[Commentary] MODERN‐DAY MIRACLES: DECLINING PER CAPITA CONSUMPTION AND INCREASED AWARENESS OF ALCOHOL'S DAMAGE IN A DRINKING‐ORIENTED SOCIETY

Some years ago a colleague noted that in France the population had performed the reverse of the biblical miracle of turning water into wine. By treating wine as a necessary component of most meals and many other social occasions, and downplaying the intoxicating properties of alcohol and the damage related to it, despite high consumption rates, it appeared that wine was routinely being transformed into water. As reported in the paper by Messiah and colleagues [1] and elsewhere [2], France is among several countries, including Italy [3], that have experienced a dramatic decline in their per capita consumption rate in recent decades. The intensive alcohol control and harm reduction campaign from the early 1990s [4, 5] appears to have reinforced this decline and also produced greater awareness of alcohol-related issues. Thus the modern-day miracle of turning wine into water, has been upstaged, it appears, by two subsequent miracles, that of reducing the volume of alcohol that needs to be transformed, along with increased awareness of the negative potency of alcoholic beverages. The provocative research paper by Messiah and colleagues [1] signals the challenges of comparing findings from non-identical survey methods, questions the appropriateness of the CAGE instrument in documenting population level trends, and leaves one wondering about the social dynamics and implications of declining alcohol use in France. It is masterful understatement: focusing on just a few questions from two surveys conducted in Île-de-France, it nevertheless stimulates a reflection of secular changes vis-à-vis alcohol in France and explores perceptions of alcohol use during this transformation. The authors suggest that since the increase in the positive CAGE response was evident for both genders (greater for females than males), there is more going on here than just the impact of using survey methods that are not, strictly speaking, comparable. This explanation, while reasonable, is not sufficient. It is feasible that the telephone interview methodology used in 2005 in contrast to in-person interviews used in the first survey [1] may stimulate a greater willingness to report deviant drinking, and furthermore, this method may be more of a stimulus among women than men. Although the paper provides a preliminary estimate that the percentage of subjects reporting four drinks per occasion has declined between the two surveys, it is nevertheless surprising that the two surveys appear to have no additional information on quantity and frequency of consumption, or on patterns of drinking or frequency of high volume drinking. One wonders how self-reported data on consumption levels and patterns would have enhanced the story relating to the increase in the proportion reporting troubles with alcohol [6]. Furthermore, the authors might have offered some contextual information, drawn from other sources, indicating which sectors of the French population were most (or least) responsive to the multi-faceted alcohol control campaign of the 1990s. This paper points to a comparison of several trends – using a combination of archival data and self-report survey findings, for example: per capita sales and high risk drinking; high risk drinking and damage from alcohol; per capita sales of alcohol and damage rates; high risk drinking and/or per capita sales, and perceptions of personal problems with alcohol. Given the accumulated evidence from major projects over several decades [7-9], it is reasonable to expect that a change in overall consumption rate is positively linked with damage from alcohol at the population level. It has also been shown that the proportion of high risk drinking in a population is associated with alcohol-related harm [10, 11]. In Canada there has been a modest increase in overall per capita consumption since 1996 [12, 13] and during this time the percent reporting 5+ drinks on one occasion has also increased [14, 15]. In the United Kingdom there has been substantial increase in overall consumption concurrent with high-risk drinking and public disruption from alcohol along with a rise in liver cirrhosis mortality [16]. It is not surprising that one might find similar trends in the proportion reporting high risk drinking and overall sales of alcohol in a population. Various analyses in the United States and Australia have shown that the roughly 20% who drink the most, consume about 85% of the alcohol [e.g. 17]. It is indeed possible that the two are causally linked. They are likely also influenced by other variables such as increased access to alcohol and marketing, and possibly are evidence of social contagion and collectivity of drinking cultures [7, 18]. However, is it reasonable to expect a positive relationship between a decline in per capita consumption at the population level and the proportion of people reporting personal drinking practices considered to signal alcohol-related troubles? The authors imply that it is, by referring to their contrary findings as paradoxical [1]. However, this linkage is more tenuous than the others noted above between alcohol sales, high risk drinking and damage from alcohol. Unlike the other variables, in this case, the respondents are being asked to report on behaviour that they suspect is deviant. Also, cultural perceptions of alcohol, acceptable drinking behaviour, mores and knowledge of alcohol campaigns may all impact on these responses. In the context of the association between secular trends in the management of alcohol and self-reported problematic behaviour, a more important question is how the public responds to increased controls on alcohol, rather than if there is a close match between official sales of alcohol and self-reported problems using the CAGE. It appears that there has been a combination of widely mixed messages in France in recent decades: a long tradition of easy access to alcohol and deeply ingrained consumption of alcohol in many social settings, combined with recent strong and multi-dimensional controls on promotion and campaigns against drinking and driving and other interventions. It is not surprising to find greater awareness of alcohol issues in this context, and a questioning of old practices and greater sensitivity to personal drinking habits. However, it is not clear whether the reported increase in the CAGE responses are primarily an indication of an actual change in behaviour, reflect an enhanced sensitivity to alcohol issues, are confounded by the differences in the methodology of the two surveys, or involve a combination of these factors. The paper points to a rich agenda for future work, and also signals that further analyses build on additional data on drinking levels and patterns, and perceptions of alcohol controls and personal drinking behaviour.

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