Alcohol and Drinking - Theories, Models and Interventions for Health Behaviour Change

Health Psychology: Theory, Research and Practice - David F. Marks 2010

Alcohol and Drinking
Theories, Models and Interventions for Health Behaviour Change

’I would not put a thief in my mouth to steal my brains.’

William Shakespeare, Othello


In this chapter, we discuss theories and research about alcohol consumption and the causes, prevention and treatment of drinking problems. Ambivalent attitudes to alcohol have characterized many cultures from the distant past to the present day. A description of the physical and psychosocial dangers of drinking is followed by an examination of contrasting theories about the causes of excessive drinking. We conclude with a critical discussion of recent approaches to the prevention and treatment of drinking problems.

The Blessing and Curse of Alcohol: Past and Present Attitudes

The oldest solid evidence of an alcoholic (ethanol) beverage comes from Jiahu, China, where in 7,000 BC farmers fermented rice, grapes, hawthorn berries and honey in clay jars (Curry, 2017). Ethanol’s intoxicating power has made it an object of concern — and sometimes outright prohibition. Most societies have felt an ambivalence, trying to strike a balance between moderate drinking for happy relaxation and drinking to get drunk.

The regular use of alcohol by many eminent artists, composers and writers is well documented. Fyodor Dostoyevsky, Henri de Toulouse-Lautrec, Pyotr Ilyich Tchaikovsky, Ernest Hemingway, F. Scott Fitzgerald, William Faulkner, Edgar Allan Poe, John Cheever, Truman Capote, Dylan Thomas, Jack London, Marguerite Duras and Dorothy Parker are all known to have been frequent users of alcohol. Alcohol’s role in artistic and literary work is undeniable, but there are also the ’downsides’ to consider, such as depression and suicide.

One important reason for drinking alcohol is the effect that it has on feelings and emotions. Sayette (2017) reviewed the effects of alcohol on emotion in social drinkers. Masculine gender norms in some Western cultures tend to constrain expressions of emotion, especially warmth and affiliation among men. Men appear to benefit more than women from drinking alcohol, which helps them to ’loosen up’, smile, share feelings and interact socially. In other cultures, these abilities occur freely among both men and women without any need for alcohol.

Current views on alcohol as a social problem can be traced back to the eighteenth century when distilled spirits became available for the first time in Europe. Because of their relative cheapness, they were popular with the English working class. William Hogarth’s 1751 prints Beer Street and Gin Lane (Figure 11.1) contrasted the supposedly harmless effects of drinking beer with the dire consequences of drinking spirits. Notice the sense of industriousness and well-being in Beer Street: many people are working and the only shop that is boarded up is the pawnbrokers. In Gin Lane, nobody is working except the busy pawnbroker and there is a grim depiction of emaciation, death and the neglect of children.

Figure 11.1 Hogarth’s Beer Street and Gin Lane


Source: Trusler, J., Hogarth, J. and Nichols, J. (1833). The Works of William Hogarth. London: Jones & Co

Since the early nineteenth century popular beliefs about the dangers of alcohol have been shaped by temperance societies. Beginning with the American Temperance Society in 1826 and then spreading to other countries, their influence has been enormous in bringing about the era of American prohibition from 1920 to 1934 and also in helping to establish the standard medical opinion, especially in the USA, that alcoholics can never return to moderate drinking but can only be cured by remaining abstinent for the rest of their lives. A range of views can be found among different temperance societies, some simply preaching moderation and the avoidance of excess, some taking the view that spirits are intrinsically dangerous while weaker alcoholic drinks are harmless, some believing that alcohol is highly addictive for everyone, others that it only presents dangers for a small minority of individuals with a predisposition to become addicted. Of particular historical importance were the Washingtonians in the USA in the 1840s. These were self-help associations running regular meetings along the lines of religious revivalist groups with an emphasis on the confessions of the repentant sinner and an appeal to a ’Higher Power’ for support. This particular tradition remains strong today in Alcoholics Anonymous, which has branches in almost every North American and British town of any size and in many other countries.

With the exception of some countries with majority Muslim populations, alcohol is legally obtainable in most regions of the world. The predominant view is that it is ’alright in moderation, harmful in excess’. We review the evidence for this view in the next section. Here we focus on the undisputed harm that occurs as a consequence of regular heavy drinking and of ’binge drinking’, both now seen as major problems in many countries. The WHO reported that 3.3 million deaths in 2012 were due to harmful use of alcohol (World Health Organization, 2014e). The report drew attention to the fact that alcohol increases people’s risk of developing more than 200 diseases, including liver cirrhosis and some cancers. In addition, harmful drinking can lead to violence and injuries, and can make people more susceptible to infectious diseases such as tuberculosis and pneumonia. Overall, 5.1% of the global burden of disease and injury is attributable to alcohol, as measured in disability-adjusted life years (DALYs). Rehm et al. (2009) estimated that 3.8% of global deaths could be attributed to alcohol, adding that ’Disease burden is closely related to average volume of alcohol consumption, and, for every unit of exposure, is strongest in poor people and in those who are marginalized from society’ (Rehm et al., 2009: 2223). Reviewing the situation in the European Union, Anderson and Baumberg (2006) pointed out that, among young people (aged 15—29), 25% of male mortality and 10% of female mortality is attributable to alcohol.

Alcohol problems and approaches to prevention and treatment vary greatly from country to country due to the specific cultural and historical circumstances. In Britain, one source of concern has been binge drinking among young men and women. Many city centres on weekend evenings are notorious for the large numbers of extremely drunk and disorderly young people (Raistrick, 2005; Plant and Plant, 2006). Another concerning issue has been drinking among pre-teens. The UK Millennium Cohort Study found 1.2% of 11-year-olds reported having been drunk and 0.6% reported having had five or more drinks in a single episode (Kelly et al., 2016). The British government has been much criticized for contributing to increased drinking among youth by liberalizing the drinking laws under the influence of the Portman Group, a drinks industry public relations organization, while ignoring medical and other professional opinion opposed to liberalization.

Babor and Winstanley (2008) reviewed papers on the alcohol experiences of 18 countries in a study commissioned for the journal Addiction from 2004 to 2007. One problem is the high level of consumption prevalent in the former socialist countries. In Russia, during the Gorbachev era from 1985, public health initiatives led to a 25% reduction in consumption, which was followed by dramatic increases in male life expectancy. These reforms were subsequently abandoned and consumption increased again with concomitant increases in health problems (Zaridze et al., 2014). A problem confronting many countries wishing to address alcohol problems is the powerful influence of international drinks companies. Babor and Winstanley (2008) noted that potentially expanding markets, such as India, Nigeria, China and Brazil, are being targeted with ’highly sophisticated western marketing techniques’. At the same time, the papers which they review mention specifically that the drinks industry is an obstacle to an effective alcohol policy in India, Nigeria, the UK, Thailand, South Africa and Mexico. The alcohol industry resists regulation of marketing, claiming that the industry is responsible and that self-regulation is effective, mirroring the tobacco industry (Savell et al., 2016).

