Nordic Studies On Alcohol and Drugs: Editorial Research Reports

NAT
Nordic Studies on Alcohol and Drugs

6/07
Contents
Editorial 561
Research reports
Claes Törnqvist Twenty then – today about thirty-five. The meaning
of alcohol in a life course perspective�� _____________________________ 563
Anders Bergmark Guidelines and evidence-based practice –
a critical appraisal of the Swedish national guidelines for
addiction treatment _____________________________________________ 589
Mats Berglund Commentary on the paper by Anders Bergmark___ 600
Mads Uffe Pedersen Evidence-based practice in “the real world” ____ 605
Overview
Pia Mäkelä & Heli Mustonen & Esa Österberg Does beverage
type matter?_____________________________________________________ 617
Making use of alcohol and drug research

Introduction� ____________________________________________________ 632
Robin Room National variations in the use of alcohol and
drug research: Notes of an itinerant worker� ________________________ 634
Matilda Hellman Public use of and communication about alcohol
research ________________________________________________________ 641
Hildigunnur Ólafsdóttir Reflections on the use of alcohol research ___ 646
Katariina Warpenius & Marja Holmila Connecting alcohol research
and prevention practice: Lessons learned from PAKKA _ ____________ 652
Emilie Rapley The use of alcohol research in Eurocare’s lobbying
activities _______________________________________________________ 656
Book reviews
Harald Klingemann
��&
�� Linda
��
Carter Sobell
�� (eds.) Promoting
��
self-change from addictive behaviors. Practical implications for policy,
prevention, and treatment (by Dorte Hecksher) _____________________ 662
Tuukka Tammi Medicalising prohibition: Harm reduction
in Finnish and international drug policy (by Harry G. Levine)________ 664
NAT vol. 24, Innehåll/Contents 667
NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 24. 2007 . 6 559

Nordisk alkohol- & narkotikatidskrift
V o l . 2 4, 2 0 0 7 ( 6 ) , H e l s i n g f o r s

V o l . 2 4, 2 0 0 7 ( 6 ) , H e l s i n k i
Nordic Studies on Alcohol and Drugs by STAKES, the National Research and Development Centre for
Welfare and Health (Finland), in co-operation with the Nordic Center for Alcohol and Drug Research
(NAD). The Journal is supported by the National Institute for Alcohol and Drug Research (SIRUS),
(Norway), the Norwegian Wine Monopoly (Vinmonopolet), the Swedish Ministry of Health and Social
Affairs, Alkoholpolitisk Kontaktudvalg, the Ministry of Health (Denmark), and Alko Inc. (Finland).
Editorial board
Researcher Astrid Skretting (chair), National Institute for Alcohol and Drug Research SIRUS, Oslo
Ph.D. Hildigunnur Ólafsdóttir, Reykjavík Akademy, Reykjavík, Iceland
M.Pol.Sc. Thomas Karlsson, Alcohol and Drug Research Group, STAKES, Finland
Associate Professor Philip Lalander, Department of Humanities and Social Science, University of
Kalmar, Sweden
M.Soc.Sc. Petra Kouvonen, Nordic Center for Alcohol and Drug Research, Helsinki, Finland
Research professor Morten Grønbæk Alcohol Research Department, National Institute of Public Health,
Copenhagen, Denmark
Editor-in-chief
Kerstin Stenius
phone: +358 - (0)9 - 3967 2197
Editors
Johan Sandelin Matilda Wrede-Jäntti Ylva Sjöblom
phone: +358 - (0)9 - 3967 2198
Assistant editors
Leif Vind, Denmark Martin Stafström, Sweden
e-post: lv@crf.au.dk e-post: martin.stafstrom@smi.mas.lu.se
Elin Bye, Norway Rafn M. Jónsson, Island
e-post: ekb@sirus.no e-post: rafn@publichealth.is
English language revision

Mark Phillips
Editorial office
STAKES, P.O.Box 220, FIN-00531 Helsinki, Finland
Telefax E-mail Website

+358 - (0)9 - 3967 2052 nat@stakes.fi http://www.stakes.fi/nat/
Graphic design
Anders Carpelan
Subscription price: 26 EUR (200–250 DKK, NOK or SEK) 6 issues.
Free copies of the English Supplement may be ordered from the editorial office, nat@stakes.fi
ISSN 1455-0725 Vammalan Kirjapaino Oy 2007
560 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 4 . 2 0 0 7 . 6

Editorial
K e r s t i n S t en i us
Guidelines for treatment – national

ambitions and local implementation
In 2002, the Swedish National Board of Health and

Welfare initiated a project with the aim of establishing guidelines
for the entire addiction treatment system, including both the health care and
social services parts.
The core of this work was the reviews produced within five expert groups,
in which most of the Swedish alcohol and drug treatment researchers were
involved. The reviews started out from the so-called SBU-review by Berg
lund et al (2003), but some new aspects were covered as well as the latest
research findings. The reviews summarized the literature according to an
evidence grading, where RCT-studies had the highest rank. The five expert
groups summarized the findings on early identification and prevention, as-
sessment instruments and documentation, psychosocial and medical treat-
ment of drug abuse, psychosocial and medical treatment of alcohol abuse
and the treatment of pregnant women. (See Malmström 2007).
After five years of work, in 2007, the guidelines were published by the
National Board of Health and Welfare (Nationella riktlinjer för missbruks-
och beroendveård 2007), with altogether 53 recommendations formulated
by a group of treatment administrators, providers and researchers. During
the autumn of 2007 these guidelines and recommendations have been pre-
sented at a number of regional conferences all over Sweden, attended by
several thousands, mainly staff from the treatment systems. The implemen-
tation efforts have thus begun.
Guidelines for the treatment of alcohol and drug abuse have also recently
been produced in Norway and Finland. Even though there has been an ex-
change of knowledge and methodologies across the borders, there are inter-
esting national differences in working procedures and implementation that
would be worth analyzing. The Swedish way is characterized by an attempt
to include diverging views in the expert groups, to reach consensus, and
to put much effort into a nationwide implementation. But it also includes
training material and a preparation and call for a continuous discussion
(making use of the internet) at local level concerning the implementation.
Following on from a centrally administered, heavy and slow moving policy

machinery, a perhaps more exciting confronta- (EVP) into perspective, highlighting that EVP
tion emerges with the reality of treatment. only constitutes a small part of high quality care.
Hopefully the implementation will be prop- Using Danish data, he sounds out a warning that
erly evaluated. The real effect of this ambitious therapists can be so blinded by demands to use
Swedish project may not be the introduction of the “right” methods, that they will forget what the
new treatment methods, but the establishment of client really needs. He also shows that evidence
new routines as well as changes in the structure has to be developed locally, fitting the treatment
of the treatment system. setting and the client group of the facility.
In this issue, Anders Bergmark (2007), mem- The Swedish project report coincides with
ber and chair of one of the expert groups, gives what may in the future be regarded as a turning
his critical remarks on the work carried out on point in the history of treatment research, when
Swedish guidelines and its usefulness, with fur- the hopes put on evidence-based methods (a nec-
ther comments by Mats Berglund, the main au- essary step) were succeeded by a focus on the
thor of the SBU-report. importance of the functioning of the treatment
In another article, Mads Uffe Pedersen (2007) system or common factors in treatment.
puts the significance of Evidence Based Practice
REFERENCES
Berglund, Mats (2007): Commentary
��
on the paper by narkotikatidskrift 24 (5): 504–509
Anders Bergmark. Nordic Studies on Alcohol and Nationella riktlinjer för missbruks- och bereondevård.
Drugs 24 (6): 600–604 Vägledning för socialstjönsten och hälso- och
Bergmark, Anders (2007): Guidelines and Evidence sjuklvårdens verksamhet för personer med miss-
Based Practice – a critical appraisal of the Swed- bruks- och bereondeproblem (2007). Lindesberg:
ish national guidelines for addiction treatment. Socialstyrelsen
Nordic Studies on Alcohol and Drugs 24 (6): Pedersen, Mads Uffe (2007): Evidence
��
Based
589–599 Practice in “The Real World”. Nordic
��
Studies on
Malmström, Ulf (2007): Nationella riktlinjer för Alcohol and Drugs 24 (6): 605–616.
missbruks- och bereondevård. Nordisk alkohol- &
562 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 4 . 2 0 0 7 . 6

Research
Claes Törnqvist
report
Twenty then – today ABSTRACT

C. Törnqvist: Twenty then – today about
about thirty-five thirty-five. The meaning of alcohol in a

life course perspective
Aim
The meaning of alcohol Studying changes between the ages of
in a life course perspective 20 and 35 in the use of alcohol and its
meaning to the user and the relation of
this to cultural background.
Aim and point of departure of DATA AND Method
the study Qualitative interviews with 42 persons
In the mid-1980s the present author, together in Malmö, Sweden, aged approximately
with Margareta Norell, conducted a qualitative 20 years (21 women, 21 men) belonging
investigation of the meaning that alcohol has to 3 groups, differing in social
for persons some twenty years of age (19–22) characteristics, in their use of alcohol
in three different social environments in the and the meaning it had for them. 34
Swedish city of Malmö. The study was of both of them were interviewed again in a
cultural sociological and social psychological follow-up study 15–16 years later.
character. It resulted in two articles (Norell & Results and conclusions
Törnqvist 1997; Törnqvist 1999) and a doc- At the age of 35, when matters of work,
toral dissertation, Berättelser om ruset. Alko- family and raising of children had
holens mening för tjugoåringar (Narratives become of central importance, alcohol
on intoxication. The meaning of alcohol for no longer had the much more central
twenty-year olds) (Norell & Törnqvist 1995). role in their lives it had had at the age
Those studied in the respective social en- of 20, when intoxication had helped
vironments were 1) young employed persons them create a collective illusion of
whose ideal regarding alcohol was to achieve future success at their goals. Alcohol
a moderate and controlled degree of intoxica- still played a role in their lives, however,
tion (cf. Ambjörnsson 1988), referred to here helping to support their feelings of
as the employed group, 2) young students who closeness to their partners, of being
aimed at achieving a “civilized” level of intox- good parents and of succeeding in their
ication, referred to as the student group, and work. Drinking, usually involving wine,
3) young persons with a more pronounced was primarily on weekends in a family
subcultural style, referred to here as the peo- setting, the woman typically taking the
ple-in-black group due to their dark attire, initiative here. The continental European
who tended to feel that in becoming intoxi- custom of going out occasionally on
weekday evenings to drink beer with job
This study was supported by the Swedish National
Institute of Public Health and the Swedish Research colleagues had become more frequent.
Council.
NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 4 . 2 0 0 7 . 6 563

Twenty then – today about thirty-five
Those without a family or a cated they “triumphed” over others. The employed group
partner differed somewhat and the student group were selected to basically represent
in their pattern of drinking. the “broad majority” of young people, whereas the people-
Effects of one’s social in-black group, who had a rather characteristic view of life,
environment at the age of 20 were selected as an example of a subculture of the time that
on the use of alcohol and the was readily identifiable in public places. A question we
meaning it had for one at posed to all of these young people was “How would you like
the age of 35 were evident. your life to be in the future, if you were free to choose?”
Keywords This was followed by the question “How do you think your
Alcohol consumption, life will be in ten years, say?” The thoughts of the employed
meaning of alcohol, age, group centred very much on the idea that at that future time
culture, gender, longitudinal they would have stopped going out to have a good time and
study, life course to smoke “hash” and would instead be sitting in front of their
perspective, interviews, TV set with their spouse and children, and that on weekends
qualitative methodology. they would drink a little together with their spouse in even-
tempered Swedish style. A typical conception the student
group, in turn, had was that they would continue to develop
a civilized continental European style of drinking charac-
teristic of their having become well established and of the
social status they had gained. The young avantgarde or peo-
ple-in-black group, in contrast, showed a certain ambivalent
reservation toward things, seeming to be afraid of waking up
in their thirties, taking a hard look at themselves in the mir-
ror and taking note of the fact that they were still frequenting
bars and drinking beer, without their dreams for the future
having come true.
About 15 years later we obtained an answer to the question
of how life in general and their alcohol culture had turned
out for them through conducting a follow-up study, inter-
viewing 34 of the original 42 again in the years 2001–2002,
when they were 35–38 years of age. We studied how they
had successively established themselves in various adult
fields of endeavour and the role that alcohol had played in
this – in relation to their work, their living conditions, their
founding of a family and how they spent their free time.
The article aims at illuminating the place that alcohol had
in their adult lives at that point and the meaning it had to
them, as well as how it related to their life situation and life-
style. The basic question of interest was how the conditions
of life these young persons had encountered at the beginning
of adulthood had affected their subsequent life projects as
adults and their associated life course. This question is dealt
564 NORDIC STUDIES ON ALCOHOL AND DRUGS VOL. 24. 2007 . 6

with in detail in the book Ny vuxenhet i of age has been regarded as a plateau in
ett livsloppsperspektiv (Törnqvist & Norell the phase of becoming established in life,
2007), in English New Adulthood and Its through the individual’s level of perform-
Sequel from a Life Course Perspective. The ance in most areas concerned with getting
scope of the present article is limited to ahead being at the highest point during
conclusions that could be drawn concern- that period (Rapoport & Rapoport 1975).
ing the meaning of alcohol in a life course Describing the individual’s advancement
perspective. through life in terms of separate stages is
Longitudinal studies concerned with problematical, since cultures differ from
use of alcohol and narcotics are fairly rare one another in the stages that can be said
within the Nordic countries, particularly to occur and when. In a life course per-
studies of a qualitative character. Although spective, in contrast, social context is re-
a variety of qualitative ethnographic stud- garded as an important factor, changes in
ies of alcohol culture have been carried out society being taken into account. The peri-
in the Nordic countries (Alasuutari 1990; ods of time that different stages of life can
Elmeland 1996; Sulkunen 1983; Norell be said to encompass have also changed in
& Törnqvist 1995; Pape 1997; Lalander the course of history, changes brought on
1998), none of them are longitudinal in by the reflexive modernization processes
character or take a life course perspective. that various societies have undergone in
The present longitudinal study of the role recent decades (Giddens 1991; Beck 1994)
of alcohol in the life patterns of adults dif- being a case in point. As a result of such
fering in the youth cultures to which they changes, people need increasingly to take
belonged at the onset of adulthood aims at measures on their own to deal with the
filling this gap in Nordic alcohol research. risks and uncertainty connected with the
The only other longitudinal study on the breakup and transformation of modern
use of alcohol that has been carried out in industrial society and maintain a sense of
the Nordic countries and employs a quali- personal identity.
tative methodology is Adalbjarnardottir’s The complex relations between suc-
(2002) Icelandic investigation of the effect ceeding generations shown in many tran-
of psychosocial maturity on the use of alco- sitions that are of an individual or family
hol during adolescence. In the Cambridge membership character can be studied from
Scientific Abstract there is no longitudinal a life course perspective (Hareven 2000).
study of alcohol use at all of ethnographic Karl Mannheim’s (1956/1992) definition
or qualitative character listed under the of the generation concept contributes to an
social science heading. understanding of the life course perspec-
What does use of a life course perspective tive. In terms of Mannheim’s cultural psy-
as a basis for interpreting reality mean? It chology, a generation – which consists of
rejects for one thing the idea derived from individuals who are basically in the same
a life cycle perspective of there being defi- phase of life – is formed through each hav-
nite “stages” through which people pass ing grown up under social and historical
in the course of their lives. In a life cycle conditions that were roughly the same, the
perspective the period of 35 to 40 years experiences they have in common follow-

ing them throughout life as a part of their tafsson 2003). An overview by Fillmore
life course. From a life course perspective, et al. (1993) of 20 longitudinal studies
social background is thus regarded not as from 15 different countries showed there
a static background variable but as some- to be a decrease in alcohol consumption
thing directly linked to historical condi- with increasing age, both for women and
tions. Gender is not considered a static for men. Also, although men tended to
variable either, since the meaning that drink more than women, the difference
gender is assigned is dependent upon both decreased with age. It was also noted that
time and place. A life course perspective the level of alcohol consumption shown in
focuses on the direction a person’s life and youthful years tended to set a standard for
individual development takes. Such a per- how much people drank later in life, those
spective helps one to understand the com- drinking more than others in their younger
plex interaction between the fundamental years tending to do so in their later years
factors shaping one’s life. Although his- as well.
torical and social changes strongly affect a It has been found (Neve et al. 2000) that
person’s life and the decisions one makes, when people marry and have children they
such decisions are not based on historical generally drink less. This has been shown
conditions alone. What may well seem a to be the case for men in particular, their
sensible level of drinking for someone who drinking habits after marriage tending to
is 25 may not seem a sensible level at all at become more like those of women (Kunz
the age of 35, age thus being important for & Graham 1996).
gaining an understanding of the interac- A marked change in alcohol culture in
tion between the different factors affecting the Nordic countries during the last few
a person’s life. Ethnicity is another such decades has been that the drinking pat-
factor, separate ethnic groups in society terns of women have become increasingly
differing in the conditions under which similar to those of men, women appearing
they live, both material and cultural. in greater numbers than earlier in pubs,
An individual’s pattern of free-time ac- bars and the like traditionally frequented
tivities is generally established early in by men (Pape 1997). Drinking habits have
adulthood. For men and women alike, the also become more continental European
drinking of alcohol tends to be associated through a greater consumption of drinks
with free-time activities (Kunz & Graham of lower alcohol content such as beer and
1996; Lalander 1998). The alcohol culture wine, as opposed to strongly alcoholic
people show varies, however, with both drinks (Leifman & Gustafsson 2003). This
gender and age and with whether or not a “Europeanization” has also meant that
person has established a family. It can also control of the consumption of alcohol has
readily shift in response to changes in the been shifted more and more to the individ-
course of a person’s life. ual as opposed to authorities. Alcohol con-
Studies from a wide variety of countries sumption and light intoxication have also
provide a picture of alcohol consumption increasingly become a part of everyday life
by people of different ages fairly similar to rather than being viewed as something re-
that of people in Sweden (Leifman & Gus- served primarily for weekend festivities.
566 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 4. 2 0 0 7 . 6

A question that can be asked is to what partnerships and marriages thereafter. In

extent do people with differing lifestyles addition, many men and women alike, in
generally adopt the ways of a modern con- broad segments of society at least, have
tinental European alcohol culture. expectations or the experience of having
During periods of rapid social change, more than one type of job in the course of
life courses of certain types can become their working life, sometimes in combina-
more frequent. Phenomena during such tion with each other, which increases the
periods concerning the historical context complexity of the planning needed within
at the moment, people’s readiness to act, the framework of the life courses, or the
close ties between persons developing, family histories, of those involved. What
and the time schemes needed for certain role do alcohol and the intoxication it can
actions to take place can link individu- produce play in relations between men
als in a complex way with social changes and women today?
that occur (Elder & Shanahan 1997). In the In the Nordic countries it is generally
modern double-career family, the timing necessary nowadays that the woman in a
of things can also be decisive for many job- family have a job in order for the family to
related matters important to each and for get by economically. In Sweden the tran-
the couple’s common project of creating a sition from the woman in a family being
happy family situation and doing the best a housewife to her having a job occurred
they can for their children (Frønes 1997). during the 1960s, which means that those
In line with the reflexive modernization born in that decade were the first whose
that has occurred, the individual tends in life course involved socialization under
a marriage or partnership today to be freed such conditions. Men and women today
to a considerable extent in economic, so- thus share the responsibility for support of
cial and cultural terms from many of the their family economically, in addition to
obligations of a more absolute character sharing responsibility for care of the chil-
that existed earlier, a marriage or partner- dren and maintenance of the home, at the
ship being viewed primarily as a relation- same time as caring for children is also the
ship between two persons who love each responsibility of society generally. The for-
other, rather than as a contract anchored mal symmetry created between men and
in their relations to their parents and close women in the respects just named may
relatives or in religion (Beck 1994; Beck & become unsymmetrical in reality, both in
Beck-Gernsheim 2002; Giddens 1991). In spatial and in temporal terms, however
Sweden the modernization process this (Friberg 1990). Although, as already indi-
represents has proceeded further than in cated, one cannot speak of any universal
any other country in Europe, as can be phases in the life course of people gener-
seen in the large numbers of divorces and ally, either temporally or in terms of con-
separations that have occurred. The risk tent, certain basic characteristics can be
is thus increasing of families breaking up, assumed to have applied to the time of life
which in turn means the life histories of involved for many of those who took part
larger numbers of persons being coupled in the present investigation. In Sweden to-
together through the establishment of new day, women as well as men 35–39 years

of age as a group have a very high rate of complex and contradictory than earlier,
employment. Many of them also live in a making it more difficult to achieve a sta-
marriage or partnership and have at least ble sense of identity as an adult (Kristeva
one child, although living under such con- 1990). The type of identity one wishes to
ditions at that age is more common among have appears more to be something that
women than among men, at the same time can be “negotiated” through creating a rea-
as the proportion of persons who live sonably coherent account, or life history,
alone has increased during the 1990s. The of oneself to assign one the meaning that is
average age of women at the time of first aimed at (Giddens 1991). Another aspect
giving birth to a child has increased since of the individualization process taking
the 1960s, its being more common than place today is the standardization of cul-
earlier for women to give birth to their first tural patterns which is occurring through
child at the age of 30 or more; also, about a globalization of the media. In Sweden, for
fifth of the women who are 35 years of age example, continental European preferenc-
have not yet given birth to a child (Hoem es regarding food and drink are becoming
& Hoem 1997). A general pattern has been adopted increasingly.
established of women first being employed Young people today need at some point to
before they go on to establish a family. It create an individual identity for themselves
can be asked how women’s postponement in order to appear socially competent and
of having children, in a marriage or part- deal effectively with the difficulties with
nership, has affected the alcohol culture which an adult individual in modern soci-
of both men and women, as seen in a life ety is faced. The “social timetable” of the
course perspective. In contrast to how it life course of people has changed, creation
was a generation before, it is not at all un- of an individual identity taking longer than
usual today for the parents of small chil- it did earlier. It can be asked at what point
dren to be 40 years of age or older. What one actually becomes “grown up” in Swe-
are the drinking habits of working parents den today and whether everyone becomes
who have small children and how is their completely adult in a traditional, stable
use of alcohol related to the situation with sense. The conditions people are confront-
which they are faced? ed with in going through different phases
It would appear indeed, as Beck (1994) of their development from adolescence to
argues, that society is in a state of reflexive young adulthood can strongly affect their
modernization. This speaks for its being life projects as adults and their life course
best to behave in a reflexive way both to- as it unfolds. One can ask what effects the
ward oneself and toward “reality” gener- experience with alcohol a person has had
ally, even if the relativizing of things that late in adolescence and at the outset of for-
this brings about can lead to a strong feel- mal adulthood has on the person’s relation
ing of ambivalence. Although the sense of to alcohol at the age of about 35 and what
identity people have appears to be more effects, positive or negative, alcohol has on
fragmented than earlier, this does not im- the creation and maintenance of a modern
ply it has been lost completely in mod- sense of identity as an adult individual.
ern society. Rather, identity seems more

Participants had occurred in terms of their having chil-

The young people approximately 20 years dren, and what can be said regarding their
of age of varying background who were in- use of alcohol and the role it had played
terviewed in the earlier investigation were in their lives?
selected by use of a “snowball” approach
(Burgess 1984). After we had come in con- The “employed group”
tact with and interviewed a person from The persons who belonged to the em-
one of the three categories and the person ployed group had grown up in an apart-
was found to be appropriate as a participant ment house area in the Fosie section in the
in terms of the profile the interview gave, southern part of Malmö, a section which
we could use the information and the good at the time had a cultural and socioeco-
will the interview had generated as a help nomic profile similar to that of the city of
in finding further participants belonging to Malmö as a whole. The cultural and socio-
that category, the process being continued economic profile of that section of the city
until three groups of appropriate size had has changed radically since then, persons
been collected and interviewed. of immigrant background and those with
In the present investigation, efforts were social or economic problems being over-
made to come in contact with and enlist represented in comparison to the city gen-
the participation of as many as possible of erally. A large part of this group had re-
those interviewed in the earlier investiga- mained in the area through their twenties
tion, some 15–16 years before. The same and been gainfully employed. The group
group designations – those of the employed consisted originally of 16 persons (8 wom-
group, the student group and the people- en and 8 men). Five of the women could be
in-black group – are used in reference to interviewed in the follow-up study. Two of
both the earlier and the present investiga- the other three provided brief information
tion, despite the conditions of life having when they were phoned up, whereas the
changed radically for the members of each third could not be reached. Six of the eight
of the three groups since the earlier study men that belonged to the group could be
took place – the vast majority of persons interviewed, and we were able to obtain
in all three groups now being employed, information by phone from one of the
those who were once students long since other two. Half of those in the group as a
having completed or dropped out of their whole lived in apartments in the southern
studies, and those once dressed in black part of the city, and several of the others
attire no longer being dressed in that way. lived in private dwellings either in the city
What social characteristics did the or nearby. Only two of the women, both
members of these three groups show in living alone with their child(ren), were liv-
the present investigation, conducted when ing in the same section of the city as ear-
they were at about the age of 35–38, under lier, in fact on the same floor in the same
what conditions were they living, what apartment building as each other. The ma-
education had they attained, what occupa- jority of the women who were interviewed
tion did they have, what family life or pair in the follow-up investigation were work-
relationship(s) had they established, what ing in lower- to middle-level positions in

the service, health care and administrative their child(ren) living with them under
sectors. The men were working as crafts- conditions of shared custody, with the ex-
men of various types, the majority having ception of one of the women, who had the
made successful careers thus far. The level sole care of her three daughters, each with
of education in the group as a whole was a different father, and care of a grandchild
fairly low. It was typical for them to have as well.
completed two years of high school. One
of the women was the only member of the The “student group”
group who had a college education. Sev- Most of the student group grew up in an
eral members of the group had been out of apartment-house area at the edge of the
work for limited periods of time. Hyllie section in the southwestern part of
All but one of the men had a child, the Malmö, about a kilometre to the northwest
number of children per family varying be- of the Fosie section where the employed
tween one and three, two children being group was living at the time. Living in
the most usual. The age of the women at the Hyllie was considered, then just as it
the birth of their first child ranged from is today, to be “finer” in terms of status
20 to 24 years, which is clearly rather than living in Fosie. At the time the earlier
young as compared with women in Swe- interview took place, the majority of the
den generally. The men were somewhat student group had left home to live in dor-
older than this (median age 27), and also mitories or elsewhere in connection with
differed more from one another in age, the start of their studies at the university.
when their first child was born. All the Today, most of those in the group live ei-
persons in the group as whole with one ther in Malmö or in some neighbouring
child or more had either initially or at community. Some who have remained in
some later time lived with their partner the Malmö region are living in the western
and child(ren) under family conditions, part of the city, largely in apartment hous-
although the permanence of this relation- es, the rest of this group living in commu-
ship varied. Half of them had separated nities not far from Malmö. The three who
from their partner, the typical pattern be- left the Malmö region entirely were living
ing that of the relationship having ended in cities at a considerable distance from
after a relatively short time. Only two of Malmö, in a single-family house in each
the persons had established a family again case.
after that. The men who at the time they The original group consisted of 14 per-
were separated had a child, and when the sons (7 women and 7 men). All of the men
present investigation took place were liv- and five of the women were interviewed
ing either as a single person entirely or in this follow-up study. Most of those in
separate from someone they were together the group had completed a program of
with, had their child(ren) living with them education at the university, the majority of
at least part of the time and maintained them having begun their studies directly
daily contact with them. The women who after completing high school. Two of the
were separated from their partner, all but men, neither of them having completed
one of them living without a partner, had their university education, had started a

firm, with success differing. Several of the and were able to finance their existence to
women with children were without a full- a large extent by short-time jobs and unem-
time job and had failed to make use of their ployment compensation. As with the other
university education in the work they did. two groups, most of them had remained
The women as a group were engaged in in the Malmö region. Two of the women
middle-class jobs of rather differing char- were living in the respective families they
acter, including esthetically oriented jobs had established in rural areas in southern
in designing or in advertizing, work as an Sweden, and two of the men had moved to
educational consultant, and being a politi- other large cities in Sweden. The remain-
cian. The men with a university education ders of the group were living in apartments
were engaged in jobs, likewise of a mid- near the center of Malmö.
dle-class character, as engineers, lawyers Eleven of the twelve who had been in-
and teachers. terviewed earlier could be interviewed
Just as in the employed group, all the again (6 women and 5 men). Three of the
members of this group, except for one of men had acquired a college or university
the men, had children. The number of education and were working within jour-
children varied between one and three, nalism or law. The remaining two had
two children being the most usual number pursued ambitions of theirs in the enter-
for the men and three the most usual tainment industry or the media. The ma-
number for the women. The women were jority of them had had experience with
somewhat younger than the men at the part-time jobs of various types. All of the
time of the birth of the first child, 25–28, women except one had a college or uni-
the median age for the men being 30, the versity education and had studied either
variation in age also being greater for the cultural or linguistic subjects or psychol-
men. The majority of those in the group ogy, or been trained in social work. This
had established a family. In three cases, had led for the most part to publicistic or
separation from their partner had later oc- cultural work or work within the media,
curred, in each case after a family relation- largely of a freelance nature or connected
ship had been maintained for a period of with specific projects. Both the men and
about 5 years. the women had in common that they be-
gan their higher-education studies decid-
The “people-in-black” group edly later, at 25–30 years of age, than the
The people-in-black group had lived at the student group did.
time of the first interview near the center The group also showed a different pat-
of Malmö, though they had grown up at tern than the other two groups in regard
various locations, both within the city and to establishing family life and having chil-
outside of it, some of them not far from dren. Only two of the men and three of
where the employed group and the stu- the women had children. For those who
dent group members had lived at that time. had children, their age at the birth of the
At around 20 years of age they had been first or the only child varied considerably,
drawn to the center of the city, where they being 27 and 36, respectively, for the two
found music and a bohemian way of life men, and 24, 26 and 32, respectively, for

the three women. The two men were each booked up that he doubted we would suc-
living in a long-term relationship with ceed in arranging an interview with him.
their partner. Of the three men who had The two women, in turn, seemed reluctant
no child, one had had various relation- to be interviewed and, although they fi-
ships of short duration, another had been nally agreed to it, both of them cancelled
together with a partner but without living later. Insofar as we know, neither of them
with her, and the third had had sporadic had any problems with drugs. Our impres-
relationships. In contrast to the men, all of sion was that they felt ambivalent about
the women had established at some time a letting things about themselves be known
genuine family or pair relationship, two of to persons whom they thought were linked
them since then having separated, one of in some way with public authorities. For
them living alone with her child and the those belonging to this group generally, a
other living as a single person. tendency to be skeptical of public authori-
ties and distrust them could be noted, both
Attrition in the initial interview and in this one. The
Most of those interviewed earlier who failure of so many in this group to take part
failed to participate in this follow-up in the follow-up interview reduces the
study because of our not being able to confidence, of course, that can be placed
contact them or its not being possible to in the interpretations made of what they
interview them belonged to the employed reported as a group.
group, there being five persons from that The two persons from the student group
group who did not take part in the present who failed to take part this time were both
study, as opposed to two from the student women. One could not be located, whereas
group and one from the people-in-black the other could not be reached because of
group. Of the five from that group who her being in a foreign country at the time.
failed to participate, there were two (a man A factor that could be thought to contrib-
and a woman) we were unable to reach. ute to its being only women in this group
Although we talked by phone with the oth- who failed to participate could be that the
er three (a man and two women), this did women in the group related to one another
not result in an interview. Regarding the less closely than the men did. Even though
man and the woman we did not succeed not all the men in the group were still in
in reaching, the man had not known any of contact with one another, they neverthe-
the others very well and we were unable to less knew where all of the others lived,
find him, and the woman, said to be living and the jobs and family relations they had.
with a man who was an addict, had moved Obtaining this information made it possi-
from Malmö and we had no means of lo- ble to gain contact with all of them quite
cating her either. The man from the group readily. It was difficult, however, to reach
of three we talked to without getting an in- some of the woman, due to a lack of such
terview spoke of a lack of time because of information.
his work and of other activities he was en- The only member of the people-in-black
gaged in. A friend of his warned us of this, group whom we were unable to interview
saying that the man was always so heavily was a man who took his life while in his

twenties. This can be seen as suggestive of had for them, which was carried out when
the difficulties that can beset the journey they were about 20. In an article such as
into adult life and of the particularly in- the present one, very limited in length,
tensive efforts to achieve and maintain a emphasis had to be placed on providing
sense of identity that this group may have a summary of the results, although it was
needed to make. also the intention to insofar as possible
provide a bridge between the phenomeno-
Methods – interviews and logical use of quotations representative
evaluation of them in character and the overall conclusions
The data collection method employed drawn concerning the meaning of alcohol
here, that of qualitative research inter- for these persons from a life course per-
views (Kvale 1997), was the same as used spective.
in the investigation carried out when the
subjects were about twenty years of age. Alcohol in a life course
A spirit of openness was sought so as to perspective
encourage participants to express them- What had happened in the life course of
selves as they saw fit, though structure the participants regarding their use of al-
was also sought so as to enable the mat- cohol and the meaning it had to them be-
ters of concern to be taken up within the tween the ages of about 20 and 35?
limited time available. Subjects were to
report both on their current life situation “If you compare then with now, it’s
and their journey in arriving there. Various been dramatic in just about every way.
themes were considered, in current terms ... A transition ... What’s happened in
and life course terms alike, one of them the different groups in the course of
being the role of alcohol, attention being time is interesting. At the age of 20,
directed at questions of how drinking typi- everyone drank a lot. That’s the way it
cally took place, both during the week and was. Now so little is drunk in families
on weekends, and how their use of alcohol with children or by people who live
at parties and for enjoying themselves had alone.” (Cecilia from the people-in-
changed between when they had been 20 black group)
and the current time.
The interviews (approximately 1 1/2 The most striking change for the par-
to 3 hours in length) were recorded and ticipants as a whole between the ages of
transcribed. The text obtained was read about 20 and 35, regardless of the group
through first in a phenomenologically to which they belonged – as exemplified
closely involved and then in a more dis- by the rather representative quotation just
tanced manner (Riœur 1988). In interpret- given – seemed to be that alcohol and in-
ing the material, note was made in partic- toxication had become less meaningful
ular of themes that appeared repeatedly, to them. In our earlier study of the lives
these being analyzed carefully. The inter- of these persons as 20-year olds (Norell
pretations made were compared with the & Törnqvist 1995) we found that during
results of the study of the meaning alcohol intoxication in the company of others of

