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Should alcohol problems still be tackled by reducing total consumption?

  • Alkohol och narkotika

In the 1970’s the publication “Alcohol Control Policies in a Public Health Perspective – the Purple Book” stated that the average amount of alcohol consumption in a society directly affects the amount of problems experienced by the society. Is the most effective way to reduce alcohol problems still through policies aimed at reducing total consumption? This was one of the key questions at an open session during the biannual Nordic Alcohol and Drug Researchers’ Assembly (NADRA) in Helsinki 31.8-2.9 2016.

Professor emeritus Pekka Sulkunen presenting










- Among experts the total consumption model has served as a leading alcohol policy doctrine for several decades. However, its implementation has been rare, professor emeritus Pekka Sulkunen says. Obstacles have been business interests, low esteem of public health interests relative to fiscal ones and difficulty of justifying restricitive availability and tax measures

- People do not do “total consumption”, they drink here and now. It´s not easy for politicians to argue that people who drink moderately should comply with limited opening hours of the alcohol shops, Sulkunen says.

Consensus about the public good

According to Sulkunen the total consumption model recommends a universalistic approach to social control. It assumes that it is possible to find a consensus about the public good, and that political systems have the capacity to implement policies to promote it.

- These are demanding conditions seldom met, and the neoliberal turn in the 1980s throughout the world made things worse. How do you incorporate universalism with difference? If everybody is to be treated the same way, individuals will have to sacrifice their right to what I call intimacy: being separate from others, unique and different.

Sulkunen says that this contradiction appears in the methodology of the total model consumption research. It can only measure what is common in any use of alcohol: quantity and frequency of intake of the molecule ethanol.

- To be viable, this limitation must be overcome. Pure quantitative epidemiology must be complemented with a sociology of drinking as people actually practice it. Regulations must be targeted at observably harmful drinking, not at “total consumption” that people do not understand, Sulkunen says.

Substantial but spotty influence

Professor Robin Room, from the Centre for Alcohol Policy Research at La Trobe University in Melbourne, Australia, provided a historical perspective by presenting the influence of the Purple Book in anglophone countries. According to Room the influence was substantial but spotty.

Professor Robin Room presenting

- Part of the influence was through its main message, drawing together emerging lines of work which have since flourished, that the amount a population drank mattered for public health, pointing to a rationale which had become neglected for licensing and control of alcohol sales.

In political and policy terms the book, however, had little effect.

- One of the reasons was that it aimed directly against powerful economic interests. At the moment the book appeared, consumption had been rising and continued to do so for a few more years and the main policy direction was deregulation, making way for competitive forces to improve market efficiency.

- In intellectual terms, though, the book had strong and lasting influence. It had longevity as a cited source, was a seedbed for whole research traditions and formed a lasting network for interchanges and a tradition of international collaborative studies, Room says.

Relevance for current debates

Senior researcher Pia Mäkelä from the National Institute for Health and Welfare in Finland, talked about the relevance of the Purple Book for current debates. The Finnish government is about to renew the obsolete Alcohol Act from 1995 and the debate has been intense with public health proponents on one side of the continuum and the alcohol industry lobby and activists for market liberalization on the other side.

Senior researcher Pia Mäkelä presenting









In one thread of the debate “8 myths about alcohol policy” have been presented. Three of these “myths” pertain to ideas that are based either on the Purple Book or its successor Alcohol Policy and the Public Good: “Total consumption should be reduced in order to reduce alcohol-related harm”, “A tight alcohol control policy protects public health” and “The largest proportion of alcohol-related harm arises from the large majority of drinker, who drink less than the small number of heavy drinkers”.

- One of the counter-claims for the first idea is that the reduction in consumption is mainly limited to moderate drinkers. The evidence show quite the contrary. The higher the population´s mean consumption is, the greater the proportion of heavy drinkers, Mäkelä says.

In terms of the second statement, that a tight alcohol control policy protects public health, some have argued that it doesn´t, referring to the study published in the journal Alcohol & Alcoholism by Poikolainen in 2015. The study states that a tight alcohol policy doesn’t reduce disability adjusted life years due to alcohol, according to a comparison of 30 OECD countries.

Mäkelä says there is a problem in the inference.

- No inference on causal effects or lack thereof can be made on the basis of the study. Confounding factors are not controlled for, the societies differ in innumerable ways and the effect of one factor can´t be separated by a cross-sectional correlation analysis, like in the study.

A universalistic approach

According to the third idea in the Purple Book, the largest proportion of alcohol-related harm arises from the large majority of drinkers, who drink less than the small number of heavy drinkers. Here opponents argue that we shouldn´t punish the moderately drinking majority because of the few who have problems, but instead we should just concentrate our efforts on helping the problem drinkers.

- Universal policies are most effective also for heavy drinkers, because their consumption moves in concert with the rest of the population. In addition, also moderately elevated risks matter, because they apply to a large number of people. Finally, it’s easy to recognize the heavy drinkers when the prime time for the prevention of harms is long gone, but universal policies prevent many risky drinkers from turning to problem drinkers in the first place, Mäkelä concludes.

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