There is a strong relationship between age at first use of alcohol and the prevalence of lifetime alcohol abuse and alcohol dependence. The younger the age at onset of drinking, the higher the likelihood of adult dependency (Grant and Dawson, 1997). The rates of lifetime dependence declined from more than 40% among individuals who started drinking at ages 14 or younger to roughly 10% among those who started drinking at ages 20 and older. Before looking at interventions, we need to understand the impacts of alcohol on physical and mental health.

The Dangers and Possible Health Benefits of Drinking Alcohol

In this section, we consider evidence of the health risks associated with the consumption of alcohol as well as the possible health benefits. A brief summary of the major risk factors is given in Box 11.1.

Box 11.1 Risks of Alcohol Consumption

Risks from any single occasion of heavy drinking:

· Driving, industrial and household accidents: falls, fires, drowning.

· Domestic and other forms of violence as perpetrator.

· Domestic and other forms of violence as victim.

· Unwanted pregnancies; HIV or other sexually transmitted diseases following unprotected sexual exposure.

Risks from regular heavy drinking:

· Death from liver cirrhosis and acute pancreatitis.

· Increased risk of cardiovascular disease and certain cancers.

· Problems caused by alcohol dependence.

· Exacerbation of pre-existing difficulties such as depression and family problems.

· Loss of employment; reduced career prospects.

Risks to women who drink during pregnancy:

· Foetal alcohol syndrome.

· Miscarriages and premature babies.

· Cognitive and behavioural problems of the developing child.

An analysis of the research findings on the health hazards of drinking is considerably more complicated than is the case for smoking. Whereas smoking is dangerous even for low levels of consumption, and increasingly so for heavy smokers, the dangers to health of alcohol consumption are not always found for light and moderate drinkers, who may even experience health benefits compared with non-drinkers. We therefore examine the evidence for risk associated with heavy drinking, and go on to consider the possible benefits of light and moderate drinking.

To begin with, it is necessary to define ’light’, ’moderate’ and ’heavy’ drinking. We adopt the British system in which one ’unit’ is assumed to equal 8 g of alcohol or one glass of wine of average strength, half a pint (250 cc) of normal strength beer, and a single measure (25 ml) of spirits. Strong wines and beers may contain up to twice this amount of alcohol. Moderate drinking is an average level of 3/2 units a day for men/women, respectively; less than half of that level can be regarded as light drinking and anything over 7/5 regular daily units can be regarded as heavy drinking.

Liver Cirrhosis and Acute Pancreatitis

Prolonged heavy drinking is known to be the main cause of liver cirrhosis, a serious condition that frequently results in death. Using figures provided by the British Department of Health, the Academy of Medical Sciences (2004) noted a four- to five-fold increase in deaths from chronic liver disease in the UK from 1970 to 2000, with over nine-fold increases among young men and women. Using more recent figures, the UK Office for National Statistics estimated that mortality from liver disease had doubled from 1991 to 2007 (Office for National Statistics, 2009). While some of these changes are attributable to increased rates of hepatitis C infection, effects that are themselves exacerbated by alcohol consumption, the main reason for the changes are increases in levels of heavy drinking. Although it receives much less publicity than liver cirrhosis, acute pancreatitis is another frequently fatal disease that is often caused by heavy drinking. Goldacre and Roberts (2004) surveyed hospital admissions for this disease in England from 1963 to 1998, noting that they have more than doubled over the 35-year period, with particularly large increases among the younger age groups. These changes closely parallel the patterns of increased alcohol consumption over this period of time.


The evidence linking alcohol consumption to cancer has been reviewed in detail by Bagnardi et al. (2001). They considered the evidence for three levels of consumption, 14, 21 and 28 units a week, and found associations increasing at each level for cancers of the oral cavity and pharynx, larynx, breast, liver, colorectum and stomach. In a more recent study of 109,118 men and 254,870 women from eight European countries, Schütze et al. (2011) estimated that 10% of all cancer cases in men and 3% of cases in women are attributable to alcohol consumption. The most strongly associated are those of the upper aerodigestive tract (44% and 25% of male and female cases respectively), liver (33% and 18%) and colorectum (17% and 4%). The association with breast cancer is weaker, but of particular importance because this is one of the most common causes of premature death in women. Schütze et al. estimated that 5% of cases are attributable to alcohol. This corresponds closely to an earlier estimate by Hamajima et al. (2002), who conducted a detailed re-analysis of data from 53 studies with a total sample size of over 150,000. They found that there was a clear relationship with risk increasing steadily from teetotallers through to those drinking more than five units a day. They concluded that alcohol could be the cause of about 4% of deaths from breast cancer. A similar finding of a small increase in risk at low levels of consumption was reported by Chen et al. (2011) in a 28-year follow-up of 105,986 US nurses. However, the increase in risk was quite modest and, as Hamajima et al. (2002) pointed out, it needs to be interpreted in the context of the possible beneficial effects of moderate alcohol consumption, which is discussed later in this chapter.

A significant proportion of regular alcohol-using males are also smokers. Survey data indicate that approximately 7% of 15—54-year-olds in the USA are co-dependent on alcohol and tobacco (Anthony and Echeagaray-Wagner, 2013). Since 1957 it has been established that the effect of joint exposure to high amounts of alcohol and tobacco on risk of oral cancers confers an excess risk of major proportions, with one estimate being an excess risk of 18.4:1 (Rothman and Keller, 1972). The effects of alcohol and tobacco on excess risk of cancer are not simply additive: they actually multiply. A recent meta-analysis showed that there is a positive synergistic (multiplicative) effect of alcohol and tobacco use for cancer of the oesophagus (Prabhu et al., 2014). The observed combined effect of alcohol and tobacco was almost double the effect that would be expected if synergy did not happen.

Drinking during Pregnancy

This has been the subject of much controversy in recent years. US medical authorities invariably recommend that pregnant women should avoid alcohol completely, while in many other countries the usual advice is that low levels of consumption do no harm. Very heavy drinking is the cause of foetal alcohol syndrome, in which the child suffers from a particular type of facial abnormality as well as mental impairment and stunted growth. It has also been established that heavy drinking is associated with miscarriages, premature births, low birthweight and a variety of cognitive and behavioural problems in the developing child. While it may seem tempting to infer from this that there must be some increase in risk even for light drinking, there is in fact surprisingly little evidence that this is the case.

