Has the boozing Finn been tamed? Changes in the relationships between drinking, intoxication, and alcohol-related harm when turning from a spirits-drinking country to a beer-drinking country.
In the 1950s and 1960s, there were great efforts to change the Finnish spirits and intoxication-centered drinking culture into a more cultivated one, the general aim of which was to decrease harm from drinking. The main strategy was to affect people's choice of beverage, so that spirits consumption would be replaced by milder beverages. The main proponent of this alcohol policy line was Pekka Kuusi, Director and later Director General of the alcohol monopoly Alko (Bruun & Makela, 1977). The most visible components of this policy line were the great wine campaign starting in 1959, and the introduction of medium beer in grocery stores in 1969 (Ahonen, 2007; Sulkunen, 2000). These attempts failed, however. The consumption of mild alcoholic beverages did increase, but at least to begin with, this did not happen as a process of substitution, i.e., the new drinking practices involving mild beverages did not replace the old practices, but instead it was a process where the new drinking practices came in addition to the old ones (Makela, 1975). As a result, total consumption, heavy-drinking occasions, and alcohol-related harm all increased considerably both after the wine campaign and after the introduction of medium-strength beer (Makela et al., 1981). It was only later in 1989-1992, in connection to the severe depression in Finland, that the consumption of spirits declined.
Many other countries also share the aspirations of Kuusi. Room (1992) refers to the phenomenon of a "dream of a better society," an idea that has been common in temperance cultures, and before him Olsson (1990) has used the term "dream of a better order" for the same phenomenon in Sweden. In Room's terms, modifying the drinking culture was a "wet response" to intoxication-related drinking problems, as opposed to the "dry response" of controls and restrictions. According to Room, the more rigorous "strict version" of the wet response had not been supported by research evidence, i.e., there was no evidence that a drinking culture could be modified on purpose so that consumption would increase and harms would decrease. However, the "softer version", i.e., that harms increase less than consumption had occurred at times. The Finnish case, where the central method to achieve cultural change was to affect beverage choice, is a special case of the more general aspiration of trying to modify the drinking culture.
Today, Finland can be categorized as a beer country, and a wet drinking culture in the sense that the level of consumption has grown to be relatively high and the number of abstainers is low. Yet, the characteristics of a dry drinking culture remain, in the sense that binge drinking has become even more common than it used to be, and subsequent problems are also common (Makela & Osterberg, 2007). However, there is a possibility that even if the rate of harms has increased, the drinking culture has become more moderate in the sense that there is less harm per liter of alcohol consumed. Indeed, Kortteinen & Elovainio (2003) claimed, on the basis of cross-sectional data, that the Finnish drinking culture has softened in the sense that even if intoxication is still common, there is less bad behavior attached to it. Similarly, already decades ago Virtanen (1982) who, on the basis of previous studies, observed that drinking of small quantities had increased, claimed that the drinking culture has softened and become more moderate.
The aim in this article is to study whether we can see evidence of "taming," "domestication," or "softening" of Finnish drinking patterns in terms of either trends in intoxication drinking or in terms of decreasing harms per liter of alcohol consumed. This examination of history functions as a test to whether the alcohol policy strategy has worked, the idea of which was to affect harms through manipulating beverage choice, which was expected to work via changing drinking patterns. Hence, this analysis design allows an assessment of the effect of changing to mild beverages without analyses on the associations between beverage-specific alcohol consumption series and harm rates. This has the advantage that the problem of uncontrollable individual-level selection that is likely to strongly affect these associations can be avoided. For example, the groups that wish to get intoxicated by drinking the beverage that is the cheapest source of ethyl alcohol are likely to have an increased risk of harms; the beverage preferences of these groups will vary as the prices of beverage groups change, and hence the harms associated with a given beverage will change over time. The disadvantage in the analysis is that the numerous other developments in society at large that may simultaneously have influenced the trends cannot be controlled for, and hence it cannot be proven that the changes that have or have not taken place are caused by changes in beverage choice. The results obtained need to be considered as one piece of evidence that make up one piece of a bigger puzzle.
