 p.

Tuukka Tammi’s dissertation, Medicalis-ing Prohibition, is a serious, thought-

ful, subtle, dignified and remarkably mature work of scholarship. It consists of six chap-ters, five of them published in leading jour-nals or edited books, and one new chapter, the title of the work, which develops themes from the others and extends them in original and sometimes bold ways.

Medicalising Prohibition illuminates a complicated and shifting phenomenon: the place of harm reduction within the drug polices of Finland and to some extent other countries, especially since the early 1990s. In the new summarizing chapter he writes:

“The concept of harm reduction is typi-cally associated with a drug policy strat-egy that employs the public health ap-proach and where the principal focus of regulation is on drug-related health harms and risks… The general conclu-sion of this study is that rather than posing a threat to a prohibitionist drug policy, harm reduction has come to form part of it. The implementation of harm re-duction by setting up health counselling centres for drug users – with the main focus on needle exchange and extending substitution treatment – has implied the creation of specialised services based on medical expertise and an increasing in-volvement of the medical profession in addressing drug problems. At the same time the criminal justice control of drug use has been intensified. Accordingly, harm reduction has not entailed a shift

to a more liberal drug policy nor has it undermined the traditional policy with its emphasis on total drug prohibition. Instead, harm reduction in combination with a prohibitionist penal policy consti-tutes a new dual-track drug policy para-digm.” (emphasis added)

In developing his conception of a two-track approach to drug policy, Tammi first observes that Finland has fully embraced harm reduction within a medical framework and system. In the early 1990s, harm reduc-tion was barely heard of in Finland; nowa-days it is successfully integrated into Finn-ish health care and services. Second, and contrary to the early hopes of some research-ers including myself, he also finds that the acceptance and integration of harm reduc-tion has not reduced coercive and punitive criminal justice policies. In Finland, and to some extent in other countries, harm reduc-tion has been thoroughly adopted without a substantial softening in the legal status and criminal justice handling of drug users.

This is an important and original finding, one I have begun using in my own work on understanding the dramatically increasing numbers of cannabis and other drug arrests in the U.S. and Europe since the 1980s. I’d like to see the insight become an important part of the growing understanding of the place of harm reduction policies within con-temporary drug policies – which Tammi cor-rectly and courageously identifies as “prohi-bition.”

In each of the other five chapters (the original articles), Tammi examines in depth various aspects of the harm reduction move-ment, its implementation, effects and con-sequences. The first chapter asks, “Has the drug policy in Finland changed?” He finds that it has, but in a contradictory fashion. Al-though written before he had fully worked out the dual track understanding, the chap-ter describes empirically some of what he later explicitly conceptualized.

The second chapter, on “three factions” within the harm reduction movement, uses


original data about Finland and other Euro-pean countries to distinguish serious profes-sional and political differences in perspec-tive and approach within the developing, international, harm reduction traditions.

The third chapter discusses “the struggle over the concept of harm reduction in the 1997 Drug Policy Committee in Finland.” It shows how the police and other criminal justice authorities interpreted harm reduc-tion in a way that allowed them to continue doing much of what they had already been engaged in. Tammi finds that for the criminal justice system in Finland and at least some other places in Europe, harm reduction has involved a change in vocabulary but not by and large in practice.

The fourth chapter focuses on needle ex-change programs and tells how they came to be adopted within Finland in the context of the HIV and AIDS epidemic. This is an im-portant story and Tammi has pulled together a great deal of information making it avail-able for the first time for researchers in and outside of Finland.

The fifth chapter contrasts the views of patients and their families on the one hand, and those of medical and other authorities on the other, showing them often at odds in their understanding both of the nature of the problem and the best remedies to apply.

Medicalising Prohibition is very well writ-ten and its English does the thing that good writing must: it gets out of the readers’ way allowing us to see what the author has seen. And to an extent that is rare even among very good writers, Tammi does not repeat him-self. Indeed he seems allergic to redundancy. Read together, the chapters in Medicalising Prohibition appear not as discrete articles, but as parts of a “book,” an unusually clear and thoughtful one.