In a report for the British Department of Health, Gray and Henderson (2006) reviewed research on the foetal effects of low to moderate alcohol consumption and binge drinking, concluding that, for most outcomes, there was no consistent evidence of adverse effects from low alcohol consumption, although there was some evidence of harmful effects of binge drinking on neurodevelopment. More recently, in a useful and challenging review of research findings on many dos and don’ts for pregnant women, Oster (2013) notes that there has been much research but few findings of harmful effects of low to moderate levels of alcohol consumption. In a large-scale Australian study, Robinson et al. (2010) obtained data on weekly alcohol consumption at 18 and 34 weeks for 2,900 women with follow-up testing for child behavioural problems when the children were aged 2, 5, 8, 10 and 14. They found no evidence of an increase in behavioural problems when mothers drank up to 10 units a week as compared with those who were abstinent. In a recent Danish study of 1,628 women and their children, Skogerbø et al. (2012) found that low to moderate alcohol consumption in early pregnancy had no statistically significant associations with assessments of cognitive functioning of the children at age 5. Similarly, Kelly et al. (2013) carried out a seven-year follow-up of 10,534 children born in the UK between 2000 and 2002 and found no evidence of unfavourable cognitive or behavioural effects on children whose mothers were light drinkers during pregnancy compared with abstainers. In fact, the children of light drinkers performed slightly better on a number of measures.

In contrast to these studies, which may be regarded as good news for women wishing to drink lightly or moderately during pregnancy, two recent studies indicate that light drinking, especially in the first trimester, is associated with some negative birth outcomes. Andersen et al. (2012) investigated outcomes for 92,719 Danish women and reported that light drinkers, as compared with abstainers, showed an increased risk of miscarriage during weeks 13—16, but no increase later in the pregnancy. Nykjaer et al. (2014) investigated outcomes for 1,303 UK women and found that light drinkers in the first trimester were more likely than abstainers to have premature and low birthweight babies. Experts in the field have pointed out a number of methodological weaknesses in these studies, which make interpretation of the results difficult (Savitz, 2012; Science Media Centre, 2014). However, given the importance of the issue and the current state of uncertainty about the evidence, women would probably be best advised to adopt the cautious approach of abstinence, at least in the first trimester of their pregnancy.

Health Benefits of Drinking

The possible benefits of light to moderate drinking have been the subject of a great deal of research and considerable controversy over more than 50 years. The main focus of attention has been cardiovascular disease (CVD), where most studies have reported a U- or J-shaped function, with light and moderate drinkers being at substantially lower risk than both abstainers and heavy drinkers. In a detailed review of publications from 1950 to 2009, Ronksley et al. (2011) found the evidence supporting the protective effect of light to moderate drinking to be compelling. Overall, the relative risk for alcohol drinkers for CVD mortality was 25% lower than for non-drinkers, with the lowest risk for light drinkers with consumption levels between 7 and 14 units a week. In the case of mortality from strokes, there was relatively little indication of a protective effect for light drinkers and a very pronounced negative effect for heavy drinkers. In a review of papers published from 1980 to 2010, Roerecke and Rehm (2012) found that light drinking was associated with a reduced risk of ischaemic heart disease incidence and mortality, but they were cautious in their interpretation of this finding, pointing out that there was considerable variation in the extent of the apparent protective effects reported in different studies.

In addition to an association with reduced risk of CVD, there is also some evidence that light drinking is associated with a reduced risk of death from cancer when compared with abstainers. This is surprising in view of the evidence which we have already noted, that cases of some types of cancer are more frequent among light drinkers. However, in a meta-analysis combining data from 18 studies published up to April 2012, Jin et al. (2013) found that light drinkers (up to 11 units a week) had a 9% reduction in all-cancer mortality, while heavy drinkers (over 44 units a week) had a 31% increase when compared with non/occasional drinkers.

After considering the costs and benefits of alcohol consumption in relation to different diseases, the natural question to ask is, how is consumption related to all-cause mortality? In addition to their analysis for CVD, Ronksley et al. (2011) also examined this evidence. Of the 84 studies that provided data for CVD, 31 also provided data for all-cause mortality, indicating that there was a J-shaped relationship, with light drinkers having a 13% reduction in mortality compared with abstainers, and heavy drinkers a 30% increase.

The results of these and other studies are not entirely consistent with each other, especially for the purpose of establishing upper limits for safe drinking, but they are at least consistent with the statement that men and women in good health who drink moderately are not taking any significant risk with their physical health. The additional claim that light to moderate drinking is actually beneficial to health is more open to doubt. Although non-drinkers do have higher mortality rates than drinkers, this may be only because the category of non-drinkers includes a substantial number of individuals who have given up drinking because of poor health. This is a useful illustration of the statistician’s dictum that ’correlation does not entail causation’. It could be that not drinking is a cause of poorer health but, equally well, it could be that poor health is a cause of not drinking. The latter view was first analysed in detail by Shaper et al. (1988), using data from 7,000 middle-aged men, confirming that those who suffered from health problems cut down or abstained from drinking. The argument was subsequently developed by a number of other critics, notably Fillmore and her associates (Fillmore et al., 2007). An alternative possibility is that a third, ’background’ variable could be the cause of both good health and moderate drinking. An example of such a background variable might be having an optimistic style of personality. We discuss the links between personality and health in Chapter 18.

Recent reviews have gone some way towards meeting these criticisms, by dividing abstainers into ex-drinkers and life-long abstainers, and still finding a protective effect for light drinkers. However, a range of further criticisms of this interpretation have been put forward by Fekjær (2013). He points out that light drinking has been shown by various studies to have an apparent protective effect not only against CVD but also against a wide range of diseases, many of which have no obvious physiological connection with alcohol consumption. Thus while plausible biological mechanisms have been proposed for protective effects against CVD (Brien et al., 2011), it is difficult to imagine that this could also be done for such diverse conditions as asthma, gallstones, osteoporosis, hearing loss and Alzheimer’s disease. Since the peak protective effects always seem to occur at very similar levels of light drinking, there are grounds for suspecting that we are not dealing with a panacea so much as a flaw in research design. Fekjær argues that the latter is the case. He points out that most studies have been conducted in countries where light or moderate alcohol consumption is very much the prevailing norm, and statistically associated with high social status, while non-drinkers are on average of lower social status and education with less healthy diets and levels of exercise, and many other characteristics which are correlated with poor health. As discussed in Chapters 4 and 5, social inequalities are strongly associated with health.