The analysis is conducted by examining, first, how drinking patterns as well as self-reported and register-based harms have developed. The self-reports come from a dataset collected every 8 years since 1968. Second, we study whether there is a decrease in the number of harms per liter of alcohol consumed using both the aggregate level register data and the self-report data. If there has been a taming of drinking patterns, it would be expected to have had the strongest effect on consequences related to the state of intoxication, e.g., on violence and injury, rather than on chronic health harm or dependence symptoms. Figure 1 shows the development of per capita consumption of all beverages combined and of strong alcoholic beverages, and the share that strong alcoholic beverages make of all recorded consumption. On the basis of this, if the changes in harms per liter were due to a switch to milder beverages, it would be expected that the greatest changes would have happened in the 1960s and towards the end of the 1980s or in the beginning of the 1990s.
[FIGURE 1 OMITTED]
The change in the drinking culture has been reflected even more strongly in the drinking of women than in that of men (Makela, Mustonen, & Huhtanen, 2010), and therefore the individual-level analyses presented are gender-specific. However, data on gender-specific assaults is not available, and women's alcohol-induced mortality is too rare for it to be analyzed separately. Differences in the changing drinking culture across generations and age groups are outside the scope of the study.
Data and methods
Both aggregate level, i.e., register data, and individual-level self-reported data are used. The advantage with the aggregate level data over self-reported data is that subjective opinion and memory effects among those experiencing harms from drinking have lesser impact on whether one is counted as having experienced the harm in question (in mortality series no such subjective effects exist, while in the assault series their role is greater, as not all assaults are reported to the police). However, in the register-based data a bias in the temporal comparisons may occur when the definitions and the official or de facto inclusion criteria for given harm categories have changed.
Aggregate level data include per capita consumption (recorded plus estimated unrecorded consumption combined) and rates of assault, deaths from alcoholic diseases of the liver (Finnish classification codes: before 1969 unofficial figures from Statistics Finland; 5710 in 1969-1986; 5710-5713 in 1987-1995; K70 in 1996-2009), alcohol poisoning (E880 until 1968; E860 in 1969-1986; E851 in 1987-1995; X45 in 1996-2009) and from "AAA" (alcoholism and alcohol psychoses--codes ICD 322 and 307 until 1968; 303 and 291 in 1969-1995; F10 in 1996-2009--in addition to alcohol poisonings as listed above). Consumption data come from the official statistics of THL, and data on assaults and on causes of death from the official statistics of Statistics Finland.
The individual level data came from the Finnish Drinking Habits Surveys carried out in 1968, 1976, 1984, 1992, 2000, and 2008. The study population consisted of Finns aged 15-69 years excluding those living in the Aland Islands (0.5% of the population) and, since 1984, the homeless and the institutionalized (1.5%).
In each year, the surveys were conducted in the fall as face-to-face interviews. Response rates have been high, despite the falling trend (Table 1). The whole dataset consists of 16,385 individuals with 7,893 women and 8,492 men. In the first four surveys, a stratified two-stage cluster sampling design was used, and the surveys were carried out by the staff of the Finnish state alcohol monopoly Alko. In 2000 and 2008, the sample was drawn from population census records using simple random sampling and carried out by Statistics Finland.
The annual volume of consumption, or mean consumption, was calculated on the basis of the amounts consumed on all drinking occasions within a period of time preceding the interview that varied between l week and 12 months (survey period), depending on the average drinking frequency of the respondent. In choosing the length of the period, the aim was to get information on four previous drinking occasions (e.g., if drinking frequency was "four to five times per week," the survey period was 1 week, and if it was "about once in 2 months," the survey period was 8 months; for details, see Simpura, 1987 and Makela, 1971), but the consumption in all drinking occasions in that period was asked about. The volume consumed in the survey period was scaled into a year by multiplying with a constant (e.g., a volume from a one-week period was multiplied by 52). In regression models, mean consumption was categorized into quintiles on the basis of the combined 1968-2008 data, separately for men and women.
The extent to which the survey measurement has been able to cover the recorded consumption, i.e. the coverage rate, has varied across the survey years (Table l). The coverage is particularly low in 1984 and it is higher than average in 1992. As a result, the changes in per capita consumption are clearly smaller in 1984-2000 than suggested by the survey data. This should be kept in mind when interpreting the results below: The changes pointing in opposite directions in the middle years can be "smoothed" by the reader.