their age they could create a sort of land Although alcohol was assigned lesser
of opportunity, an illusion regarding the importance than earlier, it was still con-
future. Intoxication enabled them to considered to be normal enough at the age of
sider collectively how they measured up 35 for a person to engage in its use, devia-
to others of their age and to confirm their tion from this calling forth certain aston-
having the potential in their future lives as ishment, as illustrated by the quotation
adults, through the conscientiousness and above. Alcohol and certain intoxication
resolve they were capable of, to get ahead thus continued being viewed as natural in-
in a career and to succeed in life generally. gredients in life that members of all three
As 20-year olds their lives were filled both groups were expected to relate to, alcohol
with tremendous expectations and with still having meaning in their lives.
extreme apprehensions. Under the effect
of intoxication, a whole flock of quiver- Relational scenarios
ing “I’s” could be transformed into a self- “On Fridays we tend to have a quiet
confident “we”. The process of becoming evening at home. We want to be by
intoxicated had a marked element of play. ourselves or together with the chil-
Those involved in gatherings of this sort dren. Carina and I take a nice evening
were testing themselves, without danger of meal. The children have usually had
the consequences such testing could have supper by then and gone out. We take
in the soberness of everyday reality. a juicy steak or whatever and a glass of
No such strong need of intoxication with a wine. Having wine on Friday evenings
meaning of this sort was evident when these is pretty usual.” (Kenneth, from the
same groups of persons had become 35. employed group)
“‘Aren’t you going to have anything In creating their adult lives, people as-
to drink?’ ‘No thanks’, I say. ‘Are you sign increasing importance to the variety
driving? Are you pregnant? Are you of new areas in which they are involved,
religious?’ Those are the things people whereas meeting with groups of friends
think of. Although it seems phony to and acquaintances as they did earlier
explain things like that now, people tends to no longer have the role it once
still wonder sometimes. My reaction is had. Their attention is directed to an in-
to shrug my shoulders and say, ‘There’s creasing extent at new relationships, the
nothing strange about that at all.’ family life they have established and their
There’s nothing to explain, yet things work. What primarily steers their drinking
have changed now to people asking, then is the life situation they have estab-
‘What! Don’t you even drink wine? It’s lished as adults and their need of feeling
so nice having wine with your meal’, themselves confirmed in that, as opposed
which was something you didn’t say to the search after a sense of cultural iden-
when you were 20. But now there are tity they were engaged in as 20-year olds.
lots of people who think I miss out on When they relax at the end of a week’s
what I should be enjoying.” (Kathy work as 35-year olds, their use of alcohol
from the people-in-black group) depends very much upon whether they

live in a family they have established, and whether one of them is truly loved by
in a pair relationship, as a single parent the other may be far from clear. Problems
with one or more children, or as a single of this sort can be accentuated by the trials
person. The drinking habits and views to- and tribulations of everyday life, by diffi-
ward alcohol of those who live in a family culties within the family or in connection
relationship appear to represent an ideal with one’s work, or by both partners being
and to be the basis for a dominant form of employed outside the home and being so
alcohol culture. Such an alcohol culture, taken up by matters concerned with their
manifested in the quotation above from a career that they have little time and en-
member of the employed group, was rep- ergy for each other. The breakup of rela-
resented in all three groups, but was most tionships today is not at all unusual. The
clearly evident in the student group. The “holy hours” of spending time together on
majority of the members of that group had weekends consuming food and wine to-
established a family and they clearly cher- gether can serve as a kind of glue, helping
ished family ideals. to hold a marriage or partnership together
and keep it intact. The woman appears to
“We often get together with close be more of a driving force than the man
friends on weekends. Either we pre- in maintaining a family alcohol culture of
pare a meal for them or we do it Dutch this sort. The drinking of wine is some-
treat, the group coming with their own thing perhaps more womanly than manly
food and drink. We start off having a in character in this phase of life, as the fol-
game of some sort and a grill out back lowing quotation suggests:
and take a drink or two. Then we sit
down together with the children, have “On Fridays, after being at the pool
a good meal, and drink and spend the for a swimming course, we usually get
evening then enjoying ourselves.” (Pe- home at about seven to seven-thirty or
ter from the student group) so and have a cozy evening of it then.
I don’t spare costs at all, not that I
Eating good food and drinking wine in spend a lot on clothing and that sort
the security of the family circle or together of thing, but food and drink are re-
with other couples, as exemplified by the ally important. After I’ve bought some
quotation above, appears to have a special groceries, we have a quick meal, since
meaning in itself. It helps people confirm we’ve gotten home so late, and we go
their having succeeded in creating a warm on drinking. At the moment we usu-
family relationship for themselves, or liv- ally have wine twice a week.” (Cecilia
ing together happily with their partner. from the people-in-black group)
Intoxication can make it easy for them to
experience themselves as being both loved The conditions for family life that Beck
and capable of loving, even if this is not and Beck-Gernsheim (2002) consider to
the case. Things are not always as they ap- be typical of reflexive modernism can be
pear on the surface. The relation between discerned here, those of the man and the
two people may not function as it should, woman each pursuing a career and ex-

periencing a need of self-realization in of men occurs between the ages of about

connection with it, their likewise taking 30 and 40, wine being the alcoholic drink
responsibility for family life and attempt- the two tend to agree upon drinking for the
ing to work together to maintain it, a situa- most part, the woman being the one who
tion that can lead to conflicts and tensions. assumes the position of planning and ini-
The authors argue that although there is an tiating this.
ideology of gender equality in joint efforts In the present study it was observed that
to resolve such tensions and conflicts, it from a life course perspective the relative
is the woman who assumes the major re- position of women and men in determin-
sponsibility for seeing to it that family life ing the consumption of alcoholic drinks
functions as it should and finding solu- appears to undergo a considerable change,
tions to things. This was also found to be at the age of 20 men determined very much
the case in the present study in connection themselves the types and amounts of the
with each of the three groups. It is exem- alcoholic beverages they consumed, but by
plified by the quotation above, in which age 35 women having assumed the domi-
the woman tells of seeing to it that the two nant role within the family in regard to
of them can eat and drink well when the drinking habits. How is it then with wom-
weekend arrives. en or men who are single or who share the
In a study of Swedish people’s alcohol care of a child with a former partner?
consumption conducted by Leifman and
Gustafsson (2003) at about the same time “It was one of the weekends she [her
as the present investigation was carried daughter] spent with Kalle [the girl’s
out, the picture just presented of the wom- father] and I got to drinking while I was
an’s role in a relationship in connection out enjoying myself. Drinking really
with the use of alcoholic beverages was puts me into a good mood. I felt that
shown to apply very clearly to women at after being taken up with things the
the age of 35–40. The authors found alco- whole time for two weeks ’It’s my turn
hol consumption to be highest for people now to go out and have a good time’.”
in their early twenties and to then decrease (Susan from the employed group)
with age until about 30 for men and 35 for
women. For men the level thus reached Quite a number of the participants were
tended to remain, whereas for women an living either as single parents with one
increase occurred on into their early for- or more children or as single persons.
ties. The typical drink for men was found The life situations of these two types ap-
to be beer of high alcohol content, whereas peared to have left their stamp on the use
for women it was wine. A clear tendency of alcohol by these persons and how they
was evident in both men and women for viewed its use, as the quotation above
a decrease in the consumption of strong suggests. As a group, these persons were
beer as compared with wine to occur with more ambivalent in their views on drink-
increasing age. This suggests that within ing and celebrating than those living in a
a family context a certain harmonizing of family relationship. Single parents living
the drinking habits of women and those with their child(ren) tended to express

caution toward the use of alcohol, feeling has just broken up and has really begun
that a child should be protected against swinging the bottle” (slight changes in
the risks that the consumption of alcohol the quotation were made for clarity’s
involves. Thus, they waited to drink until sake). (Erik from the student group)
the child(ren) left the table, or until their
former partner took his/her turn in car- The motives for single persons in go-
ing for the child(ren), the latter allowing ing out to drink and have a good time can
them to go out dancing or to meet with depend upon whether they are “eternal
other single persons. In contrast, those singles” or are persons who have recently
living in a family relationship considered become single due to the breakup of a re-
their drinking of alcohol together with lationship. One possibility for those of the
meals on weekends to provide a positive latter category, as exemplified in the quo-
atmosphere, both for themselves and for tation just given, is that they seek a stable
the child(ren). The restrictions the single relationship with someone through going
parents placed on drinking in front of their frequently to places where they can drink
child(ren) could be thought to represent a and enjoy themselves with the aim of find-
secret longing to go out and meet some- ing someone. Another possibility is to seek
one. Their drinking together with those contact of a more general sort in efforts to
in a similar situation could be interpreted overcome the feeling of being alone that a
as their saying, in effect, “Despite our not separation has brought on, or that the fact
having a relationship with anyone, we’re of being single as such creates.
succeeding well in caring for our children
and protecting them.” Getting together in “When you drink now it’s more in the
this way was most common among the company of others. You sit and chat
employed group members. and have some food or snacks. It’s the
sort of thing that didn’t interest you
“I have the good fortune of having lots so much earlier. In the summers you
of close friends who are very temper- go and visit friends with a house of
ate in their drinking. In addition, I their own where you can have a grill
have a small bunch of reasonably close in the back yard. You sit and drink
friends about 35 to 45 who go out and pilsner and shoot the breeze. You’re
booze it up a lot. All of them are single completely satisfied with that, you get
and, like me, have just broken up with back home again in good season and
someone. They’ve returned to about you feel fine the next day.” (Mikael
how things were back in their teens from the employed group)
and early twenties through their begin-
ning to live it up again. They’re look- For persons who have been single for
ing for a new partner and the feeling of an extended period of time and are partly
security that goes with it, but the men resigned to this, there are typical patterns
aren’t searching as desperately as the of drinking related directly or indirectly
women are, since it’s the women who to their desire to have a partner and to
want children. Everyone in the group their not having one. They may empha-

size, as in the quotation above, that they According to Beck and Beck-Gernsheim
are on close terms with one or more fami- (2002), one should regard as important
lies and have good times and take drinks the manner of relating to one another that
with them. They are apologetic in telling people show prior to their forming a re-
of their visiting dance halls and the like, lationship, after a relationship has ended
as though that were an admission of their and between successive relationships. The
not having established a steady relation- efforts of single persons and single parents
ship with someone and of their being a to find meaning in the use of alcohol can
failure in this respect. Some singles, on be viewed within such a context.
the other hand, represented here primarily
by certain members of the people-in-black Approaches to alcohol
group, appear to have ceased going out to bordering on both the new and
drink in the company of others almost en- the old
tirely. This can mean their having given The life situation the participants had cre-
up hope of being able to establish a rela- ated for themselves by the age of 35, both
tionship with someone. in terms of the partner relationships they
The drinking on weekends that most of had established and the alcohol culture
those who were interviewed engaged in, they had adopted, was found to be colored
which basically represents a normal level by the cultural style characterizing the ap-
of drinking, can be seen as providing them proach to drinking and alcoholic festivi-
a form of relaxation from the stresses to ties they had shown some 15 years earlier.
which they were exposed in everyday life Thus, although at the age of about 35 there
and as reflecting in some way how they were considerable similarities between the
experienced the life situation in which employed group, the student group and
they found themselves at the age of 35 or the people-in-black group in their relation
so concerning, as the case might be, such to alcohol, there were also noticeable dif-
matters as their sense of attachment to ferences. How during periods of intoxica-
their child(ren) and their enjoyment of be- tion at the age of 20 participants had dealt
ing with them, how they managed as sin- with certain questions central to their lives
gle persons to provide adequately for their appeared to still affect how they viewed
child(ren), how they succeeded at their job alcohol and intoxication 15 years later.
and at tasks of other sorts with which they
were confronted, how they experienced “I’m quite often in the company of oth-
their family life and/or their relation to ers who don’t drink either. I’d never go
their partner and, to the extent this ap- with my children ... to a party where I
plied, their continued hope of establishing knew people would be sitting around
a family. drinking. I have no difficulty in being
Within the framework of reflexive mo- together with people like that when
dernity, in which it is by no means self- I’m alone, but I don’t sit down with
obvious that a family one has established them when I’m with my children,
will be permanent, new patterns of living since I don’t feel that that’s anything
and new cultural forms are developed. for them. I’m grown up enough to say

’No, I don’t want any, but go ahead It really livens things up. There are
and take some yourself’ and to leave if lots of people like that you can go and
things get to be too wild.” (Kicki from visit. It’s really great. There are friends
the employed group) of ours like that in Malmö. We take a
taxi when we go there. Night life as it
Although nearly all members of the was before is nothing for us now.” (Ulf
employed group lived or had lived under from the student group)
family or family-type conditions, their
manner of speaking about the use of al- Those in the student group spoke again
cohol in a family situation differed from and again of their “family”, both concern-
that of members of the student group. This ing everyday things and in connection
can be seen in the attention they directed with parties, such as in the example just
at the dangers they felt children were sub- given. There is a both manifest and con-
jected to if they were exposed to drinking scious ideal of everything being in the
by adults, a view the quotation above ex- best interests of the family. When a person
emplifies. This was true in particular of is 35, it is not enough to simply make it
persons who were single and had one or known that one has established a family if
more children, a situation more frequent in one wants to give the impression of hav-
the employed group than in the other two ing succeeded with this. In contrast, when
groups. These persons tended to consider one was 20, it was quite possible, in a state
it important that they control their impuls- of intoxication, to create in an illusionary
es (behave properly) and to be fearful of way the feeling in oneself that one’s goals
their being unable to succeed at this. They for the future of succeeding and of living
conceived themselves as being a threat to in a family that one had created had al-
the children at hand through their difficul- ready been achieved. There was no realis-
ties in maintaining control of their own tic conception of what quality of life such
impulses, despite their being proud other- accomplishments might provide one with.
wise of their ability to take responsibility Now at the age of 35, however, the impor-
and remain disciplined. Their caution in tance of creating positive bonds within the
the use of alcohol in front of children can family had become evident. In drinking
be seen as an effort to not let their impul- together with one’s partner on weekends,
sivity have a detrimental effect on those one endeavored to experience a sense of
dependent upon them. One can note, how- closeness and a confirmation of one’s hav-
ever, that this defensive approach toward ing a happy relationship with each other
use of alcohol in front of children was not and managing things, despite the strains
always maintained. In situations that ap- and stresses of each having a job to hold
peared completely safe, children were al- down. Alcohol having taken on a role of
lowed to take part in festivities involving this sort shows a process of maturing to
use of alcohol. have occurred since one was 20. At that
time, one believed that happiness consist-
“Both food and drink are served ... ed of having achieved a particular position
Families with children are often there. in terms of the work one did and the rela-

tions one had. One took no account of what employed group than within the student
this actually meant and how one would group. Various models for living together
feel during the journey there. By this time, – prior to formation of a pair relationship,
in contrast, one had experience with what as well as after the breakup of a relation-
the efforts that were needed meant. One ship, and between successive relation-
understood that happiness is not the su- ships – are evident within the employed
perficial accomplishment of having work group. The uncertainty of having no clear
and having a family but rather the abil- partner at hand can create a strong identi-
ity to be happy together in the situation fication with one’s child. This can be seen
in which one found oneself. Alcohol had perhaps as representing a displacement of
more the meaning now of its being someone’s own feeling of needing to be cared
thing one gathered around and that could for and one’s desire to be recognized as an
contribute to relationships within the fam- individual. According to this line of rea-
ily being experienced as functioning well soning, protecting one’s children from al-
and being rewarding. Indirectly that also cohol can be regarded, in effect, as a way
implied that it was not self-obvious that of protecting oneself.
family life functioned as one hoped, even
if one might seek, through the extraordi- “Living it up reached more or less a
nary state that alcohol put one in, a confir- high point while I was studying. We
mation of one’s living up to the ideals of a often went to taverns and restaurants
“bourgeois family culture”. The difficulties or sat at home and drank. I continued
that a perspective of reflexive modernity in- with that until I was about twenty-six
volves have to do with one’s living increas- or twenty-seven. Then that dropped
ingly within a “self-culture” (Beck & Beck- off, but when I moved to Göteborg
Gernsheim 2002) in which one needs to I continued on with it in high gear,
negotiate with one’s partner on the basis of my going on with adult studies there
one’s own individual needs (Giddens 1995) putting me into a kind of second child-
rather than considering it to be obvious that hood. But now ... I just can’t function
one’s family will remain intact. right anymore when I have a hangover.
From this standpoint, one can see there I can’t work properly when I drink
to be two different regenerative strategies and there’s lots of work I need to do
in connection with the use of alcohol man- on weekends, so it’s very seldom that
ifest here, members of the employed group I drink.” (Johan from the people-in-
endeavoring through the cautious use of black group)
alcohol to defend the better interests of
their children, members of the student Members of the people-in-black group
group, in contrast, defending the practice sometimes reflected on the role of alco-
of drinking within the family circle. The hol in dealing with crises, as reflected in
tendency, typical of reflexive modernity, this quotation. In the life course of various
of not regarding the furtherance of family members of that group, alcohol had served
life as being a self-obvious goal appears many times as a means of preserving their
to be more clearly manifest within the sense of self when they felt downtrodden

or attacked and in need of support. The reflexivity they showed toward themselves
group’s members had continued drinking and toward others.
as they had done at the age of 20 for a long- One can readily see in the student group
er period of time than members of the other how the middle-class successful-family
groups did, returning to it as well in peri- ideal that they expressed harmonized with
ods of crisis and uncertainty. They lived in the meaning that drinking on weekends
the conviction that in order for life to func- had for the pair or family involved. The
tion properly one had to take oneself as the dominant alcohol culture this could be
starting point. Their regenerative strategy said to represent involved the conception
can be formulated as declaring that if one of a stable pair relationship and a happy
feels good one is in a position to give to family life. During a period in which there
others. To the extent they felt established appears to be an increasing sense of inse-
and secure in the adult arena and fully ac- curity through cultural changes that are
cepted there, alcohol had lost its meaning occurring and through the individualiza-
for them. Although they had needed alco- tion in society becoming greater, this can
hol at one time to create illusions for them be regarded as a kind of contradiction,
and a feeling of triumph, they no longer but also as resisting such tendencies. One
needed it when they had come far enough should also not assign undue weight to
to get by fully on their own, their being at a present-day individualizing tendencies,
point then where they had neither become since the dream of a happy life and how it
shining stars nor floundered completely. can be achieved is so strongly anchored in
They still understood alcohol as being both an historical and a cultural sense. In
linked with the overcoming of crises, the line with this, there is also a highly mod-
protection of one’s ego strength, and the ern bourgeois family goal based in part on
ability to create and maintain the form of a traditional conception of a working-class
adult living one sought in which one got culture in which the family is seen as the
by on one’s own strength and created one’s hub in a kind of life circle, and in which
own individuality. the memory of times characterized by a
The individualized way about them highly stable and cohesive family situ-
and the self-culture that could be noted ation is still alive, along with the idea of
in those members of the employed group one’s being able to get by without needing
who had failed to succeed in maintaining to enlist the support of anyone else.
a relationship with an adult partner, or
had had difficulties in this respect, were New forms of alcohol culture
even more clearly established in the peo- “I always went out drinking earlier.
ple-in-black group, the members of which I regret having done that so much. It
were reflexively conscious of the fact that isn’t particularly much fun ... You
everything can change, at the same time as have to stand around in line and wait,
they had confidence in their ability to deal and you end up paying a lot. Every-
with crises. A consciousness of how they body’s drunk. No, it’s a lot better now.
had used alcohol in their efforts to achieve A bunch of us, guys I work with and I,
an adult sense of identity was part of the go out after work one evening a month,

sit around, drink a few beers and talk and femininity, and beer with weekdays,
about things. It’s much more fun than relationships at the place of work, things
being out running around town.” (Rob- one did in public and manliness. Except
ert from the employed group) for certain special occasions at work when
drinks were normally taken, drinking was
One thing that at the time of the earlier considered to be something that should
investigation distinguished members of only be done during one’s free time.
the people-in-black group from the em- How had it come about that, whereas
ployed group and the student group mem- in about the mid-80s it had been typical
bers was the approach taken toward drink- for 20-year olds with a “normal” style
ing on weekdays. As outsiders of sorts, of living to feel that drinking during the
one expression of their sense of identity week was taboo, matters had changed very
was to go to taverns weekday evenings to much for many of these persons some 15
drink (Norell &Törnqvist 1995; Törnqvist years later, at the age of about 35, when
1999). In contrast to this, in the present many of them felt that under appropriate
investigation all three groups considered circumstances drinking on weekdays was
drinking during the week to be something quite all right? The fact of their having es-
one should be cautious about. Members tablished themselves as members of the
of the employed group and the student working force could be one explanation of
group regarded it, however, as becoming this. When people are 20 they can be full
increasingly a part of “normal” behavior, of uncertainties regarding the future and
especially when one drank together with their chances later of obtaining the sort of
colleagues from one’s job, as exemplified work they want. This could have made it
by the quotation above. Most of the women seem dangerous to the participants then
and men alike who spoke of doing this were to deviate from the norm of only drinking
very much engaged in their work and want- on weekends and to have been a sign of
ed to deepen and maintain close personal failure, except for members of the people-
contacts with their colleagues in this way. in-black group, who sought the opportu-
There were clear differences between nity to drink at such times. When some 15
beer and wine regarding conceptions as- years later all those taking part in the in-
sociated with drinking them, as well as in vestigation then knew they had succeeded
terms of when, under what conditions and all right in living and working in the adult
by whom they were most likely to be con- world, and also knew of there being a cul-
sumed. Wine was a highly accepted drink ture in which work colleagues went out
on weekends, whereas beer was regarded to drink beer with each other during the
as particularly appropriate for get-togeth- week, partly with the aim of strengthen-
ers with work colleagues on evenings during their feeling of togetherness, they were
ing the week, it also being considered to ready enough to take advantage of this.
be a drink primarily for men. The partici- Also, during the 15 years that had passed,
pants appeared to associate wine above all the Skania region of southern Sweden in
with leisure time, weekends, the more inti- which most of them lived, as well as Swe-
mate sphere, close personal relationships, den generally, had been increasingly influ-

enced by the drinking habits of central and this in mind, one can wonder why, for the
southern Europe, where it is an everyday student group and people-in-black group
matter to go out to bars, pubs and restau- members and their partners, drinking only
rants to drink beer and wine (Leifman & on weekends did not suffice for clarifying
Gustafsson 2003). In addition, the par- their joy at being a pair. One reason for this
ticipation of women in the working force can be that drinking at home in that way
had increased, which made it increasingly was no longer considered taboo and was
important to them to strengthen their con- also regarded as a sign that one subscribed
tacts with their colleagues at work. The to an ever more internationalized way of
changes that occurred generally were not thinking and acting. Another reason can be
limited, however, to drinking connected that the possibilities for showing their af-
with relations at the place of work. fection for each other in this way on week-
ends seemed insufficient, their feeling the
“On weekdays we usually drink just need for this during the week as well.
water and milk. Sometimes, though, I In attempts to explain this, one can note
take a weak beer, and now and then we that family life appears to be exposed to
drink a glass of wine, although that’s strains and stresses to an increasing ex-
not the usual thing.” (Peter from the tent. In many relationships the two are not
student group) even accustomed to eating supper together
during the week; their parallel lives and
It was not unusual, at least in the student separate jobs and spare-time interests can
group, as exemplified in the quotation just make it appear impractical for them to at-
given, and the people-in-black group, to tempt to do so in a routine way. The free-
drink wine with meals on evenings dur- time interests of the child(ren) can also
ing the week. To what extent was this also lead to the one or the other parent driving
a sign of Europeanization? In answering to where sports activities take place and
that one needs to take account of the con- possibly taking part in activities there as
ditions under which the participants were well, likewise making it difficult for the
living and the meaning they assigned to two to get together at home on weekday
the drinking of wine. It was primarily pairs evenings.
to which members of the student group All of this illustrates the difficulties
and the people-in-black group belonged there are today for couples 35 years of age
who drank wine – their doing so serving or thereabouts to live together in a manner
to emphasize the two of them representing supportive of what would otherwise be
a happy pair. In contrast, for the employed their ready access to the intimacies of eve-
group members with a partner the risk they ryday life in their living together. Deep-
felt there to be of their child(ren) being ening their everyday contacts with each
influenced in a negative way if they vio- other by eating and drinking wine together
lated the norm of keeping what they did at can enhance their feeling of closeness and
home apart from what they did while out be supportive of their relationship, where
enjoying themselves tended to restrict very family relationships today are exposed to
much their drinking of wine at home. With so many forces that tend to disrupt them.

Conclusions to deal with. Their now having developed

Those who participated in the study ap- an adult identity and having managed to
pear today to be living a reasonably well- get by all right in so doing, intoxication of
anchored existence, after having been able the sort they had experienced at the age of
to test themselves against the realities of 20 had been drained of much of its mean-
everyday life and see how things went in ing. They no longer had the same need as
terms of both their expectations and their before of being able to “live it up” with the
apprehensions regarding life as an adult. help of alcohol.
At the age of 35, they were living less in Establishing an intimate relationship
the future and more in the present than with someone, having a child and starting
they had done at the age of 20, when they a new job all typically lead to a change in
had been much concerned about how a person’s pattern of alcohol consumption.
their lives would develop, regarding re- One no longer needs to go on with one’s
lations with others, founding of a family hopes and expectations alone when one
and becoming established occupationally knows that, having become an actor on the
or professionally. They now saw what adult stage one can establish and maintain
their efforts had resulted in. Regardless of relationships effectively with other adult
which of the three groups they belonged individuals, hold down a job and have
to, the vast majority appeared to be basi- the feeling of doing something creative or
cally satisfied with life and what they worthwhile. A state of “generativeness”,
had achieved thus far. Even if life had not as it has been called (Erikson 2000), devel-
reached up to their highest expectations, it ops – the person being able to care deeply
had hardly become what they had some- for someone, establish a relationship with
times been fearful of. Although a certain that person, have children and guide a new
degree of disillusionment is unavoidable, generation toward adulthood. Whereas as
one comes to gradually experience how a 20-year old one is taken up with ques-
one can deal effectively with the demands tions of how one can get by, as a 35-year
placed upon one as an adult. old one is less preoccupied with concep-
At the age of 35, those in the three groups tions regarding oneself as such and more
no longer felt the strong need they had ear- oriented to what one wants to be involved
lier of support by others of their own age in and take responsibility for. “We are that
in creating illusions that they could take which we love” (Erikson ibid., p. 118), be it
control of things and assume responsibili- our children, relationships with others or
ties adequately (the employed group), real- our work. Such a view of life is not one of
ize their ambitions of establishing a family there being natural laws in terms of which
(the student group) or have the willpower people all do basically the same thing at
needed to make their dreams become reali- some particular age. Rather, it is the idea
ty (the people-in-black group). This had re- that what one does is a function both of
quired their taking responsibility for their the historical and cultural situation one is
lives on a daily and hourly basis, keeping in and of where one is located in one’s in-
their goals in mind, and managing to get dividual life course (Berman 1995; Kotre
by on their own in situations far from easy 1984). In the present context one can note

there being clear differences between the It appears as though a form of alcohol
employed group, the student group and culture emphasizing one’s living together
the people-in-black group at both the indi- happily with one’s partner and in the fam-
vidual and the cultural level. ily constellation one has established is a
Alongside all of this, one can also note dominant one, its being regarded by a great
that many people make use of alcohol reg- many people as the ideal for how they
ularly, also in their adult lives, one reason want or would wish to live. Yet achieving
for this being that there is no absolute se- this has its costs. In a world that appears to
curity in what one does, however strong be becoming increasingly individualized,
one’s identification may be with goals one a successful relationship between two per-
is pursuing and the relationships one has. sons requires the ability both to negotiate
There is a continual search for identity, and to make adjustments where needed
asking oneself who one is and how life as (Giddens 1991). Taking alcoholic drinks
a whole functions, with a need of positive during the evening on weekends can be
reinforcement. Alcohol can serve as a cat- seen as often representing a highly impor-
alyzer, one that facilitates such reinforce- tant element in efforts to maintain the feel-
ment. For the employed group such rein- ing of two people loving each other and
forcement can be the feeling that one is having a happy family life. It is important
caring for one’s children properly, for the to note that it is the woman who tends to
student group the feeling that one’s fam- assume the more dominant role than the
ily life is functioning as it should, and for man in this scenario. Whereas at 20 it was
the people-in-black group the belief that thoughts regarding the future that seemed
one is functioning well and that one has most important, at 35 what is seen as most
something genuine to offer. The idea that important is to have a happy family life.
one’s life situation is as one would like This latter ideal is one so powerful that
can be reinforced by the search for mean- Beck and Beck-Gernsheim (2002) would
ing that the use of alcohol involves. The place it on a par with religion. In an in-
question can be of how one functions as creasingly individualized world, a truly
a partner, as a single parent with one or meaningful life would seem to be found
more children, or as a single person. This in closeness to one’s partner and one’s
life situation as one experiences it does children. The role that alcohol can play
not reflect some mechanical identification in helping people to feel that they have
of a cultural character one has with be- succeeded at this should not be underes-
ing a person of the sort found within the timated.
employed group, the student group or the The reinforcement of a feeling of this
people-in-black group, even if rather many sort tends to be concentrated above all to
of the employed group members are single weekends. At the same time, one can note
persons with a child or children, many of a clear tendency for other, more every-
the student group members are living in day forms of drinking to take place with
a stable relationship with a partner, and increasing frequency, forms coupled in
many of the people-in-black group mem- particular with drinking habits in central
bers are single. and southern Europe. It is becoming more

and more common, for example, for cou- that one can note, men and women living
ples and families generally to occasionally and working together generally to perhaps
combine eating with the drinking of wine. a greater extent than at any previous time
It is not at all unusual either for people to in history (Castells 2000).
go out and drink beer together with their Translation: Robert Goldsmith
colleagues after work occasionally. Drink-
Claes Törnqvist, University lecturer in psychology
ing beer with one’s colleagues in a public Department of Psychology
place also symbolizes one’s ability to func- Lund University
tion well both in one’s work and in a pub- Box 213
222 00 Lund, Sweden
lic place. As women are coming to play an
E-mail: Claes.Tornqvist@psychology.lu.se
increasingly strong role in public life, there
is also an acceleration of individualization
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Research
Anders Bergmark
report
Guidelines and ABSTRACT

A. Bergmark: Guidelines and evidence-
evidence-based practice based practice – a critical appraisal of the

Swedish national guidelines for addiction
treatment
A critical appraisal of the Swedish national Evidence-based practice (EBP) has
guidelines for addiction treatment been advocated since the beginning of

the 1990s and is today, at least within
the western hemisphere, an established
doctrine in many professional fields. This
Introduction holds true also for addiction treatment.
Evidence-based practice (EBP) has been advo-
1 Over time EBP has come to signify a
cated since the beginning of the 1990s and is more general orientation to a scientifically
today, at least within the western hemisphere, secured knowledgebase and by this partly
an established doctrine in many professional obscuring the fact there exists different
fields. This holds true also for addiction treat- and to some extent contradictory opinions
ment. One important example of this develop- on how EBP should be implemented. The
ment is the production of practice guidelines. paper aims at an analysis of the newly
In the following an analysis and discussion of published Swedish national guidelines
the recently published (February 2007) Swed- for addiction treatment. The analysis
ish national guidelines for addiction treatment addresses several dimensions of the
will be presented. These guidelines cover guidelines: a) The quality of the guidelines
almost 200 pages and deal with several top- in terms of their scientific underpinning.
b) The usefulness of the guidelines, i.e.
ics. The focus here will be on what arguably
to what extent it is possible to use the
constitute the most important issues: psycho-
guidelines in actual practice. c) How the
social and pharmacological interventions for
guidelines were produced (time-aspects,
alcohol and drug problems. The analysis aims
involvement of experts and the role of
to deal with several dimensions of the guide-
the National Board of Health and Welfare
lines: a) The quality of the guidelines in terms
as the responsible organisation). d) To
of scientific underpinning, b) The usefulness
what extent the guidelines have been
of the guidelines, i.e. to what extent it is pos-
developed with reference to and from
sible to use the guidelines in actual practice,
discussion of some of the major scientific
c) How the guidelines were produced (time-
controversies related to the EBP issue.
aspects, involvement of experts and the role
Keywords
of the National Board of Health and Welfare
Guidelines, evidence-based practice,
as the responsible organisation), d) To what
psychosocial interventions.
extent the guidelines have been developed
with reference to and from a discussion of
the rivalry between the earlier manifestation

