ReviewAlcohol and public health
Introduction
Alcoholic beverages have been used in human societies at least since the beginning of recorded history. Fermented drinks were prepared and consumed in most parts of the world before the European colonial expansion, which changed the cultural position of alcohol nearly everywhere.1 New forms of alcoholic beverages were introduced, and a product prepared within the household and community was gradually transformed into an industrial commodity available at any time and virtually any place. As part of the contemporary dynamic of globalisation, this process continues today in much of the developing world.
Accompanying the near ubiquity of alcoholic beverages in human history has been a lively appreciation of the social and health problems caused by drinking. Whether in Greece, Palestine, or China, ancient texts speak eloquently about such problems. Every major world religion has at least some strands that counsel abstinence from alcoholic beverages. In most countries where Protestant Christianity was strong, substantial temperance movements in the 19th century at first sought individual pledges to abstain and eventually pressed for national prohibition. When these movements lost momentum, a new compromise was reached: alcohol was no longer viewed as a threat to all, but rather to a small subclass of “alcoholics”, or in today's technical terms, people who were alcohol dependent. It became the task of health professionals, among others, to cure alcoholism, and the task of science to discover its basis as a key to treatment and prevention.
Scientific attention to alcohol problems has accelerated during the past 30 years, when substantial advances have occurred in our understanding of drinking problems as well as their prevention and treatment. In this review our discussion of these advances is organised into three subtopics: the epidemiology of alcohol's role in health and illness; the treatment of alcohol use disorders as part of the public health response; and prevention and policy research. We do not cover here the substantial advances in neuroscience and genetic studies in recent years, since these are reviewed elsewhere2 and as yet have little relevance for public health approaches to alcohol problems.
In our review of the evidence, we have emphasised both the medical and public health implications of alcohol use. Whereas medical approaches are appropriate responses to alcohol problems in health care settings, they need to be complemented by population-based public health interventions to address the broad dimensions of alcohol problems at the level of communities and nation states.
Section snippets
Alcohol and health outcomes
It has long been known that alcohol consumption is responsible for increased illness and death.3 Recent research has contributed substantially to our understanding of the relation of drinking to specific disorders, and has shown that the relation between alcohol consumption and health outcomes is complex and multidimensional. Alcohol has been shown to be causally related to more than 60 different medical conditions,4 in most but not all cases detrimentally. Not only volume of consumption, but
Treatment of alcohol-use disorders
When a diagnosis indicates that an individual has a mental or behavioural disorder related to alcohol use, several important clinical decisions must be made about the type, setting, and intensity of the intervention. Among heavy drinkers without evidence of severe alcohol dependence, an intervention in primary care aimed at the reduction of drinking to moderate levels of consumption may suffice. By contrast, chronically alcohol-dependent people and other drinkers with high levels of alcohol
Policy research and options
Published evidence on prevention programmes and policies for reducing alcohol-related problems has been substantially strengthened in recent years. Studies in the field now include well-designed experimental trials not only of programmes aimed at individuals, but also of community-oriented approaches107 and even of national policies.108 Unfortunately, the cultural coverage of the research is somewhat restricted: policy and prevention research tends to be particularly strong for English-speaking
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