Tammi writes very much from inside the world he is studying, but he retains the dis-tance and perspective to coolly, carefully describe what he finds. The social worlds he writes about are to some extent strange, odd, peculiar, even eccentric. He does not try to soften that or pretend that views of the

various social actors are always consistent or even make sense. In the spirit of Michel Foucault, he lets the strange remain strange. But he does not exaggerate or even highlight much the oddness of what he finds. Like a gentle, humane, empathetic anthropologist from an advanced civilization, or even a far away galaxy, he offers detailed descriptions and summaries of the often contradictory things the participants themselves are saying and doing, and the often contradictory ways that drug policy actually operates.

Tammi points out in various places in his chapters that influential individuals and groups in Finnish society regularly say that they seek to bring about what they call “a drug-free society.” The United States of America, where I come from, also has pow-erful groups, including the U.S. government, which likewise proclaim their commitment to a “drug-free society.” I’d like to briefly consider that concept of a drug free society, for it is part of the ideological support for the punitive criminal justice policy “track” that Tammi finds mostly untouched by the advance of harm reduction. The ideal and goal of a drug-free society are, I suggest, truly strange.

The same people and groups who unabashedly claim they seek a drug-free so-ciety never suggest that they seek or could reasonably expect to get a crime-free society, or a sickness-free society, a waste-free soci-ety, an intolerance-free society, or even an ignorance-free society. In all these and many other cases, everyone recognizes that hu-man beings are living and therefore imper-fect creatures, and that no society or culture can be free of problems – of crime, sickness, waste, intolerance or ignorance. In all cases, the wisest observers and participants, and even others not so wise, understand that it is sensible to try to reduce these problems, to shrink and minimize them. But nobody thinks we can be free of them. Except, for drug use. For drug use (and not just abuse) it is still perfectly acceptable for eminent and supposedly reasonable people to claim to seek perfection through social policy.


If that was the only problem with the no-tion of the drug-free society that would be quite a lot. But there is another problem: the concept it uses of “drug.” Everyone, in-cluding school children, understands that alcohol is an intoxicating substance, that alcohol is a drug. Many people understand that tobacco also contains a serious psycho-active drug: nicotine. And people who think for a moment also know that coffee, tea and even Coca-Cola contain substantial amounts of caffeine, which the pharmacologists (and our own bodies) tell us is also a psychoactive and physically active drug with substantial effects. A substantial number of pharma-ceutical substances are also psychoactive, including natural and synthetic opiates such as morphine and fentenyls. There are prescription sedatives and tranquilizers in-cluding widely-used benzodiazepines like Valium. There are stimulants including pre-scription amphetamines and also anti-nar-colepsy drugs, and substances such as Ritlin given to children. And there is a new class of drugs, the SSRIs – the serotonin reuptake inhibitors – of which Prozac is one, as are some illegal drugs.

Despite this abundance of psychoactive drugs all around us, prominent and respect-ed individuals and organizations, including two U.S. Presidents named George Bush, and the U.S. government, have strongly called for a drug-free society. The United Nations

has even called for a “drug-free world.” All of this is not just odd or strange. It is not even just impractical or wildly utopian. Rather, I suggest that the goal of a drug-free society is best captured in a term that was used in other contexts by the great British writer Isaiah Berlin. The goal of a drug-free society is what Berlin called “incoherent.” The idea does not hold together. It actually does not make sense.

Tuukka Tammi touches upon this immense problem with the notion of the drug-free so-ciety only briefly and indirectly. He is more clinical than I am willing to be, at least right now. But his work on the character, spread and limits of harm reduction opens a path for further research and discussion about the real-world meanings and impacts of the often hidden drug policies routinely operat-ing all around us. Medicalising Prohibition, from its title on, asks the right questions, and in seeking answers successfully contributes to making visible some of the poorly under-stood system of world-wide drug prohibi-tion, including its more punitive goals and often well-hidden punitive effects. I hope he inspires other such work.