Guidelines and evidence-based practice
of EBP, where the individual practitioner based treatment for alcohol and drug prob-
is responsible for critically appraising the lems published by the SBU (2001; revised
evidence, and the production of “expert English version, Berglund et al. 2003). But,
guidelines” and e) Have some of the major as will be pointed out in the following, it
scientific controversies related to the EBP is unclear to what extent the relation be-
issue (as the Dodo bird verdict and the re- tween the two documents is based purely
searcher allegiance effect) been taken into on authority (i.e. the fact that both the SBU
consideration? and NBHW are state agencies) and whether
Although only one “case” is analysed in or not the guidelines represent an uncriti-
the following, it can be argued that some cal reproduction of the SBU’s review.
of the aspects discussed have a bearing on
a more general level concerning the pro- Are the guidelines evidence-
duction and usefulness of practice guide- based?
lines. At the same time the analysis can Although the concept of evidence by no
be described as a product of an “insider means has a self-evident meaning, it can
perspective”, since the present writer par- nevertheless be claimed that evidence, as
ticipated in some of the preparatory work a minimum requirement, should be char-
for the guidelines. 2 Even though such an acterised by transparency, both in terms
involvement can be regarded as a serious of systematic and articulated procedures
complication with respect to the objectiv- as well as a complete display of the refer-
ity of the analysis (increasing the probabil- ences to the studies that have been used in
ity for a partisan or an overly critical anal- order to establish evidence. In both these
ysis), it can also be regarded as an asset respects the guidelines discussed here are
in the sense that some important informa- seriously flawed. The actual recommenda-
tion, not accessible in the actual text, con- tions in the text are based on narrative re-
cerning the process of developing them is views produced by groups of experts, but
known to the present writer. these reviews are not present in the text
The guidelines are published by the (they can, however, be reached through the
Swedish National Board of Health and homepage of NBHW). But the correspond-
Welfare (NBHW) but have no legal status ence between the reviews of the experts
and are thus not mandatory for practition- and the recommendations is often very
ers to follow. But at the same time it is weak. In the summary of the expert report
claimed that the guidelines will be used on psychosocial interventions for drug
as a document of reference in the surveil- problems, the coordinators of the group
lance of treatment agencies, which is a write: “The situation concerning misuse of
major responsibility for the NBHW, and opiates is contradictory. On the one hand
in this respect it can be said to constitute the SBU-study identifies some positive
a document with – at least in theory – a results; on the other hand other reviews
regulative power over treatment practice and meta-analyses reach different conclu-
(Socialstyrelsen 2007, 29). sions” (Socialstyrelsen 2007, 146; author’s
An important source for the guidelines translation). Given that the guidelines are
is the comprehensive review on evidence- claimed to be based on the expert reports

it is unclear on what the following recom- that are put forward, and with that, no
mendations for drug misuse are based on: real opportunity to disagree or critically
On the highest level of evidence (1, in a ev- evaluate the scientific basis of the recom-
idence-hierarchy consisting of four levels) mendations. In this respect the guidelines
five different interventions are identified; are clear-cut examples of the type of docu-
Cognitive behavioural therapy with focus ments which is heavily criticized by pro-
on the misuse; Brief intervention/Moti- ponents for the type of EBP put forward
vational Interviewing; CRA-treatment; by Sackett and colleagues (Sackett et. al
Dynamic therapy; Family therapy with a 2000).
focus on misuse and dependency. Further- The lack of references is also striking
more it is claimed, also on the “highest in relation to other attempts to establish
level of evidence”, that common factors which interventions can be considered to
for the interventions identified as effective represent “best practice”. Notwithstanding
are: a clear structure; a focus on misuse that the Cochrane Collaboration (which
and dependency; clear definitions of the can be considered to be the most prestig-
interventions; and that the interventions ious EBP organisation) has produced sev-
are manual based (Socialstyrelsen 2007, eral reviews that come to radically differ-
52–53). For anyone that reads the expert ent conclusions than those presented in
report on treatment for drug problems it the guidelines, this is not mentioned or
becomes quite clear that none of these rec- commented on in any way (this is, e.g.,
ommendations has unambiguous support true for psychosocial interventions for
in the report. Instead, it seems like the opiate problems, with or without substitu-
source of these recommendations is the tion treatment, and for treatment with nal-
SBU-study from 2001. This might be seen trexone for alcohol problems; see Amato et
as reasonable, but since the lack of empiri- al. 2004; Mayet et al. 2004; Srisurupanont
cal support for these general characteristics & Jarusuraisin 2004).
of the interventions designated as effective The lack of references is also conspicu-
is also valid for the SBU-study, the oppo- ous in the parts of the guidelines that deal
site is the case. Neither is there any pres- with conceptual issues. In connection with
ence of the criticism directed towards the a discussion on the definition of “treat-
SBU-study (se e.g. Bergmark 2001; Mäkelä ment”, and the introduction of another
2001; Poikolainen 2002; Thorsen 2001). version of the concept, there are no refer-
When it comes to the second basic ences to previous attempts on the subject.
component for achieving transparency This stands out not only as a violation of
the guidelines are extremely underdevel- institutionalised standards concerning sci-
oped. As already mentioned, no parts of entific writing, but also as something even
the experts’ narrative reviews are present worse, given the fact that a substantial part
in the text, but beyond this, there is also of the suggested definition has previously
an almost complete absence of references been put forward by others.
altogether. The reader has no possibilities
to see the sources (with the exception of
the SBU-study) for the recommendations

Can the guidelines be used in mends underlines that any effective inter-
practice? vention has to be clearly defined. Beside
The legitimacy for the production of this, no evidence (i.e. studies or reviews)
guidelines is, by and large, founded on for the general characteristics of the inter-
the assumption that they will improve ventions that are designated as effective
practice in the sense that practitioners are provided, neither in the guideline text
will use them to make informed clinical nor in the SBU-study.
decisions. This idea is in turn dependent The next problem connected with the
on a number of circumstances if it is to be actual use of the guidelines is on what ba-
realised, i.e. if some prerequisites are not sis should – e.g. in the case of a specific
fulfilled the usefulness of guidelines is put individual seeking treatment for alcohol
in question. problems – the practitioner choose one in-
A major problem with many guidelines tervention before the other. One possible
concerning non-medical interventions rationale for such a decision could be spec-
is that they are poorly operationalised ifications of the suitability/effectiveness of
(Wambach et al. 1999), and hence more or the recommended interventions concern-
less difficult to use as a point of reference ing different types of alcohol problems.
for actual clinical practice. They tend to But no such specifications can be found in
lack specificity in the sense that recom- the text: On the contrary, it is clearly stated
mendations are articulated in an equivocal that no such specifications are made: “One
or global fashion that provides little or un- question that is not explicitly dealt with in
clear information. This problem is clearly the guidelines below is for which groups
present in the guidelines in focus here: The or where (specific organisational settings,
interventions listed for alcohol problems author’s brackets) the recommendations
are the same as for drug treatment (stated shall be valid” (Socialstyrelsen 2007, 42;
in the section above), but three more in- author’s translation).
terventions are added; twelve-step pro- In the section of the guidelines that deals
grammes; interactional therapy and moti- with the knowledge-base for psychosocial
vational treatment. But the mere listing of interventions for alcohol problems it is
eight different interventions, only nomi- claimed that “Several specific psychoso-
nally defined, does not provide a strong cial treatment interventions have positive
knowledgebase for the decisions of prac- effects... Specific methods show better ef-
titioners. The only supplemental guidance fects than unspecific” (Op. Cit., 207) The
to the labels of the interventions is the term “specific psychosocial treatment” is
assertion that a common ground for all of defined as an intervention that is based on
the recommended interventions is a clear a specific or systematic method or tech-
structure; a focus on misuse and depend- nique. 3
If we, for the time being, leave
ency; clear definitions of the interventions the possible objections to this definition
and that they are manual-based. It seems aside, and take a closer look at some of the
somewhat contradictory that a guideline underlying material (i.e. the expert report
text which gives no substantial definitions that deals with psychosocial interventions
whatsoever of the interventions it recom- for alcohol problems) for the state of affairs

concerning specific interventions, yet an- ity, but is more likely to be an effect of the
other problem arises. In the expert report fact that NBHW is a central bureaucracy
the issue of specific interventions is elabo- which has a “natural” tendency of involv-
rated in the following way “No specific ing a large number of individuals and or-
intervention is more effective than any ganisations. All in all 57 individuals have
other” (Socialstyrelsen 2007, 203). Since been directly involved in producing the
this conclusion is also present in the SBU- guidelines; 14 in a “project group” mainly
study and the text of the guidelines explic- consisting of administrators from NBHW;
itly states that conclusions from the SBU 15 in a “reference group” with a mix of
on psychosocial interventions for alcohol experts and representatives for different
problems remain unaltered by adding the authorities and interest groups; 28 experts
new studies and reviews scrutinized by in the 5 expert groups. To a large extent
the expert group, there can be little doubt the choice of external participants seems
that the conclusion identifying a lack of to have been governed by a sort of “demo-
differences in outcome concerning differ- cratic” principle; there is a wide range of
ent types of specific interventions can be representatives from different authorities
considered as a part of the guidelines text. and interest groups, and an equal share of
Given that, how can it be explained that experts from social science and medicine.
only eight interventions are recommend- Both the size of the group and the profes-
ed? Obviously much more than eight psy- sional rivalry between social and medical
chosocial interventions can be identified scientist are likely to have contributed to
as “specific” by using the definition pro- the long time span.
vided by the guidelines. It can be claimed The time aspect can be considered as
that the guidelines should have – if an am- a factor of major importance; the fact that
bition of consistency is cherished – recom- much of the work in the expert groups was
mended any specific intervention instead done in the 2002 and 2003 but the actual
of the eight that actually are provided in guidelines was published first in 2007
the text. puts a strain on the relation between the
recommendations and the knowledge-
The production of the base as it appears today. In the guidelines
guidelines one can, e.g., see an emphasis on the ben-
In almost every aspect the guidelines stand efits of combining naltrexone or acamp-
out as characterized by the fact that the rosate with psychosocial interventions.
work was organised within the NBHW. This conclusion can be regarded as highly
The work with planning and substanti- questionable in light of the results from
ating the guidelines started with a series the major study in that specific area, i.e.
of seminars during the year 2000, but the the COMBINE study (Anton et al. 2006).
final product was not finished until Feb- A major difference can be identified
ruary 2007. The substantial time span be- between the expressions of the EBP idea
tween initiating and publishing the guide- in countries with a strong “welfare state”
lines could be interpreted as a sign of the tradition, as Sweden, and countries with
seriousness and ambition to provide qual- weaker inclination in that direction, as

e.g. the US. The Swedish NBHW guide- EBP) of EBP with reference to two basic
lines lack in many respects local competi- models of the same. The first and more
tion (the presence of the review from the original one is built around the individual
SBU is no real problem since it is by and practitioner’s active scanning of the scien-
large accommodated within the guide- tific literature in line with the following
lines). This is true both in a formal sense scheme: a) formulating clinical questions;
(materialised through specific agreements b) searching for the best evidence; c) criti-
between the two authorities) as well as cally appraising this evidence; d) applying
in the actual conclusions that are put for- this evidence to patients, and; e) evaluat-
ward. In the US, a substantial number of ing the impact of this application” (Upshur
problems seem to emanate from the fact & Tracy 2004, 198).
that a large amount of agencies (state and This scheme for the use of EBP is to a
federal), professional organisations, and large extent built on the idea of a rational
interest groups have ambitions to articu- procedure that generates what could be
late guidelines and thereby delimit good called an “enlightened practitioner”. The
practice from bad. This rivalry between major criticism against this version of EBP
different producers of practice advice has been directed towards its lack of real-
seems to bring along a more heightened ism in the sense that it is not used in prac-
awareness of the problems connected with tice (and that it is extremely demanding to
practice guidelines and the general organi- actually use). In the case of medical doc-
sation of the EBP project. Gambrill (2006, tors it has been observed that they general-
342) writes that many conceptions of EBP ly do not perform the critical appraisal of
“could be described as business as usual, the evidence by themselves, but rather rely
for example, continuation of unrigorous on pre-appraised literature, i.e. evidence
research concerning practice claims, in- evaluated by others (Guyatt et al. 2000).
flated claims of effectiveness, lack of at- This has brought on the distinction be-
tention to ethical concerns such as involv- tween evidence users and evidence-based
ing clients as informed participants, and practitioners, where the former, which
neglect of application barriers” (p. 342). seem to constitute a substantial major-
ity, do not live up to the five points listed
The enlightened practitioner above. This generates yet another problem;
or guidelines – rival which criteria should an evidence user ap-
conceptions of EBP ply in order to identify which evidence
Over time EBP has come to signify a more that can be considered to be the “best”
general orientation to a scientifically se- (i.e. best practice)? The most common re-
cured knowledgebase and by this partly sponse to this problem has been the use
obscuring the fact that there exists differ- of an “evidence hierarchy”. Unfortunately
ent and to some extent contradictory opin- this does not solve the problem since there
ions on how EBP should be implemented. is no consensus concerning how such hi-
With a certain amount of simplification it erarchies should be constructed. Upshur
is possible to describe the actual use (or and Tracy (op. cit.) identifies seven sugges-
perhaps better, the ideas of how to practice tions for such evidence hierarchies within

the medical field, which they characterise models outlined above has gained consid-
as highly divergent and non-commen- erable attention in the international litera-
surable. The same dilemma is identified ture (see e.g. Gambrill 2006; Rosen et al.
by Petrosino (2003, 184) concerning the 2003; Upshur & Tracy 2004), the NBHW
“standards of evidence” for school-based guidelines contain no comments whatso-
drug prevention: “Each of the seven efforts ever on this subject. Instead it seems like-
used a different approach to identifying ly, as pointed out above, that the guide-
standards for evidence and evidence for lines will be used in order to put pressure
standards”. on practitioners to use the interventions
The second basic model for the use of that are designated as effective. This will
EBP can to a certain extent be regarded as a mainly be achieved by the surveillance
re-active alternative to the model outlined that NBHW has to perform of treatment
above. Instead of an independent, critical- agencies, i.e. the use of non-listed inter-
ly appraising practitioner this model puts ventions might lead to criticism and pre-
emphasis on the necessity of guidelines. scriptions from the NBHW.
Rosen et. al. (2003, 209) clearly position
themselves behind this model when dis- Major methodological
cussing how EBP should be used within considerations? The Dodo bird
the field of social work: ”Rather than con- and researcher allegiance
tinue to place unrealistic expectations for During the last 30 years the Dodo bird’s
the use of research on practitioners, social verdict – i.e. the general equivalence of
work and its researcher should assume re- outcomes from different modalities of psy-
sponsibility and increase efforts to devise chotherapy – has developed into a major
decision-making aids for practitioners”. controversy between the “common fac-
This suggestion is materialised by Rosen tor” position and the “medical model”
et al. through their identification of guide- (with an emphasis on specific ingredients)
lines as the most important component for of psychotherapy. In the book “The great
the implementation of EBP. But this model Psychotherapy Debate” Wampold (2001)
has also received criticism; as is the case delivers massive empirical support for the
with the first model, guidelines also suffer common factor position by systemically
from the weakness that they generally are analysing the empirical evidence concern-
not used by practitioners (Howard & Jen- ing psychotherapy outcome.
son 1999; Bergmark & Lundström 2002). A cornerstone in his analysis is the ne-
To the extent that guidelines de facto are cessity to separate absolute efficacy from
used, critics have pointed out that the relative efficacy. While absolute efficacy
top-down structure in guidelines might can be established by comparing the out-
de-professionalize those who make use come from a given treatment intervention
of them in the sense that they are reduced and comparing it to the outcome for a non-
to executors of a given set of procedures, treatment control group, relative efficacy
leaving little or no room for concerns of requires a comparison between two (or
the individual client or patient. more) treatment interventions. Absolute
Although the rivalry between the two efficacy has been established for psycho-

therapy in many studies (Wampold op. can also be said to include (as an aspects
cit., 58) but cannot be used to disprove the that has evolved during the controversy
Dodo bird effect; if the treatment interven- over the Dodo bird effect) the problem con-
tion is efficacious it cannot be established nected to “researcher allegiance”. The re-
if the effect is due to common or specific in- searcher’s allegiance effect refers to the ex-
gredients. Proof of relative efficacy, on the tent to which the researcher believes that
other hand, would constitute evidence of any of the involved treatments in a given
the presence of specific ingredients, since trial is efficacious. This effect has turned
the difference in outcome between differ- out to be of substantial importance; Lubor-
ent treatment interventions implies effects sky et al. (1999, 103) write: “The results of
that are related to specific ingredients. both past analyses and of the present one
However, the most elaborated studies have imply that the researchers allegiance tends
not yet been able to establish the presence to be strongly associated with the differ-
of significant differences between different ential outcomes of the treatments. For the
modalities of psychotherapy (Luborsky et present study each of the three allegiance
al. 2002). Furthermore, in a meta-analysis measures are significantly associated with
of component studies of psychotherapy, the effect size of the treatments compared,
i.e. studies designed to identify the spe- and the combination of the allegiance
cificity of a given psychotherapeutic in- measures shows a very large association
gredient4, Wampold and Ahn (2001) have with treatment outcomes (r=.85!)”. It is
shown that there is no evidence that the easy to agree with Messer and Wampold
specific ingredients of psychotherapy are when they write: “How odd it is, then, that
producing or contributing to the benefits we continue to examine the effects of dif-
of psychotherapy. ferent treatments (accounting for less than
A central consequence of these findings 1% of the variance) when a factor such as
is that it is of fundamental importance the allegiance of the researcher accounts
– if we want to be able to organise the evi- for nearly 70% of the variance” (Messer &
dence of treatment outcome in a rational Wampold 2002, 23).
fashion – to pay attention to the difference None of these important methodologi-
between comparisons of two alternatives cal considerations or their consequences
of bona fide treatments and comparisons for the EBP project are discussed in the
between a bona fide treatment and what guidelines or in the SBU-study. On the
is commonly referred to as standard treat- contrary, as pointed out above, there is an
ment (or alternatives in the same line). explicit adherence to the fact that “no spe-
In the addiction field, Finney (2000) has cific treatment is more effective than any
expressed serious doubt about whether other”, but no comments whatsoever can
treatment outcome reviews can become be found concerning the consequences of
meaningful without the adoption of a this empirical finding. The conclusion fits
“truly standardised” bona fide comparison like the hand in the glove with the Dodo
treatment (he suggests that MET should be bird verdict, but no awareness of, or atten-
adapted as such a comparison standard). tion to, this fact can be found in the guide-
The discussions of the Dodo bird verdict lines.

Final remarks do find it necessary to deal with the diffi-

This paper has aimed to critically review culties that are involved, it also has conse-
the Swedish national guidelines for addic- quences for our relation to the EBP move-
tion treatment. Most readers will probably ment. The hunt for a manualised “best
have few doubts about the present writer's practice” will cease to be the only mean-
overall impression of the guidelines; I find ingful objective, and we must find new
them to be seriously flawed in terms of sci- strategies for improving treatment through
entific rigour and quality, and I predict that research. If nothing else we should at least
very few practitioners will be able to make discuss what might be ahead of us.
use of them to make informed clinical de- Be that as it may, by and large EBP still
cisions. However, this critique should not – at least in the fields characterised by psy-
be seen as a general critique of the efforts chosocial interventions – has the character
to build a scientifically solid knowledge- of a project; a normative projection of the
base for addiction treatment (it is hard to hopes invested in the future, a legitimacy
conceive any rational argument in favour of what potentially rather than what actu-
of an unscientific approach), but rather as ally has been achieved. The Swedish na-
an emphasis on the fact that the difficul- tional guidelines for addiction treatment
ties associated with such efforts are often cannot be acknowledged as a product of
underestimated or ignored. To some extent scientific progress or a useful document
such an approach can be seen as an obsta- for practice, but even so, it is not unlikely
cle for the general development of the field that a similar document will appear in an-
at hand. Should we just continue on the other seven years.
same old track with reference to a legitima- Anders Bergmark, professor
Addiction Research Group
cy based on the hope that future research
Department of social work
in the end will actually be able to identify Stockholm University
the specific and efficacious ingredients of sveavägen 160, SE-106 91 Stockholm
addiction treatment interventions? If we E-mail: anders.bergmark@socarb.su.se
Notes
1) Evidence-based practice (EBP) is here used 4) ��
Component studies comes in two major
as fully congruent with the term evidence- forms; dismantling designs and additative
based medicine (EBM). designs where the former involves the com-
2) I acted as one (of two) coordinators for the parison between treatment A and treatment
expert group reporting on the knowledge- A without a given specific ingredient of
base concerning psychosocial interventions treatment A. In the additative design treat-
for drug misuse. ment A is compared with treatment A with
3) ��
The opposite goes for unspecific interven- the addition of a specific ingredient which
tions, i.e. interventions not based on a spe- is believed to effecacious.
cific or systematic methods or techniques
(se Socialstyrelsen, 2007, p. 34).

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Commentary
Mats Berglund
Commentary on the paper by

Anders Bergmark
I have been invited by the Editor to comment on the paper by

Anders Bergmark. We were both involved in the work with
the Swedish national guidelines for addiction treatment. I was
a member of the reference group and I made no contributions to
the expert literature reviews or conclusions. However, I was able
to comment on the different reports from the experts and also on
the first versions of the final reports written by the project group.
I also attended meetings of the expert group working with drug
use disorders, with Anders Bergmark as coordinator. Previously
I was chairman of the Swedish SBU group on alcohol and drug
problems. Bergmark was not a member of this group. My posi-
tion as professor of addiction psychiatry also involves treating
patients regularly, unlike Bergmark.
I agree with Bergmark that the preparation of the Swedish
Guidelines is of considerable general interest to the theme of
evidence-based practice. In Sweden as well as in other Nordic
countries social science has had a strong impact on alcohol pol-
icy through the work of many brilliant researchers such as Kettil
Bruun and Ole Jörgen Skog. Swedish medical research in the
alcohol field has also had a long tradition, with Magnus Huss
and Leonard Goldberg as prominent scientists. Robin Room was
director of SoRAD at Stockholm University during the last dec-
ade and has had major influence on the development of Swed-
ish alcohol policy in recent years.
While research in social science and medicine has a long tra-
dition in Scandinavia, research into intervention and treatment
using randomised controlled trials, RCTs, did not begin until
the 1980s. Important Swedish studies have concerned the ef-
fects of short intervention for risky alcohol consumption and
methadone treatment for heroin addiction. RCT studies became

Commentary to Bergmark
common in the 1990s in Swedish clinical to have been a member of the SBU group
research and had a strong influence on the (one exception was made).
development of evidence-based medicine. When preparing the Guidelines, the ex-
SBU is a state agency responsible for pert groups could use all published sys-
evaluation of medical technology includ- tematic reviews. In addition criticism of
ing treatment of mental disorders. The the conclusions of the SBU report was fa-
Swedish SBU report on treatment for al- cilitated by the exclusion of previous SBU
cohol and drug problems was based on members from expert chairs.
systematic reviews/meta-analyses of RCT The efforts to reduce or eliminate the
studies. The Swedish version was pub- presumed medical bias in the SBU report
lished in 2001 and a revised English ver- while transforming systematic reviews
sion in 2003. into guidelines were clearly not success-
The National Board of Health and Wel- ful. The conclusions were very similar.
fare (NBHW) consists of two large divi- Bergmark himself argues that “it is unclear
sions, one for medical disorders (includ- ... whether or not the guidelines repre-
ing psychiatry and disorders with both sent an uncritical reproduction of SBU’s
psychiatric and substance use diagnoses) review”. He suggests that the similarities
and one for social issues (including treat- could be based “purely on authority (i.e.
ment of both alcohol and drug disorders). the fact that both SBU and NBHW are state
The latter division was responsible for agencies)”.
producing the guidelines. But what did all the experts do during
Leading Swedish social scientists felt the years 2000–2007? They certainly had
that the SBU report was seriously biased a lot of time to correct the presumed bias
towards a medical perspective, and this of the SBU report in their summaries of
strongly influenced the organisation when available systematic reviews. Bergmark
the Swedish Guidelines were produced. In suggests that the wrong experts were in-
order to balance the influence from medi- volved. “To a large extent the choice of
cal scientists, social researchers were well- external participants seems to have been
represented in the organisation. governed by a sort of ‘democratic princi-
The project group was responsible for ples’ ... and an equal share of experts from
formulating the guidelines, which were social science and medicine”. He himself
based on the experts’ opinions as well was one of them. Another possibility could
as those of the members of the reference be that the SBU conclusions were robust
group. The plan was to also include writ- enough to withstand criticisms from the
ten statements from the expert groups in experts in describing state-of-the-art treat-
the guidelines. The project group, of which ment for alcohol and drug problems.
the chairman was a social scientist, was to Bergmark criticises the lack of transpar-
resolve differences between opinions of ency of the report, i.e. that the expert opin-
the experts. Five different expert groups ions are only available on the Web and not
were appointed, each of them co-chaired in the report itself. I agree with this opin-
by one social and one medical scientist. ion. However, when reading these Web-
The medical scientist was not permitted based papers, it is obvious that some of

them would have required considerable BINE study and the Swedish recommen-
improvement if they were to be published dation concerning the combined treatment
in the report. These authors have had many with acamprosate and naltrexone.
years to do so and I understand the deci- Similarly, guidelines for agonist treat-
sion to write a summary report. But it is ment for opioid dependence were pub-
nevertheless a weakness of the guidelines. lished separately while the guidelines
Bergmark expresses the opinion that the were being produced. Consequently, the
previous critical papers of the SBU report medical scientists continued to update
should be discussed in the guidelines. I do the literature during this period. Perhaps,
not understand why. The SBU report is a therefore, the delay may have been caused
systematic review. The NBHW publica- more by the rivalry between Bergmark and
tion is guidelines. In addition these papers NBHW than between social and medical
have been carefully answered by the SBU scientists.
authors and published in the same jour- The present guidelines contain many
nals as the critical papers. The SBU group other weaknesses, some which are criti-
has also revised its work in view of the cised by Bergmark. As I see it, what is
earlier criticism, and this was published important about this long journey in pro-
in English in 2003. ducing these guidelines is that it was pos-
Bergmark is critical of the poor cor- sible to produce them at all. To be able to
respondence between the coordinator’s integrate medical and social concepts and
report and the final recommendations results into one single guideline report is
regarding psychosocial interventions for an important success for the project group
drug problems. But he does not mention and for all the experts who have contrib-
that the experts in the group had different uted to the guidelines. Bergmark stresses
opinions and that a new systematic review US examples of successful cooperation be-
was produced in order to resolve differ- tween medical and social scientists. I sug-
ences of opinion. When this did not re- gest that this was also the case in the work
solve the disagreement, the project group on the Swedish guidelines.
had to take the final decision according to The NBHW plans to revise the guidelines
the predefined rules. in one or two years. This is positive. The
This type of disagreement certainly de- scale of the work to integrate the overall
layed the production of the guidelines. In area of alcohol and drug prevention and
fact the Swedish Medical Products Agen- treatment into one guideline report inevita-
cy initiated a new systematic review that bly involves a lot of weaknesses. Revision
included meta-analyses and recommen- involves much less work than the original
dations regarding medication for alcohol work. Ideally the expert reports should be
dependence. This report was produced published in such a revision but some of
and published before the publication of them have to be considerably improved
the guidelines (www.lakemedelsverket.se before such publication is possible.
2007) and the results were available to the I personally have presented the guide-
project group before the guidelines were lines to users in one of the local meetings
published. The report included the COM- and the attendance rate and the interest

was very high. For me it is obvious that view that it was a major failure. Hope-
the people working with clients/patients fully the guidelines could, in the future,
with substance use disorders welcome the contribute to better understanding and co-
guidelines. Similar experience has been operation between the medical and social
reported from others who have presented systems in prevention and treatment of al-
the guidelines in other places in Sweden. cohol and drug use problems.
At the NBHW website it is reported that Mats Berglund, professor
all local presentations of the report were Clinical Alcohol Research
over-booked and that over 6,000 people at- Universitetssjukhuset MAS, Ingång 108
SE-205 02 Malmö
tended the presentations. This is definitely
E-mail: Mats.Berglund@med.lu.se
a success story that contradicts Bergmark’s

Research
Mads Uffe Pedersen
report
Evidence-based practice ABSTRACT
in “the real world”

M.U. Pedersen: Evidence-based practice
in “the real world”
The term evidence-based practice
(EBP) has developed into a mantra not
just within the medical area of treatment,
but within the psychosocial realm of
treatment as well. Today, decision-
makers and funding authorities are
increasingly demanding that psychosocial
How to define evidence-based
treatment should be evidence-based
psychosocial practice (EBP)
and that the different types of treatment
When reading different guidelines and various
facilities should attempt to adapt to
critical surveys of guidelines for treatment,
this, inter alia by providing offers that
you could almost be led to believe that a treat-
are reputed to be evidence-based. In
ment facility can establish an EBP by using
this article, EBP is viewed under a
treatment methods such as cognitive-behav- slightly different perspective than the
ioural therapy (Carroll et al. 1994; Azrin et al. one usually used when discussing
1994; Kelley et al. 2002; Winters et al. 2002), it. It is claimed that evidence-based
motivational interviewing (Dunn et al. 2001; counselling and therapeutic methods
Secades-Villa et al. 2004), contingency manage- only account for a small part of the
ment (Higgins et al. 1994; Griffith et al. 2000), strategies that are relevant for treating
methadone treatment (Carroll et al. 2001; Car- clients with substance and/or alcohol
roll & Onken 2005), 12-step counselling (Sique- misuse. In the first part of the article,
land & Crits-Christoph 1999; Stoffel & Moyers EBP is defined and placed in relation
2004; Weiss et al. 2005), multisystemic treat- to evidence-based counselling/therapy
ment (Curtis et al. 2004), familiy therapy (Stan- (EBC/T). In the article’s second part,
ton & Shadish 1997), and others. the relevance of – not least – EBC/T in
The above-mentioned methods, only to be the “real world” is discussed. The real
seen as examples, have proven themselves su- world is defined as, among other things,
perior to standard support in randomised con- “what clients receive, not what they are
trolled trials (RCTs) and, if they are to be truly offered” and “what clients need, not what
superior, in meta-analyses of RCTs (see the the system needs”. This is illustrated by
discussing two Danish research projects
evidence hierarchy, Phillips et al. 1998). This
that demonstrate, inter alia, that what is
is not how EBP will be defined for the pur-
received does not have much in common
poses of this article. Thus a distinction must
with what is offered.
be made between on the one hand EBP, which
KEYWORDS: Substance misuse,
can be linked to general guidelines for good
treatment, evidence-based paractice,
treatment, and on the other hand evidence-
counselling, therapy, organisation.
based counselling/therapy (EBC/T), which

Evidence-based practice in “the real world”
covers the specific type of special inter- 10. Decisions about treatment setting
vention methods that are nearly always should be based on the clients’ treat-
referred to when RCT and meta-analyses ment goals, preferences, severity of de-
are involved (including the methods men- pendence, the presence of co-morbid
tioned above). disorders, cognitive and social func-
Below are examples of 20 pointers ex- tioning and relapse history (includ-
tracted from the NIDA Principles of Drug ing other specific target group such as
Addiction Treatment and the NDARC adolescents, gender and indigenous
Guidelines for Alcohol Treatment (NDARC patients) (NDARC).
2005). These are merely examples of 11. Addicted or drug-abusing individu-
“strong advice”. Advice like this will be als with coexisting mental disorders
linked to EBP in what follows, which does should have both disorders treated in
not include medical advice. an integrated way.
1. No single treatment is appropriate for 12. Counselling (individual and/or group)
all individuals (NIDA). and other behavioural therapies are crit-
2. Treatment needs to be readily available ical components of effective treatment
(NIDA). for addiction. (Approaches to Drug Ad-
3. Effective treatment attends to multiple diction Treatment section discusses de-
needs of the individual, not just his or tails of different treatment components
her drug use (NIDA). to accomplish these goals.) (NIDA and
4. Screening for high-risk consump- NDARC = Psychosocial Interventions.)
tion should be widely implemented 13. An organised approach to treatment
(NDARC). is most effective supported by careful
5. Assessment for more intensive inter- case and progress notes (NDARC).
vention should be conducted in a semi- 14. Psychosocial relapse prevention strate-
structured, narrative style (NDARC). gies are recommended for use with all
6. Assessment should lead to a clear, moderate to severely alcohol depend-
mutually acceptable treatment plan ent patients (NDARC).
(NDARC). 15. Treatment does not need to be volun-
7. The treatment and services plan must tary to be effective (NIDA).
be assessed continually and modified as 16. Possible drug use during treatment must
necessary to ensure that the plan meets be monitored continuously (NIDA).
the person's changing needs (NIDA). 17. Treatment programs should provide as-
8. Remaining in treatment for an adequate sessment for HIV/AIDS, hepatitis B and
period of time is critical for treatment C, tuberculosis and other infectious dis-
effectiveness (NIDA) and the intensity eases, and counselling to help patients
of interventions should vary; with cli- modify or change behaviours that place
ents with more severe problems receiv- themselves or others at risk of infection
ing more intensive treatments (patient (NIDA).
matching) (NDARC). 18. Recovery from drug addiction can be
9. When possible, clients should be offered a long-term process and frequently re-
a choice of intervention (NDARC). quires multiple episodes of treatment

(NIDA). cal practice. Increased expertise is re-

19. Extended care: Attention should be giv- flected in many ways, but especially in
en to the clients’ retention in treatment more effective and efficient diagnosis
and social support networks (NDARC) and in the more thoughtful identifica-
20. Extended care: Aftercare should be tion and compassionate use of indi-
structured and assertive, with follow- vidual patients' predicaments, rights,
up of missed appointments (NDARC). and preferences in making clinical de-
Behind each of these items there usually cisions about their care.
lie a number of deliberations, possibili- By best available external clinical
ties and strategies which can be brought to evidence we mean clinically relevant
use in order to meet the overall objectives research, often from the basic sciences
of the guidelines. EBC/T is placed under of medicine, but especially from pa-
item 12. From the link http://www.nida. tient centred clinical research into the
nih.gov/PODAT/PODAT10.html you can accuracy and precision of diagnostic
reach an itemised roster of which methods tests (including the clinical examina-
are recommended and can be considered as tion), the power of prognostic markers,
EBC/T. 1 and the efficacy and safety of thera-
It may be discussed whether the above peutic, rehabilitative, and preventive
guidelines are even exhaustive for estab- regimens.
lishing good treatment (we shall return to Clinicians who fear top-down
this), but it is probably beyond discussion cookbooks will find the advocates of
that EBC/T only constitutes a minor part evidence-based medicine joining them
of the strategies linked to treatment efforts. at the barricades. Some fear that evi-
This brings us to the closest we get to an dence-based medicine will be hijacked
officially recognised definition of EBP – by purchasers and managers to cut the
below are 5 excerpts from Sackett and his costs of health care. This would not
colleagues’ understanding of EBP (seen as only be a misuse of evidence-based
a synonym of evidence-based medicine).2 medicine but suggests a fundamen-
tal misunderstanding of its financial
Evidence-based medicine is the con- consequences. Doctors practising evi-
scientious, explicit, and judicious use dence-based medicine will identify
of current best evidence in making de- and apply the most efficacious inter-
cisions about the care of individual pa- ventions to maximise the quality and
tients. The practice of evidence-based quantity of life for individual patients;
medicine means integrating individual this may raise rather than lower the
clinical expertise with the best avail- cost of their care.
able external clinical evidence from Evidence-based medicine is not re-
systematic research. stricted to randomised trials and meta-
By individual clinical expertise we analyses. It involves tracking down the
mean the proficiency and judgment best external evidence with which to
that individual clinicians acquire answer our clinical questions.
through clinical experience and clini-

As is clear from the excerpts from Sack- age and which offers were made to clients.
ett et al., it would be a misunderstanding to Some of the results of the study were:
reduce EBP to being tantamount to EBC/T.
It is also a misunderstanding to focus ex- Example 1. Intensity
clusively on RCT/meta-analyses, just as it First, 70% of all drug misusers admitted
would be completely erroneous to exclude to Danish outpatient treatment received 3
professional and individual judgment. counselling sessions or less during the first
In the following section, it will be dem- three months of treatment (after they were
onstrated that while EBC/T is a lesser referred to a treatment facility). But of
component of EBP, EBP is again a lesser course, all were offered more treatment.
part of what will henceforth be defined as Second, In Denmark it is mandated by
EBT (evidence-based treatment). And not law that opiate users in methadone treat-
only that – EBC/T is also but a very small ment must be offered psychosocial treat-
part of the practice that is viable in the real ment, but 80% of all methadone users
world of misuse treatment. receive 3 or less counselling sessions dur-
ing the first three months in methadone
How to define “the real world” treatment. But they are, of course, offered
The definition of reality for the purposes counselling.
of this article is very simple. It goes as fol- Third, Usually these counselling ses-
lows: sions involve the prescription of medicine
• “The real world” is what the clients get, or a kind of “here and now” fire-fighting
not what they are offered. which should be defined as an attempt to
• “The real world” is what the clients solve or reduce a tangible “here and now”
need, not what the system needs. problem.
• “The real world” is much more than Of course these (fire-fighting) counsel-
EBP. ling sessions are very often extremely im-
portant and very often reduce the client’s
 “The real world” is what the clients “here and now” problems, but they are not
receive, not what they are offered what we usually mean by evidence-based
In the following, the results from a nation- methods. More predominantly, they tend
wide study of misuse treatment in Den- to be experience-based, focusing on solv-
mark will be used as the empirical basis ing urgent, hands-on problems. It seems
(Pedersen & Nielsen 2007; see http://www. we have to accept that what we usually
crf-au.dk/0020.asp). Case reports from 443 mean by EBC/T is currently not relevant
representatively selected drug misusers for about 70% of clients admitted to Dan-
enrolled in treatment from July 1, 2005 to ish outpatient treatment (and 80% of the
July 1, 2006 were analysed. Representa- methadone users).
tivity was assessed by checking the study Fourth, 20 to 30% of drug misusers in
group against the Danish national register outpatient treatment completed treatment
for drug misusers enrolled in treatment. as planned. Conclusion: No compliance
The study group only deviated negligibly was reached with 70 to 80% of the cli-
from register information regarding gender, ents.