Intoxication consumption was defined as the volume consumed during those drinking occasions that led to a blood alcohol content (BAC) of more than .1%. Other consumption is the remainder of the total volume of consumption.
BAC was estimated for each reported drinking occasion on the basis of the amount of alcohol consumed, duration of drinking and the weight of the respondent, using the following formula (Simpura, 1987): (amount of 100% alcohol in grams) -7 x (duration of drinking in hours) / (0.68 x respondent's body weight in kg).
The duration of drinking was obtained for all the drinking occasions that fell within the survey period by asking about the starting and ending times of the drinking.
Compared with recent modifications, the formula used is similar except that it assumes the proportion of body water to be 55% for both males and females, as opposed to the recommended assumption of 49% for females and 58% for males. All the original variables for the early years are no longer available, and we cannot update the BAC estimates. Therefore, the estimated BAC values that were used might be somewhat underestimated for females.
The annual number of drinking occasions, intoxication occasions, and occasions when a given number of drinks was consumed were derived from the measurements on the individual drinking occasions, but based only on the one week preceding the interview, i.e., on an "ordinary autumn week." The numbers were scaled to a year to avoid presentation of very small numbers and many decimals. The one-week measure is too short, i.e., it results in too much random variation, to be used in regression models where harm is predicted, but it is a more clear-cut alternative for purposes of aggregate-level description. When estimates are presented on the frequency of drinking a given number of drinks, it is assumed that one drink equals 1.5 centiliters (ca. 12 grams) of alcohol.
Two measures of harm were used. The first, which was assumed to be more responsive to changes in drinking patterns and in drinking culture, was available in 1976-2008 and is here called consequences of drinking. It measures different types of harm from individual drinking occasions, often linked to intoxication. In 2000 and 2008, the respondents were asked: "Next I shall mention some situations which may arise when using alcohol. Respond, using options in card X, how often in the past 12 months you have been in such situation when using alcohol ... (1) quarrel or argument, (2) scuffle or fight, (3) accident or injury, (4) loss of money or other valuable items, (5) damage to objects or clothing and (6) driving a car under the influence of alcohol?" The response options were "Not once," "1-2 times," "3 times or more often." In 1976, 1984 and 1992, the question was otherwise similar, but instead of asking "how often," the question was "has it happened that," with response options yes and no. In order to make the responses comparable, in 2000-2008 the latter two response categories were combined. The internal consistency of these questions was found to be satisfactory (standardized Cronbach's alpha = 0.86 in 2008), and all the variables loaded to one factor. The six variables with values 0 and 1 were summed, resulting in a sum variable "consequence index" with values from 0 to 6.
The second category of harm measures dependence symptoms. In all survey years, the respondents were asked: "Do you ever feel, that you use alcohol more often than you actually would like to?", "Do you ever feel, that you use greater quantities of alcohol than you actually would like to?", and "How often do you find yourself drinking more than you have initially planned to?" The response options were: "often," "occasionally," "seldom," and "never." The internal consistency of these questions was found to be good (standardized Cronbach's alpha = 0.82), and all the variables loaded to one factor (a fourth available variable was dropped, as this improved the internal consistency of the scale). The three variables with values from 0 to 3 were summed, resulting in a sum variable dependence index with values from 0 to 9.
Methods used consist of simple means and frequency counts and rates, and of suitable regression models. The change in trends was assessed by either Normal or Poisson (for counts) regression models. The p for trend is reported in text, where the fitted time trend is 1 = 1968, 2 = 1976, 5 = 2000, and 6 = 2008. The two intervening study years (1984, 1992) are left out from these tests for two reasons. These years deviate a lot from other years in coverage rate (which creates a bias in estimates), and they also had some anomalies in the application of the sampling design (which does not affect estimates but which causes challenges in correct estimation of the standard errors and p values).