Harry G. Levine, Professor of Sociologyqueens College and the graduate CenterCity university of new yorkflushing, new york 11367, uSae-mail: [email protected]


NATContents 2007

Nordisk alkohol- & narkotikatidskrift

Vol. 24

Nummer 1

LEDARE _________________________________________________________________________3

ARTIKLARKaren Elmeland & Susanne Villumsen Udviklingen i danskernes holdninger til alkoholforbrug og alkoholpolitiske spørgsmål ____________________________________5Johanna Levälahti Sociala nätverk och socialt stöd i återhämtningsprocessen från alkoholmissbruk ____________________________________________________________23Mats Anderberg & Mikael Dahlberg Interbedömarreliabilitet – ett tillförlitligt mått på standardiserade intervjuer? _______________________________________________45

KOMMENTARLeena Warsell Hur skilja socialt ansvar från socialt ansvar? __________________________59

RECENSIONERSusanna Alakoski Svinalängorna (av Ingalill Österberg) _____________________________62 Petra Kouvonen & Astrid Skretting & Pia Rosenqvist (eds.) Drugs in the Nordic and Baltic Countries. Common concerns, different realities (av Mikko Lagerspetz) _____64 Jørgen Anker & Vibeke Asmussen & Petra Kouvonen & Dolf Tops (eds.) Drug Users and Spaces for Legitimate Action (av Johan Edman) ______________________66

LANDSRAPPORTERRafn Jónsson Rapport fra Island __________________________________________________71Leif Vind Rapport fra Danmark ___________________________________________________72Elin Bye Rapport fra Norge _______________________________________________________77Martin Stafström Rapport från Sverige ____________________________________________80Matilda Wrede-Jäntti Rapport från Finland ________________________________________82

MEDDELANDEKerstin Stenius Litauiskt intresse för nordisk alkoholpolitik _________________________84

TIIVISTELMÄT _________________________________________________________________87

REGISTER ÖVER INNEHÅLLET 2006 _____________________________________________89

Nordic Studies on Alcohol and Drugs


Number 2

EDITORIAL ____________________________________________________________________103

RESEARCH REPORTSSharon Rödner Sznitman Drugs and gender: A contradictory project in interviews with socially integrated men and women who use drugs _________________107Jeanette Østergaard Mind the gender gap! When boys and girls get drunk at a partyWhen boys and girls get drunk at a party __127Jakob Demant Youthful drinking with a purpose. Intersections of age andIntersections of age and sex in teenage identity work _____________________________________________________149Jukka Törrönen & Antti Maunu Whilst it's red wine with beef, it's booze with a cruise! Genres and gendered regulation of drinking situations in diariesGenres and gendered regulation of drinking situations in diaries _____________177

COMMENTARIESManne Forssberg Gender, party and intoxication __________________________________200Elina Oinas Making gender matter – different approaches to gender and partying ____203

RepliesAntti Maunu Gender theory and empirical research. A reply to Elina Oinas _______210Jeanette Østergaard Differences between quantitative and qualitative research methods ___________________________________________________________________212

INTERVIEWPauliina Seppälä The forgotten body – Interview with philosopher Sara Heinämaa __214

BOOK REVIEWSPhilip Lalander & Mikko Salasuo (eds.) Drugs and youth cultures—global andDrugs and youth cultures—global and local expressions (by Jaana Lähteenmaa) _________________________________________219Peter Gundelach & Margaretha Järvinen (eds.) Unge, fester og alkoholUnge, fester og alkohol (by Ellen O. Millar) _____________________________________________________________221Alexandra Bogren Female Licentiousness versus Male Escape. Essays onEssays on Intoxicating Substance Use, Sexuality and Gender (by Suvi Ronkainen & Sanna Väyrynen) ______________________________________________________________226

Number 3

EDITORIAL ____________________________________________________________________233

RESEARCH REPORTSDitte Andersen & Margaretha Järvinen Harm reduction – ideals and paradoxes _______235Antti Weckroth Drug-related harm according to opiate users on buprenorphine treatment _______________________________________________________253

Commentaries on harm reductionAstrid Skretting Harm reduction – any limits? _________________________________270Henrik Thiesen Harm reduction, focusing on severe alcohol misuse in Copenhagen _____________________________________________________________280Tuukka Tammi How I would describe 21st century drug policy to Kettil Bruun ____288


Morten Hulvej Jørgensen & Tine Curtis Intergenerational dynamics inteenage alcohol use. Two scenarios on a single night in the Danish countrysideTwo scenarios on a single night in the Danish countryside ______291Michel Craplet Prevention of alcohol- and tobacco-related harms. Education or control – must we choose? _________________________________________299