Signs would seem to indicate that we defined above). Similarly, 20 facilities of-
are facing an enormous compliance prob- fered couples therapy but only 11 facilities
lem within substance abuse treatment. had counsellors actually trained in couple
EBC/T conceivably plays a larger role in therapy; and finally 18 facilities proffered
countries where drug misusers enrolled in to offer family therapy, while only 13 had
treatment make up a smaller and highly an employee actually trained in this. On
motivated (and selected) part of the drug top op this, couples therapy and fam-
misuser population (possibly more finan- ily therapy were often vaguely defined.
cially well-off, as well) than in places One hypothesis here is that management
(like the Nordic countries) where different at these residential institutions is under
forms of treatment guarantees mean that strong pressure from referring authorities
the treatment population is much more to employ what they consider to be EBC/T.
variegated and perhaps – as a consequence While EBP – which also includes proper
– comprised by drug misusers with a high screening and assessment; different match-
severity index in a physical, psychological ing strategies; an individual service plan;
as well as a social sense. Maybe one of the focusing on multiple needs, etc. – did not
most important benefits of physician-pre- appear to play any major role in considera-
scribed heroin lies in the resulting higher tions concerning the treatments’ outcome.
degree of compliance achieved with pa- In conclusion, clients very often do not
tients. actually receive what they are offered and
a sizeable group either receive no psycho-
Example 2. Methods social support or a very limited amount
Another problem lies in the fact that what of such support, predominantly hinging
treatment facilities advertise as offers for upon disbursing medicine or solving ur-
clients may not necessarily be what cli- gent and specific “here and now” prob-
ents actually receive. Thus in post-millen- lems. Yet treatment systems are not what
nial Denmark it has almost been de rigeur should be criticised for this. Rather, it may
to offer Cognitive-Behavioural Therapy be the widespread rhetoric (which cen-
(CBT), family therapy and couples thera- tres almost exclusively on EBC/T) and a
py. 47 residential institutions were asked skewed research focus (too little attention
a) which methods they offered clients; paid to, say, fire-fighting and strategies to
and b) which methods they were trained/ increase compliance and thus increase
educated in using. “Trained” was defined show-ups).
as involving a diploma proving that the
counsellor had received at least one year  “The real world” is what the clients
of training in that particular counselling/ need, not what the system needs
therapeutic method, including at least 15 One problem often discussed with re-
whole days of training and supervision. gard to EBC/T is its top-down nature. If a
20 residential institutions advertised that method that has proved effective in RCTs
they employed CBT, but only 12 facilities does not prove effective on a client, it must
had a minimum of one counsellor trained be the client that is the problem – not the
for at least one year in this method (as method (see Sackett et al. 1996). In the fol-

lowing, there will be examples of a) that a different Therapeutic Communities (hier-

large group of substance misusers receiv- archical TCs or democratic TCs), 12-step
ing offers from methods that purport to be treatment facilities, or social educational
evidence-based do not in effect fare very programmes. They offered the whole range
well in treatment; the question being what of cognitive therapy, behaviour therapy
was actually offered to those who did not and/or 12-step counselling.
benefit from the EBC/T offerings; did they The table clearly shows that from groups
simply have to take what they could get? 1, 2 and 3, only 4%, 21% and 40%, re-
– and b) that it is apparently very locally spectively, went through with treatment
determined who in fact benefits from the as planned. In other words, right from the
offered EBC/Ts. The examples build on the start it is possible, based on a EuropASI in-
Danish Registration and Information Sys- terview immediately prior to treatment, to
tem (DanRIS, see English version: http://
3
single out several groups of women with a
www.danris.dk/default_en.asp). high probability of dropping out of treat-
ment. Staffers working at the treatment
Example 1. Methods versus needs facilities were asked what they would
565 women enrolled at 23 residential in- do about the group of women who were
stitutions participated in the project. This clearly not benefiting from treatment. Sub-
group was representative of women en- sequently, they were asked about the pos-
rolled in drug-free residential treatment sibility of implementing different strate-
in 2004 to 2005 and partially responded to gies for those women in risk of early drop-
queries outlined by the European Addic- out. Some of them said it was not possible
tion Severity Index (all 30-days questions because it would sabotage the programme;
and other selected questions). The pur- others said they lacked the resources for
pose was to identify groups of women that undertaking this kind of individualised
could from their enrolment be categorised focusing on needs; while a third group of
as being at high risk of early drop-out. Us- facilities concluded that they had to do
ing cluster analysis, the 5 groups below something about it – but they really did
were singled out (regarding method and not know what. In other words, there was
elaboration, see Pedersen 2007). such a fixation on the established method
All 23 treatment centres were either that there was no vision of a more need-
oriented approach. In yet other words, the
Table 1. 565 women from 23 treatment external and general guidelines have be-
centres divided into 5 groups on the basis of
come emphatically determining for treat-
a prediction score (see ibid)
ment. The system has colonised the “real
Completion of world”, so to speak.
Score n Programme
Group 1 >=0<2 21 4% Example 2. General versus local evidence

Group 2 >=2<6 117 29% Just as different EBC/Ts do not function
Group 3 >=6<10 197 40% equally well on all clients, all methods for
Group 4 >=10<14 180 52% pinpointing groups at risk do not function
Group 5 >=14 50 64%
equally well at all treatment facilities. As

Table 2. PPC1 applicability to the two categories of residential institutions

Completion of programme
PPC19 does not work PPC19 works
12 treatment centres n 11 treatment centres n
Group 1 20% 5 0% 16
Group 2 42% 53 19% 64
Group 3 40% 84 40% 113
Group 4 41% 80 60% 100
Group 5 45% 45 77% 30
41% 242 43% 323
1) PPC = Prediction Programme Completion
shown in Table 2, it is possible – using que- treatment facilities (Pedersen 2007), a fact
ries from EuropASI – to single out groups that will be dealt with in the following
at risk, but this scale clearly worked better section.
at some treatment facilities than others. In Differently put, a great many drug mis-
Table 2, the 23 treatment facilities are di- users do not benefit from treatment meth-
vided into facilities where the prediction ods otherwise defined as EBC/T and at the
scale did not work (n=12), and facilities same time, the same assessment tools can-
where it did (n=11). not be meaningfully applied to all facili-
It does not make much sense to apply the ties. So two things are required: a) that the
prediction scale to the 12 facilities on the clients’ needs are put above the counsel-
left, while the scale becomes all the more ling or the therapeutic method and b) to
relevant regarding the 11 facilities listed develop local evidence (i.e. local tools for
to the right. The reason why the predic- identifying groups at risk).
tion scale did not work at the 12 facilities
could not be explained by different clients  The “real world” is much more than
or different courses (same age, same sever- EBP
ity score and same percentage completing As has already been made clear, EBP
treatment). Moreover, it could not be ex- amounts to much more than just EBC/T. In
plained by the treatment programme; the the following, it will be demonstrated that
mean age of the counsellors was the same, furthermore, EBP is again but a small part
and the distribution by gender (staff) was of EBT (evidence-based treatment). This is
the same. More pertinently, it was also illustrated by the Table below.
found that the counsellors from the 11 fa- Evidence-based treatment (EBT) consists
cilities where the prediction scale worked of three different types of practice: Experi-
more often than the counsellors from the ence Based
12 facilities where the prediction scale did Practice, evidence-based practice and
not work could furnish proof of having organisational-based practice, respec-
received some kind of psychotherapeutic tively. By experience-based practice, is
training (could produce a diploma). This meant a specific practice with a specific
was the only identifiable, significant dif- client. Experience-based practice is very
ference between the two categories of often seriously underestimated. Being

Table 3. Evidence-based treatment
Experience based Evidence-based Organisational based

practice practice practice
Description Local, specific, internal experi- Integrating, external, Local policy-making
ence with: research-based guidelines – Management
– Social work/treatment in and methods – Decision-making
general – Negotiation
– The target group and Guidelines – Coordination, planning
relevant other target groups
– Establishing trust, working – Take in practice
alliance, compliance Methods – Decoupling practice
– Planning, coordination of (EBC/T) – Self-evaluation practice
specific client courses in a
specific local context – Etc.
– Communication about
specific cases
– Communication in general
– Etc.
To increase communicative To increase research-based To increase organisational
Objective
competencies technological competencies competencies
Strategy Training Education Organisational development
Perspective Local General Context
Clients This client Groups of clients The client context
good at telling about edifying examples, is of government agencies and decision-mak-

often seen by researchers as being rather ers from other focus areas including the
boring because these examples cannot be health care system in general, the prison
understood as evidence-based in the way and probation service, etc.) These nego-
this term is usually used. Nevertheless it tiations also involve which options the or-
is through experience-based practice that ganisation makes available to clients, etc.
psychosocial EBP becomes implemented. This is where the take in practice enters
There can be no EBP without experience- the picture. This concept refers to the ex-
based practice. Most people will probably tent to which the organisation seeks out,
acknowledge this as a fact of life, yet this discovers and implements different recip-
type of practice generally finds little room ies (methods, strategies, controlling mech-
in discussions concerning good practice. anisms; see Røvik 1998: 14f). Also, by
Organisational-based practice involves decoupling practice, is meant which strat-
conditions concerning the entire organi- egies the organisation adopts in order to
sation which have implications for client keep different recipies distinct from each
treatment. You could say that the entire other so that a possible discrepancy be-
question hinges upon a sort of local pol- tween recipies does not lead to insoluble
icy-making where leaders, counsellors conflicts (say, treatment with physician-
and other decision-makers to a higher or prescribed heroin within a facility also
lesser degree negotiate towards reach- offering drug-free treatment). Self-evalu-
ing decisions regarding treatment. This ation practice refers to which strategies
also includes negotiations with decision- the organisation employs for evaluating
makers outside the organisation (e.g. heads its own practice. If there is no self-evalu-

ation, bad strategies, wrong decisions, etc. higher degree involve ingredients from ex-
will go unchanged, perhaps leading to out- perience-based and organisational-based
and-out treatment errors for years on end. practice in its efforts to describe what con-
Under the heading organisational-based stitutes good practice.
competencies also comes a practice born
of negotiations and decisions concerning Discussion
working conditions, resources, salary con- Above, a distinction has been made be-
ditions, ethics, etc., which may all be of tween EBT (evidence-based treatment),
great significance for treatment of the cli- EBP (evidence-based practice) and EBC/T
ents involved. (evidence-based counselling/therapy). The
On the whole, EBT is not something attention focused on EBC/T in recent years,
you can calibrate. It is like a big kettle into often misplaced, sometimes seems to have
which you toss a plethora of ingredients done more harm than good. Often, it has
such as experience, communication skills, contributed towards creating a top-down
training, techniques, guidelines, policy, regime, which is not what Sackett et al.
decision-making, take in practice, working intended with evidence-based practice
environment, resources, compliance and (which they call evidence-based medicine).
much more. All this is stirred together and In Bergmark’s article (in this volume), the
sometimes it all suddenly congeals into a Swedish guidelines are criticised for lack-
greater whole – and sometimes it does not. ing quality. But the question of quality is
Obviously, what comes out of this boiling perhaps the least of all the problems. There
stew is not happenstance. There is a cer- are far greater problems at issue.
tain likelihood that if the stew consists of The first problem lies in the total fixation
the right ingredients, it will also taste good. on EBC/T instead of EBP and EBT. As has
But it does not take more than one wrong been made clear, the question of whether
spice added, too little or too much heat to employ cognitive-behavioural therapy,
under the kettle, a little too sloppy pre- Motivational Interviewing, etc. has lesser
paratory work, etc. before the whole thing significance for EBP. Likewise, RCTs and
tastes really bad – regardless of whether meta-analyses will definitely not solve all
you are applying Cognitive-Behavioural the problems we are facing today. In the
Therapy or some other EBC/T. So you may bigger picture, EBC/T will probably not
rely on a certain degree of probability, but make that great a difference. Thus some-
even though the ingredients are known, thing would seem to indicate that the ef-
the resulting stew will never be the same fect of drug and alcohol misuse treatment
every time. has not generally improved during the
Precisely the fact that it is not random course of the last 30 years (see Prendergast
what you use as ingredients in the stew is 2000). Nonetheless we have in that same
what justifies qualitative as well as quanti- period been given a number of EBC/Ts and
tative treatment research. For this reason, different guidelines for good treatment
the arguments put forward in this article (Pedersen 2005). The lack of improvement
should by no means be seen as a rejection in drug and alcohol misuse treatment may
of EBP. Yet research should also to a far be attributable to several conditions which

only makes it more imperative that we about experience or organisational-based

widen our focus. This is not to say that we practice. This has led to a lack of focus
can be indifferent to this type of research. on policy-making, management, decision-
Thus EBC/T can be a very important ingre- making, education, working conditions,
dient in the stew. Not only concerning the communication, compliance, etc. When
effect of treatment, but also with regard to resources are lacking there may even be an
communication between employees in the interest in not ensuring too much compli-
organisation. ance.
The second problem is that often there So it is definitely not merely a question
is only scant interest as to what the clients of research quality. It is at least as much
actually receive and whether the EBC/Ts a question of proper focus. It is therefore
that are so highly visible in today’s dis- urgent that we start focusing on the real
cussion are at all relevant to the majority world of drug and alcohol misuse treat-
of drug misusers enrolled in treatment. ment, including a) evidence-based practice
This article would argue that these EBC/Ts as a whole; b) experience-based practice;
play a lesser role for the vast majority of c) organisational-based practise, d) what it
clients in Danish drug abuse treatment. is that clients are actually receiving; and
The significant majority of drug misusers e) what they actually need. This should
enrolled in outpatient misuse treatment not be misunderstood. EBP is indeed of
would never make it to completion in a the highest importance. Absence of EBP is
long-term EBC/T programme. This is not like lasagna without pasta. EBC/Ts are the
to say that some of the elements in these spices which can make a difference, but
methods could not be efficacious in estab- they should not be overestimated.
lishing compliance, fire-fighting, etc. But
this is something we actually know far too Mads Uffe Pedersen, head of the center
Centre for Alcohol and Drug Research
little about.
Nobelparken Building 1453, 3.
The third problem is that the wealth of Jens Chr. Skou's Vej 3
discussion about EBC/T and EBP seems to DK-8000 Aarhus C
have completely obscured any discussion E-mail: mup@crf.au.dk
Notes
1) From the link above, only regarding drug as the foundation for later understandings
misuse. In the NDARC Guidelines, EBC/Ts of EBP (see Webb 2001).
are placed under the heading of “Psychoso- 3) Any residential institution treating drug
cial Interventions”. misusers in Denmark is under obligation to
2) See Sackett & Rosenberg 1995 and Sachet et submit necessary data to DanRIS if they are
al. 1996. Sackett’s and colleagues are pione- to have clients referred paid for by public
ers in establishing what they call evidence- agencies.
based medicine; their definition has served

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Overview
Pia Mäkelä Heli Mustonen Esa Österberg
Does beverage type ABSTRACT

P. Mäkelä & H. Mustonen & E. Österberg:
matter? Does beverage type matter?

The purpose of this article is to review
the associations of different beverage
types with different types of harm and
discuss their likely causes. The key
issue is whether alcohol policy can
Introduction influence the occurrence of harms by
There is a long-standing interest in Finland affecting consumers’ beverage choices.
in the relative harm associated with beer and This is dependent on the following
wine consumption, on the one hand, and spir- questions addressed in this article:
its consumption, on the other. The interest has 1) Does beverage choice affect alcohol-
been visible both in the scientific literature and related harm if quantity of alcohol is
in practical alcohol policy. In the first research equal?
programme issued by the Finnish Foundation 2) Does beverage choice impact the
for Alcohol Studies for 1951–1957, described quantity of alcohol consumed?
by Kettil Bruun as “scientists’ response to the 3) Can beverage choice influence the
pleas for help from alcohol policy makers” nature of the drinking situation and
(Bruun 1957, 199), one of the major contribu- thereby quantities and harm?
tions was The Effects of Distilled and Brewed The literature review did not reveal
Beverages by Martti Takala, Toivo A. Pihkanen great differences between different
and Touko Markkanen. The differential effects beverages with regard to harm if
of mild and strong beverages were also ad- equal amounts are drunk, although
dressed in the 1950s by Pekka Kuusi (The Liq- it seems that spirits are somewhat
uor Question and Alcohol sales Experiment in more closely associated with alcohol
Rural Finland), when he assessed the impacts poisonings and aggressive behaviour.
of the beer and wine outlets that were opened Our results showed that spirits have
in rural areas on an experimental basis (Kuusi a prominent role in Finnish binge
1952; Kuusi 1957). Kuusi concluded in The drinking: the proportion of spirits
Liquor Question: “If alcohol policy is judged consumed increases in direct proportion
on the original and only sensible criterion in to the amounts of alcohol consumed
this field, i.e. against the extent of harmful ef- on individual drinking occasions. We
fects, then we can only conclude that our al- conclude that it would be unwise to
cohol policy makes a fundamental mistake in encourage consumers to favour spirits.
favouring strong alcoholic beverages.” (Kuusi Currently, the difference in taxes on
1952, 350, our translation). spirits and mild alcoholic beverages in
An account of the differential treatment of Finland is larger than the corresponding
spirits and milder alcoholic beverages in prac- difference in harm per litre of ethyl

Does beverage type matter?
alcohol. However, an equal tical alcohol policy is provided in the 75th anniversary his-
rate of taxes would make tory of the Finnish State Alcohol Monopoly (Alko) by Martti
spirits much cheaper per Häikiö, who describes the 1959–1968 period as a beer and
litre of ethyl alcohol than wine favouring era (Häikiö 2007, 159). As late as 1978, Alko
other beverages. Based on defended its alcohol policy by arguing that “the level of acute
our review, this situation alcohol-related harm tends to decrease in direct proportion
would in all probability lead to the alcohol content of the beverage consumed” (Alkon teh
to an increase in alcohol- tävä ja toimintalinja 1978, our translation).
related harm. The 1980s and 1990s saw a waning of interest in Finland
in the relative harmfulness of different beverage types. How-
ever the most recent Finnish overview of the differential ef-
fects of alcoholic beverages dates from this same period, i.e.
the early 1990s. Its emphasis was twofold: it addressed the
differential effects of the same quantities of alcohol depend-
ing on beverage type and as a new contribution it presented
empirical results on the true strength at which different bev-
erages were consumed (Simpura et al. 1993; 1996).
In recent years there has been a revived interest in these
questions, particularly in the context of the optimal taxation
of alcoholic beverages. In this review we are interested in the
associations of different types of alcoholic beverages with
different types of harm. We will discuss whether these dif-
ferent associations are likely to reflect a causal relationship,
or whether the most probable explanation lies in other fac-
tors that possibly affect both the choice of beverage and the
consequent harms.
 Choice of beverage in its context

Apart from the fact that they all contain ethyl alcohol, al-
coholic beverages differ quite widely from one another in
their other properties, including their strength, taste and the
impressions and images they invoke. It follows that differ-
ent beverages do not lend themselves in the same way to
satisfying consumers’ multiple needs. The question we need
to ask, then, is how the intended use of alcoholic beverages,
drinking situations and individual preferences influence the
choice of beverage, the amount of alcohol consumed and
consequent harms (Figure 1). It is clear that the single most
important factor with regard to the occurrence of violence,
accidents and other types of harm associated with individual
drinking occasions is the quantity of alcohol consumed. The
quantities consumed on a single drinking occasion tend to

Individual properties Alcohol policy

– Sex, age, socio-economic status
Demand Supply
– Needs and preferences – Prices
– Availability
– Alternatives
Purpose of drinking
– Thirst, with a meal, social
lubricant, intoxicant
+ Nature of drinking situation
3
Choice of beverage type
– Beer, wine, spirits
– Beverages within beverage type
2
Amount of alcohol consumed
– On a single drinking occasion
– In the longer term
1
Harmful effects
– Diseases associated with long-term use, accidents, violence, public disturbance etc.
1 to 3 relate to the numbered questions set out in the introduction.

Figure 1. Impact of beverage type on harms
vary sharply depending on the purpose fied. After all, if heavy taxes are levied on
of drinking (e.g. to wash down a meal or spirits, people can still get drunk on e.g.
to get drunk), and that in turn is associ- medium-strength beer or wine. From an
ated with the choice of beverage type. alcohol policy point of view, therefore, the
That choice can be steered and influenced interest lies in whether the effects indicat-
by means of alcohol policy, say by adjust- ed by the broken lines in Figure 1 actually
ing beverage-specific excise duties, but the exist, i.e.
key issue is whether by manipulating the 1) whether the choice of beverage type is
choice of beverage type it is possible to indirectly connected to alcohol-related
fluence the level of alcohol-related harm. If harm if the quantity of absolute alcohol
the association between the choice of bev- consumed and the nature and purpose
erage type and the prevalence of harm is of the drinking situation is standard-
due solely to individual variation in needs ized, e.g. in an experimental setting;
and preferences and to differences in the 2) whether the choice of beverage type has
intended uses of alcohol, then manipula- a direct impact on the quantity of abso-
tion of people’s choices of beverage type lute alcohol consumed; in other words,
by means of taxation will have no effect on do people drink larger quantities of
the level of harms and is therefore unjusti- spirits than wine or beer, for instance,

when they are used for the same pur- nal factors confounding the relationship.
pose, e.g. as an intoxicating substance However the evidence from these studies
or as a social lubricant; and is not particularly persuasive with regard
3) can the choice of beverage type influ- to the harm caused by long-term drinking,
ence the purpose or nature of the drink- and they have also attracted criticism be-
ing situation, and thereby the quantities cause of the difficulty of generalizing to
consumed and the level of consequent real life situations where matters are com-
harm? plicated by a whole array of intervening
There is as yet no conclusive scientific factors. On the other hand, there are also
evidence on these various effects. In this epidemiological studies on the prevalence
article we will be using both existing and of different types of harm in people who
new research evidence to analyse the pos- prefer different types of beverages. In these
sible effects that are at play in the relation- studies the quantity of alcohol consump-
ship between beverage types and alcohol- tion is typically standardized by means of
related harm. First, based on the existing statistical models. There is a particularly
literature, we aim to establish what is cur- large body of research on the question of
rently known about the effects of consum- whether different types of beverage have
ing the same quantities of alcohol in the a different effect on coronary heart disease
form of different alcoholic beverages by re- (CHD). We begin with this line of work be-
viewing epidemiological and experimental cause it also provides a good illustration
studies in which the quantity of alcohol of the limitations of the epidemiological
consumption is controlled. We then look research evidence.
at new research results on the associations Most of the recent reviews on the associ-
between beverage type and quantities of ations between alcohol and CHD conclude
alcohol consumed. Our main emphasis that moderate drinkers are at a lower risk,
and contribution, however, is the discus- and furthermore that this association re-
sion at the end of the paper, where we ad- flects a causal relationship (e.g. Rehm et
dress and interpret the existing research al. 2003). However, the size of the impact
knowledge and the new results in the light varies by age and gender, and drinking
of the three questions listed above. habits have a bearing on the level of risk:
binge drinking has no protective effect, but
Differences in the harmful in fact it can increase the risk of CHD.
effects of different beverage There has been much interest in the ques-
types when the quantity of tion of whether a certain type of drink has
alcohol consumed is the same a greater protective effect than others. Re-
We begin by reviewing the research evi- view articles have suggested that the pro-
dence on the possible differences in the tective effect is mainly attributable to ethyl
harmful effects of different types of alco- alcohol rather than any other substance
holic beverage, assuming that the quantity in alcohol (Rimm et al. 1996). However,
of absolute alcohol consumed is the same. in a review from 2003 Grønbæk, present-
Some experimental studies have been re- ing also potential biological mechanisms,
ported, which are able to control exter- defends the possibility that wine-drinking

may afford additional protection beyond the results of individual epidemiological stud-
beneficial effects of ethyl alcohol. ies on the differential effects of different
There is an abundance of epidemio- beverages types cannot be trusted. Such
logical studies on the effects of different results have been published on the effects
beverage types on CHD or mortality in of different beverages on e.g. liver cirrho-
general. Some suggest that beer, others sis, different cancers and gout. Earlier re-
that wine and others still that spirits have views have concluded that strong alcoholic
a greater protective effect than other bev- beverages show a closer association than
erages, although the reports in favour of other beverage types with oesophagal can-
wine seem to be somewhat more numer- cer (Longnecker 1995), but a recent review
ous than the reports favouring other bever- by Boffetta and Hashibe (2006) observes
ages (Rimm et al. 1996; Grønbaek 2003). that the research evidence on the differen-
However, it seems that the better health tial effects of different beverage types on
of wine drinkers mainly has to do with cancers of the mouth and upper digestive
their better health habits and their better tract is contradictory and that alcohol it-
social background. For instance, it has self is probably the main causative agent.
been reported that wine drinkers smoke In Finland, Poikolainen et al. (2002)
and drink less than others, that they have studied the day-to-day variation in the re-
a healthier diet, and that they come from tail sale of alcoholic beverages and in fa-
a better social background (Barefoot et tal alcohol poisonings in 1983–1999. The
al. 2002; Mortensen et al. 2001). Indeed, results showed that the number of deaths
Mortensen and colleagues (2001, p. 1844) from alcohol poisonings correlated more
conclude that “wine drinking is a general closely with sales of spirits than with total
indicator of optimal social, cognitive, and alcohol sales, suggesting that in Finland
personality development in Denmark”. spirits account for more fatal alcohol poi-
A study in California showed that when sonings than other alcoholic beverages.
certain key health habits and education In other words, although it is possible to
were controlled for, wine drinkers’ 30 per drink beer and wine in large enough quan-
cent lowered risk of hospitalization for tities to die of alcohol poisoning, this is
CHD was reduced to 10 per cent. In other more likely to happen with spirits.
words, the better health of wine drinkers When the effects of the same quantities
is explained not so much by the character- of alcohol are considered from the point
istics of wine, but by the characteristics of of view of accidents and violence, the
the people who prefer wine. key concern is whether different bever-
It is quite difficult then to draw a clear ages cause different kinds of behaviour
and coherent picture of the differential changes. Experimental studies show that
health effects – benefits or drawbacks – of undiluted spirits, when consumed on an
different beverage types based on the epi- empty stomach, induce a faster rise in
demiological research evidence: the con- blood alcohol content and a higher maxi-
founding effects of other factors are just too mum level of blood alcohol content than
great and it is very hard, if not impossible ingestion of the same amount of absolute
to control for them altogether. In short, the alcohol in beer (e.g. Takala et al. 1957). On

the other hand, the opposite result is ob- Are certain beverage types
tained when alcohol is consumed in con- liable to be consumed in larger
nection with or immediately after a meal: quantities than others?
beer induces a higher maximum of blood If we had concluded above that beverage
alcohol content (Roine et al. 1993). Ac- type has no effect at all on alcohol-related
cording to the psychological observations harm when the quantity of ethyl alcohol
in the study by Takala and colleagues, the consumed is the same, would that auto-
consumption of spirits was more likely to matically have meant that tax or other ma-
prompt aggressive behaviour and uncon- nipulation of the choice of beverage type
trolled behavioural reactions. Beer, on can have no effect on the related harms?
the other hand, was more closely associ- Things are not quite as simple and straight-
ated with difficulties of perception and forward as that: real life is not a laboratory
inappropriate responses to stimuli. Other where people who drink different types
studies using experimental designs, some of beverages are served exactly the same
in laboratory environments and others in amount of alcohol. Another important
more natural settings, have also reported a consideration from an alcohol policy point
closer association for spirits than for beer of view is whether the choice of beverage
with both verbal and physical aggressive- type influences the quantities consumed
ness (Boyatzis 1974; Pihl et al. 1984; Mur- if individual preferences and the purpose
doch and Pihl 1988), although this may be and nature of the drinking situation are
based more on the anticipated effects of a the same (broken line arrow 2 in Figure 1).
certain type of beverage than on the bever- We move on now to review the research
age’s actual physical properties (Pihl et al. results on how beverage type is associated
1984). with heavy consumption and binge drink-
All in all it can be concluded that by far ing. The research design does not allow
the single most important factor with re- us to control for individual preferences or
spect to alcohol-related harm is the quanti- the nature of the drinking situation, so the
ty of ethyl alcohol consumed at one sitting following description of the associations
and in the longer term. The choice of bev- between beverage type and heavy con-
erage type has only marginal significance sumption are not necessarily indicative
on top of this effect. However, it seems of causal effects. We revert to the alcohol
that the volume of spirits consumpiton is policy implications of our observations in
a more crucial factor than consumption of the Discussion.
other alcoholic beverages with respect to
fatal alcohol poisonings, and there is quite  What do heavy consumers drink?
persuasive evidence that spirits have a It is often assumed that heavy drinkers
greater effect on aggressive behaviour than seize every opportunity to ingest alcohol,
beer and wine. As for CHD, the scientific regardless of whether it is available in the
verdict is still out on whether wine has a form of spirits or milder alcoholic bever-
greater protective effect than other alco- ages, and thus that they consume large
holic beverages, and on whether spirits are quantities of all types of beverages. On the
more likely to cause certain cancers. other hand the public perception at least

in Finland often associates heavy con- Table 1. Percentage breakdown of heavy

sumption above all with spirits. We have users’ annual consumption by beverage type
analysed the results of the 2006 Alcohol

Beer, Wine Spirits
and Drug Study (Mustonen et al. 2007) Cider
and compared the breakdown of different All users 63 20 17
demographic groups’ annual consumption
Heavy users (10%) 66 15 19
between beer, wine and spirits in 100 per
Heavy users (5%) 63 15 22
cent alcohol. For our analysis of heavy
Heavy users (1%) 63 15 21
consumption, we focused on the top 10,
Source: Alcohol and Drug Study 2006 (Stakes)
5 and 1 per cent of alcohol consumers. In
these groups of heavy consumers, spirits
accounted for around one-fifth of total con- its, on the other hand, varied systematical-
sumption (Table 1). Among all consumers, ly according to the quantities consumed:
spirits accounted for 17 per cent of total the heavier the binge drinking episode, the
annual consumption, among others than greater the proportion of spirits. This result
heavy consumers (using the 10 per cent applied to both men and women (results
definition) the figure was 16 per cent. Ac- not shown in the table). In other words the
cording to these questionnaire data, then, results of the Drinking Habits Survey in-
spirits account for a slightly larger propor- dicate that spirits had a prominent role in
tion of total consumption among heavy Finnish binge drinking in 2000.
consumers than they do in the total popu- The limits used in this analysis for
lation. heavy drinking at one sitting (7, 13, 20 and
27 servings), describe heavy binge drink-
 What do people drink on heavy ing, but it should be pointed out that the
drinking occasions? drinking of even as high number of drinks
In the Drinking Habits Survey in 2000 (Met- as 20 is not extremely rare among Finn-
so et al. 2002; Mustonen et al. 2001), data ish men. For example, in the 2006 Alco-
was collected on the quantities of different hol and Drug Study, 21 per cent of men
beverages consumed on the respondents’ and 4 per cent of women reported at least
most recent drinking occasions. These one annual occasion when they consumed
data allow us to review choices of bever- more than 18 servings. In the age group
age type on heavy drinking occasions. 20–34, the figures were 36 and 5 per cent,
Beer accounted for around 60 per cent respectively.
of the total consumption of pure alcohol
on all reported drinking occasions, while  Who drink mild alcoholic beverages
wine and spirits accounted for around 20 and who drink spirits?
per cent each (Table 2). On heavy drinking According to the 2006 Alcohol and Drug
occasions the share of beer was otherwise Study, women consumed 90 per cent and
the same as on other drinking occasions, men 80 per cent of their alcohol intake
but in the heaviest binge drinking episodes during the past year in the form of wine
the proportion of beer consumption was or milder beverages (Figure 2). Within the
somewhat lower. The proportion of spir- category of mild alcoholic beverages, the

Table 2. Percentage breakdown by beverage type of total alcohol consumption on all drinking
occasions and on binge drinking occasions.
Percentage share of beverage type
Number of drinking
occasions Beer Wine Spirits
Share of 100% alcohol consumed on all
6 383 59 21 20
drinking occasions
Less than 10 cl consumed at one sitting
5 010 59 24 17
(less than 7servings)
More than 10 cl consumed at one sitting
1 373 61 10 29
(7+ servings)
399 60 6 34
(13+ servings)
120 51 4 45
(20+ servings)
45 42 4 54
(27+ servings)
Source: Drinking Habits Survey 2000 (Stakes)
preferences between men and women dif- cially among women but also among men,
fer more clearly. While men consume more wine-drinking increases significantly with
than half of their annual absolute alcohol rising income. Among women in the high-
intake in beer and less than 10 per cent in est income bracket, wine accounts for 46
cider, women consume more or less equal per cent of total alcohol consumption,
amounts of beer and cider. Among women, whereas the proportion among women in
wine accounts for a much larger propor- the lowest income bracket is around 20
tion of total alcohol consumption than per cent. The corresponding proportions
among men. for men are 17 and 9 per cent.
In younger age groups both men and
women prefer to drink mild alcoholic Discussion
beverages, beer and cider (Figure 3). In  Beverage types and harms in real life
the age group 15–29 these beverages ac- The real-life observation that the use of
count for more than three-quarters (79%) different types of alcoholic beverages is as-
of men’s total alcohol consumption and sociated with different amounts of harm is
for almost three-quarters (70%) of wom- explained, on the one hand, by the physi-
en’s consumption. Among women, wine cal properties of alcoholic beverages and
consumption increases with age particu- the social and cultural rules that govern al-
larly at the expense of cider, but also at the cohol use (Mäkelä 1983); and on the other
expense of spirits. Among men, the pro- hand by the availability of different bever-
portion of both wine and spirits consump- ages, as regulated by alcohol taxation and
tion increases with age, particularly at the other alcohol policy measures. These fac-
expense of beer but to some extent at the tors are crucial in explaining for instance
expense of cider. why a different type of beverage is more
The popularity of wine in older age closely associated with harm in one country
groups may have to do not only with ac- or at one point in time than in another
quired tastes but also with wealth. Espe- country or at another point of time.