Accidents and Psychosocial Problems

The importance of drink-driving as a cause of road traffic accidents, and the deaths of drivers, passengers and pedestrians, is universally acknowledged. The risk begins even at the lowest blood-alcohol levels and increases proportionately thereafter (Anderson and Baumberg, 2006). Legislation lowering the maximum permitted level of blood-alcohol, increasing the amount of police attention paid to drink-driving, and the introduction of random breath testing are all measures that have been shown to reduce fatalities (Room et al., 2005).

The legalization of marihuana in many states of the USA has meant a higher incidence of combining the recreational use of alcohol with cannabis. Since the 1970s it has been known that skilled performance is worse under the influence of alcohol and cannabis together than with either drug alone, with some evidence of synergistic effects (Casswell and Marks, 1973; Marks and MacAvoy, 1989). Brady and Li (2014) studied trends in alcohol and other drugs detected in drivers who were killed within one hour of a motor vehicle crash in six US states (California, Hawaii, Illinois, New Hampshire, Rhode Island and West Virginia) over the period 1999—2010. Of 23,591 drivers studied, it was reported that 39.7% tested positive for alcohol and 24.8% for other drugs. The prevalence of non-alcohol drugs rose from 16.6% in 1999 to 28.3% in 2010, whereas the prevalence of positive results for alcohol remained stable.

Alcohol consumption has also been shown to be a factor in many other kinds of injuries, including deaths from falls, fires, industrial accidents and drowning. In a 16-year follow-up study of Finnish men, Paljärvi et al. (2005) found that heavy drinking was associated with an increased frequency of fatal injury, the risk being highest among those who reported the highest annual number of heavy drinking occasions. In a study of 11,536 patients with non-fatal injuries attending 28 emergency departments in 16 countries, Borges et al. (2006) found the relative risk to be considerably greater among those who had been drinking within six hours of injury.

Anderson and Baumberg (2006) reviewed an extensive range of studies from many countries demonstrating an association between heavy drinking and a variety of personal and social problems, including violent assaults and homicide, marital violence and marital breakdown, child abuse, impaired work performance, depression and suicide. To what extent is alcohol to blame? This raises all of the usual chicken-and-egg problems of interpreting statistical correlations. For example, does drinking incite people to commit crimes or do criminals drink to reduce their fear before carrying out the crimes which they have already decided to commit? Do people take to drink in an effort to ameliorate their psychological problems, or are these problems caused by heavy drinking? These issues of correlation and causation are difficult to resolve, but are neatly circumvented by the following excellent and fully valid health education slogan: ’If you drink because you have a problem, then you will end up with two problems.’

The Effects of Alcohol and Causes of Alcohol Dependence

To understand the motivation for drinking and problems of dependence it is best to begin by considering the psychological effects of alcohol. These effects are much influenced by culture and by people’s expectations about potential benefits, including enjoyment, stress reduction and increased sociability (Anderson and Baumberg, 2006). This explains why it is consumed in social gatherings, such as parties and weddings, when people wish to interact in a much more relaxed and informal way than they might otherwise, and also why heavy drinking is common among people with psychological problems. Alcohol dependence is widespread among people suffering from anxiety disorders, and the use of alcohol to induce sleep is also known to aggravate sleep disorders because it leads to increased wakefulness and arousal a few hours later (Anderson and Baumberg, 2006).

Let us now look more closely at the question of why some people develop drinking problems while others do not. Here a number of contrasting theoretical perspectives need to be considered. They are not mutually exclusive in the sense that this can sometimes be said of theories in the natural sciences. The discerning reader will notice various ways in which elements of each can be consistent with elements of the others. They are best thought of as reference points that are useful aids to thinking about the issues. A brief summary of the main theoretical views is given in Table 11.1.

Genetic Theories

Genetic theories propose that some people have an inherited predisposition to develop drinking problems. Those who are convinced of the overwhelming importance of heredity believe that certain people are ’born alcoholics’, destined to succumb to alcoholism almost as soon as they take their first drink. Perhaps surprisingly, this ’biological determinist’ view is also attractive to manufacturers of alcoholic drinks. They can argue that the born alcoholic is bound to have a drink and become an alcoholic sooner or later, however much the availability of drink is restricted. The rest of us can drink as we wish without running the risk of becoming alcoholics.


While it is certainly true that alcohol problems tend to run in families, this is not in itself enough to prove the existence of genetic influences. Drinking habits can be passed on from parents to children as the result of upbringing and imitation just as much as they may be passed on through genes. The most widely cited evidence for genetic influences comes from twin and adoption studies. Twin studies are based on comparisons of the concordance rates for drinking patterns in monozygotic (MZ, identical) and dizygotic (DZ, fraternal) twins. The theory behind this is that both types of twin grow up in the same family environment, so that a greater concordance for the 100% genetically similar MZ twins than for the 50% similar DZ twins is evidence of genetic effects. Adoption studies examine whether adopted children grow up to acquire similar drinking habits to their biological parents, or whether they are more influenced by their adopting parents.

Twin and adoption studies have been used to estimate ’heritability’, a statistical assessment of the relative importance of hereditary and environmental influences which can take values from 100% for fully inherited characteristics to 0% for those which are purely environmentally determined. In practice, heritability estimates for drinking patterns have varied greatly from study to study, partly as the result of methodological problems that are difficult to overcome, and partly because the estimates vary as a function of what is measured. The highest estimates have sometimes been found for ’chronic alcoholism’ and sometimes for ’teetotalism’; some have found greater heritability for males than females, and some the exact opposite (see, e.g., Heather and Robertson, 1997). In so far as generalizations have been made about the heritability of alcohol problems, figures of 50—60% have sometimes been suggested (Anderson and Baumberg, 2006). However, Walters (2002) carried out a meta-analysis of 50 studies and concluded that heritability was quite low, unlikely to be higher than 30—36%. Verhulst et al. (2015) suggest the figure is close to 50%.

Given the increasing popularity of DNA-based research, it is not surprising that there have been a number of attempts to demonstrate specific genetic loci for alcohol problems, but these have only met with modest success (Cook and Gurling, 2001; Anderson and Baumberg, 2006). As with other forms of human behaviour, there are likely to be a multitude of complex genetic routes that may make some individuals more likely than others to become problem drinkers (Palmer et al., 2012). For example, there may be inheritable differences in the way that alcohol is metabolized, so that some people find its effects pleasant, others unpleasant, some find it takes more alcohol, others less, to achieve the same effect. There may be differences in genetic predisposition to experience anxiety, so that some are predisposed to drink more than others on discovering that it temporarily suppresses anxiety.

