Introduction

Joseph Townsend lives in Great Britain in the large metropolitan area of Birmingham. Concerned about the number of street people in his downtown neighborhood who were regularly intoxicated, Joseph organized his neighbors and many local shops to set up a storefront recovery center where alcohol-dependent people could get counseling and where meetings of self-help groups, e.g., Alcoholics Anonymous, could be held. The storefront recovery center was a big success, with many clients coming and going every day. After the center had been operating successfully for six months, Joseph noticed, during his regular walks through his neighborhood, that the number of people intoxicated on the street had not decreased. In fact, there appeared to be many more now than before. “ How could this be,” he wondered, “ after all the work we have done?”

In another community, Silver City, a small multi-ethnic town in New Mexico (USA), Mary and Charles Lopez, parents of two children, 15 and 18 years old, were concerned about the amount of drinking by local young people. They were fearful that their daughter and son might drink, and they were concerned about the risk of harm to their children and others in their community as a result of teenage drinking. Other parents joined them in assisting the local schools to adopt a health curriculum that informed young people about the risks of alcohol and other drugs. The school curriculum was widely and effectively implemented, and was popularly received by the community.

Introduction

The Social Norms Subsystem represents the social dynamics that influence rates and patterns of alcohol consumption in the community. The “norm” is a basic concept of social science, referring to informal social rules or proscriptions defining acceptable and unacceptable behavior within any social group, organization, or larger social structure, such as a village, small town, or city.

Norms are reflected in the homogeneity of behavior observable among any people with sufficient social contact and exposure. This homogeneity can exist even across entire societies with sufficient common exposure to language, social values, mass messages, and images. The US as a whole exhibits a notable homogeneity of values, despite regional differences in styles of behavior and values, as subgroups with their own common heritages (and languages) also are influenced by the larger social collectivity. For example, with respect to drinking norms, a three-generation study of Mexican-Americans (Markides, Krause & Mendes de Leon, 1988) showed that acculturation altered this ethnic group's traditional normative drinking patterns.

Drinking norms are social influences and pressures regarding acceptable drinking behavior, which may act either to encourage (permit) or to discourage (restrict) alcohol consumption. Drinking norms are part of a larger collection of norms influencing many types of individual and social behavior (see Pittman & Snyder, 1962; Pittman, 1967; Simpura, 1987; and Room, 1991). Community drinking norms reflect general attitudes about drinking and societal expectations regarding the levels of drinking considered appropriate.

Introduction

The use of alcohol can have a wide range of social, economic, and health consequences in a community. Some of these consequences, such as liver cirrhosis or alcohol psychosis and resulting hospitalizations, may result from long-term use of alcohol. Other consequences may result from the heavy use of alcohol on occasions where impairment in judgment, function, or physical skills results in injury or death of the drinker or others, and emergency medical services may be required.

Alcohol increases the risks of all types of injury or violence. For example, the frequency with which drinking and violence towards a spouse co-occur indicates that alcohol increases the risk of spouse abuse. Not all cases of spouse abuse are caused by drinking; however, the acute effects of alcohol may increase violent or victim behavior of either spouse, or violence towards a spouse may be precipitated by family disruption associated with long-term or heavy dependent drinking. Examples of accidents made more likely by alcohol impairment include motor vehicle crashes and drownings.

The Social, Economic, and Health Consequences Subsystem has three functions in the community:

(1) Definition and identification of alcohol-involved problems.

(2) Remedial or preventive response to these problems.

(3) Direction of public attention to these problems.

It is not always obvious what constitutes an alcohol-involved problem for the community. The seemingly trivial case of a hangover from drinking illustrates the subtlety of some alcohol-involved problems. Most experienced drinkers have had hangovers, and hangovers have been the subject of many comedy routines; this drinking-related outcome is not generally considered a community problem.

Introduction

The function of the Formal Regulation and Control Subsystem is to place limits on the physical and economic availability of alcoholic beverages. Most societies establish rules and controls governing the sale and availability of alcohol. In industrialized societies, these take the form of formal laws and regulations. In fact, alcohol may be, on average, the most regulated of all legal retail products. Formal regulations typically cover the production, import, wholesale distribution, and retail sales of alcohol. The government may hold a monopoly on wholesale or retail sales of alcohol. If alcohol production and retail sales are in the hands of private corporations and individuals, these activities usually are subject to licensing and regulation.