Beer Cider Wine Spirits customs and norms as well as the cultural
determinants associated with alcohol. For
MEN
instance, it is hard to imagine a wedding
All reception where people would toast with
mugs of beer or vodka rather than flutes of
15–29 champagne. Having said that, advertisers
and promoters are certainly pushing hard
30–49
to extend and expand the range of situa-
tions where different types of beverages
would have cultural approval.
50–69
All in all the differences in how alco-
0 20 40
%
60 80 100 holic beverages are suited to different pur-
poses and the de facto differences in their
WOMEN
uses are not perhaps as great as one might
All be inclined to assume at first glance. One
noteworthy factor here is that the proper-
15–29 ties of beverages vary quite markedly even
within each beverage category. People in
Finland can travel across to Estonia and
30–49
legally buy a bottle of vodka with 80 per
cent alcohol by volume, and they can walk
50–69
down to the corner shop and get a bottle
0 20 40 60 80 100 of ready-to-drink Gin Long Drink with
%
Source: Alcohol and Drug Study 2006 (Stakes) 1.2 per cent alcohol by volume. The alco-
hol content of beers sold in Finland has
Figure 2. Percentage breakdown of annual
alcohol consumption by beverage type in ranged from 0 to 16 per cent, and grocery
male and female age groups in 2006 stores and supermarkets carry wines that
contain less than 4.7 per cent alcohol by
Different beverages are chosen and used volume.
by different people and on different kinds Furthermore, alcoholic beverages are
of occasions on account of their different not always consumed in the form they
properties. Alcoholic beverages can be come from the bottle, but various mixers
used at least to quench a thirst, to wash are often added to change their original
down a meal, to get drunk, as a social lubri- taste, colour and aroma before consump-
cant or as medication. Different alcoholic tion. According to Simpura et al. (1993;
beverages are differently suited to meeting 1996), on one half of all Finnish drinking
these needs: for instance, a beer is much occasions in 1992, spirits were diluted to
better suited as a thirst-quencher after sau- strengths comparable to wine or milder.
na than a glass of red wine or whiskey. The Alcohol policy influences our choices of
ability of alcoholic beverages to satisfy peo- beverage in various ways, through taxation
ple’s needs is dependent not only on their and mechanisms to control the availability
physical properties, but also on different of alcohol. A good example of the impact of

alcohol policy is provided by the exemp- people’s choices of beverage type, but the
tion of fortified wines from ration cards in crucial issue is whether this has any effect
1952 (see Häikiö 2007, 135). In 1951, al- on the occurrence of alcohol-related harm:
cohol consumed in the form of wine ac- it is primarily through this effect that any
counted for 5.6 per cent of total alcohol tax or other policy interventions favouring
consumption in Finland, and the propor- or disfavouring different beverage types
tion of people arrested under the influence can be legitimized. As far as harms are
that had drunk wine was 3.5 per cent. concerned the single most important fac-
Two years later, the corresponding pro- tor is unquestionably the quantity of al-
portions were 19.9 and 36.8 per cent (Oy cohol consumed at one sitting as well as
Alkoholiliike Ab 1952 and 1954). In 1951, in the longer term, but what we want to
the number of wine drinkers arrested per establish here is whether the type of bev-
1,000 litres of alcohol consumed in wine erage consumed can have an independent
was less than 10, by 1953 this climbed to effect on the amount of alcohol-related
almost 30. The corresponding numbers of harms. Based on the review above, there
arrested spirits drinkers per 1,000 litres of remain many unanswered questions about
alcohol consumed in spirits were 14 and the possible differential effects of different
12, so on this basis someone could argue beverage types. However, there are indi-
that in 1953 (but not in 1951) wine was cations that spirits may have somewhat
clearly more harmful than spirits. How- more adverse effects than milder alcoholic
ever, the properties of these beverages had beverages. This does not mean to suggest
not changed at all from 1951 to 1953, but that we underestimate the harmful effects
because of the change in the relative avail- of beer consumption, for instance: beer ac-
ability of alcohol, a large proportion of counts for almost one-half of all the alco-
binge drinking had shifted from spirits to hol sold in Finland, so it clearly has to be
fortified wines. responsible for a large part of a wide range
A similar shift was observed in the early of alcohol-related harms. Below, we move
1960s when the price of spirits and forti- on to discuss the three key alcohol policy
fied wines increased at the same time as questions that were raised at the beginning
the prices of wine were reduced. This of our paper.
again led to an increase in the number of 1) Is the choice of beverage type directly
drunken arrests due to wine drinking rela- connected to harm if the amount of ab-
tive to the volume of alcohol consumed as solute alcohol consumed and the nature
wine (Häikiö 2007, 44; Ahlström & Öster- and purpose of the drinking situation are
berg 1981, 54), probably as a result of the standardized, say in an experimental set-
increased use of wine as an intoxicating ting?
substance. Our literature review showed no large or
consistent differences between different
 Can alcohol policy influence alcohol- beverage types with regard to the harm
related harm through beverage type? they caused. We did, however, see some
There is no doubt then that it is possible minor differences and potential indica-
by means of alcohol policy to influence tions of differences. It seems that spirits

are more closely associated than other order to reach the same level of ethyl alco-
beverage types with alcohol poisonings hol intake. Even wine contains about three
and aggressive behaviour. Via aggressive times the amount of liquid per one centi-
behaviour, spirits may therefore also be litre of ethyl alcohol compared to spirits.
a somewhat more important cause of vio- The easiest way to consume large quanti-
lence. It has been hypothesized that wine ties of alcohol, to carry it around and to
drinking might offer a greater protective ef- drink it unnoticed is thus to consume it in
fect against CHD and that spirits are a more the form of spirits. Spirits provide a faster,
important cause of certain cancers, but the more effective and more dependable way
evidence remains inconclusive and con- of getting drunk. Conversely, the state of
tradictory. drunkenness achieved when consuming
2) Does the choice of beverage type have milder beverages might often end up at a
a direct effect on the amounts of absolute less intensive level. With spirits, there is
alcohol consumed? also a greater chance than with milder bev-
Our results showed that spirits have a very erages that people drink more than they
prominent role in Finnish binge drinking: intended, and consequently that they get
the proportion of spirits consumed increas- more drunk. Even though there is no firm
es in direct proportion to the amounts con- scientific evidence that people are inclined
sumed on individual drinking occasions. to drink more spirits than milder alcoholic
Beer is also consumed in large quantities beverages while others factors (such as the
on binge drinking occasions, but a system- purpose of drinking) remain constant, the
atic correlation is only seen for spirits. In practical experience strongly suggests this
other words, beer is widely consumed on is the case. It is hardly a coincidence that
different kinds of drinking occasions, but one of the A-Clinic Foundation’s top tips
spirits are “needed” in order to get really on how to cut down on drinking on its
drunk. As was pointed out earlier, this as- dedicated website says: “Switch to mild-
sociation is explained not just by the causal er beverages, dilute your drinks” (http://
effect of the choice of beverage type: even www.paihdelinkki.fi/juomisen-hallinta/
in the hypothetical situation where spir- vahentamisen-vinkkeja).
its would be efficiently prohibited, these It is worth repeating here that the
heavy drinking occasions would not be strengths at which different beverages
transformed into moderate drinking ocas- are consumed differ much less than the
sions, but some other alcoholic beverage strengths at which they are sold in the bot-
would be chosen to fulfil the same purpose tle (Simpura et al. 1993; 1996): spirits are
of getting drunk. often diluted, and on half of all drinking
On the other hand, even in instances occasions they are consumed at strengths
where the intention of getting drunk has comparable to wine or milder. However
preceded the choice of spirits, we may ask the same source indicates that there is
which factors have driven that beverage marked variation in the strengths at which
choice. Compared to undiluted spirits, me- alcohol is consumed and that on up to 40
dium-strength beer drinkers need to con- per cent of all drinking occasions on which
sume eight times the amount of liquid in spirits are consumed, they are drunk at an

alcohol content of 25 per cent by volume generally thought. It is interesting to spec-

or higher. ulate on alternative historical scenarios.
3) Can the choice of beverage type influ- Let us imagine that overall alcohol con-
ence the purpose of drinking or the nature sumption in Finland today is at its current
of the drinking situation and thereby the level, but there has never been a conscious
quantities consumed and the level of con- policy to favour beer and wine, and that
sequent harm? therefore spirits accounted for almost 70
There is no question that price regulation per cent of consumption as it did 50 years
can act to change drinking habits by mak- ago, rather than for under 30 per cent as it
ing certain types of drinking situations does today. Who believes that there would
more common. In a purely hypothetical not be more alcohol-related harm than we
example, the removal of all taxes on wine have today?
would undoubtedly increase the consump- There is in fact much debate on this very
tion of wine with meals. However the crea- issue in Russia today, where consumption
tion of new drinking situations does not levels are extremely high and the number
contribute to harm reduction. Whether it is of alcohol poisonings is even higher than in
possible to reduce binge drinking by steer- Finland. Researchers there are convinced
ing people’s choices of beverage type is the that a milder policy line and a large-scale
important question. shift from vodka to beer consumption
The prime motive behind the 1960s would reduce the amount of alcohol-relat-
policy of favouring mild alcoholic bever- ed harm. Western alcohol researchers who
ages was to encourage a change in drink- have seen the consequences of the policy
ing habits and purposes of drinking: to line favouring mild alcoholic beverages
discourage binge drinking, to lower the in the Nordic countries – the increase in
amounts drunk, and to reduce alcohol-re- total consumption and in harm – have not
lated harm. However, the lesson of history argued against such a shift towards milder
is that, at least in the short term, it was un- alcoholic beverages as a way of reducing
fruitful to try and reduce binge drinking by alcohol-related harm.
favouring mild beverages. Since the 1960s In conclusion then, there is no compel-
alcohol has become a more integral part of ling scientific evidence that spirits are
everyday life and social interaction, but much more harmful than milder alcoholic
binge drinking has not decreased; quite beverages. However, based on the argu-
the contrary. The policy that favoured mild ments presented above, we feel it is rea-
alcoholic beverages lowered the threshold sonable to claim that the risks involved in
to start drinking for new groups of users drinking spirits are to some extent greater
such as women, among whom both binge than those involved in drinking milder
drinking and alcohol-related harm have beverages and it would therefore be un-
increased more sharply in recent decades wise to encourage consumers to favour
than among men (Tigerstedt 2004). spirits. There is a group of people, particu-
However, it is quite possible that in the larly heavy consumers, who calculate and
longer term this policy of favouring mild minimize the cost of obtaining ethyl alco-
beverages has had a greater impact than is hol and for whom alcohol is first and fore-

most an intoxicating substance. Especially 23.56€ (calculated for wine at 18 per cent
for this group of people, it would undoubt- abv), on wine 19.27€ (wine at 11 per cent
edly be safer if spirits were not the cheap- abv) and on beer 19.45€. So the question
est source of ethyl alcohol. could arise: why are taxes on spirits not
The lesson of the previous Finnish anal- reduced – or taxes on beer and wine not
ysis of different types of alcoholic bever- put up to at least nearly the same level
ages (Simpura et al. 1993) has sometimes as those for spirits – if the differences in
been interpreted to be that, from a harm related harm per one litre of 100 per cent
point of view, beverage type is irrelevant alcohol are not that large? In our view, this
and that the only thing that matters is the line of thinking is not justified, for as far
amount of alcohol consumed. Nonethe- as public health and social harm are con-
less, Simpura and colleagues conclude cerned the key issue is the price at which
that “the policy of favouring mild bever- different alcoholic beverages are retailed,
ages and the underlying thinking that fa- not the amount of tax that is levied on
vours softer drinking habits is a sensible them. Since the costs of manufacturing,
alcohol policy objective” (ibid., 420), with packaging and transporting spirits are sig-
which we agree. The main message of the nificantly lower per litre of ethyl alcohol
article by Simpura et al., as we interpret it, than the corresponding costs for milder
was that beverage type is not as significant alcoholic beverages, an equal rate of taxes
a factor as was believed at the time. The would make spirits much cheaper per li-
times have changed, and today it seems tre of ethyl alcohol than other beverages.
we have been drifting towards the other Based on our review above, this situation
extreme again: there are some arguments would in all probability lead to an increase
around which suggest that beverage type in alcohol-related harm.
has no significance at all. Our message is Translation: David Kivinen
that beverage type is likely to have some Pia Mäkelä, senior researcher
significance. Alcohol and drug research group
Some health economists take the view STAKES – National Research and Development
Centre for Welfare and Health
that the only acceptable tax policy is one
POB 220, FIN-00531 Helsinki
where the differences in taxes levied on al- E-mail: pia.makela@stakes.fi
coholic beverages are proportionate to the Heli Mustonen, senior researcher
external harm they cause (see e.g. Cnossen Alcohol and drug research group
2007). If spirits cause only modestly more STAKES
harm than milder alcoholic beverages, the
E-mail: heli.mustonen@stakes.fi
tax levied per litre of ethyl alcohol should, Esa Österberg, senior researcher
according to this thinking, be only slightly Alcohol and drug research group
higher for spirits than for milder alcoholic STAKES
beverages. In 2007, the tax on spirits in
E-mail: esa.osterberg@stakes.fi
Finland was 28.25€ per litre of 100 per
cent alcohol, on intermediate products

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Making use
of research
Making use of alcohol and drug

research: An introduction
“Making use of alcohol and drug research: ferent relations between science and policy
picking the best bits from the smorgasbord?” and different ways of dealing with alcohol
was the theme for the mini-seminar hosted and drug problems. True to his calling, Room
by the Nordic Centre for Alcohol and Drug presents a research programme: One way of
Research (NAD) at the annual NorDAN con- gaining knowledge of the dynamics and dif-
ference in Reykjavik on October 13th 2007. ferences would be to analyze how important
Alcohol and drug research is experiencing a research innovations, such as the “total con-
changing environment, with increasing ideo- sumption theory”, have been received and
logical conflicts, and where research has less implemented within various national frame-
of an automatic authority than one or two works, with different actors and policy-re-
generations ago. New, and sometimes high- search structures.
ly valuable knowledge cannot be claimed Matilda Hellman, one of the organisers of
as solely a product of and in the control of the seminar in Iceland, reflects upon the use
scientific peers. For example, the so-called of alcohol research, in part from a science
third sector is establishing partly new re- communication point of view. The espe-
lations to research, maybe most clearly so cially close relation between (alcohol) pol-
in the “post-corporative” Norden. A more icy and research in the Nordic countries, in
problematic phenomenon is the alcohol in- combination with a strong presence of vol-
dustry's increasingly active and inventive untary organisations, may have resulted in
involvement in the financing and use of re- a non-hierarchical and socially responsible
search. One of the leading ideas behind the kind of research, but it may also have created
Reyjkavik meeting was that researchers and a strong culture of cautiousness and consen-
representatives from the third sector would sus, where politicians and the research com-
be able to exchange views on the roles, mo- munity are expected to talk with one voice.
tives and limitations of different actors in The present more diversified scene may seem
the use of alcohol and drug research, based threatening from a consensus perspective.
on their own experiences. Hildigunnur Ólafsdóttir discusses dif-
In the following five commentaries, con- ferent uses of research. The demand for an
tributors of the workshop discuss the matter evidence base and the “technocratization”
from different aspects. Robin Room describes of research is to some extent a consequence
his experiences from four countries where of the diminishing role of the alcohol ques-
he has worked as researcher and research tion and of increasing steering of public re-
administrator: the US, Canada, Sweden and search money. Alcohol and drug research
Australia. He outlines the four different po- has further challenges in the shape of com-
litical cultures and regimes, with their dif- municating across disciplinary boundaries

Making use of research
and with professionals in the fields of treat- seeks three types of research findings, she
ment, education and policy making, and states: figures, best practices and future chal-
in the shrinking role of relevant voluntary lenges. But the unfortunate reality is that the
organisations. In political decision-making, evidence is often fragmented, different ver-
research can perhaps be more important on sions of facts are presented, and evidence
an international than national level, Ólafs- is not always comparable, or even policy
dóttir suggests. In small countries good con- relevant. (In fact, Rapley defends the rights
tacts with the media may be more important of researchers to be politically “useless”.)
in influencing decision-making than direct Finally, the industry is actively using “evi-
contacts with politicians. To summarize, the dence” to argue its cause and to gain a posi-
author suggest that researchers, if they want tion in the EU political process. As a conclu-
to influence society, must make themselves sion, Rapley notes that the relation between
much more aware of the experiences, values research and organisations lobbying for
and interests of the different consumers of public health measures in the alcohol field
research. is embedded in a complicated web “where
Katariina Warpenius and Marja Holmila evidence, stakeholders, political decision-
describe their experiences from a localised making and public opinion are interrelated”.
alcohol prevention project, PAKKA, in four The causal links between advocacy success
towns in Finland. As an example of the role and any particular factors may often be dif-
of researchers in projects aimed at an evi- ficult to identify. She ends by presenting the
dence-based policy, PAKKA is illustrative. example of the homelessness researchers
The authors argue for active contacts be- in Europe, who have organised themselves
tween researchers, politicians and the media so as to improve their understanding of the
if the aim is to achieve changes and a lasting problem of homelessness and to develop ef-
implementation of new policies. fective politics. Can this be a model for alco-
Finally, Emilie Rapley from Eurocare de- hol (and drug) researchers?
scribes the challenges in using research from This collection of commentaries will hope-
the point of view of an umbrella third-sec- fully lead to further debate about the relation
tor organization that aims at promoting the between research and research consumers in
prevention of alcohol-related harm on a the Nordic countries and Europe.
European level. The organization in general
The editors

Robin Room
National variations in the use of

alcohol and drug research
Notes of an itinerant worker
I have been a social researcher on alcohol,

and sometimes also on drugs and gam-
bling, in five countries. This is an account
along with biological researchers, at a Senate
hearing in Washington basically in support
of more money for alcohol research. Besides
of my own experience in four of those that, one California state senator took an in-
countries with the relation between social terest in the field for a while, and met with
research and the world of policy. (Norway us several times. Otherwise there was little
is excluded, since I worked there for only contact with politicians or the political proc-
six months.) In all of those countries, I was ess.
working on research which could be seen as We did have some influence on policy. But
relevant to policy: studies of patterns of use it tended to be by influencing civil servants
and problems in the general population, and or through intermediaries. The head of the
to some extent also policy impact studies. California state agency (Loran Archer) came
Let me start with some notes on the experi- to us as he started to think beyond building
ence in each country, before moving on to a treatment system as the limits of alcohol
some comparisons, reflecting on my experi- policy (see Room & Sheffield 1976). Like-
ence. wise, a group of us served as mentors to the
Prevention Division of the National Institute
Experiences as an itinerant on Alcoholism and Alcohol Abuse (NIAAA)
scholar as it moved in the same direction. The in-
 Berkeley, California, USA, 1963–1991 coming head of NIAAA (Ernest Noble) came
I started as a research assistant on the Cali- out to visit us, since he had read and been
fornia Drinking Practices Study in 1963, and persuaded by the “purple book” produced
moved up through the ranks of what even- by Kettil Bruun and colleagues (Bruun et al.
tually became the Alcohol Research Group 1975). Our work and thinking also played a
to be its director from 1977 until 1991. In role when the National Academy of Sciences
all that time, I can remember testifying in produced a 1981 report on Alcohol and Pub-
government hearings a total of twice. I was lic Policy (Moore and Gerstein 1981).
the only person to testify to a California state In the early days, we were mostly left
government agency in favour of Governor alone by the media. If they came by, the only
Jerry Brown’s inspired but doomed idea of question of interest to them was “How many
combining the state alcohol licensing and alcoholics are there in the United States?”
control agency with the state alcohol prob- By the late 1970s, the alternative community
lems treatment agency. And I testified once, newspapers were beginning to pick up on a
Revised from a presentation at a Nordic Centre for Alcohol and Drug Research workshop on “The use of
alcohol and drug research”, Reykjavik, Iceland, 13 October, 2007. Thanks to Norman Giesbrecht for his
comments.

change in the wind on thinking about alco- the other hand, the Toronto media were quite
hol—what has been called the “new public hostile to ARF, particularly on alcohol is-
health” approach—and later that gradually sues. The media and political environments
made its way into the mainstream press. were very “wet”, and the reporters could not
Nongovernmental organizations mostly had imagine that we were right in reporting that
their own policy agenda, not much attuned alcohol policy attitudes in the general popu-
to research findings. That began to change lation of Ontarians were considerably “dry-
with the rise of Mothers Against Drunk Driv- er” than those of their friends. On the other
ing (MADD), which did its homework on hand, the public health community, includ-
data which was relevant to its aims. Alcohol ing various Boards of Health, had considera-
industry interests sniffed around a few times, ble influence in alcohol policy, and success-
but showed no serious interest in funding fully opposed the provincial government’s
social research, and gradually settled into an proposed privatization of alcohol retailing
antagonistic relationship to the “new public in Ontario in 1995.
health” orientation. Very late in the game, Nongovernmental organizations were
the state alcohol monopoly systems began to often in fact supported with government
realize that researchers had something to of- funds, so that “community meetings” often
fer them in their struggle to survive. turned out to be between employees of dif-
In the U.S., the prestige and the media ferent quasi-governmental organizations.
and political attention went to biomedical Policy decisions were more consensual than
research, and to a lesser extent to clinical rein the U.S., and changes were rarely abrupt.
search. Occasionally, social scientists were During the 1990s, the federal government
called into play, as in the moves to decrimi- was in retreat in the alcohol and drug field
nalize public drunkenness in the late 1960s and in terms of its general funding of health
and 1970s, but basically the policy concep- research, so policy was mostly made at the
tion of alcohol problems was in terms of provincial level, and there were efforts to
alcoholism and the solutions were seen as make up for the absence of a national pres-
coming in the indefinite future from bio ence by interprovincial activities (Anony-
medical advances. mous 2007).
 Toronto, Ontario, Canada 1991–1998  Stockholm, Sweden 1999–2006

In Toronto, I was the Vice-President for Re- In Stockholm, I directed the new Centre for
search in a large provincial agency, the Ad- Social Research on Alcohol and Drugs at
diction Research Foundation (ARF), with re- Stockholm University. The first week I ar-
search, treatment, training and community rived, I testified on alcohol policy matters to
program functions. I testified maybe 10 times a committee of the parliament, with all 15
in all at parliamentary or city council hear- members in attendance. While the contacts
ings at various levels—nationally, in Ontario thereafter tended to be less formal, our Cen-
and in British Columbia. We had regular tre was regularly involved in contributing
meetings and some collaboration with the evidence or analyses to the policy process,
Ontario alcohol monopoly. I had moved into to parliament, to the ministry and to various
a political system which, more than in the authorities (myndigheter), and in a network of
U.S., saw social research as relevant to the contacts and discussions with civil servants.
alcohol and drug policy process, and into The Swedish tradition of commissioning of-
a tradition at ARF of offering “Best advice” ficial investigations and then inviting formal
documents to the policy process whether or submissions commenting on the investiga-
not they were asked for. tion’s report ensured that relevant researchers
Relations with the alcohol industry were were involved in the policy process.
less polarized in Canada than in the U.S. On Alcohol matters are generally more news-

worthy in Sweden than in North America, looking for partnerships with the research
and I was often involved in our regular world. My unexpected appointment as board
contacts with the press, despite my lack of President of the coordinating body for alco-
spoken Swedish. The media was generally hol and drug service agencies in Australia is
well informed, and press relations were gen- a sign of this readiness to involve research-
erally respectful. After the appointment of a ers in the world beyond the academy.
national drugs coordinator in 2002, attitudes
on illicit drugs relaxed a little in Sweden, Some comparisons
opening up the possibility for that area, too,  Each polity has its own style in terms
to become more evidence-based. of the relation between social science
Until now, at least, the alcohol industry and policy
has played much less of a role in politics in In the U.S., the style is more hands off. Most
Sweden than in politics in North America. research is funded though specific-topic
We had polite contacts, but not much more. research funding agencies—the NIAAA, in
We had more regular contacts with temper- the case of alcohol. This ensures that there
ance movement organizations, which retain is earmarked money for alcohol research—
some presence in Sweden (indeed their without this, in all four countries alcohol
membership is rising); they were among our research tends to lose out, because of the
main points of contact with civil society. topic’s location at the periphery of academic
disciplines. But, as Lorraine Midanik (2006)
 Melbourne, Victoria, Australia 2006– has charted, there has been a long-term drift
2007 towards an increasing biomedical domi-
In Melbourne, I am director of a ��
small alco- nance of what receives research funding.
hol policy research centre within a multi- Social research is generally insulated from
function agency (treatment, help lines, train- the political process, though occasionally
ing, research), as well as a professor at the the facts or the findings of some study are
University of Melbourne. My position was seen as politically shocking, and the insula-
funded by the state government as a signal tion breaks down. At least directly and in the
of increased interest in alcohol policy; the short run, social science research has little
requirement that three policy papers be pre- influence on policy.
pared for the department each year ensures In Canada, at least during my years there,
regular contact with the civil service. I had research programs continued from old mo-
testified to Victorian state parliamentary mentum. New research was viewed as an
committees several times before coming to optional extra in an era when governments
Melbourne, but since coming to Melbourne had been cutting their research commit-
contacts have been primarily through infor- ments. Despite ARF’s best efforts at dis-
mal meetings with legislative staff and civil semination and implementation in Ontario,
servants, and by my appointment to state policies with regard to specifics of access to
and federal advisory committees. alcohol, e.g., hours and days of alcohol sales,
Generally, governmental interest in the real price, and control of smuggling, overall
evidence basis for policy is as strong as in the policies seemed not much influenced by re-
Nordic countries. But the alcohol industry is search. Exceptions to this were the area of
much stronger, and wary of public health drink-driving, and the area of alcohol con-
researchers, and these attitudes carry over trol, where research had provided some sup-
also to the state liquor licensing agency. The port for the maintenance of the provincial
media is interested, and often well informed. alcohol monopolies.
An increasing number of nongovernmental Sweden, with its strong commitment to so-
agencies (often government-funded, at least cial engineering, is to some extent the social
in part) are interested in alcohol issues, and scientist’s utopia. In the alcohol policy are-

na, alcohol research tended to be a relatively A high proportion of those coming to treat-
conservative force, providing an evidence ment, in treatment modalities generally more
base to defend Swedish alcohol control poli- social than medical, are there under pressure
cies from the free-market pressures from the from the courts, often formalized in such in-
European Union (e.g., Norström 2002). In the stitutions as Drug Courts. Alcohol and drug
drugs area, there had been an era of a strong treatment agencies generally turn as much
drug-free ideology in which social research- of a blind eye as possible to the coercive
ers in the field were suspect and marginal- auspices of their client flow, since this does
ized, and little research was commissioned. not fit the idealized therapeutic model of the
This was transformed by the drugs coordina- treatment trials and textbooks. The practical
tor’s commitment to collecting an evidence focus of the U.S. treatment system is thus on
base for policy, which meant that a plethora social and criminal problems, but there is a
of small studies were carried out after 2002, strong disjunction between this and the elab-
in a considerably changed political climate orate research effort, which tends to focus
for such research. on brain pathways and the search for anti-
Australia’s traditions of alcohol and drug addiction medications.
research are largely a product of the last 20 The Canadian framing is mixed. The dis-
years. Researchers’ main influence on policy ease model is present as part of the policy
has probably been through a dense network frame, but less rigidly defined than in the
of advisory committees. Researchers and U.S. In the great U.S. battles of the 1980s
professionals have consistently insisted over whether “controlled drinking” was a
on the importance of alcohol, compared to legitimate aim of alcohol treatment (Sobell
drugs, to the political world. The message & Sobell 1995), Canada provided a welcom-
was unpalatable to the federal government ing and less ideologically rigid refuge. The
in power between 1996 and 2007, but even criminal courts have less of a gate keeping
abolishing one advisory system and erect- function on treatment than in the U.S., so the
ing another (Fitzgerald 2005) did not really treatment is generally less often coerced. As
get the federal politicians the answers they in the U.S., treatment methods are generally
wanted. Civil servants and parliamentary nonmedical, except for opiate maintenance
staff are quite committed to developing and therapy. In the research world, influenced by
using an evidence base for policies, although the U.S. (and the possibility of U.S. funding),
in an area like alcohol policy, where substan- there is a creeping biologization, but social
tial economic interests are at stake, actual and policy research appears to have held its
policy change tends to be at a glacial pace. own and even advanced, for instance in Brit-
ish Columbia.
 Each polity has its own style of Sweden has long differed from the Eng-
defining and handling alcohol and drug lish-speaking world and from much of Eu-
problems rope in defining alcohol problems primarily
In the U.S., the political framing of alcohol in terms of social welfare and workforce
problems is as “alcoholism”, and of drug participation. Despite the advent of opiate
problems as a “recurring brain disease”. This maintenance therapy, which requires some
biomedicalization of the problem definition medical input, two-thirds of Swedish treat-
has effects on research priorities, generally ment is still provided by the social welfare
assigning a marginal role to social research. system, and only one-third by the health sys-
But the framing has rather little effect on the tem. Sweden has kept a system of civil com-
actual handling of alcohol and drug prob- mitment of heavy alcohol and drug users to
lems. The lead social agency in handling treatment, mostly abandoned in Anglophone
drug problems, and increasingly also alco- countries. But the system is small (about
hol problems, is the criminal court system. 1000 cases a year)—much smaller than the

diversion from criminal courts in the U.S. or handling problems or particular policy in-
the U.K. While there is some biologization terventions. All such studies can easily be
of research, the traditions of social, crimino- justified within the bounds of a particular
logical and policy research have remained policy framing.
strong with respect to alcohol. Although What this model of the relation between
the social rejection of illicit drugs remains science and policy does not allow for is the
strong, the panic has faded, enabling a re- possibility of “abnormal science”, in Kuhn’s
surgence of social and criminological drug terminology—that research may question
research. relationships taken for granted in the domi-
Australia’s framing of alcohol and drug nant paradigm, or may bring to the fore is-
problems, like Canada’s, might be described sues which do not fit within it. Research
as mixed. In the modern era, the emergence and researchers may then play an important
of alcohol and drug research as a field came role in the construction and institutionaliza-
in the wake of public concerns over the rise tion of a new paradigm. Or, in practically-
of illicit drug use. The main framing has been oriented fields such as ours, the impulse for
in terms of public health and “harm reduc- paradigm change may come from outside the
tion”, with public health-oriented doctors research community.
providing the main conceptual matrix. The
conservative political reaction against this  A start on comparing national
framing redefined it somewhat, but did not experiences with paradigm shifts
succeed in dislodging it. Given this history, In the context of alcohol research and poli-
present-day arguments on alcohol policy, as cy, we may identify the “new public health”
it comes to the fore, are often framed in terms approach—known in Sweden as the “total
of comparisons with illicit drugs. Though consumption model”—as such a paradigm
funded through decentralized and often change. Elements of the new approach came
quixotic paths, social and policy research on to the fore in Finland after 1969, as research-
alcohol and drugs have built up quite strong ers grappled with the rise in consumption
traditions in Australia, and the media and and alcohol-related problems following an
policy worlds show interest in the results of increase in alcohol availability which was
such research. supposed to tame Finnish drinking (Tiger-
stedt 1999). The Swedish experience with
 Normal science and paradigm shifts the rise in youth consumption and problems
Funding and support for research is almost when “medium beer” was introduced also
always provided within the terms of the provided empirical background for a shift.
dominant paradigm or framing of the nature Meanwhile, Canadian researchers recog-
of the problem and of suitable solutions for nized the relation between changes in price,
it. Using Thomas Kuhn’s (1962) term in The in levels of consumption and in rates of cirr
Structure of Scientific Revolutions, research hosis deaths, pointing to the total level of
support is thus provided for “normal sci- alcohol consumption in a population as an
ence”, research projects that operate within important policy concern (Room 1991). U.S.
a given framing of the research problems. researchers found that drinking problems in
What the policy process looks for from so- the general population were widely spread
cial science is reports on such matters as but much more diffuse than in treatment
the monitoring and analysis of behavioural populations, which suggested that providing
trends, scoping and monitoring the size of treatment was at most a limited response to
problems, the identification of new and rates of alcohol problems in a society.
worrying trends, intelligence on hidden As these elements came together (for in-
behaviours, and studying the effectiveness stance in the “purple book”, Bruun et al.
and cost-effectiveness of particular ways of 1975), their first and strongest influence was

in the Nordic countries. In part this reflected When I arrived in Sweden in 1999, there
a closer connection between social science was a strong political consensus against the
researchers and the policy process, and in “harm reduction” paradigm shift in illicit
part probably a specific structure of poten- drugs which had taken root in many other
tial political influences—that Nordic tem- countries. Swedish illicit drug research-
perance movements retained some strength ers—primarily criminologists—who had
in the 1970s, and that the alcohol production been part of these international currents of
interests were relatively politically weak. In thinking were marginalized from the policy
the Canadian context, research agendas were process and indeed held at arms-length from
relatively insulated from political pressures, it. As Lenke and Olsson (2002) put it, drug
and it was recognized relatively early that “researchers and other drug policy experts
the new framing provided a defense for the were ... placed in an intellectual quarantine”.
state’s strong control of the alcohol market, Given the commitment of Swedish public
notably through the provincial alcohol mo- life to take account of research findings in
nopolies. On the other hand, the policy in- setting policy, the political solution had
fluence of the new paradigm has weakened been to commission very little social drug
in recent years; the provincial government research; a study which is not done cannot
retailers have shown little interest in con- upset a political consensus. The advent of
trolling overall consumption, and instead the drugs coordinator in 2002, and his com-
have focused on alcohol promotion, market- mitment to increasing the knowledge base
ing and increasing sales from one year to the for Swedish drug policy, played a substan-
next. tial role in breaking up this stalemate, and
In the U.S., the new paradigm advanced putting Swedish drug policy on the more
in the face of strong opposition, particularly usual Swedish path of evidence-based social
from the alcohol industries, who forced out engineering. In this case, the impulse for a
two directors of NIAAA in succession pri- change which might be seen as amounting to
marily because they had picked up the para- a paradigm shift came from the political side
digm. As one of the directors put it, looking rather than the research side.
back, he “had no choice … but to be in con- Science is international—even most of
frontation: research was leading and we had social science, though it must take account
no choice but to move” (Room 1983). of social and cultural particularities. Para-
Meanwhile, in Australia the new paradigm shifts in science thus are also usually
digm had little initial traction. A leading international. But studying and comparing
social alcohol researcher, Margaret Sargent whether and how and when a shift takes
(1979), to some extent picked up on the root in a particular society is illuminating
paradigm, but she was in the process of be- in many ways. In particular, it offers a good
ing pushed by more mainstream sociologists way to compare national practices and tradi-
out of research work. Australian attention to tions in the relations between social science
the model came in eventually in the specific and policymaking.
context of alcohol problems among Aborigi-
Robin Room, Ph.D.
nal populations in remote areas and country
School of Population Health, University of
towns, and has gradually taken hold also with Melbourne, Australia;
respect to the wider society. One reason for the AER Centre for Alcohol Policy Research, Turning
relatively late adoption of the model in Aus- Point Alcohol & Drug Centre, Fitzroy, Victoria,
tralia was that substantial investment in alco- Australia;
hol research has also come relatively late. Centre for Social Research on Alcohol & Drugs,
Paradigm shifts do not always come di- Stockholm University, Sweden
rectly from research into the policy world.