On the basis of existing research evidence, there is certainly no reason to suppose that some people are ’born alcoholics’. Although there is enough evidence to show that there is some degree of genetic predisposition towards different patterns of drinking, it seems unlikely that this is as important an influence as environmental factors. To appreciate what this means, take as an analogy the fact that some people may have an inherited proneness to develop heart disease, but whether or not they will do so still depends on whether they smoke, eat fatty foods, avoid exercise, and so on. The risks are just greater for some people than for others. Similarly, there could be many environmental reasons why drinking problems develop in those who have an inherited predisposition and also in those who do not.

Addiction, Disease and Dependence Theories

The history of these theories has been examined in a broad social and historical context by Thom (2001). Addiction theories can be traced back to the classic works of Benjamin Rush of Philadelphia and Thomas Trotter of Edinburgh, published respectively in 1785 and 1804. Rush and Trotter replaced the traditional view of habitual drunkards as moral degenerates by one in which they are victims of an addiction. Once the addiction is established, the victims lose all voluntary control over their drinking. They have become incapable of resisting their craving for the ’demon drink’. Rush and Trotter succeeded in popularizing their belief that alcohol is a highly addictive substance 70 years before the case was made for opium.

Later disease theories focused increasingly on the at-risk individual who has a predisposition to become alcoholic once he or she starts drinking. Although a predisposition to become alcoholic does not have to be hereditary (we have already mentioned that it may be the result of upbringing), nevertheless the concept of the born alcoholic proved attractive to disease theorists. In common with earlier addiction theories, disease theories emphasized craving and loss of control. The difference was that, for the later disease theorists, alcohol is only highly addictive for a small number of people. The rest of us can drink with impunity. This change of emphasis proved attractive, especially to a North American society that had abandoned prohibition, embraced personal liberty and responsibility and has a powerful drinks industry.

From the mid-1970s, the disease theory was being revised and extended, notably by Griffith Edwards and Milton Gross, to become the alcohol dependence syndrome. In this new conceptualization, the sharp distinction that had previously been made between physical addiction and psychological dependence was abolished and the syndrome was viewed instead as a psychophysiological disorder. The descriptions given by Edwards and Gross are not always very clear and tend to change from one publication to another. Box 11.2 lists the main aspects of Edwards’ more recent accounts as summarized by Sayette (2007).

The concept of the alcohol dependence syndrome has been much criticized, originally by Shaw (1979), who pointed out that much woolly thinking lies behind it. Most people, on reading the list of symptoms in Box 11.2, would conclude that anyone who drinks regularly would exhibit one or more of them to some degree. As a list, it seems consistent with the idea that, rather than being a disease, alcohol dependence is an arbitrary point that can be chosen on a continuum from the light social drinker to the homeless street drinker. Yet proponents of the syndrome insist that it is a clinical entity, admittedly with somewhat varying symptoms, which only applies to a relatively small number out of all the people who drink heavily.

Box 11.2 Symptoms of Alcohol Dependence Syndrome

According to Griffith Edwards, this includes some or all of the following symptoms:

· tolerance (a diminished effect of alcohol, usually accompanied by increased consumption);

· withdrawal symptoms following reduced consumption;

· consumption of larger amounts or for a longer time period than was intended;

· persistent desire or unsuccessful efforts to cut down or control drinking;

· excessive time spent obtaining, consuming or recovering from the effects of alcohol;

· reduction of important activities due to drinking; and

· continued drinking despite knowing that it is causing or exacerbating a physical or psychological problem.

Source: Sayette (2007)

One should not, of course, ’throw out the baby with the bath water’. No theory of alcohol use can afford to neglect the phenomenon of physical dependence associated with prolonged heavy drinking and most clearly manifested in the spectacular withdrawal symptoms that can occur following sudden abstinence. These include some of the most unpleasant to be found among all types of drug withdrawal, including tremors (’the shakes’), sweating, nausea, vomiting, hallucinations (’pink elephants’) and convulsions. Indeed, Lerner and Fallon (1985) noted that, in a significant number of cases, sudden withdrawal can actually prove fatal. The phenomenon of psychological dependence also needs to be addressed by any theory of alcohol use. While alcohol dependence syndrome may be poorly defined as a clinical entity, the psychological problems that are often associated with heavy drinking certainly need to be explained.

Learning Theories

Learning theorists consider drinking problems to develop as a result of the same learning mechanisms that are at work in establishing patterns of ’normal drinking’. They argue that the reasons why some people become problem drinkers and others do not lie in their particular personal histories of learning to drink, their present social environment in so far as it provides opportunities and encouragement to drink, and in physiological variables that may make the effects of alcohol more pleasurable or positively reinforcing for some people than others.

Operant conditioning is the type of learning that occurs when animals are trained to respond in a particular way to a stimulus by providing rewards after they make the appropriate response. In the classic experiment, hungry rats were confined in small boxes and trained to press a bar in order to obtain food pellets. This phenomenon, which was of course well known to animal trainers, pet owners and the parents of small children long before it was ’discovered’ by psychologists, has some applicability to the understanding of problem drinking. Of particular importance is the gradient of reinforcement, the fact that reinforcement which occurs rapidly after the response is much more effective in producing learning than delayed reinforcement. In the case of drinking alcohol, a small amount of positive reinforcement, such as reduced anxiety, that occurs fairly soon after drinking, may cause a strong habit to develop in spite of the counterbalancing effect of a large amount of punishment (hangover, divorce, loss of employment) that occurs much later.

Drinking, eating, smoking, drug and sexual addictions all have the ’irrational’ characteristic that the total amount of pleasure gained from the addiction seems much less than the suffering caused by it. According to learning theorists, the reason for this lies in the nature of the gradient of reinforcement. Addictive behaviours are typically those in which pleasurable effects occur rapidly, while unpleasant consequences occur after a delay. The simple mechanism of operant conditioning and the gradient of reinforcement functions, as it were, to overpower the mind’s capacity for rational calculation. Bigelow (2001) discussed the applicability of operant conditioning principles to the understanding and treatment of alcohol problems. He concludes that they have considerable relevance, but notes that there has been little interest in them in the alcohol field in recent years, in contrast to the field of illegal substance use where they continue to play quite a dominant role.