Commentaries on Craplet’s articleJostein Rise On time perspective, autonomy and various passions in health education ____________________________________________________________320Olabisi Odejide Political will is necessary to a comprehensive prevention approach 324Robert Damberg Education should give positive alternatives and focus on adults! __328

INTERVIEWKerstin Stenius “Education crucial for social change.” Interview with Pekka PuskaInterview with Pekka Puska ___330

BOOK REVIEWSRobert West Theory of addiction (by Jostein Rise & Velibor Bobo Kovac) _____________334Jessica Palm Moral concerns – Treatment staff and user perspectives on alcohol and drug problems (by Hildigunnur Ólafsdóttir) __________________________________338Tommi Hoikkala & Pekka Hakkarainen & Sofia Laine (eds.) Beyond Health Literacy. Youth Cultures, Prevention and Policy (by Jakob Demant) _________________341Petra Kouvonen & Astrid Skretting & Pia Rosenqvist (eds.) Drugs in the NordicDrugs in the Nordic and Baltic countries. Common concerns, different realities (by Mikko Lagerspetz)Common concerns, different realities (by Mikko Lagerspetz) ____344

REPORTSMatilda Hellman Developing an effective alcohol policy for Russia _________________347Kerstin Stenius The International Society for the Study of Drug Policy ______________352

NORDIC ALCOHOL STATISTICS 1993–2006 _____________________________________354

Nummer 4

LEDARE _______________________________________________________________________369

ARTIKLARJenny Cisneros Örnberg & Hildigunnur Ólafsdóttir Hur sälja alkohol? Nordiska alkoholmonopol i en tid av förändring___________________________________371Mirja Österberg Alkos ledning och den europeiska ekonomiska integrationen 1988–1994_____________________________________________________________________395

ÖVERSIKTChristoffer Tigerstedt & Esa Österberg Alkoholskadorna är fortfarande finska men har också blivit franska ____________________________________________________414

KOMMENTARAnders Ulstein Hva betyr Rosengrendommen? ____________________________________419

INTERVJUKerstin Stenius Kari Paaso om alkoholfrågan i Finland och EU ______________________425


MEDDELANDENStig Erik Sørheim Nordisk alkoholpolitikk 2007 – en situasjonsbeskrivelse___________428Øystein Bakke Klar for ekstraomganger om alkoholspørsmålet i WHO _______________433Leena Warsell Alkohol- och drogprevention på nordiskt seminarium i Bergen ________436

RECENSIONERPelle Olsson Flödder (av Philip Lalander) _________________________________________438 Martti Häikiö Alkon historia. Valtion alkoholiliike kieltolain kumoamisesta Euroopan unionin kilpailupolitiikkaan 1932–2006 (Alkos historia. Statens alkoholbolag från upphävandet av förbudslagen till EU:s konkurrenspolitik 1932–2006) (av Matti Peltonen) __________________________________________________439

LANDSRAPPORTERLeif Vind Rapport fra Danmark __________________________________________________443Rafn Jónsson Rapport fra Island _________________________________________________447Elin Bye Rapport fra Norge ______________________________________________________449Martin Stafström Rapport från Sverige ___________________________________________453Johan Sandelin Rapport från Finland ____________________________________________455

Nummer 5

LEDARE _______________________________________________________________________459

ARTIKLARJesper Andreasson & Philip Lalander Mellan idrottslig disciplin och gränslöst supande _______________________________________________________________________461Riikka Perälä Hur narkotikabrukare tolkar sina egna problem och ser på social- och hälsovårdens tjänster ______________________________________________481

RIKTLINJERUlf Malmström Nationella riktlinjer för missbruks- och beroendevård _______________504Jonas Sjögreen Allmänläkarens dilemma – riktlinjerna kolliderar med långsiktighet och individualisering ______________________________________________510Harriet Lundefors Oscarsson Reflektioner ur socialtjänstens praktikperspektiv _______513

ARTIKELAnders Bergmark Riktlinjer och den evidensbaserade praktiken – en kritisk granskning av de nationella riktlinjerna för missbrukarvård i Sverige ________________519