Poisson regression models were fitted to the harm data separately for the different survey periods. The harm indices--which can be thought of as rough estimates of the number of events that occurred to the respondent in the previous year--were the outcome variables, and logarithmized volume of drinking (as a continuous variable) was the main explanatory variable. The results are depicted as graphs of fitted values. The question of whether the effect of consumption on harm was different in one year than another was tested by an interaction term in a model that included period (as a categorical variable) and logarithmized volume of consumption as well as their interaction term as explanatory variables.
When estimating the connection between change in harms-per-liter rates and change in the proportion of all alcohol that is consumed in the form of spirits, ARIMA (Autoregressive Integrated Moving Average) models were used (Box & Jenkins, 1976). In the analyses, the presence of time trends in the raw series is filtered to achieve the stationarity requirement needed to avoid spurious associations. The noise term is also allowed to have a temporal structure which is modeled using autoregressive or moving average parameters.
In all analyses using the survey data, weights calculated by poststratification for sex, age, and geographical region were used in order to restore the population representation of the respondent sample, and the study design was taken into account in the regression models. Aggregate level mortality rates were age-standardized.
Figure 2 clearly shows the nearly constant increase in alcohol consumption in Finland since the beginning of the 1960s. It also shows that the rate of assaults and alcohol-related mortality has increased along with the increasing per capita alcohol consumption, and that the rate of increase is higher for alcoholic liver diseases than for other types of alcohol-induced mortality.
[FIGURE 2 OMITTED]
Figure 3 addresses the question of what has happened to the rate of harms per each liter of alcohol that the population consumes. According to the figure, the trends in harms per liter of alcohol consumed have been quite different for the different harm rates. The ratio of assaults per liter of alcohol consumed decreased until the first half of the 1970s, i.e., it decreased in the 1960s when the proportion of mild beverages strongly increased--but it did not decrease in the 1980s when this happened again. Alcohol poisoning mortality per liter of alcohol consumed did not decrease in either of these periods of increasing mild beverage preference. Alcoholic liver disease mortality, which represents chronic health problems from alcohol and is included as a point of comparison, has increased continually, also in terms of harms per liter of alcohol consumed.
[FIGURE 3 OMITTED]
The analysis of temporal associations between the harms per liter of alcohol consumed and the proportion of spirits consumption, as estimated by ARIMA models, showed no significant associations. The estimates for the effect of the proportion of spirits increasing by one percentage point varied between -0.005 and 0.002 and the p values varied between 0.44 and 0.75. *
Figure 4 presents survey-based trends in intoxication versus other drinking, using as the yardstick both the volume of consumption (top figures) and the frequency of drinking occasions (bottom figures). In terms of the number of drinking occasions, the share of intoxication occasions is 28% across the years among men and 11% among women, while in terms of volume of drinking the share of intoxication drinking is naturally much larger, 62% among men and 36% among women. Irrespective of this large difference in the levels, the time trends do not vary much whether we look at volumes or at the number of drinking occasions; instead, the results vary by gender. Among men, there has been a stronger increase for other types of drinking than intoxication drinking; intoxication drinking has not significantly increased (p for trend = 0.07 for volume, 0.71 for number of occasions), and its share of all consumption has decreased. Among women, intoxication consumption has increased (p for trend < 0.0001 for volume, 0.0001 for drinking occasions), and its share of all drinking has not changed beyond random variation and measurement error.
[FIGURE 4 OMITTED]
Another angle to the trends in heavy versus lighter drinking occasions is shown in Figure 5, which depicts the distribution of the number of drinks consumed in the drinking occasions of the 7 days preceding the interviews. When drinking, Finns even in the 1960s most often drank small amounts of alcohol, 1-2 drinks. In Figure 5, there is no clear sign among men of the proportion of either light- or heavy-drinking occasions increasing or decreasing. Among women, the number of heavier drinking occasions has increased much faster than that of lighter drinking occasions, so that the share of heavy drinking occasions has increased considerably.