REFERENCES Norström, T. (ed.) (2002): Alcohol in Postwar

Europe: Consumption, Drinking Patterns,
Anonymous (2007): The CCSA National Working Consequences and Policy Responses in 15
Group on Addictions Policy: Historical Over- European Countries. Stockholm: National Insti-
view. Ottawa: CCSA. [Online: http://www.ccsa. tute of Public Health and Almqvist & Wiksell
ca/CCSA/EN/Research/National_Policy_Wor- International
king_Group/] Room, R. (1983): Former NIAAA directors look
Bruun, K. & Edwards, G. & Lumio, M. & Mäkelä, back: policymakers on the role of research.
K. & Pan, L. & Popham, R.E. & Room, R. & Drinking and Drug Practices Surveyor 19:
Schmidt, W. & Skog, O.-J. & Sulkunen, P. & 38–42
Österberg, E. (1975): Alcohol Control Policies Room, R. (1991): Social science research and
in Public Health Perspective. Helsinki: Finnish alcohol policy making. In: Paul Roman (ed.):
Foundation for Alcohol Studies, Vol. 25 Alcohol: The Development of Sociological Per-
Fitzgerald, J. (2005): The Australian National spectives on Use and Abuse, pp. 311–335. New
Council on Drugs (ANCD) and governance in Brunswick: Rutgers Center of Alcohol Studies
the Australian drug policy arena. Contempo- Room, R. & Sheffield, S. (eds.) (1976): The Pre-
rary Drug Problems 32: 259–293 vention of Alcohol Problems. Sacramento:
Kuhn, T. (1962): The Structure of Scientific Revo- California State Office of Alcoholism
lutions. Chicago: University of Chicago Press Sargent, M. (1979): Drinking and Alcoholism in
Lenke, L. & Olsson, B. (2002): Swedish drug po- Australia: A Power Relations Theory. Melbour-
licy in the twenty-first century: a policy model ne: Longman Cheshire
going astray. Annals of the American Associa- Sobell, M.B. & Sobell, L.C. (1995): Controlled
tion of Political and Social Science 582: 64–79 drinking after twenty five years: How im-
Midanik, L. (2006): The Biomedicalization of Al- portant was the great debate? Addiction 90 (9):
cohol Studies: Ideological Shifts and Institutio- 1149–1153
nal Challenges. Edison, NJ: Aldine Transaction Tigerstedt, C. (1999): Alcohol policy, public
Moore, M. & Gerstein, D.R. (eds.) (1981): Alcohol health and Kettil Bruun. Contemporary Drug
and Public Policy: Beyond the Shadow of Pro- Problems 26 (2): 209–235.
hibition. Washington, DC: National Academy
Press

Matilda Hellman
Public use of and communication about

alcohol research
D rinking three or more alcoholic drinks

per week may reduce the risk of devel-
oping rheumatoid arthritis (RA). This was a
the social alcohol research. My main aim is
to discuss aspects of how (Nordic) alcohol
research is used in the public space in which
result from a large scale study from Karolins- science meets the public.
ka Institutet presented in June 2007 (Källberg
et al. 2007). In the study, greater amounts of The special research-policy
reported alcohol consumption was associat- relationship
ed with even lower risks of developing RA. There are some basic characteristics of the
However, in the initial media coverage, the public space in which the Nordic societal
researchers responsible for the study empha- problems related to alcohol use are framed
sized that they by no means were encourag- and defined. One of these characteristics
ing excessive alcohol consumption. is the relatively close interaction between
The Swedish temperance movement research and policy. According to Olsson,
IOGT-NTO quickly reacted to the reporting Ólafsdóttir and Room (2002) this relation-
with a press release (IOGT-NTO 2007) re- ship was gradually developed in the decades
minding the general public about the harms after 1950, in line with a belief in science
caused by alcohol. The press release referred and progress as well as in social science re-
to and cited the scientific EU-report “Alco- search as a tool for policy making. Alcohol
hol in Europe” (Anderson & Baumberg 2006) policies started to be seen as part of the wel-
pointing out that the risks of getting ill gen- fare policy, and knowledge acquired by sci-
erally increase directly in proportion to the entific methods as a necessary element in the
amount of alcohol consumed. planning of the welfare state. Social alcohol
In this fragmentary description of the research has played a significant role in the
course of events, we come across some in- Nordic alcohol policy field when it comes to
teresting aspects on the different actors and monitoring social developments on a popu-
arenas for public use of and communication lation level, analyzing and describing drink-
on alcohol research findings. At least the fol- ing patterns and examining characteristics
lowing arenas were involved: the research and impacts of different policy tools. The
community, in which the results were pre- role that this kind of research has played in
sented in the first place (at the 2007 annual the Nordic countries could be viewed in the
meeting of the European League Against light of theories of what is called “mode 2
Rheumatism, EULAR), the media, which knowledge production”, where knowledge is
picked up in various ways on the research generated “in the context of application” (see
results and reported on them, and some rep- Gibbons et al. 1994; Nowotny et al. 2001). In
resentatives of the voluntary organisations, societies where mode 2 knowledge produc-
who saw their responsibility in weighing up tion prevails, conditions are established in
the reports from the researchers by referring which not only science speaks to society, but
to another kind of knowledge on the risks society can 'speak back' to science, resulting
involved with consumption of alcohol. In in more open systems of knowledge produc-
this paper I will mainly discuss the role of tion. The ideal mode 2 science is transdisci-

plinary, heterogeneous, it works in varying The translator, the assistant

networks; it is flexible, non-hierarchical and Nordic social alcohol research is contextu-
characteristically it carries a social respon- alised and negotiated in different more or
sibility. There is a close interaction of many less publicly visible processes that involves
actors throughout the process of knowledge a variety of forces and actors: the scientific
production which is therefore considered community, policy making on different lev-
more socially accountable. els, the third sector, the industry and the me-
Apart from the special relationship be- dia. Even though interaction between policy,
tween science and policy, the Nordic alcohol research and the third sector has been close
policy field has also been characterized by a in this field, many circumstances seem to
strong presence of social movements, espe- indicate that some third sector actors would
cially in Norway and in Sweden, and by a like a more effective alcohol research com-
lively public alcohol policy debate. Research munication to support their own agenda.
has been highly contextualized and the com- The traditional, canonical account of the
munication between science and the public communicative relationship between sci-
active. ence and society (see Bucchi 1998) starts out
Good examples of highly contextualized with the idea that the scientific enterprise
social alcohol research tasks are projects like has become much too specialized and com-
the Swedish STAD-project, which tests and plicated to be understood by the general pub-
evaluates methods for preventing alcohol lic. Therefore, a form of mediation is needed
and drug problems (like responsible serv- in order to make scientific achievements
ing-methods), and the Finnish community- more suitable and accessible to the public.
based PAKKA project (see Warpenius & Hol- The mediation requires the intervention of a
mila 2007). new professional figure, a third person who
In line with the theories on a mode 2 wants to “bridge the gap between scientists
science we should consider research pro- and the non-scientific audience” (Bucchi
grammes designed to meet specific socially 1998). This mediator is often described as an
mandated objectives (as e.g. “wars on can- interpreter, a translator, who is reformulat-
cer”) as less integrated or contextualised re- ing scientific discourse in simpler words.
search projects. Priorities are here pre-iden- As the RA-example illustrated, third sec-
tified within a structural framework and tor organizations often work naturally as
financial resources are earmarked. A strong translators of science, when they make use
hypothesis is that the level of contextualisa- of and emphasize such results that support
tion depends on who is the orderer or the their own interests. Eurocare, a European al-
initiator of the research tasks, and on what liance of voluntary and non-governmental
kind of networks and support systems the organisations concerned with the European
research process depend. Union’s influence on alcohol policy, is dis-
The different economic and administra- cussing the use of research in its own activi-
tive structures of the knowledge producing ties, and ponder a more structured solution
institutions may have driven the alcohol re- for continuous use of alcohol research find-
search into different directions in the differ- ings. In her discussion paper, Emilie Rapley
ent Nordic countries. In order to get a picture (2007) glances at a model with a researcher-
of how the structures and financing of the based observatory developed by FEANTSA,
research centres affect the tasks of the main the European Federation of National Organi-
social alcohol and drug research centres in sations Working with the Homeless. The
the Nordic Countries, NAD has carried out Observatory is composed of a network of
an investigation that will result in a report to researchers across Europe, carrying out tran-
be presented in the spring 2008. snational research relevant to FEANTSA’s
policy agenda. Another example of an ex-

tended need for research-based knowledge on a daily basis, presented three clear tasks
by third sector players is the Finnish Blue for the alcohol researcher: 1) to present the
Ribbon Organisation, which from 2007 has overall picture of the developments of alco-
expanded its own research and investigative hol consumption and drinking patterns, 2) to
activities. comment on alcohol use, patterns, practices
It is too early to draw any empirical con- and damage developments and 3) to com-
clusions of the policy effects of these research ment – and often to take a stand – on differ-
ambitions, but the initiatives per se tell us ent alcohol policy tools and decisions. The
something. Firstly, the organisations want to roles connected to these tasks are mainly the
shrink the gap between science production popularisationist's, the interpreter's and the
and the users of science (e.g. themselves). critic's. As an underlying (weaker) discourse
Secondly, the initiative introduces a partly one can read into it the role of the participant
new role for the researcher. The researcher that wants e.g. to guide the public into un-
becomes a mediator and an assistant but po- derstanding the value of a restrictive alcohol
tentially also an activist. policy.
Only on rare occasions does the researcher
Researchers doing science intentionally step out of these roles and ac-
translation tively take part in the debate on his/her own
The communication of science to the public initiative. One good example of such a breach
is in Bucchi's canonical account reduced to is when in 2004 the researchers Jessica Palm,
a mere matter of linguistic competence. The Sharon Rödner and Kalle Tryggvesson from
researcher employing this role is translating SoRAD, Stockholm University, commented
the science language into a lay and practical on the national Swedish Alcohol Commit-
discourse. When interviewed by the media, tee's campaign on pregnancy and alcohol in
for example, the alcohol researcher makes a debate article in the daily paper Dagens Ny-
some choices about the role to play, but is of heter. They found that the campaign was ex-
course unable to fully control his/her role in aggerating the risks of low alcohol consump-
the final reporting format. tion during pregnancy, pointing out that
The role of the researcher in the public there was no sustainable scientific evidence
arena has been discussed e.g. by Väliverro- to support the abstention arguments in the
nen (1996) in his study on the publicity of campaign. The campaign was, according to
environmental problems in Finnish media. the writers, rather putting unnecessary pres-
Based on the findings in his material Väli sure on pregnant women. The researchers
verronen groups the tasks of the researcher broke with their own peers' expected public
in the public sphere into five categories: role, but they also broke with the unanimous
the popularisationist, the interpreter, the voice of policy and research, considered so
participant, the manager and the critic. The important for the argumentation behind a
popularisationist's role is telling about the restrictive alcohol policy. Whereas the role/
new research results, the interpreter's is to function of the researchers involved in the
comment on different phenomena and prob- FEANTSA’s Observatory and the Blue Rib-
lems, the participant's role is to demand po- bon would mainly be attached to a specific
litical action and to warn about threats, the (or overall) policy agenda, the function of
manager's role is to describe the use of tax the publicly participating researchers in this
money for research and market the research foetal alcohol syndrome case can be viewed
and finally, the critic's role is to interpret and as quite different and more active. The inde-
comment on research. pendent and deviant (from the point of view
Reporting on alcohol policy in the Nordic of expected consensus) view of Palm and
press and on the Internet have, at least be- colleagues on this aspect of a national alco-
tween 2005–2007, when I have followed it hol policy and its argumentation was criti-

cised by other researchers and politicians, Even though much of the alcohol research
who referred to the difficulties involved in carried out today cannot unreservedly be
the use of science for argumentation in this used for arguing in favour of any particular
particular alcohol policy matter – the sensi- standpoint or any particular question, it is
tive question of the health of pregnant wom- used on a daily basis by representatives of
en and unborn children. NGOs, politicians, civil servants and journal-
In a comment to the discussion, one of the ists in value-based arguments. It is important
participants, Kalle Tryggvesson, asks wheth- for the research community to study and to
er the article in Dagens Nyheter could have discuss new roles of research(ers) in society,
had any influence on the amount of state both in relation to state interests as well as
support that SoRAD later received from the the third sector (not to mention the relation-
Ministry of Health and Social Affairs (Trygg ship to the industry’s interests as a huge task
vesson, 2007). How much will alcohol re- on its own). Is research to be solely a tool
search be bridled and obliged to support the for developing a restrictive alcohol policy? Is
official or hegemonic policy positions? the researcher to be a translator of science for
The economic dependence on State fund- political goals, or an expert to comment on
ing has also been considered by others to af- developments, or is he/she e.g. to take a more
fect the tasks of research and its focus (Fjær independent role and initiate public discus-
2006). I want to suggest that – perhaps even sion? Or maybe all of the above? However
to a larger degree – it also affects and forms we feel about this question, there is no doubt
the public role of the alcohol researcher that looking into the functions and the roles
and to what extent he/she is able to express given to and taken by the researcher can offer
standpoints in the public arena. Consensus us insights into the rationales of this particu-
among the experts (researchers, interests lar knowledge producing field.
groups, civil servants etc.) is generally con- It is difficult to say how the claimed spe-
sidered important in this field. cial relationship between alcohol research
and alcohol policy in the Nordic countries
Conclusions influences the communicative interactions
Communicating science is a difficult task between science and the public, but one
that involves some delicate positioning be- could at least assume that a more applica-
tween the culture that science operates with- tion-oriented research would perhaps draw
in and the format in which the message is the public's and the media's attention. The
mediated to the public. In the aims of the Si- alcohol researchers – especially the ones
monyi Professorship in public understand- that carry on research on alcohol consump-
ing of science at Oxford University we find tion trends and harms at the population level
the following description of the scientist as – are indeed visible in the Nordic media cov-
the communicator: erage. However, as the research has strong
The task of communicating science to roots in the state context, it perhaps makes
the layman is not a simple one. In par- researchers on occasions more reluctant to
ticular it is imperative for the post holder step out of the commenting expert role to be-
to avoid oversimplifying ideas, and pre- come an initiator and a driving force in the
senting exaggerated claims. The limits public debate.
of current scientific knowledge should The role of scientific expertise changes
always be made clear to the public. Once as expertise becomes socially distributed.
done so, however, there is also a role for There seems to be a growing need for an
presenting speculative ideas, which can evidence base to be used by the third sector
convey to non-scientists some of the ex- in this field. This need can be seen in the
citement of doing true science. (Aims of light of the industry´s expanding involve-
the Simonyi Professorship) ment in alcohol policy questions following

the developments at the European level, but Matilda Hellman, project coordinator
it can also be viewed as a shortage in the sci- Nordic Centre for Alcohol and Drug Research (NAD)
ence communication between the research Annegatan 29 A 23
community and the people that need the FIN-00100 Helsingfors, Finland
research in their everyday work. When it E-mail: matilda.hellman@nad.fi
comes to the use of research, most caution
is often (understandably) practiced by the
research community itself.
REFERENCES
“Aims of the Simonyi Professorship” [Ref. associated with decreased risks for developing
1.11.2007. Online: http://www.simonyi. RA – Results from the Swedish EIRA study.
ox.ac.uk/aims/index.shtml] Ann Rheum Dis 66 (Suppl II): 92. Presented at
Anderson, P. & Baumberg, B. (2006): Alcohol in the 2007 annual meeting of the European Lea-
Europe. A public health perspective. A report gue Against Rheumatism (EULAR), Barcelona,
for the European Commission. [Online: http:// Spain, June 13–16, 2007
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tent_en.pdf] Rethinking Science. Knowledge and the Public
Bucchi, M. (1998): Science and the media. Al- in an Age of Uncertainty. Cambridge: Polity
ternative routes in scientific communication. Press
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Fjær, S. (2006): Den flerfaglige rusmiddelforsk- and pregnancy debate by e-mail, November
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Alfredsson, L. (2007): Ethanol consumption is

Hil di gunnur Ólaf s dóttir
Reflections on the use of

alcohol research
R esearch as an idea has almost the same

status as prevention; it is widely praised
and supported. However, if researchers want
Sometimes, new challenges cannot be met
without new knowledge, and research can
provide answers to problems. But research
their results to have an impact, there is no may have an even more important task by
plain sailing from alcohol research to how providing new ways of thinking about old
it is used. In the following, some influential issues. Science is equally often about tearing
complications related to the position of alco- down old knowledge as building up new.
hol research in society will be pointed out. Most researchers want their studies to be
Furthermore, aspects on the communication useful. To turn research results into practice
between the research field and selected areas is, however, no easy task and the relationship
of society will be shortly discussed. between research and policy has never been
simple. Svanaug Fjær (2006) recently initi-
Expectations of research ated a debate on the relationship between al-
The relevance of alcohol studies is a matter cohol research and the public administration
of continuous discussion as research may in this journal. She raised the questions how
provide material for policy decisions. Kettil a critical and creative knowledge produc-
Bruun was of the opinion that research led tion could evolve when the research com-
to the production of arguments rather than munity is so dependent on the State, and the
logical conclusions (Room 1986, see http:// research field is so ideologically loaded. For
www.arg.org/kbs/room-on-bruun.html). In a lively debate in society and for democracy
line with this view, scientific knowledge it is problematic if the relationship between
can be a valuable instrument of the current alcohol research and political power is too
debate on social affairs, but democratic deci- close, leaving little space for points of views
sions are best taken on the basis of values. that are alternative to those of the power cen-
tre.
 Best knowledge
In recent years we have seen increasing de-  Large societal questions and research
mand for evaluations of various programs In an article that Pekka Sulkunen (2007)
and policies. Some even talk about an evalu- calls “Re-inventing the Social Contract” he
ation industry. Increased interest in evi- examines how sociology has changed from
dence-based knowledge probably indicates a being a study of societies to become a study
demand for so-called “best knowledge”, the of practices. In his analysis, within the con-
best we know now, presuming that we will temporary society of contracts, partnerships,
gain more knowledge and better understand- projects, plans and voluntary commitments
ing at some time in the future. Claiming that the State is no longer regarded as having a
“more studies are needed” can, therefore, superior role or being a centre of integra-
have the consequences that policy changes tion, but rather one among several actors in
are not taken or postponed. a rhizome-like network. In this society, the

media is interested in lifestyle issues and research centers for women’s and gender
the moralities involved, the State organs studies have proved to be very important for
are interested in the impact of their own ac- continuity of research and the relationship
tions. Researchers are asked to evaluate, to between research, grass-root and policy.
identify best practices, to measure outcomes Widespread public attention for envi-
and efficiency. Neither politics nor research ronmental threats and climate change has
is dealing with large societal questions such been obtained by activities from the scien-
as the alcohol question; instead we have tific community as well as by environmen-
segmented problems defined by specialized tal groups and concerned politicians. In
expertise. It will have consequences for how this whole process, research was for some
alcohol research is used in society, if the re- time disputed but its role both for chang-
search is trapped in this narrow and techno- ing attitudes and for policy decisions is now
cratic frame. considered to be of the utmost importance.
Per Ole Träskman (2007) has described the Climate change and its consequences have
prerequisites for the Golden Age of Nordic become an issue on the international politi-
criminal policy as a period when continuity cal agenda, but there are also examples that
of the policy was important, and comparative they are affecting individual lifestyles.
research and collaboration between the Nor- Can alcohol researchers draw any conclu-
dic countries had priority. He has explained sions from the comparison of the relation-
the decline of the Golden Age through pres- ship between research and society as in
sure from the EU and the international com- the fields of humanitarian criminal policy,
munity for the Nordic countries to conform environmental concerns and women’s is-
to other countries’ harsher criminal policies. sues? Researchers in these fields are strug-
This pressure has moved law-makers from gling with the same problems as alcohol re-
using Nordic research as a basis for deci- searchers in finding a way to communicate
sions. The idea of zero tolerance for criminal with society. However, research related to
offences has been introduced to the Nordic a broader framed issue such as women’s is-
societies. In Iceland, a harsher drug policy sues and environmental concerns is more
has cleared the way for heavier sentences for likely to have an impact than an issue such
other offences, particularly sexual offences. as humanitarian criminal policy, which is
Like in the other Nordic countries, crimino- often seen as only referring to a segment of
logical research has had very little influence society. A strong relationship between the
on criminal policy (Ólafsdóttir & Bragadóttir respective researchers and the various en-
2006). vironmental groups and womens’movement
Different from the criminal policy field, has sometimes pressed the State to make use
the rising interest in women’s issues on the of research. Alcohol research today lacks
international political level is assumed to this strong connection to movements.
have brought benefits for women’s issues in
the Nordic countries. International women’s The alcohol research community
year in 1975, the UN decade for Women, and society
and World Conferences on Women above all In a segmented society researchers will nev-
served to initiate steps in Iceland towards in- ertheless interact with numerous agents. Re-
creasing knowledge, intensifying demands search questions and results can be dissemi-
for equal rights, and making women more nated to the general research community,
visible and active (Ástgeirsdóttir 2006). The other professionals, public administration,
women’s movement has been relatively suc- politicians, mass media, the alcohol market,
cessful in gaining the attention of new gen- interest groups and civil society.
erations by introducing new issues that have
had support among the grass-root. Specific

 Researchers and other professionals of evidence of good results from alcohol

Even if scientific work is usually a lonely education in schools in Babor et al.’s (2003)
work, at some stages, research is carried book: Alcohol: No Ordinary Commodity has
out in dialogue with other scientists. Re- for instance been hard to swallow for many
search ideas are discussed; interpretations working in the alcohol prevention field who
and conclusions are disputed or accepted thought they were doing a good job (see
by colleagues. Most advances in research also Craplet 2007; Rise 2007; Odejide 2007;
are developed through dialogues, so other Damberg 2007).
researchers’ responses are extremely impor-
tant.  Public administration and politicians
Alcohol research did not use to have a It has been pointed out that government of-
high esteem compared to many other re- ficials are eager consumers of research and
search fields. It was well known that the stig- that they encourage research. But they ask
ma attached to the problem drinker spilled for answers to problems as seen by them-
over to the clinicians working in the alco- selves whereas research may offer answers
hol treatment field. Those devoting their life to other questions. How public administra-
to studying problematic drinking were not tion in the Nordic countries makes use of re-
considered to be good examples of academic search is not very well documented. It may
success. This is no longer the case, probably be assumed that the degree of use of research
thanks to prominent and productive alcohol is higher in countries with well-established
researchers. national research centers such as SIRUS in
Despite this rise in academic status, it Norway and STAKES in Finland, than in
is often difficult for alcohol researchers to countries with more decentralized alcohol
reach out to researchers in other subject research.
fields or special disciplines. Alcohol re- In international politics, research has been
search has certain special obstacles, such proven to be an important vehicle regarding
as being multidisciplinary. Loyalty usually the global burden of diseases. Research may
leads most academics to rely more on and be the heaviest weighing argument when
refer more frequently to research carried nations bind themselves to international
out within the mother discipline than mak- conventions that may restrain national eco-
ing use of contributions across disciplinary nomic interests. Unpopular policy decisions
boundaries. are more likely to be accepted by the gen-
Communication with others than those eral public if they can be scientifically sup-
directly involved in research may involve ported. At home, politicians are inclined to
sharing knowledge with addiction profes- follow the national mood and they are under
sionals, other health care experts, and coun- pressure from interest groups. According
selors, specially trained persons working in to Icelandic alcohol law, local government
the field of prevention and education, social representatives have more power in alcohol
workers and the police. In a recent yearly policy than they are probably aware of. On
report for the Center of Addiction Medi- the local level, pressure from local interest
cine it is stated that the conceptual basis groups may carry more weight than research
for the services is first and foremost scien- evidence.
tific research in health sciences, psycho
logy and social sciences (http://www.saa.  Mass media
is/Files/Skra_0022712.pdf). This ideal may Contact with the media has often been very
in practice not be so easily reached because problematic for researchers and populariza-
of the above-mentioned barriers between tion of science has always been questioned
disciplines and because research evidence by the academic community. At present
may contradict clinical practices. The lack there seems to be an increasing pressure to

publish in peer reviewed journals whereas distance between researchers and the alco-
reporting to the public is not rewarded in the holic beverage industry and services than is
university environment. the case in many other European countries.
In Icelandic society, the mass media is Alcohol studies funded directly by the alco-
relatively easily accessible for researchers. A hol beverage industry have been rare in the
submitted article published in a newspaper Nordic countries.
or an interview with a scientist is more like-
ly to reach a larger readership than a paper  Interest groups and consumers
published in a peer reviewed journal. This Some of the associations which traditionally
may be a good way to reach politicians who aimed for temperance are nowadays con-
watch the mass media very carefully and use cerned with reducing alcohol use and argue
it to promote their causes. Many journalists for creating alcohol-free zones in society.
have some knowledge of social sciences and These pressure groups promote their cause
have a role in agenda-setting by framing the by providing information in order to influ-
issue. The selection of researchers as com- ence policy. Some of them may even initiate
mentators on results or changes in policy particular research projects, but more often
can be a powerful tool to steer the public they are consumers of research.
discourse. With consumerism being a penetrating
Scientific breakthroughs in alcohol re- characteristic of society it is not unexpect-
search are rare. Room and Midanik (2005) ed that the most important interest groups
note how in the USA, results from robust so- relate directly to consumption. In the Ice-
cial science studies get little attention com- landic context such interest groups may be
pared to biomedical research, the latter of classified in two different branches: consum-
which is often based upon very small clini- ers of alcoholic beverages, and consumers of
cal samples and animal studies. The general public services offered for those experienc-
public receives much of its information from ing harms from alcohol.
the mass media, but even if the mass media The so-called consumers of beverages are
can have tremendous short-term effects, it a floating group usually represented by those
often has very little long-term effect. The concerned with the high prices and low
public memory seems to be short. availability of alcohol.
Consumer of services are for instance par-
 Alcohol market ents’ groups, which offer support for parents
Groups involved in for-profit alcohol produc- and their substance-using children. They of-
tion and sales are known to be key players in ten take on the role of campaigning for better
policy debates. Representatives for alcohol services. In Iceland, the far largest interest
production and marketing may praise inde- group in the alcohol field is SÁÁ, with 8000
pendent research when it is convenient, but members. Many of the members are people
are otherwise very selective in how they rein recovery or family members of people in
act to alcohol research relevant to their field. recovery. Originally, the purpose of the asso-
In cross-national alcohol policy discussions, ciation was to fight for better treatment and
representatives of the alcohol industry have services for alcoholics, and today its major
been found to bring different views than activities are running the Center of Addic-
government officials and non-governmental tion Medicine, the main treatment center for
organizations proposing measures for im- addiction. Interest groups in Iceland have a
pact, for which scientific evidence is rather strong victimological approach which may
weak, and opposing regulations for which partly explain why personal experience
the scientific evidence for impact is rather rather than research evidence has been more
strong (Anderson & Baumberg 2006). In the central in campaigning for improved serv-
Nordic countries, there seems to be a greater ices.

 Popular conceptions and to the various types of recipients and us-

Icelandic society like many small societies ers. Research follows its own rules; science
likes to think about itself as a very special is slow and not always available when most
case. Acting rather than discussing is con- needed. Scientific results will be presented
sidered to characterize society. In line with when there is no demand for them. Besides,
the general image of society many Iceland- knowledge is unstable, not all is known and
ers think that Icelandic drinking habits are knowledge can be questioned.
extraordinary. It is also a recurring theme Another complication is that potential
in the discourse that the Icelandic alcohol recipients of research are not waiting with
policy is a failure. University students are empty baskets to be filled by news from the
sometimes surprised when they learn that it research community. They have their own
is not the heavy drinking pattern but prohi- experiences, interests, and values which can
bition of beer for most of the 20th century, a all be legitimate. If we are aware of these
large alcoholism treatment system, and high complications, alcohol researchers may
numbers of AA meetings that distinguish the increase their opportunity of a better com-
position of alcohol in Iceland. Comparative munication with society. In addition to in-
studies such as ESPAD and GENACIS have creasing the demand for relevant and critical
been valuable in bringing knowledge that alcohol research in professional practice and
is contrary to what is presumed. Old stereo in politics, the research community can add
types seem to be long-lasting in the general to the cultural capital of our fellow citizens.
population.
Hildigunnur Ólafsdóttir, Ph.D.
What is the conclusion? Reykjavik Academy
The use of alcohol research will always be a Hringbraut 121
complicated matter and difficult to predict. 107 Reykjavik, Iceland
This is both related to the nature of science, E-mail: hildigunnur@akademia.is
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views of alcohol policy. Nordic Studies on tive alternatives and focus on adults! Nordic
Alcohol and Drugs 23 (6): 393–414 Studies on Alcohol and Drugs 24 (3): 328–329
Ástgeirsdóttir, K. (2006): “Þar sem völdin eru, þar Fjær, S. ( 2006): Den flerfaglige rusmiddelforsk-
eru konurnar ekki”. Kvennaráðstefnur og kven- ningen i Norden – utfordringer til det nordiske
naáratugur Sameinuðu þjóðanna og áhrif þeirra forskerfellesskapet. Nordisk Alkohol- & Narko-
á Íslandi 1975–2005. Saga, XLIV, 2: 7–49 tikatidskrift 23 (2–3):178–182
Babor, T.F. & Caetano, R. & Casswell, S. & Ed- Odejide, O. (2007): Political will is necessary to a
wards, G. & Giesbrecht, N. & Graham, K. & comprehensive prevention approach. Nordic
Grube, J. & Gruenewald, P.J. & Hill, L. & Holder, Studies on Alcohol and Drugs 24 (3): 324–327
H.D. & Homel, R. & Österberg, E. & Rehm, J. Ólafsdóttir, H. & Bragadóttir, R. (2006): Crime and
& Room, R. & Rossow, I. (2003): Alcohol: No criminal policy in Icelannd: Criminology on
Ordinary Commodity: Research and Public the margins of Europe. European Journal of
Policy. Oxford: Oxford University Press Criminology 3 (2): 221–253
Craplet, M. (2007): Prevention of alcohol – and Rise, J. (2007): Prevention of alcohol – and
tobacco-related harms. Education or control tobacco-related harms. Education or control
– must we choose? Nordic Studies on Alcohol – must we choose? Nordic Studies on Alcohol
and Drugs 24 (3): 299–319 and Drugs 24 (3): 320–323

Room, R. & Midanik, L. (2005): Contribution of WEB PAGES

social science to the alcohol field in an era of
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60 (5): 1107–1116 preciation. [Online: http://www.arg.org/kbs/
Sulkunen, P. (2007): Re-inventing the Social Cont- room-on-bruun.html]
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Träskman, P.O. (2007): Var finns forsete? Nordisk pdf].
Tidsskrift for Kriminalvidenskab 94 (2):127–
142.