Mats Berglund Kommentarer till Anders Bergmark ______________________________530

DEBATTMats Ramstedt & Johan Svensson Att skatta införsel av alkohol till Sverige – ingen akademisk fråga? _________________________________________________________534Per Leimar Fem månader efter Rosengren-domen __________________________________538

INTERVJUUlf Rydberg Leonard Goldberg – nestor inom nordisk beroendeforskning ____________541


RECENSIONSveinung Sandberg & Willy Pedersen Gatekapital (av Philip Lalander) _______________547

MEDDELANDEJorunn Moen Rapport fra Elisad’s 19. årlige møte __________________________________549

NAD-NYTT ____________________________________________________________________552

Number 6

EDITORIAL ____________________________________________________________________561

RESEARCH REPORTSClaes Törnqvist Twenty then – today about thirty-five. The meaning of alcohol in a life course perspective ______________________________________________________563Anders Bergmark Guidelines and evidence-based practice – a critical appraisal of the Swedish national guidelines for addiction treatment _________________________589

Mats Berglund Commentary on the paper by Anders Bergmark ___________________600 Mads Uffe Pedersen Evidence-based practice in “the real world” ___________________605

OVERVIEWPia Mäkelä & Heli Mustonen & Esa Österberg Does beverage type matter? ___________617

MAKING USE OF ALCOHOL AND DRUG RESEARCHIntroduction ___________________________________________________________________632Robin Room National variations in the use of alcohol and drug research: Notes of an itinerant worker _____________________________________________________634Matilda Hellman Public use of and communication about alcohol research __________641Hildigunnur Ólafsdóttir Reflections on the use of alcohol research __________________646Katariina Warpenius & Marja Holmila Connecting alcohol research and prevention practice: Lessons learned from PAKKA __________________________________________652Emilie Rapley The use of alcohol research in Eurocare’s lobbying activities __________656

BOOK REVIEWSHarald Klingemann & Linda Carter Sobell (eds.)Klingemann & Linda Carter Sobell (eds.)& Linda Carter Sobell (eds.) Promoting self-change from addictive behaviors. Practical implications for policy, prevention, and treatment (by Dorte Hecksher) ____________________________________________________________662Tuukka Tammi Medicalising prohibition: Harm reduction in Finnish and international drug policy (by Harry G. Levine) ____________________________________664


�upplement

EDITORIALPia Mäkelä Development of alcohol-related harms in the Nordic countries: descriptions of and explanations for a mixed picture ________________________________3

RESEARCH REPORTS Mats Ramstedt Variations in alcohol-related mortality in the Nordic countries after 1995—continuity or change?__________________________________________________5Louise Eriksen & Morten Grønbæk Development in alcohol-related harm in Denmark 1990–2005 __________________________________________________________17Pia Mäkelä & Esa Österberg Upward trends in alcohol consumption and related harm in Finland _________________________________________________________________29Hildigunnur Ólafsdóttir Trends in alcohol consumption and alcohol-related harms in Iceland ________________________________________________________________47Ingeborg Rossow Trends in alcohol consumption and alcohol-related harms in Norway around the turn of the millennium ______________________________________61Mats Ramstedt Has the impact of population drinking on harm become weaker in Sweden? An analysis of the development in alcohol consumption andAn analysis of the development in alcohol consumption and alcohol-related harm in Sweden 1990–2005________________________________________73Ingeborg Rossow & Pia Mäkelä & Esa Österberg Explanations and implications of concurrent and diverging trends: Alcohol consumption and alcohol-related harm in the Nordic countries in 1990–2005 ________________________________________85