Classical conditioning refers to the process whereby a response that occurs as a natural reflex to a particular stimulus can be conditioned to occur to a new stimulus. In Pavlov’s early experiments a bell was rung shortly before food was placed in a dog’s mouth, thereby eliciting salivation as a physiological reflex. After a number of pairings of bell and food, Pavlov found that the dog salivated when the bell was rung unaccompanied by food.

A number of interesting models have been developed by applying classical conditioning principles to addictions, and Drummond et al. (1995) provided a useful survey of this now highly technical subject. One application to explain the phenomena of drug dependence, tolerance and withdrawal is the compensatory conditioned response model. Initially, when a drug is taken, a physiological ’homeostatic’ mechanism comes into operation to counteract its effects. In the case of alcohol, which has a depressing effect, the homeostatic mechanism activates the nervous system in order to maintain the normal level of activation. In the regular drinker, this gradually produces tolerance so that increasingly large quantities of alcohol are required to produce the same effect. Furthermore, the homeostatic response of nervous activation may become conditioned to stimuli normally associated with drinking, such as situations where drinking has frequently taken place in the past. If conditioned drinkers avoid alcohol in these situations, the conditioned response of nervous activation will not be balanced by the effects of alcohol, and the resultant unpleasant state of excessive activation is what is known as a withdrawal state. In this way classical conditioning can account for the close connection observed between the phenomena of tolerance and withdrawal.

The compensatory conditioned response model has considerable intuitive plausibility but there is a lack of convincing evidence for its applicability to problem drinking. Drobes et al. (2001) discussed this model and a range of alternative classical conditioning models with specific reference to alcohol dependence and they conclude that, in all cases, there is a lack of empirical evidence to support the approach.

Social learning theorists argue that classical and operant conditioning provide incomplete explanations of human learning, which also frequently depends on observation and imitation. Bandura (1977) has been particularly influential in emphasizing the importance of learning by imitation and linking it to his concept of self-efficacy, a personality trait consisting of having confidence in one’s ability to carry out one’s plans successfully. People with low self-efficacy are much more likely to imitate undesirable behaviour than those with high self-efficacy. Collins and Bradizza (2001) reviewed applications of social learning theory to drinking, noting that the evidence points to parents having the strongest influence on the initiation of adolescent alcohol use while peers are most influential in determining subsequent frequency of use.

Prevention and Treatment of Alcohol Problems


Approaches to the prevention of alcohol problems have been the subject of intense controversy in recent years. On the one hand, specialists in this field are generally in favour of measures to reduce overall levels of consumption by increasing prices and imposing restrictions on advertising, promotions and general availability. On the other hand, the drinks industry campaigns against all these approaches and in favour of educational initiatives and self-regulation. The main issues are summarized in Box 11.3. Here we briefly review the evidence in support of the ’population-based approach’, and also consider the position of the drinks industry and its influence on government policies.

The detailed reviews of the evidence cited at the foot of Box 11.3 were variously commissioned by the World Health Organization, the European Commission and the British Academy of Medical Sciences and published between 2003 and 2007. These reports concur in finding much evidence that overall levels of consumption in populations are closely associated with the extent of alcohol problems. Rossow and Norström (2013) provide a recent and thoughtful analysis of the evidence together with other related epidemiological issues in alcohol studies. Earlier in this chapter we indicated some evidence coming from the dramatic impact of changes that occurred in Russia during the Gorbachev era. We also noted the huge increase in deaths from chronic liver disease in the UK, tracking increases in levels of alcohol consumption in the period from 1970 to 2007. More generally, comparisons of different countries and of changes occurring within countries over lengthy periods of time all arrive at the same result. The World Health Organization (WHO) (2007) noted that half of the world’s consumption of alcohol is by the 10% heaviest drinkers, and that 75% of the variation across different regions in the extent of alcohol dependence can be predicted from overall levels of consumption. Much as this must disappoint the drinks industry, there are no examples of countries that have managed to maintain population levels of consumption while at the same time reducing alcohol problems.

Probably the most effective measure for reducing population levels of consumption is increased taxation. This is a policy that requires careful analysis and attention to the specific conditions of individual countries, particularly poor countries where large increases in taxation may lead to increases in the production of illicit and potentially lethal distilled liquor. But in relatively wealthy countries, increases in taxation generally lead to proportionate decreases in consumption. The WHO (2007) noted that young people’s drinking is particularly sensitive to increases in price, which can therefore reduce underage drinking as well as the extent of binge drinking among teenagers. Furthermore, and contrary to widespread belief, price increases have also been shown to have an impact on the amount consumed among older frequent and heavy drinkers.

Box 11.3 Population-Based Prevention: Expert Opinion versus the Drinks Industry

· Specialists on the prevention of alcohol problems are almost unanimous in their support for the population-based approach, which incorporates the principle that the most effective policies for reducing alcohol problems are those which reduce overall levels of consumption. These policies include higher levels of taxation on alcoholic drinks, restrictions on advertising and sponsorship, limiting opening hours for bars and imposing tight controls on which shops can sell alcohol and the hours during which they can do so.

· The population-based approach is opposed by the drinks industry because reduced overall consumption means smaller profits. They propose that ’sensible drinking’ can be encouraged by self-regulation of the drinks industry and educational initiatives. They argue that the population-based approach penalizes the majority of sensible drinkers in order to discourage the minority of irresponsible drinkers.

· Critics of the drinks industry suggest that the drinks industry claims are disingenuous because it has been clearly shown that educational initiatives are ineffective at curbing heavy drinking, and also because the drinks industry makes most of its profit from the minority of drinkers who consume well above recommended limits.

· In many countries the drinks industry has been much more successful than the alcohol experts at influencing government policies. This may be because governments do not wish to risk unpopularity by adopting population-based policies.

Sources: Babor et al. (2003); Academy of Medical Sciences (2004); Anderson and Baumberg (2006); WHO (2007)

Anderson and Baumberg (2006) examined the impact of restrictions on the sale of alcohol, including increases in the minimum legal age for purchase and measures to restrict the number of outlets and days and hours where sale is permitted. These measures have all been shown to reduce the extent of alcohol problems in a number of countries.