K atar ii na War p en iu s M arja Holm ila
Connecting alcohol research and

prevention practice: Lessons
learned from PAKKA
PAKKA: Active partners and Research interest – to study what

mixed interventions works and why?
The Local Alcohol Policy Project (PAKKA) The research interest in this project is to
was carried out between 2004 and 2007 in retest existing interventions which, on the
two Finnish regions comprised of several basis of previous studies, are (considered
municipalities. The project has had three to be the) most effective. We used a quasi-
main goals: 1) to promote responsible bev- experimental research design to determine
erage service in restaurants, with the idea whether the interventions have achieved
of decreasing related acute alcohol harms, their goal, and how it was done. Pre- and
2) to increase age-limit control (18 years in post-intervention data have been collected
Finland) and 3) to develop a model for sus- in two intervention regions and in the two
tainable prevention at the local level. In the matched comparison regions for process and
project, researchers and state-level experts outcome evaluation.
from STAKES (National Research and Devel- As in most public health trials, the role
opment Centre for Welfare and Health) have of the researchers in the PAKKA-project has
been active partners with the community been to design interventions, supervise the
organisers in planning and implementing implementation and conduct the process
interventions. and outcome evaluations. The evaluatorsʼ
Recent reviews on the effectiveness of active participation in the project imple-
alcohol political interventions recommend mentation has been necessary because the
that local communities combine commu- research interest is in creating a controlled
nity mobilisation with restrictive alcohol test situation. In an experimental design it
policies. The PAKKA project has relied on becomes important to control not only the
a mixed-intervention strategy that attempts research setting, but also the content of the
to change the social and economic environ- intervention. Consequently there has been
ments related to risky and underage drink- sustained pressure to achieve high scientific
ing. The interventions have included evi- research standards in a real-world situation
dence-based practices, such as enforcement and simultaneously to respond to local proc-
of the law forbidding alcohol sales to under- esses and needs.
age and intoxicated persons and responsible
beverage service training for shops and bars, A top-down, researcher-designed
but also supportive strategies like media project
advocacy, alcohol-free events for youth and Originally the PAKKA project was a part of
drama-based educational programs for par- the National Programme for combating al-
ents. In other words: To gain maximum util- cohol and drug related problems. Since the
ity different approaches were combined in a initiative for local action came from the na-
co-ordinated manner. tional government the project can be classi-
fied as “top-down”. To ensure the scientific

relevance of the interventions, the action the problems needing attention. There was a
plan, which stressed the methods affecting strong interest in scientific input when test-
the availability of alcohol, was developed ing the intervention’s orientation.
in co-operation between the STAKES team Especially important for the local actors
of researchers, local co-ordinators and their was concrete feedback in the form of data on
networks. Thus, the PAKKA project could intermediate outcomes (i.e. outcomes that
be characterized as a researcher-designed reflect the intermediate situation between
project. the preventive intervention and longer-term
When the planning process began, some goals like alcohol-related harm reduction).
efforts were needed to convince the local For example, dummy purchases were carried
prevention workers to adopt a science-based, out in order to test the serving of alcohol to
policy-oriented strategy. Education and in- intoxicated patrons and under-age drinkers.
formation measures had previously been This data could be presented immediately
used frequently in the two project towns, but to local workers and discussed at the local
as we know, the impact of education on the staff meetings. Such information aided local
proportion of alcohol problems is limited. actors in management, decision-making and
During the planning, the researchers there- process steering.
fore reminded the local action groups that Moreover, the results gave a neutral de-
political control measures, such as effective scription of the local situations (problems)
law enforcement and clear sanctions, are in bars and retail stores and perhaps helped
crucial for achieving effects. They stressed to overcome some of the contradictory in-
that educational measures have a value in terests between alcohol markets and control
raising awareness of certain problems, and policy.
advocating for policy changes, but have a
very modest effect on the actual prevalence Ensure ownership through media
of alcohol-related problems. strategies and political lobbying
The alcohol research literature reflects the
Active expert involvement and considerable importance placed on the role
immediate feedback of community involvement and ownership
To test the effectiveness and feasibility of of interventions. Far-reaching participation
an availability-oriented local alcohol pol- can increase potential effectiveness but more
icy it was important to influence the local importantly it may increase the likelihood
actors to actually carry out this type of in- of institutionalization of the adopted strate-
tervention. Thus an active involvement by gies.
researchers was chosen already in the im- One of the important goals for the PAKKA
plementation phase. Training and assistance project was to examine the possibilities of the
were provided by the STAKES expert team institutionalization of those forms of action
in order to support local prevention efforts. that have been shown to be effective. One
The two intervention regions could develop step in this was to create a dialogue with the
local approaches to implementation that community leaders and the key actors. As
were acceptable in their situation, as long as we know, alcohol issues are linked to many
the basic design was maintained. conflicting interests, and local decision-mak-
A special feature of the PAKKA project ers may not want to get involved with these,
was that pre-intervention research findings unless it is shown that an agreement can be
were immediately shared with the local achieved (on at least some issues).
actors already during the implementation Through media strategies and political
process. Research feedback enabled joint lobbying, the project sought to create pos-
researcher–community assessments of the sibilities for sustainable structures for al-
utility of the work and helped to identify cohol prevention. As the implementation

proceeded, research results were utilized in a project, there is a worry that the scientific
media advocacy and community mobilisa- objectivity may be lost. It is argued that re-
tion in order to gain public understanding searchers cannot make reliable assessments,
and support for prevention practices. The because they are also stakeholders, desiring
project co-ordinators were encouraged to the project to be a success. One way of easing
distribute research findings to the media. For this problem is to have several researchers in
example, the results from surveys on public the team and have some division of labour
opinion showed that there was a very high between them. Also, if the researchers fol-
community support for the policy-based allow the scientific rules of data gathering,
cohol interventions such as age-limit control analyses and reporting, purely subjective
and sanctions. conclusions will become too visible to pass
scientific scrutiny.
Exaggerated expectations on the It is also likely that the presence of the re-
political usefulness of research searchers and their attention influences the
In practice it was not easy to find the nec- prevention project—either for the better or
essary resources for long-term institution- for the worse. When this happens, evalua-
alisation. Some of the local authorities who tors do not learn how the intervention would
participated in the project had unrealistic work in normal conditions without research-
expectations. They were hoping to achieve er involvement. One should, however, not
objective knowledge on the cost-effective- exaggerate the effect researchers can have.
ness of the interventions already at a very They remain outsiders, and they can only
early phase of the project. From the research- have a passing influence in the generally
ersʼ point of view this was an impossible quite strong localities with their own ways
demand: The results simply were not there of handling things. In any case, the research
yet. interest is a true factor in demonstration
projects, and has to be discussed and ana-
Unique communities – copying lysed as such.
implementations is difficult
In community-based action the interven- Conclusions: Researchers’ active
tion is hardly ever exactly transferable to participation is needed
another locality—each community has it On the basis of lessons learned from PAKKA
own traditions and ways of working. The the project’s researchers are hopeful that lo-
PAKKA project wanted to gain information cal communities can be encouraged to pre-
on what kinds of circumstances produced vent alcohol-related problems by increasing
the achieved impact: One action could lead enforcement of law in combination with
to another and be effective, but only if it took training, community mobilization and influ-
place in the right kind of circumstances. encing public opinion.
When analysing the community context one However, the methodologies of the posi-
needs to know about the essential features tivist research paradigm have been recog-
of the community’s inner mechanisms, like nized as difficult if not impossible to em-
its traditions, cultural characteristics and ploy. In order to carry out a “proper” experi-
power structures. This understanding can ment, researchers should attempt to control
assist other regions with implementing poli- for such phenomena as selection and self-
cies based on research. presentation of participants, competition,
community history, limitation of interven-
Effects of researchers’ tions and other threats to validity. Of course
involvement in projects? one can argue that it makes little sense to
When researchers are involved in the imple- insist on “evidence-based research” in the
mentation—as well as in the evaluation—of sense of well-controlled experiments since

it is not feasible in most research settings. common goals and sticking to the research
But if the researchers carefully follow the setting, but also flexibility and compromise
scientific rules about data gathering, analysis —in one word: social skills.
and transparency there is an increased pos-
sibility to reach reliable results—and to be Katariina Warpenius, special researcher
protected against biased conclusions. Alcohol and drug research group
All in all: As long as researchers decide STAKES – National Research and Development
to be non-participating observers in com- Centre for Welfare and Health
munity projects, the genuine connection of POB 220, FIN-00531 Helsinki, Finland
alcohol research and prevention practice E-mail: katariina.warpenius@stakes.fi
will be an impossible dream. Aiming for Marja Holmila, senior researcher
Alcohol and drug research group
empirical evidence is essential for research,
STAKES
but we think it is equally important to inter-
POB 220, FIN-00531 Helsinki, Finland
pret existing evidence and results with the
E-mail: marja.holmila@stakes.fi
prevention workers. The dialogue requires

E m i l i e R a p ley
The use of alcohol research in Eurocare’s

lobbying activities
Picking the best bits from the The use of alcohol research in
smorgasbord? lobbying: A question of framing?
Matilda Hellman likened the use of alco- Striving for an ideal of “evidence-based
hol and drugs research in policy-making to policy” has become paramount in a number
“picking the best bits from the smorgasbord” of areas of social policy1. In many of these
in the background paper to the seminar. The fields, there arises the twin problem of a
understanding being that a large amount of lack of knowledge and thorough understand-
this research can be used by different inter- ing of the problem at hand (despite growing
ested parties, NGOs, politicians, journalists bodies of evidence), coupled with a press-
or civil servants, and that the “research form ing need to implement adequate policies to
a smorgasbord, from which anyone can pick resolve them. Given the ubiquity of alcohol
the pieces that suit them” (Hellman 2007). use in society (and amongst many research-
The objective of this discussion is to provide ers and policymakers, though not all lobby-
a practical overview of the use of alcohol re- ists), “the alcohol issue” can all too easily
search in Eurocare’s (the European Alcohol be observed through a purely sociological
Policy Alliance) lobbying activities in Brus- or anthropological lens. Roizen and Fill-
sels. The realities and difficulties of using re- more (2000) accurately expose this parallel
search in a cross-sectoral, multifaceted and between research “for its own sake” and the
relatively emotive and politically sensitive need for “remedies”, suggesting “our field
arena can be more appropriately likened to is under constant pressure, of course, to ad-
the “subtle art of selecting the appropriate dress itself to pragmatic ends—to the mini-
dishes and displaying them in such a way mization of alcohol problem, our ostensible
as to awaken (and satisfy) the appetite of the master problem”. In this sense, policy impli-
guests”. cations are expected to be inextricable from
Having firstly defined a conceptual frame- the evidence. In these fields, “research” in
work for the discussion, a brief overview of the form of a disinterested quest for knowl-
the work of Eurocare will follow, sketching edge, carried out in the aim of enlightening
out the difficulties faced with regards to: society on socio-cultural norms, behaviours
research (the fragmented nature of the evi- and attitudes, can seem almost irrelevant,
dence on alcohol, rarely the sole driver of and perhaps extravagant from the point of
policy change, and often political) policy the advocate, who may consider the nature
makers (engaged in balancing interests and of the problem calls for research with more
reaching compromises with varying degrees “valuable” and “useful” conclusions.
of political will with regards to alcohol) and The World Health Organisation (WHO
the alcohol industry (a legitimate stakehold- 2007) emphasizes that “rational policy mak-
er putting forward its own evidence to suit ing on alcohol requires a consideration of
commercial interests). the nature of the evidence, how the evidence
may be used, and the ways in which policy

decision-making actually occurs—the mul- avoid cross border trade and smuggling), and
tidimensional nature of the responses and Labeling (the EC is to present a draft Direc-
their dynamic interactions”. Critiques of tive on labeling at the end of the year).
the evidence-based policy model suggest it For Eurocare, lobbying on alcohol presents
is flawed by a misconception of the proc- several difficulties: first the EU has limited
esses at play, and that in fact “decisions are competence to legislate in the domain of
less about projected consequences and more public health5. DG Sanco’s Alcohol Strat-
about process and legitimation. Politics is egy is thus useful for advocacy in Member
about shaping interpretations and express- States; at EU level, it has allowed alcohol to
ing preferences” (Young et al. 2002). This secure a place on the political agenda, de-
twin nexus of process and legitimation may spite being weakened by the influence of the
appear to be somewhat obscure in our role Commission’s more powerful “big brothers”
as advocates, but nevertheless makes it all (DG Trade, DG Market, DG Agriculture, etc.)
the more fascinating and challenging in our (Ulstein 2006). Second, at European level,
day-to-day work. the aim of reducing alcohol-related harm
is competing against other strong public
Eurocare: Who we are and what health discourses for example in the field
we do of tobacco, nutrition and physical activity,
Eurocare, is an alliance of around 50 volun- the latter exemplified in the EU Platform for
tary and non-governmental organizations Diet, Physical Activity and Health on which
across Europe created in 1990, working on the Alcohol and Health Forum is modeled.
the prevention and reduction of alcohol-re- Roizen and Fillmore (2000) articulate this
lated harm2. One of the main goals is to pro- from the researchers’ perspective, but it is
mote the prevention of alcohol-related harm also true for advocates that “our consum-
in European Union decision-making; this is erist or dangerous-commodity orientation
achieved by monitoring all EU level policy to alcohol (…) obliges us to compete in a
initiatives, and carrying out advocacy cam- public-health-information-offering market
paigns directed at the European Commis- place already crowded with health warnings
sion (EC) and the European Parliament (EP) of many kinds”. The specificities of alco-
to ensure that alcohol issues are included in hol serve to further complicate the picture;
relevant policy discussions. The catalyst of parallels with tobacco or junk food are ob-
our work in recent years (and the concrete vious: indisputable public health burdens;
result of fifteen years of lobbying) has been links with social inequalities, and of course,
the “EU Strategy to Support Member States powerful industries. What sets alcohol apart
in Reducing Alcohol Related Harm”, pub- though, is the highly problematic, misunder-
lished by the Directorate General for Health stood and misused evidence on the “benefits
and Consumer Protection (DG Sanco) of the of alcohol consumption”; like it or not, the
European Commission in October 20063. A “ambiguous molecule” alcohol forms an in-
cornerstone of this strategy is the recently tegral part of most cultures across Europe,
launched Alcohol and Health Forum, a “causing deaths while saving lives, inflicting
multistakeholder platform bringing together pain while producing pleasure” (Baumberg
the industry and well as NGOs4 pledging to 2006).
commit to concrete actions to reducing alco-
hol-related harm. The cross-sectoral nature “Evidence shows that …”
of alcohol policy includes the Television The WHO (2007) states that “all policies and
Without Frontiers Directive (concerned with actions to improve public health need a firm
young people’s exposure to alcohol advertis- knowledge base (…); research and evidence
ing), Minimum Excise Duties (a report from are among a society’s most valuable and im-
the EP proposed to scrap these in order to portant tools for laying the foundation of

better strategies to improve public health”. of scientific research, an obvious difficulty is

Evidently though, the interaction between that of keeping abreast of all new evidence in
research and policy is complex, and does a field spanning a variety of disciplines.
not form a linear relationship of influence. A second concern, intrinsically linked
The “enlightenment model” (Young et al. to the first, is that not all existing data on
2002) where “research is often addressed alcohol is useable by advocates: not all evi-
not to the problem itself but to the context in dence is conclusive (answering only a set of
which that decision will be taken, providing questions it addresses); not all evidence is
a frame for thinking about it” is a useful one, comparable (both within Member States and
as it proposes a more realistic “evidence- across Europe); and not all evidence is pol-
informed policy” approach (ibid.). Weiss icy relevant. In other words, although some
(1977) suggests that in this model “the ma- evidence may be worthwhile in furthering
jor effects of research on policy may be the our knowledge of society’s relationship with
gradual sedimentation of insights, theories, alcohol, it does not propose any “remedies”.
concepts and ways of looking at the world”. And nor should it; after all, academia is a
With this in mind, the actual data Euro- highly competitive arena, in which observ-
care most commonly requires can broadly ers battle to gain recognition for their con-
be categorised under three loose headings. tributions to their understanding of society,
The first is “Figures”, and can include in- through the production of knowledge. Cra-
formation such as levels of consumption plet (2007), Chairman of Eurocare, notes
across Europe; the second concerns “Best that “referring to the research community as
Practice”, and the third concerns “Chal- ‘somewhat politically naïve’ is not an attack,
lenges ahead” such as “Why has alcohol but rather a compliment to [his] friends in
consumption increased in some countries?” the field”. Researchers should be reassured
or, “What is the role of national governments that it is at times exasperating for advocates
in tackling these issues?”. The recently pub- to attempt to “neatly package” research
lished Alcohol in Europe report (heralded findings, thus ironing out subtleties and
“The Bible”) provides many of the answers nuances of rich and multilayered data, and
to these questions; as well as being a robust almost always frustrating to be expected to
scientific report, it is also an invaluable ad- provide “silver bullets” and panaceas for
vocacy tool, which includes policy recom- politicians.
mendations (Anderson & Baumberg 2005).
The report was commissioned to form the “Evidence-based” arguments for
basis of the Commission’s strategy, and in “opinion-based” decision makers
itself represents an excellent case study of Politicians are engaged in the complex proc-
how the industry plays the “evidence game” ess of creating interfaces between policy ar-
(Baumberg & Anderson 2007; Anderson & eas, balancing interests and brokering com-
Baumberg 2006). promises; in this sense “the policy-making
However, in trying to use this data we are process has the basic aim of reconciling
often confronted by two problems. A first, interests in order to negotiate consensus,
overarching concern is the fragmented nature not implement truth” (Weiss 1977). From a
of the evidence in the alcohol field, where pessimistic perspective, this is perhaps best
seemingly many voices compete (Young et encapsulated in Keyne’s view that “there is
al. 2002). Indeed journalists, “social com- nothing a Government hates more than to be
mentators”, think tanks or research institutes well informed, for it makes the process of
all affect and influence public opinion to a arriving at decisions more complicated and
certain degrees, and may serve to entrench more difficult” (in Solesbury 2001). The role
stereotypes, which then risk appearing more of European policy makers is further com-
“truthful” than the evidence itself. In terms plicated by the need to maneuver within

the competence they are granted to balance logical. For example, that “patterns of drink-
national interests (for example, the wine ing are the best way to understand the place
growing regions) with the requirements of of alcohol in society”; that “targeted inter-
an ever expanding, and primarily economic ventions are most sensitive to cultural differ-
European Union. ences”, and that “partnerships offer the best
Further, it is no secret that politicians, opportunities to develop policies”. Funnily
despite their lack of expertise, have en- enough “Drinking in Context: Patterns, In-
trenched ideas and opinions about alcohol terventions and Partnerships”, an ICAP col-
and alcohol policy. Advocates are constantly laborative publication (Stimson et al. 2006)
exposed to biased, partial views of the evi- was recently publicised at a lunch meeting
dence: “Red wine is good for you” or “We held in the European Parliament, hosted by
don’t binge drink in Italy as they do in the German MEP Renate Sommer. Staff from the
Nordic countries”. Views on policy also re- Eurocare Secretariat attended this lunch; the
flect a certain take on the evidence: “Alcohol event was reminiscent of the spirit of the film
should not be demonised, it is an important “Thank You For Smoking”8; a sequel named
part of our cultural heritage”, “We have to “Thank You For Drinking” should be consid-
respect the principle of subsidiarity, as cul- ered, and would be highly entertaining.
tural differences mean we cannot implement This example highlights the tensions in-
blanket policies”. Marmot (2004) suggests volved in the political process, and how ap-
that “government’s willingness to act may parently sound and legitimate evidence can
shape their view of the science”; when it be put forward by the industry, in order to
comes to alcohol, the reality may be “policy counter what is regarded by the public health
based evidence” rather than “evidence based community as “legitimate” evidence. When
policy” (ibid.). the Institute of Alcohol Studies published
the Alcohol in Europe report, the British
The alcohol industry: no Beer and Pub Association (also participating
ordinary stakeholder in the Alcohol and Health Forum) attempted
The alcohol industry is undeniably a rival to undermine its scientific objectivity by
voice in the political process of “weighing “denouncing” vested interests, namely, links
up the evidence”; a strong economic asset, to temperance; they likened this to “vegetar-
with increasingly visible corporate social ians writing a report about the benefits of eat-
responsibility policies, the industry repre- ing meat”. The EFRD’s view (in Baumberg &
sents a valid stakeholder. Alcohol produc- Anderson 2007) was that those advocating a
ers unite under “legitimate fronts” through stronger EU alcohol strategy “had a biased
social aspects (SA) organisations6, such as view of the evidence base”.
the International Centre for Alcohol Policies It is precisely through the use of “evi-
(ICAP) or the European Forum For Respon- dence” and their engagement in research,
sible Drinking (EFRD), both of which are policy analysis and lobbying (activities mir-
participating in the Commission’s Alcohol roring our own work) that the industry tries
and Health Forum. Under these banners, to secure a place at the policy table, which
research, policy analysis and of course, lob- may be potentially difficult for the public
bying are carried out: in fact, it has not been health community to fight off. The WHO
uncommon to find such groups walking the (2007) stresses the “importance of the par-
same corridors of power as ourselves. ticipation of civil society organisations with-
To the layperson, the “research” and “pol- out the conflict of interests in alcohol policy
icy analysis” (e.g.: ICAP Blue Book)7 carried development, as a counter influence to the
out by these organisations may appear meth- vested trade interests, which might other-
odologically sound, and conclusive, and the wise dominate political decision making”.
(simplistic) models as comprehensive and

Concluding thoughts the scientific community needs to frame

This brief overview will have hopefully policy relevant research questions in time
served to shed some light on the difficulties for the data to be available when needed, to
involved in using alcohol research in lobby- have carried out high quality research and to
ing at European level, as well as highlighted have interpreted and disseminated the data
the organic nature of the processes, where in ways that are relevant to the policy de-
“evidence”, “stakeholders”, “political deci- bate”. FEANTSA, the European Federation
sion making” and “public opinion” are inter- of National Organisations Working with the
related, forming a vast and complicated web, Homeless, based in Brussels, has developed
from which it is often difficult to untangle an interesting model with a view to recon-
the strands. Given the fragile and precarious ciling these tensions; the European Observa-
nature of “evidence” as well as its potential tory on Homelessness, was set up over ten
for ambiguous interpretation in this process years ago, under the premise that “a good un-
(what Baumberg and Anderson describe as derstanding of the problem of homelessness
the “evidence game”), it is often impossible is the key to developing effective policies”10.
to attribute any advocacy success in Brussels The Observatory is “composed of a network
to any particular “factor”. France’s manda- of researchers across Europe, carrying out
tory pictorial labelling of alcohol beverages transnational research relevant to Feantsa’s
targeted at pregnant women is a perfect European Policy priorities” (my emphasis).
example of this. The legislation came into It is emphasised that “the close co-operation
force last year, but the process started with between academic researchers and NGOs is
a lawyer, Benoit Titran, defending a group of not always easy, but has been very useful for
mothers of children born with FAS (Foetal the quality and added value of FEANTSA’s
Alcohol Syndrome) and taking alcohol pro- work”. It may seem that motivations and
ducers to court. Using a European Directive priorities within the arena of alcohol policy
on Product Safety9 as legal basis, he argued are incompatible: the competitive and pres-
that alcohol should be treated as an “ordi- tigious field of academia, the sensitive and
nary commodity” and producers had a re- thorny political realm, and the cut-throat
sponsibility of warning pregnant women of commercial world of the alcohol industry.
the dangers of alcohol consumption. Gradu- There is a continuous need to reflect on
ally gaining political support, this eventu- strategies and to rethink the ways in which
ally snowballed into the current legislation. we, as advocates, engage with the research,
While Titran was a lawyer in the north of and consider the most effective means of
France, he became aware of the problem of advocating, with credibility and weight, the
FAS from his father, a paediatrician who had implementation of evidence-based alcohol
conducted research within his hospital in policies.
the same region. It is, however, impossible
to untangle the interlinked roles of evidence, Emilie Rapley, Policy and Public Affairs Officer
existing legislation, political support, resil- Eurocare EU Liaison Office,
ience and personal conviction. Rue des Confédérés 96-98, 1000 Brussels,
The WHO (2007) concludes that “to con- Belgium
E-mail: emilie.rapley@europanytt.no
tribute constructively to the policy debate,

NOTES Anderson, P. & Baumberg, B. (2006): Stake-

holders’ views of alcohol policy. Nordic
��
1) See Young et al. (2002), Packwood (2002).
Studies on Alcohol and Drugs 6 (English
2) For more information, see http://www.euro-
Suppl.): 393–413
care.org/abu/what.html
Baumberg, B. & Anderson, P. (2007): The
3) “An
��
EU strategy to support Member States in
reducing alcohol related harm”, COM (2006)
European Strategy on Alcohol: A Landmark
625 final. [Online:
��
http://ec.europa.eu/health/ and a Lesson. Alcohol and Alcoholism 42
ph_determinants/life_style/alcohol/alcohol_ (1): 1–2
com_en.htm]. Craplet, M. (2007): Prevention of alcohol-
4) Including Eurocare and eight of its members. and-tobacco-related harms: Education or
5) Competence for public health is left to Member Control- Must We Choose? Nordic Studies
States, although Article 152 of the Treaty states on Alcohol and Drugs 24 (English Suppl.):
the EU’s obligation to ensure a high level of 299–319
human health protection in the definition and Marmot, M. (2004): Evidence Based Policy or
implementation of all Community policies and Policy Based Evidence? British Medical
activities. Journal 328: 1–2
6) For a more detailed discussion, see Anderson, Packwood, A. (2002): Evidence Based Policy:
P. (2003): The Beverage Alcohol Industry’s Rhetoric and Reality. Social Policy and
Social Aspects Organisations: A Public Health Society 1 (3): 262–271
Warning. Eurocare Paper. Roizen, R. & Fillmore, K. (2000): The Coming
7) ICAP Blue Book: Practical Guides to Alcohol Crisis in Alcohol Social Science. Nordic
Policy and Prevention Approaches. [Online:
��
Studies on Alcohol and Drugs 17 (English
http://www.icap.org/Publication/ICAPBlue-
Suppl.): 91–104
Book/tabid/148/Default.aspx]
Solesbury, W. (2001): Evidence Based Policy:
8) This 2005 Jason Reitman film is a satire of a lob-
Whence it Came and Where it’s Going
byist defending the tobacco industry yet trying
(working paper). ESRC Centre for Evidence
to remain a role model for his 12-year-old son.
9) DIRECTIVE
��
2001/95/EC of the European Parlia-
Based Policy and Practice
ment and of the Council of 3 December 2001 Stimson, G. & Grant, M. & Choquet, M. &
on general product safety. See
��
also “Consumer Garrison, P. (2006): Drinking in Context:
protection, Labels and warnings” (Conference Patterns, Interventions, and Partnerships.
Presentation), Eurocare Bridging the Gap London: Routledge
Conference, Helsinki November 2006. [Online:
�� Ulstein, A. (2006): No Ordinary Partner.
http://btg.health.fi/?i=107586]. Nordic Studies on Alcohol and Drugs 6
10) Feantsa European Observatory on Homeless- (English Suppl.): 499–508
ness. [Online:
��
http://www.feantsa.org/code/en/ Weiss, C. (1977): Research for Policy’s Sake:
pg.asp?Page=23]. The Enlightenment of Social Research.
Policy Analysis 3 (4): 531–545
World Health Organisation (2007): Second Re-
port of the Expert Committee on Problems
REFERENCES Relating to Alcohol Consumption, Geneva
Anderson, P. & Baumberg, B. (2005): Alcohol Young, K. & Ashby, D. & Boaz, A. & Grayson,
in Europe: A Public Health Perspective. L. (2002): Social Science and the Evidence-
London: Institute of Alcohol Studies based Policy Movement. Social Policy and
Society 1 (3): 215–224.

Book
reviews
The book serves three purposes. First of

all, it provides a historical, conceptual and
research-oriented presentation of the field of
self-change, and alcohol and drug addiction;
secondly, through five chapters, self-change
is described in a broader context; and thirdly,
The third wave of it provides a number of chapters on the use
research on self-change of the knowledge of self-change in policy,
prevention and treatment. The final chapter
Klingemann, Harald
�� &
�� Carter
��
Sobell, Linda (eds.)
�� of the book provides information directed
(2007): towards the actual process of self-change
Promoting self-change from addictive behaviors. from addictive behaviour, and contains lists
Practical implications for policy, prevention, and of assessment instruments to promote self-
treatment. New York: Springer, 260 p. change and assess problem severity, as well
as relevant websites grouped country-wise.
T hrough 11 well-written chapters the edi-

tors Klingemann and Sobell have deliv-
ered a comprehensive book on the subject of
As a phenomenon, ‘self-change’ has been
subject to both research and discussion dur-
ing the last 30 to 40 years. Research on the
self-change. Researchers from USA, Canada, subject has, from time to time, been able to
and Europe are represented as authors and elicit an almost denying response among
contribute with results from current research both professionals and the general public
projects, methodological and conceptual re- (chapter 1; Chiauzzi & Liljegren 1993). But
views, and historical accounts of this area of how can we, according to this book, under-
research. According to this publication, the stand self-change? One answer could be: In
field of research on self-change suffers from different ways, depending on e.g. the sub-
conceptual and methodological inconsisten- stance of interest and the specific socio-cul-
cies, such as diverse conceptualisations of tural setting. According to chapter 10, the
treatment and intervention, or variations of use of a specific drug might in one socio-
time in recovery among research samples. cultural setting elicit the characterisation of
The term self-change is used throughout the deviant behaviour; while in another context
book to describe the process of: ‘change in it might not be perceived particularly devi-
a persons substance use in the absence of ant or socially unacceptable. In Western so-
formal treatment or help’ (chapter 1). Other cieties, the cessation of smoking tobacco is
concepts, such as spontaneous remission, commonly thought to be obtained through a
denoting a process of sudden and unexpect- process of self-change, whereas the cessation
ed change without a designable reason, are of alcohol and drug abuse is rarely perceived
omitted in the text. Despite Sobell’s initial within the realm of a self-change process.
exclusion of the use of other terms to des- The endpoint of change from addictive be-
ignate the process of self-change, concepts haviour may well vary in different cultural
such as: untreated remission, natural re- settings. In some societies an accepted goal
covery, and spontaneous recovery, slip their might be moderation of intake of the spe-
way into different chapters of the book. This cific drug. In other cultural settings the only
may reflect the rather different types of be- acceptable goal of a (self-)change process
haviour change presented in the book; from would be a complete cessation of intake of
self-change of alcohol and drug addiction to the drug. In general, the book provides the
desistance of crime (chapter 6.4) or recovery reader with varied knowledge and well-
from problem gambling (chapter 6.3) as well researched arguments on the subject of ‘self-
as the aforementioned methodological in- change’. Self-change is described in relation
consistencies. to very different types of behaviour, such as
662 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 24. 2007 . 6

eating disorders and stuttering. In line with ‘recovery can only be reached through treat-
this, a chapter on self-change from differ- ment’.
ent affective disorders, could have been rel- The second wave of research on self-
evant as well. Comparing self-change from change encompasses studies focusing specif-
social phobia with self-change from addic- ically on the exploration and assessment of
tion, research indicates some similarities of the phenomenon and its prevalence. These
individual predictors of recovery (e.g. being studies are primarily based on standardised
employed and presenting less psychopatho- procedures applying both quantitative and/
logical symptoms when tested) (Vriends et or qualitative methods.
al. 2007). If we assume the second wave is still in
If one objective of the book is to argue that motion, a central question might be what
self-change from addiction is neither sponta- the third wave of research on self-change
neous nor unexplainable, but is to be regard- is going to bring. Could it be, as suggested
ed as a rather common process influenced by in chapter 7, to provide a model for change,
intrinsic and extrinsic factors (e.g. personal, which encompasses those who manage to
interpersonal and social), then the objective change addictive behaviour on their own?
is met. As one would believe from the title Or will it be a more proactive wave, in terms
of the book ‘Promoting self-change...’ a dis- of ‘popularizing’ the notion of self-change,
tinct objective is to draw attention to possi- to obtain a public acceptance of process as
ble consequences for treatment and preven- being common, and the phenomenon as
tion from this line of research. The relatively widespread? Maybe the book itself can be
high prevalence rates of self-change from perceived as part of a third wave in terms
different addictive behaviours might actu- of researchers creating an overview of the
ate the continuous study of both the barriers field, and communicating: major findings;
to treatment and the ways in which people similarities to other fields of research; and
actually change. Throughout the book, ques- directions for policy, treatment, and preven-
tions such as “What triggers the process of tion. A central objective of this third wave is
change?” and “When is the change process then to make sure knowledge on self-change
initiated?” are pointed out as central themes is available, not just to other researchers
for further research. through peer-reviewed journals, but also to
people influencing politics and treatment, as
The first, the second, and maybe well as to the people making changes of their
a third wave? own addictive behaviour.
In the second chapter of the book a histori-
Dorte Hecksher, PhD
cal line of research on self-change is pre-
Centre for Alcohol and Drug Research
sented as consisting of at least two waves. Bygning 1453, Jens Chr. Skous Vej 3
The first wave comprises more methodologi- 8000 Århus C, Denmark
cally loose and imprecise studies, and states E-mail: dh@crf.au.dk
self-change from addiction as a separate
phenomenon, as well as outlining pertinent REFERENCES
themes for further research. The knowledge
Chiauzzi, E.J. & Liljegren, S. (1993): Taboo
on self-change, derived from these studies,
topics in addiction treatment. Journal of
was primarily side effects of research stud-
Substance Abuse Treatment 10: 3003–3316
ies focusing on other subjects (e.g. general
Vriends, N. & Becker, E.S. & Meyer, A. &
population studies on addictive behaviour,
Williams, S.L. & Lutz, R. & Margraf, J.
or the effect of treatment intervention). In
(2007): Recovery from social phobia in the
spite of this, it served to undermine common
community and its predictors: Data from a
beliefs on addiction: such as the perception longitudinal epidemiological study. Journal
of ‘addiction as an irreversible condition’, or of Anxiety Disorders, 21 (3): 320–337.