Personregister 2007/Authors’ index 2007

ARTIKLAR/RESEARCH REPORTSAnderberg, Mats & Dahlberg, Mikael: Interbedömarreliabilitet – ett tillförlitligt mått på standardiserade intervjuer? ____________________________________________________1/45Andersen, Ditte & Järvinen, Margaretha: Harm reduction – ideals and paradoxes ___3/235Andreasson, Jesper & Lalander, Philip: Mellan idrottslig disciplin och gränslöstsupande ____________________________________________________________________5/461Bergmark, Anders: Guidelines and evidence-based practice – a critical appraisal of the Swedish national guidelines for addiction treatment ____________________________6/589Bergmark, Anders: Riktlinjer och den evidensbaserade praktiken – en kritisk granskning av de nationella riktlinjerna för missbrukarvård i Sverige _____________5/519Cisneros Örnberg, Jenny & Ólafsdóttir, Hildigunnur: Hur sälja alkohol? Nordiska alkoholmonopol i en tid av förändring _________________________________________4/371Craplet, Michel: Prevention of alcohol- and tobacco-related harms. Education or control – must we choose? ____________________________________________________3/299Curtis, Tine: See Jørgensen, Morten Hulvej _____________________________________3/291Dahlberg, Mikael: Se Anderberg, Mats __________________________________________1/45Demant, Jakob: Youthful drinking with a purpose. Intersections of age and sex in teenage identity work ______________________________________________________2/149Elmeland, Karen & Villumsen, Susanne: Udviklingen i danskernes holdninger til alkoholforbrug og alkoholpolitiske spørgsmål ____________________________________ 1/5Eriksen, Louise & Grønbæk, Morten: Development in alcohol-related harm in Denmark 1990–2005 ___________________________________________________ Suppl/17Grønbæk, Morten: See Eriksen, Louise______________________________________ Suppl/17Järvinen, Margaretha: See Andersen, Ditte ______________________________________3/235Jørgensen, Morten Hulvej & Curtis, Tine: Intergenerational dynamics in teenage alcohol use. Two scenarios on a single night in the Danish countryside ___________3/291Lalander, Philip: Se Andreasson, Jesper ________________________________________5/461Levälahti, Johanna: Sociala nätverk och socialt stöd i återhämtningsprocessenfrån alkoholmissbruk _________________________________________________________1/23Maunu, Antti: See Törrönen, Jukka ____________________________________________2/177Mäkelä, Pia: See Rossow, Ingeborg ________________________________________ Suppl/85Mäkelä, Pia & Österberg, Esa: Upward trends in alcohol consumption and related harm in Finland __________________________________________________ Suppl/29Ólafsdóttir, Hildigunnur: Se Cisneros Örnberg, Jenny ___________________________ 4/371Ólafsdóttir, Hildigunnur: Trends in alcohol consumption and alcohol-related harms in Iceland _________________________________________________________ Suppl/47Pedersen, Mads Uffe: Evidence-based practice in “the real world” ________________6/605Perälä, Riikka: Hur narkotikabrukare tolkar sina egna problem och ser på social- och hälsovårdens tjänster _____________________________________________________5/481Ramstedt, Mats: Has the impact of population drinking on harm become weaker in Sweden? An analysis of the development in alcohol consumption and alcohol-related harm in Sweden 1990–2005_________________________________ Suppl/73Ramstedt, Mats: Variations in alcohol-related mortality in the Nordic countries after 1995—continuity or change? __________________________________________ Suppl/5


Rossow, Ingeborg: Trends in alcohol consumption and alcohol-related harms in Norway around the turn of the millennium ______________________________ Suppl/61Rossow, Ingeborg & Mäkelä, Pia & Österberg, Esa: Explanations and implications of concurrent and diverging trends: Alcohol consumption and alcohol-relatedharm in the Nordic countries in 1990–2005 ________________________________ Suppl/85Rödner Sznitman, Sharon: Drugs and gender: A contradictory project ininterviews with socially integrated men and women who use drugs ______________2/107Törnqvist, Claes: Twenty then – today about thirty-five. The meaning of alcohol in a life course perspective ___________________________________________________6/563Törrönen, Jukka & Maunu, Antti: Whilst it's red wine with beef, it's booze with a cruise! Genres and gendered regulation of drinking situations in diaries _________2/177Villumsen, Susanne: Se Elmeland, Karen _________________________________________ 1/5Weckroth, Antti: Drug-related harm according to opiate users on buprenorphine treatment ___________________________________________________________________3/253Österberg, Esa: See Mäkelä, Pia ___________________________________________ Suppl/29Österberg, Esa: See Rossow, Ingeborg _______________________________________ Suppl/85Österberg, Mirja: Alkos ledning och den europeiska ekonomiskaintegrationen 1988–1994 _____________________________________________________4/395Østergaard, Jeanette: Mind the gender gap! When boys and girls get drunk at a party ___________________________________________________________________2/127