Each of the reports referred to in Box 11.3 note that the global drinks industry is deploying sophisticated modern marketing techniques aimed at young people, including lifestyle advertising, promotions involving sporting teams and events, rock concerts and festivals, fashion shows and carnivals, as well as the development of new products specifically aimed at young people, such as ’alcopops’ and ’pre-mix cocktails’. Agostinelli and Grube (2002) reviewed advertising on alcohol counters, including warnings on alcoholic products, with a number of interesting proposals. Unfortunately, research to date has been mainly concerned with participants’ assessments of the impact of this type of advertising rather than its effectiveness in reducing misuse. It can also be argued that such efforts are a drop in the ocean in comparison with the amount of money that the drinks industry spends on product promotion. An alternative approach, deeply unpopular with the drinks industry, is the introduction of bans on advertising and sponsorship. Although earlier research had indicated that bans have little or no effect on overall consumption, Saffer and Dave (2002) argued that this research is flawed. They use an economic model to analyse pooled data from 20 countries over 26 years and conclude that advertising and sponsorship bans can reduce overall consumption by 5—8%. They note that increases in levels of consumption often stimulate the introduction of bans, but that reductions in consumption often lead to the rescinding of bans, as has happened in recent years in Canada, Denmark, New Zealand and Finland.

One area of legislation to control the dangers of alcohol use, which more and more countries are adopting, is strictly enforced drink-driving laws, with severe penalties for offenders. It is now almost universally agreed that this has played an important role in reducing traffic fatalities. It even commands the support of the drinks industry, which, in view of the high level of public support for the laws, would be foolish to oppose it.

The other main preventive measures that have been much analysed are health education initiatives with the aim of preventing alcohol misuse. Unfortunately, the evidence here indicates that they are not very effective. Health education generally appears to improve knowledge about the effects of alcohol and attitudes to it, but has no effect on the amounts actually consumed. Midford and McBride (2001) reviewed alcohol education programmes in schools, noting that, in the USA, efforts have been hampered by an excessive emphasis on abstinence, while in Europe and Australasia the emphasis has been on ’sensible drinking’. Although they detect a few promising signs in recent developments, the general finding is that these programmes have either failed to achieve any effects or, at best, have produced very small effects. Foxcroft et al. (2003) reviewed reports of 56 interventions aimed at young people aged 25 or under that showed substantially similar conclusions.

The ineffectiveness of educational campaigns designed to encourage sensible drinking perhaps explains why the drinks industry is happy to support them and even participate in them. Although this may seem an unnecessarily cynical view, there are some reasons for taking it seriously. Heather and Robertson (1997) pointed out that the drinks industry derives a good part of its profits from very heavy drinkers. In a 1978 survey of Scottish drinking habits, it was estimated that 3% of the population were responsible for 30% of total alcohol consumption. The loss of this source of profits would be crippling to the drinks industry. Hence the continued profitability of the industry requires the existence of a substantial percentage of very heavy drinkers. This provides another salient example of a conflict of interest between good public health and profits in industry.

In considering international perspectives at the beginning of this chapter we noted that the drinks industry is often mentioned as an obstacle to effective alcohol policy. A good example is provided by the UK in recent years. Heather and Robertson (1997) described attempts by the Portman Group, an organization funded by the British drinks industry, to influence academic debate on alcohol policy by financial offers to academics to encourage them to mount critiques of research supporting the population-based approach. The Institute of Alcohol Studies (2003) commented on the influence of the Portman Group on a decision of the British government to extend permitted drinking hours in England and Wales. The Portman Group was also a key influence on the British government’s 2004 alcohol harm reduction strategy (Plant, 2004). This document is replete with positive references to the drinks industry and the Portman Group, emphasizing the value of educational programmes and other drinks industry initiatives, while rejecting any increases in taxation or legislation to control advertising and availability. In 2009, the Chief Medical Officer, Sir Liam Donaldson, proposed in his annual report that the government should introduce a minimum price policy for alcohol, stating that ’Implementing this minimum price-per-unit policy would save an estimated £1 billion every year, impact high-risk drinkers more than others and eliminate cheap supermarket drink that young people binge on’ (HMSO, 2009: 23). The then Prime Minister Gordon Brown promptly rejected this proposal, saying it is important to protect the interests of ’the sensible majority of moderate drinkers’, a comment that accords perfectly with the views of the British drinks industry. In 2006 the Portman Group set up a sister organization, Drinkaware, apparently with some government support, and whose activities, like those of its parent organization, seem designed to ’divert attention away from population-level strategies that limit the availability, price and promotion of alcohol, and thus threaten corporate profits, towards those focused on individual responsibility’ (McCambridge et al., 2014). The authors also note that these organizations are continuing to enjoy success in countering the one government policy that is most feared by the drinks industry: the introduction of minimum unit pricing.

Paralleling the activities of the Portman Group in the UK, Jernigan (2012) analysed the activities of the International Center for Alcohol Policies (ICAP), funded by the international drinks industry and established in the USA in 1995. Jernigan argued that much of the material published by ICAP appears to be a direct attempt to counter the publications being put out concurrently by the World Health Organization. While superficially mirroring the WHO publications, those of ICAP were heavily dependent on research involving collaborations with the drinks industry and highly selective literature reviews which typically arrive at conclusions either supporting the position of the drinks industry or at least emphasizing high levels of disagreement among researchers. The ICAP publications frequently recommend alcohol policies that are known to be ineffective. The WHO went to some lengths to distance itself from ICAP and similar organizations, as is evident from the following extracts from a 2013 letter from its director to the British Medical Journal:

The development of alcohol policies is the sole prerogative of national authorities. In the view of WHO, the alcohol industry has no role in the formulation of alcohol policies, which must be protected from distortion by commercial or vested interests.

WHO is grateful to the many researchers and civil society organizations that keep careful watch over the behaviour of the alcohol industry. This behaviour includes direct industry drafting of national alcohol policies, or drafting through the International Center for Alcohol Policies and other entities or ’public health consultants’, which it funds. As documented in recent reports, some of the most effective policy options to reduce the harmful use of alcohol, as defined by WHO, are conspicuously absent in these policies (Chan, 2013).


A brief synopsis of alternative approaches to treatment is given in Table 11.2. These range from rehabilitation centres offering in-patient treatment over several weeks or months to brief interventions offered by doctors, nurses or other professionals. One area receiving a lot of media hype is the increasing use of ’talking cures’. These are therapies involving one-to-one or one-to-many face-to-face or self-help techniques designed to change experience and behaviour. There are many such therapies, but the most popular over recent decades have been cognitive behavioural therapy, motivational interviewing, mindfulness-based relapse prevention, and Acceptance and Commitment Therapy (ACT).