The new dual-track to a more liberal drug policy nor has it
undermined the traditional policy with
drug policy paradigm its emphasis on total drug prohibition.
– an important and Instead, harm reduction in combination

with a prohibitionist penal policy consti-
original finding tutes a new dual-track drug policy para-
digm.” (emphasis added)
Tuukka Tammi
Medicalising prohibition: Harm reduction in Finnish In developing his conception of a two-
and international drug policy. Helsinki: Stakes, 2007, track approach to drug policy, Tammi first
151 p.
observes that Finland has fully embraced
harm reduction within a medical framework
T uukka Tammi’s dissertation, Medicalis-

ing Prohibition, is a serious, thought-
ful, subtle, dignified and remarkably mature
and system. In the early 1990s, harm reduc-
tion was barely heard of in Finland; nowa-
days it is successfully integrated into Finn-
work of scholarship. It consists of six chap-
ish health care and services. Second, and
ters, five of them published in leading jour-
contrary to the early hopes of some research-
nals or edited books, and one new chapter,
ers including myself, he also finds that the
the title of the work, which develops themes
acceptance and integration of harm reduc-
from the others and extends them in original
tion has not reduced coercive and punitive
and sometimes bold ways.
criminal justice policies. In Finland, and to
Medicalising Prohibition illuminates a
some extent in other countries, harm reduc-
complicated and shifting phenomenon: the
tion has been thoroughly adopted without a
place of harm reduction within the drug
substantial softening in the legal status and
polices of Finland and to some extent other
criminal justice handling of drug users.
countries, especially since the early 1990s.
This is an important and original finding,
In the new summarizing chapter he writes:
one I have begun using in my own work on
understanding the dramatically increasing
“The concept of harm reduction is typi-
numbers of cannabis and other drug arrests
cally associated with a drug policy strat-
in the U.S. and Europe since the 1980s. I’d
egy that employs the public health ap-
like to see the insight become an important
proach and where the principal focus
part of the growing understanding of the
of regulation is on drug-related health
place of harm reduction policies within con-
harms and risks… The general conclu-
temporary drug policies – which Tammi cor-
sion of this study is that rather than
rectly and courageously identifies as “prohi-
posing a threat to a prohibitionist drug
bition.”
policy, harm reduction has come to form
In each of the other five chapters (the
part of it. The implementation of harm re-
original articles), Tammi examines in depth
duction by setting up health counselling
various aspects of the harm reduction move-
centres for drug users – with the main
ment, its implementation, effects and con-
focus on needle exchange and extending
sequences. The first chapter asks, “Has the
substitution treatment – has implied the
drug policy in Finland changed?” He finds
creation of specialised services based on
that it has, but in a contradictory fashion. Al-
medical expertise and an increasing in-
though written before he had fully worked
volvement of the medical profession in
out the dual track understanding, the chap-
addressing drug problems. At the same
ter describes empirically some of what he
time the criminal justice control of drug
later explicitly conceptualized.
use has been intensified. Accordingly,
The second chapter, on “three factions”
harm reduction has not entailed a shift
within the harm reduction movement, uses

original data about Finland and other Euro- various social actors are always consistent
pean countries to distinguish serious profes- or even make sense. In the spirit of Michel
sional and political differences in perspec- Foucault, he lets the strange remain strange.
tive and approach within the developing, But he does not exaggerate or even highlight
international, harm reduction traditions. much the oddness of what he finds. Like a
The third chapter discusses “the struggle gentle, humane, empathetic anthropologist
over the concept of harm reduction in the from an advanced civilization, or even a far
1997 Drug Policy Committee in Finland.” away galaxy, he offers detailed descriptions
It shows how the police and other criminal and summaries of the often contradictory
justice authorities interpreted harm reduc- things the participants themselves are saying
tion in a way that allowed them to continue and doing, and the often contradictory ways
doing much of what they had already been that drug policy actually operates.
engaged in. Tammi finds that for the criminal Tammi points out in various places in
justice system in Finland and at least some his chapters that influential individuals
other places in Europe, harm reduction has and groups in Finnish society regularly say
involved a change in vocabulary but not by that they seek to bring about what they call
and large in practice. “a drug-free society.” The United States of
The fourth chapter focuses on needle ex- America, where I come from, also has pow-
change programs and tells how they came to erful groups, including the U.S. government,
be adopted within Finland in the context of which likewise proclaim their commitment
the HIV and AIDS epidemic. This is an im- to a “drug-free society.” I’d like to briefly
portant story and Tammi has pulled together consider that concept of a drug free society,
a great deal of information making it avail- for it is part of the ideological support for
able for the first time for researchers in and the punitive criminal justice policy “track”
outside of Finland. that Tammi finds mostly untouched by the
The fifth chapter contrasts the views of advance of harm reduction. The ideal and
patients and their families on the one hand, goal of a drug-free society are, I suggest, truly
and those of medical and other authorities strange.
on the other, showing them often at odds in The same people and groups who
their understanding both of the nature of the unabashedly claim they seek a drug-free so-
problem and the best remedies to apply. ciety never suggest that they seek or could
Medicalising Prohibition is very well writ- reasonably expect to get a crime-free society,
ten and its English does the thing that good or a sickness-free society, a waste-free soci-
writing must: it gets out of the readers’ way ety, an intolerance-free society, or even an
allowing us to see what the author has seen. ignorance-free society. In all these and many
And to an extent that is rare even among very other cases, everyone recognizes that hu-
good writers, Tammi does not repeat him- man beings are living and therefore imper-
self. Indeed he seems allergic to redundancy. fect creatures, and that no society or culture
Read together, the chapters in Medicalising can be free of problems – of crime, sickness,
Prohibition appear not as discrete articles, waste, intolerance or ignorance. In all cases,
but as parts of a “book,” an unusually clear the wisest observers and participants, and
and thoughtful one. even others not so wise, understand that it
Tammi writes very much from inside the is sensible to try to reduce these problems,
world he is studying, but he retains the dis- to shrink and minimize them. But nobody
tance and perspective to coolly, carefully thinks we can be free of them. Except, for
describe what he finds. The social worlds drug use. For drug use (and not just abuse) it
he writes about are to some extent strange, is still perfectly acceptable for eminent and
odd, peculiar, even eccentric. He does not supposedly reasonable people to claim to
try to soften that or pretend that views of the seek perfection through social policy.

If that was the only problem with the no- has even called for a “drug-free world.” All
tion of the drug-free society that would be of this is not just odd or strange. It is not even
quite a lot. But there is another problem: just impractical or wildly utopian. Rather, I
the concept it uses of “drug.” Everyone, in- suggest that the goal of a drug-free society
cluding school children, understands that is best captured in a term that was used in
alcohol is an intoxicating substance, that other contexts by the great British writer
alcohol is a drug. Many people understand Isaiah Berlin. The goal of a drug-free society
that tobacco also contains a serious psycho- is what Berlin called “incoherent.” The idea
active drug: nicotine. And people who think does not hold together. It actually does not
for a moment also know that coffee, tea and make sense.
even Coca-Cola contain substantial amounts Tuukka Tammi touches upon this immense
of caffeine, which the pharmacologists (and problem with the notion of the drug-free so-
our own bodies) tell us is also a psychoactive ciety only briefly and indirectly. He is more
and physically active drug with substantial clinical than I am willing to be, at least right
effects. A substantial number of pharma- now. But his work on the character, spread
ceutical substances are also psychoactive, and limits of harm reduction opens a path
including natural and synthetic opiates for further research and discussion about
such as morphine and fentenyls. There are the real-world meanings and impacts of the
prescription sedatives and tranquilizers in- often hidden drug policies routinely operat-
cluding widely-used benzodiazepines like ing all around us. Medicalising Prohibition,
Valium. There are stimulants including pre- from its title on, asks the right questions, and
scription amphetamines and also anti-nar- in seeking answers successfully contributes
colepsy drugs, and substances such as Ritlin to making visible some of the poorly under-
given to children. And there is a new class stood system of world-wide drug prohibi-
of drugs, the SSRIs – the serotonin reuptake tion, including its more punitive goals and
inhibitors – of which Prozac is one, as are often well-hidden punitive effects. I hope he
some illegal drugs. inspires other such work.
Despite this abundance of psychoactive
drugs all around us, prominent and respect- Harry G. Levine, Professor of Sociology
ed individuals and organizations, including Queens College and the Graduate Center
two U.S. Presidents named George Bush, and City University of New York
the U.S. government, have strongly called Flushing, New York 11367, USA
for a drug-free society. The United Nations E-mail: hglevine@Qc.edu

NAT
Contents
2007
Nordisk alkohol- & narkotikatidskrift

Vol. 24
Nummer 1
LEDARE__________________________________________________________________________ 3
ARTIKLAR
Karen Elmeland & Susanne Villumsen Udviklingen i danskernes holdninger
til alkoholforbrug og alkoholpolitiske spørgsmål_ ____________________________________ 5
Johanna Levälahti Sociala nätverk och socialt stöd i återhämtningsprocessen
från alkoholmissbruk_____________________________________________________________23
Mats Anderberg & Mikael Dahlberg Interbedömarreliabilitet – ett tillförlitligt
mått på standardiserade intervjuer? ________________________________________________45
KOMMENTAR
Leena Warsell Hur skilja socialt ansvar från socialt ansvar?___________________________59
RECENSIONER
Susanna Alakoski Svinalängorna (av Ingalill Österberg)______________________________62
Petra Kouvonen & Astrid Skretting & Pia Rosenqvist (eds.) Drugs in the Nordic
and Baltic Countries. Common concerns, different realities (av Mikko Lagerspetz)______64
Jørgen Anker & Vibeke Asmussen & Petra Kouvonen & Dolf Tops (eds.)
Drug Users and Spaces for Legitimate Action (av Johan Edman)_______________________66
LANDSRAPPORTER
Rafn Jónsson Rapport fra Island_ __________________________________________________71
Leif Vind Rapport fra Danmark_ ___________________________________________________72
Elin Bye Rapport fra Norge________________________________________________________77
Martin Stafström Rapport från Sverige_ ____________________________________________80
Matilda Wrede-Jäntti Rapport från Finland_ ________________________________________82
MEDDELANDE
Kerstin Stenius Litauiskt intresse för nordisk alkoholpolitik__________________________84
TIIVISTELMÄT__________________________________________________________________87
REGISTER ÖVER INNEHÅLLET 2006______________________________________________89

Number 2
EDITORIAL_____________________________________________________________________103
RESEARCH REPORTS
Sharon Rödner Sznitman Drugs and gender: A contradictory project in
interviews with socially integrated men and women who use drugs__________________107
Jeanette Østergaard Mind the gender gap! When
��
boys and girls get drunk at a party ___127
Jakob Demant Youthful drinking with a purpose. Intersections
��
of age and
sex in teenage identity work______________________________________________________149
Jukka Törrönen & Antti Maunu Whilst it's red wine with beef, it's booze with a
cruise! Genres
��
and gendered regulation of drinking situations in diaries______________177
COMMENTARIES
Manne Forssberg Gender, party and intoxication___________________________________200
Elina Oinas Making gender matter – different approaches to gender and partying _____203
Replies
Antti Maunu Gender theory and empirical research. A reply to Elina Oinas ________210
Jeanette Østergaard Differences between quantitative and qualitative research
methods _ ___________________________________________________________________212
INTERVIEW
Pauliina Seppälä The forgotten body – Interview with philosopher Sara Heinämaa _ __214
BOOK REVIEWS
Philip Lalander & Mikko Salasuo (eds.) Drugs
��
and youth cultures—global and
local expressions (by Jaana Lähteenmaa) __________________________________________219
Peter Gundelach & Margaretha Järvinen (eds.) ��
Unge, fester og alkohol
(by Ellen O. Millar)______________________________________________________________221
Alexandra Bogren Female Licentiousness versus Male Escape. Essays
��
on
Intoxicating Substance Use, Sexuality and Gender (by Suvi Ronkainen &
Sanna Väyrynen) _______________________________________________________________226
Number 3
EDITORIAL_____________________________________________________________________233
RESEARCH REPORTS
Ditte Andersen & Margaretha Järvinen Harm reduction – ideals and paradoxes________235
Antti Weckroth Drug-related harm according to opiate users on
buprenorphine treatment_ _______________________________________________________253
Commentaries on harm reduction
Astrid Skretting Harm reduction – any limits? _ _________________________________270
Henrik Thiesen Harm reduction, focusing on severe alcohol misuse
in Copenhagen ______________________________________________________________280
Tuukka Tammi How I would describe 21st century drug policy to Kettil Bruun_____288

Morten Hulvej Jørgensen & Tine Curtis Intergenerational dynamics in
teenage alcohol use. Two
��
scenarios on a single night in the Danish countryside _______291
Michel Craplet Prevention of alcohol- and tobacco-related harms.
Education or control – must we choose? _ _________________________________________299
Commentaries on Craplet’s article
Jostein Rise On time perspective, autonomy and various passions in
health education_ ____________________________________________________________320
Olabisi Odejide Political will is necessary to a comprehensive prevention approach 324
Robert Damberg Education should give positive alternatives and focus on adults!___328
INTERVIEW
Kerstin Stenius “Education crucial for social change.” Interview
��
with Pekka Puska ____330
BOOK REVIEWS
Robert West Theory of addiction (by Jostein Rise & Velibor Bobo Kovac)______________334
Jessica Palm Moral concerns – Treatment staff and user perspectives on alcohol
and drug problems (by Hildigunnur Ólafsdóttir) ___________________________________338
Tommi Hoikkala & Pekka Hakkarainen & Sofia Laine (eds.) Beyond Health
Literacy. Youth Cultures, Prevention and Policy (by Jakob Demant) __________________341
Petra Kouvonen & Astrid Skretting & Pia Rosenqvist (eds.) Drugs
��
in the Nordic
and Baltic countries. Common
��
concerns, different realities (by Mikko Lagerspetz) _____344
REPORTS
Matilda Hellman Developing an effective alcohol policy for Russia_ _________________347
Kerstin Stenius The International Society for the Study of Drug Policy _______________352
NORDIC ALCOHOL STATISTICS 1993–2006_ _____________________________________354
Nummer 4
LEDARE________________________________________________________________________369
ARTIKLAR
Jenny Cisneros Örnberg & Hildigunnur Ólafsdóttir Hur sälja alkohol?
Nordiska alkoholmonopol i en tid av förändring___________________________________371
Mirja Österberg Alkos ledning och den europeiska ekonomiska integrationen
1988–1994_____________________________________________________________________395
ÖVERSIKT
Christoffer Tigerstedt & Esa Österberg Alkoholskadorna är fortfarande finska
men har också blivit franska _____________________________________________________414
KOMMENTAR
Anders Ulstein Hva betyr Rosengrendommen?_____________________________________419
INTERVJU
Kerstin Stenius Kari Paaso om alkoholfrågan i Finland och EU_______________________425

MEDDELANDEN
Stig Erik Sørheim Nordisk alkoholpolitikk 2007 – en situasjonsbeskrivelse___________428
Øystein Bakke Klar for ekstraomganger om alkoholspørsmålet i WHO________________433
Leena Warsell Alkohol- och drogprevention på nordiskt seminarium i Bergen_________436
RECENSIONER
Pelle Olsson Flödder (av Philip Lalander)__________________________________________438
Martti Häikiö Alkon historia. Valtion alkoholiliike kieltolain kumoamisesta
Euroopan unionin kilpailupolitiikkaan 1932–2006 (Alkos historia. Statens
alkoholbolag från upphävandet av förbudslagen till EU:s konkurrenspolitik
1932–2006) (av Matti Peltonen)___________________________________________________439
LANDSRAPPORTER
Leif Vind Rapport fra Danmark_ __________________________________________________443
Rafn Jónsson Rapport fra Island_ _________________________________________________447
Elin Bye Rapport fra Norge_______________________________________________________449
Martin Stafström Rapport från Sverige_ ___________________________________________453
Johan Sandelin Rapport från Finland_ ____________________________________________455
Nummer 5
LEDARE________________________________________________________________________459
ARTIKLAR
Jesper Andreasson & Philip Lalander Mellan idrottslig disciplin och gränslöst
supande________________________________________________________________________461
Riikka Perälä Hur narkotikabrukare tolkar sina egna problem och ser
på social- och hälsovårdens tjänster_______________________________________________481
RIKTLINJER
Ulf Malmström Nationella riktlinjer för missbruks- och beroendevård ________________504
Jonas Sjögreen Allmänläkarens dilemma – riktlinjerna kolliderar med
långsiktighet och individualisering _______________________________________________510
Harriet Lundefors Oscarsson Reflektioner ur socialtjänstens praktikperspektiv ________513
ARTIKEL
Anders Bergmark Riktlinjer och den evidensbaserade praktiken – en kritisk
granskning av de nationella riktlinjerna för missbrukarvård i Sverige_________________519
Mats Berglund Kommentarer till Anders Bergmark_______________________________530
DEBATT
Mats Ramstedt & Johan Svensson Att skatta införsel av alkohol till Sverige –
ingen akademisk fråga?__________________________________________________________534
Per Leimar Fem månader efter Rosengren-domen___________________________________538
INTERVJU
Ulf Rydberg Leonard Goldberg – nestor inom nordisk beroendeforskning_____________541

RECENSION
Sveinung Sandberg & Willy Pedersen Gatekapital (av Philip Lalander)________________547
MEDDELANDE
Jorunn Moen Rapport fra Elisad’s 19. årlige møte___________________________________549
NAD-NYTT_____________________________________________________________________552
Number 6
EDITORIAL_____________________________________________________________________561
RESEARCH REPORTS
Claes Törnqvist Twenty then – today about thirty-five. The meaning of alcohol
in a life course perspective_______________________________________________________563
Anders Bergmark Guidelines and evidence-based practice – a critical appraisal
of the Swedish national guidelines for addiction treatment__________________________589
Mats Berglund Commentary on the paper by Anders Bergmark____________________600
Mads Uffe Pedersen Evidence-based practice in “the real world” ____________________605
OVERVIEW
Pia Mäkelä & Heli Mustonen & Esa Österberg Does beverage type matter? ____________617
MAKING USE OF ALCOHOL AND DRUG RESEARCH

Introduction____________________________________________________________________632
Robin Room National variations in the use of alcohol and drug research:
Notes of an itinerant worker______________________________________________________634
Matilda Hellman Public use of and communication about alcohol research___________641
Hildigunnur Ólafsdóttir Reflections on the use of alcohol research ___________________646
Katariina Warpenius & Marja Holmila Connecting alcohol research and prevention
practice: Lessons learned from PAKKA _ __________________________________________652
Emilie Rapley The use of alcohol research in Eurocare’s lobbying activities___________656
BOOK REVIEWS
Harald Klingemann
��
&
��
Linda Carter Sobell (eds.) Promoting self-change from
addictive behaviors. Practical implications for policy, prevention, and treatment
(by Dorte Hecksher) _____________________________________________________________662
Tuukka Tammi Medicalising prohibition: Harm reduction in Finnish and
international drug policy (by Harry G. Levine)_ ____________________________________664

Supplement
EDITORIAL
Pia Mäkelä Development of alcohol-related harms in the Nordic countries:
descriptions of and explanations for a mixed picture_ ________________________________ 3
RESEARCH REPORTS
Mats Ramstedt Variations in alcohol-related mortality in the Nordic countries
after 1995—continuity or change?__________________________________________________ 5
Louise Eriksen & Morten Grønbæk Development in alcohol-related harm
in Denmark 1990–2005___________________________________________________________17
Pia Mäkelä & Esa Österberg Upward trends in alcohol consumption and related
harm in Finland__________________________________________________________________29
Hildigunnur Ólafsdóttir Trends in alcohol consumption and alcohol-related
harms in Iceland_________________________________________________________________47
Ingeborg Rossow Trends in alcohol consumption and alcohol-related harms
in Norway around the turn of the millennium_______________________________________61
Mats Ramstedt Has the impact of population drinking on harm become weaker
in Sweden? An
��
analysis of the development in alcohol consumption and
alcohol-related harm in Sweden 1990–2005________________________________________73
Ingeborg Rossow & Pia Mäkelä & Esa Österberg Explanations and implications
of concurrent and diverging trends: Alcohol consumption and alcohol-related
harm in the Nordic countries in 1990–2005_________________________________________85

Personregister 2007/Authors’ index 2007
ARTIKLAR/RESEARCH REPORTS
Anderberg, Mats & Dahlberg, Mikael: Interbedömarreliabilitet – ett tillförlitligt mått på
standardiserade intervjuer? _____________________________________________________ 1/45
Andersen, Ditte & Järvinen, Margaretha: Harm reduction – ideals and paradoxes____3/235
Andreasson, Jesper & Lalander, Philip: Mellan idrottslig disciplin och gränslöst
supande _____________________________________________________________________5/461
Bergmark, Anders: Guidelines and evidence-based practice – a critical appraisal of the
Swedish national guidelines for addiction treatment _____________________________6/589
Bergmark, Anders: Riktlinjer och den evidensbaserade praktiken – en kritisk
granskning av de nationella riktlinjerna för missbrukarvård i Sverige ______________5/519
Cisneros Örnberg, Jenny & Ólafsdóttir, Hildigunnur: Hur sälja alkohol? Nordiska
alkoholmonopol i en tid av förändring_ _________________________________________4/371
Craplet, Michel: Prevention of alcohol- and tobacco-related harms. Education or
control – must we choose? _____________________________________________________3/299
Curtis, Tine: See Jørgensen, Morten Hulvej ______________________________________3/291
Dahlberg, Mikael: Se Anderberg, Mats ___________________________________________ 1/45
Demant, Jakob: Youthful drinking with a purpose. Intersections of age and sex
in teenage identity work _______________________________________________________2/149
Elmeland, Karen & Villumsen, Susanne: Udviklingen i danskernes holdninger til
alkoholforbrug og alkoholpolitiske spørgsmål _ ____________________________________ 1/5
Eriksen, Louise & Grønbæk, Morten: Development in alcohol-related harm
in Denmark 1990–2005 ____________________________________________________ Suppl/17
Grønbæk, Morten: See Eriksen, Louise______________________________________ Suppl/17
Järvinen, Margaretha: See Andersen, Ditte_______________________________________3/235
Jørgensen, Morten Hulvej & Curtis, Tine: Intergenerational dynamics in teenage
alcohol use. Two scenarios on a single night in the Danish countryside _ ___________3/291
Lalander, Philip: Se Andreasson, Jesper_ ________________________________________5/461
Levälahti, Johanna: Sociala nätverk och socialt stöd i återhämtningsprocessen
från alkoholmissbruk _ _________________________________________________________ 1/23
Maunu, Antti: See Törrönen, Jukka _____________________________________________2/177
Mäkelä, Pia: See Rossow, Ingeborg _ ________________________________________ Suppl/85
Mäkelä, Pia & Österberg, Esa: Upward trends in alcohol consumption and
related harm in Finland ___________________________________________________ Suppl/29
Ólafsdóttir, Hildigunnur: Se Cisneros Örnberg, Jenny____________________________ 4/371
Ólafsdóttir, Hildigunnur: Trends in alcohol consumption and alcohol-related
harms in Iceland __________________________________________________________ Suppl/47
Pedersen, Mads Uffe: Evidence-based practice in “the real world” _________________6/605
Perälä, Riikka: Hur narkotikabrukare tolkar sina egna problem och ser på social-
och hälsovårdens tjänster ______________________________________________________5/481
Ramstedt, Mats: Has the impact of population drinking on harm become weaker
in Sweden? An analysis of the development in alcohol consumption and
alcohol-related harm in Sweden 1990–2005_________________________________ Suppl/73
Ramstedt, Mats: Variations in alcohol-related mortality in the Nordic countries
after 1995—continuity or change? ___________________________________________ Suppl/5

Rossow, Ingeborg: Trends in alcohol consumption and alcohol-related harms
in Norway around the turn of the millennium _______________________________ Suppl/61
Rossow, Ingeborg & Mäkelä, Pia & Österberg, Esa: Explanations and implications
of concurrent and diverging trends: Alcohol consumption and alcohol-related
harm in the Nordic countries in 1990–2005 _ ________________________________ Suppl/85
Rödner Sznitman, Sharon: Drugs and gender: A contradictory project in
interviews with socially integrated men and women who use drugs _ ______________2/107
Törnqvist, Claes: Twenty then – today about thirty-five. The meaning of alcohol
in a life course perspective _ ___________________________________________________6/563
Törrönen, Jukka & Maunu, Antti: Whilst it's red wine with beef, it's booze with
a cruise! Genres and gendered regulation of drinking situations in diaries __________2/177
Villumsen, Susanne: Se Elmeland, Karen__________________________________________ 1/5
Weckroth, Antti: Drug-related harm according to opiate users on buprenorphine
treatment ____________________________________________________________________3/253
Österberg, Esa: See Mäkelä, Pia _ ___________________________________________ Suppl/29
Österberg, Esa: See Rossow, Ingeborg________________________________________ Suppl/85
Österberg, Mirja: Alkos ledning och den europeiska ekonomiska
integrationen 1988–1994 ______________________________________________________4/395
Østergaard, Jeanette: Mind the gender gap! When boys and girls get drunk
at a party _ ___________________________________________________________________2/127
ÖVERSIKTER/OVERVIEWS
Mustonen, Heli: See Mäkelä, Pia_______________________________________________ 6/617
Mäkelä, Pia & Mustonen, Heli & Österberg, Esa: Does beverage type matter?_ _______6/617
Tigerstedt, Christoffer & Österberg, Esa: Alkoholskadorna är fortfarande finska
men har också blivit franska __________________________________________________4/414
Österberg, Esa: Se Tigerstedt, Christoffer_________________________________________4/414
Österberg, Esa: See Mäkelä, Pia _ _______________________________________________6/617
DEBATTER/DEBATES
Leimar, Per: Fem månader efter Rosengren-domen _______________________________5/538
Ramstedt, Mats & Svensson, Johan: Att skatta införsel av alkohol till Sverige –
ingen akademisk fråga? ________________________________________________________5/534
Svensson, Johan: Se Ramstedt, Mats ____________________________________________5/534
KOMMENTARER/COMMENTARIES
Berglund, Mats: Commentary on the paper by Anders Bergmark ___________________6/600
Berglund, Mats: Kommentarer till Anders Bergmark ______________________________5/530
Damberg, Robert: Education should give positive alternatives and focus on adults!__3/328
Forssberg, Manne: Gender, party and intoxication ________________________________2/200
Hellman, Matilda: Public use of and communication about alcohol research ________6/641
Holmila, Marja: See Warpenius, Katariina _______________________________________6/652
Lundefors Oscarsson, Harriet: Reflektioner ur socialtjänstens praktikperspektiv _____5/513
Malmström, Ulf: Nationella riktlinjer för missbruks- och beroendevård _ ___________5/504
Maunu, Antti: Gender theory and empirical research. A reply to Elina Oinas _______2/210

Odejide, Olabisi: Political will is necessary to a comprehensive prevention
approach _ ___________________________________________________________________3/324
Oinas, Elina: Making gender matter – different approaches to gender and partying __2/203
Ólafsdóttir, Hildigunnur: Reflections on the use of alcohol research ________________6/646
Rise, Jostein: On time perspective, autonomy and various passions in health
education ____________________________________________________________________3/320
Rapley, Emilie: The use of alcohol research in Eurocare’s lobbying activities ________6/656
Room, Robin: National variations in the use of alcohol and drug research:
Notes of an itinerant worker ___________________________________________________6/634
Sjögreen, Jonas: Allmänläkarens dilemma – riktlinjerna kolliderar med
långsiktighet och individualisering _ ___________________________________________5/510
Skretting, Astrid: Harm reduction – any limits? __________________________________3/270
Tammi, Tuukka: How I would describe 21st century drug policy to Kettil Bruun ____3/288
Thiesen, Henrik: Harm reduction, focusing on severe alcohol misuse
in Copenhagen _______________________________________________________________3/280
Ulstein, Anders: Hva betyr Rosengrendommen? _________________________________4/419
Warpenius, Katariina & Holmila, Marja: Connecting alcohol research and
prevention practice: Lessons learned from PAKKA _______________________________6/652
Warsell, Leena: Hur skilja socialt ansvar från socialt ansvar? _______________________ 1/59
Østergaard, Jeanette: Differences between quantitative and qualitative
research methods _____________________________________________________________2/212
INTERVJUER/INTERVIEWS
Rydberg, Ulf: Leonard Goldberg – nestor inom nordisk beroendeforskning __________5/541
Seppälä, Pauliina: The forgotten body – Interview with philosopher
Sara Heinämaa _______________________________________________________________2/214
Stenius, Kerstin: “Education crucial for social change.” Interview with
Pekka Puska _________________________________________________________________3/330
Stenius, Kerstin: Kari Paaso om alkoholfrågan i Finland och EU ___________________4/425
RECENSIONER/BOOK REVIEWS
Demant, Jakob: Tommi Hoikkala & Pekka Hakkarainen & Sofia Laine (eds.):
Beyond Health Literacy. Youth
��
Cultures, Prevention and Policy ___________________3/341
Edman, Johan: Jørgen Anker & Vibeke Asmussen & Petra Kouvonen & Dolf Tops (eds.):
Drug Users and Spaces for Legitimate Action _____________________________________ 1/66
Hecksher, Dorte: Harald Klingemann & Linda Carter Sobell (eds.): Promoting
self-change from addictive behaviors. Practical implications for policy,
prevention, and treatment _____________________________________________________6/662
Kovac, Velibor Bobo: See Rise, Jostein _ _________________________________________3/334
Lagerspetz, Mikko: Petra Kouvonen & Astrid Skretting & Pia Rosenqvist (eds.):
Drugs in the Nordic and Baltic Countries. Common concerns, different
realities (på svenska) ___________________________________________________________ 1/64
Lagerspetz, Mikko: Petra Kouvonen & Astrid Skretting & Pia Rosenqvist (eds.):
Drugs in the Nordic and Baltic countries. Common concerns, different
realities (in English) _ _________________________________________________________3/344
Lalander, Philip: Pelle Olsson: Flödder _ ________________________________________4/438
Lalander, Philip: Sveinung Sandberg & Willy Pedersen: Gatekapital _ ______________5/547

Levine, Harry G.: Tuukka Tammi: Medicalising prohibition: Harm reduction
in Finnish and international drug policy ________________________________________6/664
Lähteenmaa, Jaana: Philip Lalander & Mikko Salasuo (eds.): Drugs and
youth cultures—global and local expressions ____________________________________2/219
Millar, Ellen O.: Peter Gundelach & Margaretha Järvinen (eds.): Unge, fester
og alkohol _ __________________________________________________________________2/221
Ólafsdóttir, Hildigunnur: Jessica Palm: Moral concerns – Treatment staff and
user perspectives on alcohol and drug problems _________________________________3/338
Peltonen, Matti: Martti Häikiö: Alkon historia. Valtion alkoholiliike kieltolain
kumoamisesta Euroopan unionin kilpailupolitiikkaan 1932–2006 (Alkos
historia. Statens
��
alkoholbolag från upphävandet av förbudslagen
till EU:s konkurrenspolitik 1932–2006) _________________________________________4/439
Rise, Jostein & Kovac, Velibor Bobo: Robert West: Theory of addiction _ ____________3/334
Ronkainen, Suvi & Väyrynen, Sanna: Alexandra Bogren: Female Licentiousness
versus Male Escape. Essays on Intoxicating Substance Use, Sexuality and Gender ___2/226
Väyrynen, Sanna: See Ronkainen, Suvi _________________________________________2/226
Österberg, Ingalill: Susanna Alakoski: Svinalängorna ______________________________ 1/62
LANDSRAPPORTER/COUNTRY REPORTS
Bye, Elin: Rapport fra Norge _ ___________________________________________________ 1/77
Bye, Elin: Rapport fra Norge _ __________________________________________________4/449
Jónsson, Rafn: Rapport fra Island ________________________________________________ 1/71
Jónsson, Rafn: Rapport fra Island _______________________________________________4/447
Sandelin, Johan: Rapport från Finland __________________________________________4/455
Stafström, Martin: Rapport från Sverige __________________________________________ 1/80
Stafström, Martin: Rapport från Sverige _________________________________________4/453
Vind, Leif: Rapport fra Danmark _________________________________________________ 1/72
Vind, Leif: Rapport fra Danmark ________________________________________________4/443
Wrede-Jäntti, Matilda: Rapport från Finland ______________________________________ 1/82
MEDDELANDEN/NOTES
Bakke, Øystein: Klar for ekstraomganger om alkoholspørsmålet i WHO _ ___________4/433
Hellman, Matilda: Developing an effective alcohol policy for Russia _______________3/347
Moen, Jorunn: Rapport fra Elisad’s 19. årlige møte _ ______________________________5/549
Stenius, Kerstin: The International Society for the Study of Drug Policy ___________3/352
Stenius, Kerstin: Litauiskt intresse för nordisk alkoholpolitik _ _____________________ 1/84
Sørheim, Stig-Erik: Nordisk alkoholpolitikk 2007 – en situasjonsbeskrivelse ________4/428
Warsell, Leena: Alkohol- och drogprevention på nordiskt seminarium i Bergen _____4/436
GUEST EDITORIAL
Mäkelä, Pia: Development of alcohol-related harms in the Nordic countries:
descriptions of and explanations for a mixed picture __________________________ Suppl/3
NAD-NYTT __________________________________________________________________5/552

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NAT

Nordic Studies on Alcohol and Drugs

Making use of alcohol and drug research

NAT vol. 24, Innehåll/Contents 667

NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 24. 2007 . 6 559

Nordic Studies on Alcohol and Drugs

English language revision

Telefax E-mail Website

ISSN 1455-0725 Vammalan Kirjapaino Oy 2007

560 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 4 . 2 0 0 7 . 6

Guidelines for treatment – national

In 2002, the Swedish National Board of Health and

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562 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 4 . 2 0 0 7 . 6

Twenty then – today ABSTRACT

about thirty-five thirty-five. The meaning of alcohol in a

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A question that can be asked is to what partnerships and marriages thereafter. In

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568 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 4. 2 0 0 7 . 6

Participants had occurred in terms of their having chil-

NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 24. 2007 . 6 569

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periencing a need of self-realization in of men occurs between the ages of about

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Conclusions to deal with. Their now having developed

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in Sweden up to 1996. Stockholm: Univ. Norell, M. & Törnqvist, C. (1995): Berättelser

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Guidelines and ABSTRACT

evidence-based practice based practice – a critical appraisal of the

A critical appraisal of the Swedish national Evidence-based practice (EBP) has

guidelines for addiction treatment been advocated since the beginning of

In the following an analysis and discussion of published Swedish national guidelines

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