ÖVERSIKTER/OVERVIEWSMustonen, Heli: See Mäkelä, Pia ______________________________________________ 6/617Mäkelä, Pia & Mustonen, Heli & Österberg, Esa: Does beverage type matter? _______6/617Tigerstedt, Christoffer & Österberg, Esa: Alkoholskadorna är fortfarande finska men har också blivit franska __________________________________________________4/414Österberg, Esa: Se Tigerstedt, Christoffer ________________________________________4/414Österberg, Esa: See Mäkelä, Pia _______________________________________________6/617

DEBATTER/DEBATESLeimar, Per: Fem månader efter Rosengren-domen ______________________________5/538Ramstedt, Mats & Svensson, Johan: Att skatta införsel av alkohol till Sverige – ingen akademisk fråga? _______________________________________________________5/534Svensson, Johan: Se Ramstedt, Mats ___________________________________________5/534

KOMMENTARER/COMMENTARIESBerglund, Mats: Commentary on the paper by Anders Bergmark __________________6/600Berglund, Mats: Kommentarer till Anders Bergmark _____________________________5/530Damberg, Robert: Education should give positive alternatives and focus on adults! _3/328Forssberg, Manne: Gender, party and intoxication _______________________________2/200Hellman, Matilda: Public use of and communication about alcohol research _______6/641Holmila, Marja: See Warpenius, Katariina ______________________________________6/652Lundefors Oscarsson, Harriet: Reflektioner ur socialtjänstens praktikperspektiv ____5/513Malmström, Ulf: Nationella riktlinjer för missbruks- och beroendevård ___________5/504Maunu, Antti: Gender theory and empirical research. A reply to Elina Oinas ______2/210


Odejide, Olabisi: Political will is necessary to a comprehensive prevention approach ___________________________________________________________________3/324Oinas, Elina: Making gender matter – different approaches to gender and partying _2/203Ólafsdóttir, Hildigunnur: Reflections on the use of alcohol research _______________6/646Rise, Jostein: On time perspective, autonomy and various passions in health education ___________________________________________________________________3/320Rapley, Emilie: The use of alcohol research in Eurocare’s lobbying activities _______6/656Room, Robin: National variations in the use of alcohol and drug research: Notes of an itinerant worker __________________________________________________6/634Sjögreen, Jonas: Allmänläkarens dilemma – riktlinjerna kolliderar med långsiktighet och individualisering ___________________________________________5/510Skretting, Astrid: Harm reduction – any limits? _________________________________3/270Tammi, Tuukka: How I would describe 21st century drug policy to Kettil Bruun ___3/288Thiesen, Henrik: Harm reduction, focusing on severe alcohol misuse in Copenhagen ______________________________________________________________3/280Ulstein, Anders: Hva betyr Rosengrendommen? _________________________________4/419Warpenius, Katariina & Holmila, Marja: Connecting alcohol research and prevention practice: Lessons learned from PAKKA ______________________________6/652Warsell, Leena: Hur skilja socialt ansvar från socialt ansvar? ______________________1/59Østergaard, Jeanette: Differences between quantitative and qualitative research methods ____________________________________________________________2/212

INTERVJUER/INTERVIEWSRydberg, Ulf: Leonard Goldberg – nestor inom nordisk beroendeforskning _________5/541 Seppälä, Pauliina: The forgotten body – Interview with philosopher Sara Heinämaa ______________________________________________________________2/214Stenius, Kerstin: “Education crucial for social change.” Interview with Pekka Puska _________________________________________________________________3/330Stenius, Kerstin: Kari Paaso om alkoholfrågan i Finland och EU __________________4/425