None of the treatments outlined in Table 11.2 is a panacea. Reviewing the literature to determine the truth about the effectiveness of particular approaches is no easy task. It is necessary to cut through the hype that frequently accompanies study findings. More frequently than ever, authors of studies, sponsors and journals are using positive spin and exaggerated claims to promote findings in the media and increase altmetric scores. Miller and Wilbourne (2002) provided an extensive review of the amount and quality of the evidence concerning the efficacy of different treatment programmes. They examined studies of 48 different types of treatment, rating each study for its methodological adequacy and then placing the treatments in rank order. Alcohol brief interventions (ABIs) of advice given by general practitioners, nurses and at hospital emergency departments are well supported by the evidence. Whitlock et al. (2004) noted that reductions in amount consumed, and in the proportion of participants who reduced their drinking to moderate or safe levels, were maintained up to four years after the interventions. Bertholet et al. (2005) reviewed brief interventions, brief treatments given at primary care facilities to individuals attending for reasons other than alcohol-related problems. After examining 19 trials that included 5,639 individuals, they concluded that these interventions were effective in reducing alcohol consumption measured at 6 and 12 months after the interventions.

Because ABIs are effective as well as being much less expensive than other forms of treatment, they have become increasingly popular. The main problem that has been identified by researchers is the difficulty that has been experienced in persuading general practitioners to undertake them. Roche and Freeman (2004) proposed that practice nurses could take over the function. Platt et al. (2016) reviewed 52 trials with 29,891 individuals. ABIs reduced the quantity of alcohol consumed by an average of 0.15 of one standard deviation. Neither the setting nor the content significantly moderated intervention effectiveness, but interventions delivered by nurses had the most effect in reducing quantity (d = −0.23) but not frequency of alcohol consumption. Brief advice was found to be the most effective in reducing quantity consumed (d = −0.20). However, let’s be clear that the average effect of ABIs on consumption is modest: only 0.15 of one SD. That represents a reduction of only one or, at most, two drinks from the drinker’s daily consumption of alcohol. Hardly a cure!

Of the other types of treatment reviewed by Miller and Wilbourne, there is evidence for the effectiveness of motivational interviewing. None of the remaining 46 types of treatment considered by Miller and Wilbourne received much support from outcome studies, although cognitive behavioural therapy (CBT) appeared to be more effective than psychotherapeutic approaches. Furthermore, and in spite of its enduring popularity, there are few good quality studies that provide support for the approach of Alcoholics Anonymous and their abstinence-based ’12-step facilitation programme’. However, the AA’s perfectly reasonable insistence on anonymity and the associated difficulty of forming properly randomized control groups make it difficult to scientifically evaluate.

Another approach under the umbrella of mindfulness-based relapse prevention (MBRP) has been receiving publicity over recent decades. This technique has been applied to problem drinking as well as other substance use disorders (Witkiewitz et al., 2005). Meditation itself is an ancient mental discipline from the Buddhist tradition, which surfaced in the West as a technique for producing relaxation in the 1960s and 1970s. Early studies claimed a specific and reliable psychophysiological effect that could act as a therapeutic aid for drug abuse and alcoholism (Wallace et al., 1971; Benson and Wallace, 1972). Many Western people tried using meditation to reduce psychological stress and stress-related health problems.

Findings have been mixed, although many studies have produced positive results. Bowen et al. (2014) reported a trial in which 286 participants were randomly assigned to one of three groups: traditional 12-step facilitation, cognitive behavioural relapse prevention and MBRP. At six-month follow-up the CBT and MBRP groups both had lower relapse rates than the 12-step group and, after 12 months MBRP was outperforming both of the other groups.

Goyal et al. (2014) carried out a systematic review to determine the efficacy of meditation in improving stress-related outcomes (anxiety, depression, stress/distress, positive mood, mental health-related quality of life, attention, substance use, eating habits, sleep, pain, and weight) in adult clinical populations. Results were unimpressive overall. Mindfulness meditation showed moderate evidence of improved anxiety at eight weeks and at three to six months, depression at eight weeks and at three to six months, and pain, and low evidence of improved stress/distress and mental health-related quality of life. However, Goyal et al. (2014) found low or no evidence of any effect of meditation on positive mood, attention, substance use, eating habits, sleep and weight. They also found no evidence that meditation was better than any active treatment such as drugs, exercise and other behavioural therapies.

There is a need for large-scale, well-controlled clinical trials to evaluate new treatments and therapies. None invented to date is a panacea, and the prospect of finding one is a remote possibility. There is too much profit in the drinks industry to conceive of prohibition or sustained tax increases, the only measures that could effectively reduce the prevalence of alcohol-related illnesses and deaths. So if you like a ’tipple’, drink on dear reader, make merry, and hope for the best!

Future Research

1. Clarification of the health risks and possible benefits of light to moderate drinking, including heart disease and risks to the unborn child.

2. Studies to examine the role of learning processes, including classical and operant conditioning and social learning in the development of alcohol dependence and problem drinking.

3. Investigations to establish the physiological and psychological mechanisms of dependence, tolerance and withdrawal symptoms.

4. Evaluation of the relative effectiveness of different approaches to the treatment of problem drinking, including brief and opportunistic interventions, motivational interviewing, mindfulness-based relapse prevention and self-help organizations.


1. Most cultures both past and present have an ambivalent view of the use of alcohol. This ambivalence is often associated with the view that alcohol is harmless, possibly beneficial, in moderation, but harmful in excess.

2. There is a sharp conflict between addiction and disease models of alcoholism, which are particularly prevalent in North America where life-long abstinence is considered to be the only cure for the alcoholic, and psychological models, which are more common in Europe, where drinking in moderation is sometimes considered to be a viable objective.

3. Drinking has been shown to cause liver cirrhosis, pancreatitis, strokes, various cancers and, in the case of drinking during pregnancy, damage to the unborn child. Most of these physical health risks are confined to the heavy drinker.

4. There is some evidence that light alcohol consumption may be protective against heart disease. The greatest physical risk taken by the moderate drinker and by the occasional binge drinker is the risk of accidental injury or death — especially, but not exclusively, traffic accidents.

5. Heavy drinking has been shown to be associated with a substantial proportion of violent assaults and homicide, marital violence, marital breakdown and child abuse.

6. Hereditary and environmental factors both make a substantial contribution to alcohol consumption.

7. The nature of physical and psychological dependence on alcohol is not well understood; at present, conditioning and learning models represent the most promising approach.

8. The most effective methods for preventing alcohol problems include high taxation, advertising bans and restricted availability. The drinks industry is a powerful lobby against these measures and few political leaders would dare to risk unpopularity by introducing them.

9. Brief interventions from general practitioners, including ’opportunistic interventions’, have modest effectiveness in producing reductions in consumption.

10. For individuals seeking treatment for alcohol problems, motivational interviewing and mindfulness-based relapse prevention may be helpful. However, evaluations have not been conclusive and none of the treatments invented to date is a panacea.