Alcohol – No Ordinary Commodity
From a public health perspective, alcohol consumption plays a major role in morbidity and mortality on a global scale.
In the past fifty years, considerable progress has been made in the scientific understanding of the relationship between alcohol and health. Ideally, the cumulative research evidence should provide a scientific basis for public debate and governmental policy making. However, much of the scientific evidence is reported in academic publications in a way that has little apparent relevance to prevention or treatment policy.
Alcohol is a product that enters into many aspects of social life in practically every part of the world. But alcohol is no ordinary commodity. Social customs and economic interests should not blind us to the fact that alcohol is a toxic substance. It has the potential to adversely affect nearly every organ and system of the body. No other commodity sold for ingestion, not even tobacco, has such wide-ranging adverse physical effects. For this reason, the public health response to the prevention of alcohol-related problems requires extraordinary measures, some of them relatively painless for a society to implement, others more demanding in terms of resources, ingenuity, and public support.
As the scientific basis for alcohol policy begins to take shape, it is becoming apparent that there is no single definitive, much less politically acceptable approach to the prevention of alcohol problems; a combination of strategies and policies is needed.
If this realization is sobering, so too is the conviction that alcohol policy is an ever-changing process that needs to constantly adapt to the times if it is to serve interests of public health.
A number of studies have examined the relationship between drinking patterns and alcohol dependence.
Independent of how drinking is measured, the more a population engage in sustained or recurrent heavy alcohol consumption, the higher the rate of alcohol dependence. Both average volume of drinking and the pattern of drinking larger amounts on an occasion are related to the prevalence of dependence, and the risk of dependence increases linearly with increased drinking.
The nature and the direction of causality, however, are not clear. Dependence may perpetuate heavy drinking, or heavy drinking may contribute to the development of dependence, or these two mechanisms may operate reciprocally.
The fact that alcohol has self-reinforcing potential is of fundamental importance to understanding the dynamics of the relationship between a population and its drinking. Thus, the higher the average amount of alcohol consumed in a society, the greater the incidence of problems experienced by society. Consequently, one way to prevent alcohol problems is through policies directed at the reduction of average alcohol consumption.
Alcohol dependence was originally developed as a clinical construct that applies primarily to persons in treatment. But recent evidence strongly suggests that milder degrees of habit or dependence are widely distributed in the population and are associated with increased experience of problems.
Dependence is a matter of continuities and variations with broader expressions than the extremes seen in the clinic. Mild dependence is associated with a significant public health burden because it is common and severe dependence, although less common, is likely to be associated with an intense clustering of problems.
Alcohol dependence has many different contributory causes including genetic vulnerability, but it is a condition that is contracted by exposure to alcohol. The heavier the drinking the greater the risk. The challenge to public health is to identify policies that make it less likely that drinkers will contract dependence, and the consequent predictability in behaviour pattern damaging to the individual and costly to society.