RECENSIONER/BOOK REVIEWSDemant, Jakob: Tommi Hoikkala & Pekka Hakkarainen & Sofia Laine (eds.): Beyond Health Literacy. Youth Cultures, Prevention and PolicyYouth Cultures, Prevention and Policy __________________3/341Edman, Johan: Jørgen Anker & Vibeke Asmussen & Petra Kouvonen & Dolf Tops (eds.): Drug Users and Spaces for Legitimate Action ____________________________________1/66Hecksher, Dorte: Harald Klingemann & Linda Carter Sobell (eds.): Promoting self-change from addictive behaviors. Practical implications for policy, prevention, and treatment ____________________________________________________6/662Kovac, Velibor Bobo: See Rise, Jostein _________________________________________3/334Lagerspetz, Mikko: Petra Kouvonen & Astrid Skretting & Pia Rosenqvist (eds.): Drugs in the Nordic and Baltic Countries. Common concerns, different realities (på svenska) __________________________________________________________1/64Lagerspetz, Mikko: Petra Kouvonen & Astrid Skretting & Pia Rosenqvist (eds.): Drugs in the Nordic and Baltic countries. Common concerns, different realities (in English) _________________________________________________________3/344Lalander, Philip: Pelle Olsson: Flödder ________________________________________4/438Lalander, Philip: Sveinung Sandberg & Willy Pedersen: Gatekapital ______________5/547


Levine, Harry G.: Tuukka Tammi: Medicalising prohibition: Harm reduction in Finnish and international drug policy _______________________________________6/664Lähteenmaa, Jaana: Philip Lalander & Mikko Salasuo (eds.): Drugs and youth cultures—global and local expressions ___________________________________2/219Millar, Ellen O.: Peter Gundelach & Margaretha Järvinen (eds.): Unge, fester og alkohol __________________________________________________________________2/221Ólafsdóttir, Hildigunnur: Jessica Palm: Moral concerns – Treatment staff and user perspectives on alcohol and drug problems ________________________________3/338Peltonen, Matti: Martti Häikiö: Alkon historia. Valtion alkoholiliike kieltolain kumoamisesta Euroopan unionin kilpailupolitiikkaan 1932–2006 (Alkos historia. Statens alkoholbolag från upphävandet av förbudslagenStatens alkoholbolag från upphävandet av förbudslagen till EU:s konkurrenspolitik 1932–2006) ________________________________________4/439Rise, Jostein & Kovac, Velibor Bobo: Robert West: Theory of addiction ____________3/334Ronkainen, Suvi & Väyrynen, Sanna: Alexandra Bogren: Female Licentiousness versus Male Escape. Essays on Intoxicating Substance Use, Sexuality and Gender __2/226Väyrynen, Sanna: See Ronkainen, Suvi ________________________________________2/226Österberg, Ingalill: Susanna Alakoski: Svinalängorna _____________________________1/62

LANDSRAPPORTER/COUNTRY REPORTSBye, Elin: Rapport fra Norge ___________________________________________________1/77Bye, Elin: Rapport fra Norge __________________________________________________4/449Jónsson, Rafn: Rapport fra Island _______________________________________________1/71Jónsson, Rafn: Rapport fra Island ______________________________________________4/447Sandelin, Johan: Rapport från Finland _________________________________________4/455Stafström, Martin: Rapport från Sverige _________________________________________1/80Stafström, Martin: Rapport från Sverige ________________________________________4/453Vind, Leif: Rapport fra Danmark ________________________________________________1/72Vind, Leif: Rapport fra Danmark _______________________________________________4/443Wrede-Jäntti, Matilda: Rapport från Finland _____________________________________1/82

MEDDELANDEN/NOTESBakke, Øystein: Klar for ekstraomganger om alkoholspørsmålet i WHO ___________4/433Hellman, Matilda: Developing an effective alcohol policy for Russia ______________3/347Moen, Jorunn: Rapport fra Elisad’s 19. årlige møte ______________________________5/549Stenius, Kerstin: The International Society for the Study of Drug Policy __________3/352Stenius, Kerstin: Litauiskt intresse för nordisk alkoholpolitik _____________________1/84Sørheim, Stig-Erik: Nordisk alkoholpolitikk 2007 – en situasjonsbeskrivelse _______4/428Warsell, Leena: Alkohol- och drogprevention på nordiskt seminarium i Bergen ____4/436

GUEST EDITORIALMäkelä, Pia: Development of alcohol-related harms in the Nordic countries: descriptions of and explanations for a mixed picture _________________________ Suppl/3

NAD-NYTT _________________________________________________________________5/552

Nat6W2007[1]

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