Taken together, the share of heavy-drinking occasions in terms of the number of drinks drunk at a time (Figure 5) has been stable (among men) or increased (among women) while the share of intoxication occasions (estimated BAC 1 per mille or more; Figure 4) has decreased or remained stable, respectively. That is, among women the number of drinks has increased without a corresponding increase in intoxication, and among men the development in intoxication drinking similarly lags behind. This indicates that the duration of drinking has increased (and/or that the population has gained weight). Indeed, when in 1968 the average duration of all drinking occasions was 2.9 hours, it was 3.5 hours in 2008 (median increased from 2 to 2.5 hours) and, as an example, for those occasions when 8-12 drinks had been consumed, the average duration increased from 4.9 hours to 6.6 hours (and median from 4 to 6 hours). The increasing duration of drinking applied to women as well as men.
[FIGURE 5 OMITTED]
Self-reported consequences from individual drinking occasions, which can be interpreted as intoxication-related harm, have not increased (Figure 6), while self-reported dependence symptoms first increased with increasing per capita consumption, until the 1990s. After that, reporting of dependence symptoms increased at a slower rate than per capita consumption or it even decreased.
[FIGURE 6 OMITTED]
The possible change in the connection between consumption and self-reported harm on the basis of survey data was examined by regression models, the results of which are depicted in Figure 7. On the basis of Figure 7 (top part) it seems that there were more consequences from individual drinking occasions for each liter of alcohol consumed in 1976 than there were in later years (p for interaction between period and consumption < 0.0001 for men, p = 0.01 for women), which could be interpreted to mean that the drinking patterns of Finns would have become more moderate from 1976 onwards. Other than this, there were very little systematic differences.
[FIGURE 7 OMITTED]
Figure 7 (bottom part) shows similar results also for dependence symptoms, which are included as a point of comparison. The connection between consumption and self-reported dependence symptoms in the first year available, 1968, deviated from other years, too, but in the opposite direction than was the case with the consequence index (p for interaction between period and consumption < 0.0001 for men, p = 0.02 for women). This can be interpreted to mean that each liter of alcohol resulted in less dependence symptoms in l968, and more thereafter.
The aim with the analyses presented was to find out whether there is evidence of a change in the Finnish drinking culture in a direction of moderation in terms of less intoxication and less harms per liter of alcohol consumed despite the fact that per capita consumption and heavy drinking occasions have increased. The analyses do not yield any consistent or definitive answers, but they do give some interesting insights.
The results clearly showed that the development in men's and women's drinking patterns has been different. Among men, the share that heavy drinking occasions make of all drinking occasions has been stable, and the share of intoxication occasions, i.e., occasions with a high estimated BAC, has declined. Among women, the share of heavy drinking occasions has increased and the share of intoxication occasions has been stable. The reason for these differences between heavy drinking occasions and intoxication occasions is that, with given amounts of alcohol drunk, the duration of drinking occasions has lengthened. When interpreting this result, it is good to note that a feature considered to be part of traditional Finnish drinking culture is that alcohol has been given a special position and meaning in the drinking occasion. That is, alcohol has been raised to the center of the action rather than given a more instrumental role, e.g., serving other purposes such as being a nearly invisible tool for easier socialization or being a part of a meal. Spending more time with the same amount of alcohol could be a sign of taming of drinking patterns or of changing attitudes towards drinking: There is no similar hurry today to get all the alcohol drunk as there may previously have been, but instead more time is taken to spend the evening that serves also other purposes than the drinking.
The harm data yielded mixed results. All register-based harm series showed increasing trends and so did self-reported dependence symptoms, but self-reported intoxication-related consequences did not. We could first look at the harms related to more chronic heavy alcohol use, which serve here as a point of comparison for the intoxication-related consequences. Liver disease mortality per each liter of alcohol consumed by the population increased very strongly, more so than for other types of mortality. The evidence from the individual level data on chronic harms also shows an increase but earlier: Respondents reported more dependence symptoms per each liter of alcohol consumed after 1968 than at that year.
When it comes to intoxication-related harms, assaults per each liter of alcohol consumed decreased until the first part of 1970s, suggesting some kind of moderation of drinking patterns; however, thereafter the harm-to-consumption ratio for assaults changed direction and has been on the increase, suggesting not moderation of drinking patterns but rather the opposite. It remains an open question whether other factors than alcohol consumption relating to social disruption have played a key role in this shifting trend. Alcohol poisoning mortality per liter of alcohol consumed was relatively stable and did not decrease in the periods when the share of mild alcoholic beverages increased, i.e., here there was no support for a beneficial cultural change. The result from the individual-level analysis for intoxication-related consequences for each liter of alcohol consumed was that these were at a higher level in 1976 than thereafter--this result supported the idea of cultural change at the end of the 1970s.
So, the greatest changes--in addition to the higher level of total consumption--have not occurred for intoxication-related harm but for harm related to chronic heavy drinking. The traditional dry Finnish drinking pattern, i.e., that alcohol was consumed seldom but then in large amounts (Makela et al., 1981), may have been bad for the social order but it appears to have been clearly healthier for the liver and probably also for dependence symptoms. In other words, when the new wetter drinking practices have been added on top of the old dry drinking practices, this has not diminished the acute harms, but instead the types of chronic alcohol-induced harms that were traditionally the problem of wet drinking cultures have become a problem also in Finland.
There are several limitations in the data. First, the perspective of 40 years is interesting, but the period spans such a long time that many other factors have changed that are impossible to take into account in empirical analyses; real life is very far from ceteris paribus conditions. This affects particularly the analyses of the aggregate level data. General societal change, e.g., changes in the extent of social disruption, norms, or punishment and sentencing practices for assaults, as well as specific possible changes in how the harm data are collected, categorized, and defined affect the rate of alcohol-related harm and hence also the harm-to-consumption ratio. With regard to individual-level data, falling response rates are always a challenge to making reliable analyses about change. Also, it is known that trends in self-reported harm vary in a complex manner. They are affected by changes in real-life, objective alcohol-related incidents, but also by changes in norms and attitudes, so that even if in reality the rate of harms was unchanged, they may be reported less in a more alcohol liberal period than in a less liberal period (Room, 1991).
At this point, the conclusion must be that there is no unambiguous evidence to support the idea that Finnish drinking patterns would have become more moderate or that Finnish drinking would have been tamed, even if there are some signs that point in this direction. This also means that the Finnish case does not lend much support for the "softer version of the wet response" to problems from drinking (Room, 1992). With regard to possibilities to affect intoxication-related drinking problems through modifying beverage preferences, the conclusion must also be that the effectiveness of this approach does not receive any clear support from the Finnish case.
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* Assault: b=-0.003, p=0.86, model=(1,1,0): Liver diseases: b=-0.005, p=0.44, model=(0,1,1): Fatal alcohol poisoning: b=0.002, p=0.631, model=(1,1,0): "AAA": b=0.001, p=0.75, model=(0,1,0). Models are indicated by: order of autoregressive parameters (AR), order of differencing, and order of moving-average parameters (MA).
AUTHOR'S NOTE: This study received funding from the Academy of Finland (no. 118426, 137685). The data collection was partially funded by a grant from the Finnish Foundation for Alcohol Research, for which funds were obtained from the Finnish alcohol monopoly Alko. Grateful acknowledgment is made to Kimmo Herttua for conducting the ARIMA modeling. For additional information about this article contact: Pia Makela, National Institute for Health and Welfare. Department of Alcohol, Drugs and Addiction. P.O. Box 30. FI-00271, Helsinki. Finland. E-mail: email@example.com.
TABLE 1 Descriptive characteristics of the Drinking Habit Surveys of Finns aged 15-69 Survey year 1968 1976 1984 1992 2000 2008 Respondents, men 1370 1393 1782 1709 945 1297 Respondents, women 453 1442 1842 1737 987 1428 Respondents, total 1823 2835 3624 3446 1932 2725 Response rate, % 97 96 94 87 78 74 Drinking occasions in 7 previous days, N 1385 2793 2986 3850 2161 3120 Total (recorded+estimated unrecorded) per capita consumption 3.4 7.0 7.6 8.5 8.8 10.4 Change, % - 107 8 12 4 17 Mean consumption in survey 1.6 3.0 2.5 4.0 3.3 3.9 Change, % - 85 -18 63 -18 21 Coverage (mean / per capita) 48 43 32 47 37 38
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|Publication:||Contemporary Drug Problems|
|Date:||Dec 22, 2011|
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