Physical availability of alcohol may be limited through regulations controlling: the forms in which alcohol can be sold; the types, numbers, densities, and locations of retail outlets; the hours and days of the week retail sales are allowed; the minimum age to purchase or drink alcohol; serving practices; the potential liability of those serving alcohol; and the social accessibility of alcohol. Economic availability of alcohol may be regulated through taxation of alcohol sales, alcohol price restrictions and controls, and restrictions on the promotion and advertising of alcohol.

Formal regulations are publicly codified statements of societal values. Thus, the Formal Regulation and Control Subsystem is influenced by the Social Norms Subsystem, which reflects social expectations related to the use of alcohol and the community's level of concern about alcohol-involved problems.

Alcohol issues are a cause today for intense public health concern in most countries of the world. That assertion is valid for rich nations whose encounters with drink have long histories, and poorer regions where the adverse consequences of alcohol may begin to threaten national development.

Within the modern Public Health perspective, alcohol, the commodity itself, is an issue of concern as well as the problems which drinking generates. The reason for taking this position is the overwhelming strength of the research evidence showing that the more an individual drinks, the greater the risk of that person sustaining alcohol-related harm. Similarly, the higher the national per capita alcohol consumption, the greater will be the alcohol-related burden of costs and damage for that society.

The Public Health perspective is also illuminated by studies which demonstrate the immense variety in types and degree of the problems which can be caused by drinking. The concerns must be with the sum of small problems as well as with large problems, with harm done to the family or bystander as well as the direct consequences for the drinker themselves, with acute mishaps as well as chronic illness, and with the problems which occur in the social as well as the medical domain. These matters cannot be tidied away by directing our responses solely at ‘ the alcoholic’.

Dr Harold Holder' s analysis brilliantly exemplifies this perspective. While not discounting the background importance of national alcohol policy responses, he offers an analysis at the level of local community.

Introduction

Alcohol is made available to consumers through the Retail Sales Subsystem. Alcohol may be legally or illegally produced. It is produced and distributed by a beverage industry (which may or may not be located within the community system) and sold in a variety of forms and quantities, through several types of retail outlets. Within the Retail Sales Subsystem, two key factors – retail availability and consumer demand for alcohol – interact to determine the level of retail sales of alcohol in a community, which is equivalent to the overall level of consumption.

In industrialized countries, the Retail Sales Subsystem is affected by the formal licensing and regulation of retail alcohol outlets. Restraints and restrictions on retail availability of alcohol, including zoning and other local regulation of alcohol outlets as businesses, are inputs to the Retail Sales Subsystem from the Formal Regulation and Control Subsystem. Even if, as in non-industrialized communities, alcohol is available through indigenous private production and sale, rather than formally licensed shops or bars and restaurants, such transactions still constitute a Retail Sales Subsystem.

The Retail Sales Subsystem for alcohol is a part of the community's overall retail marketplace. As part of the economic structure of a community, outlets for the sale of alcohol are influenced by the same types of economic factors that influence retail outlets for other non-durable (consumable or disposable) goods, such as food, clothing, motion pictures, cosmetics, and automobiles.

Introduction

The goal of prevention is to reduce the future occurrence of alcoholinvolved problems, which (as defined in this book) are the natural products (output) of the community system. How to develop effective long-term interventions or changes in this complex, open, and adaptive system is neither simple nor obvious. As an adaptive system, the community will not be affected by prevention programs or efforts that make no changes in the system's structure or processes. Furthermore, the system will adjust to and compensate for prevention efforts that do alter its natural arrangements. Such community system adjustments hamper the potential long-term effectiveness of any prevention intervention and are the most serious obstacle to cost-effective alcohol problem prevention in the long term.

For example, consider what happens in the community if enforcement against drinking and driving is increased, and, as a result of publicity about increased enforcement, drivers believe their chance of being detected and arrested for driving under the influence (DUI) is now much higher (i.e., perceived risk of arrest increases). If the actual risk of arrest has increased only slightly (so that it is much lower than the new perceived risk), then, over time, drivers will learn that their perceived risk is much too high. As a result, they will naturally return to their prior drinking and driving behavior, and little or no long-term reduction in alcohol-involved crashes will result. Similarly, consider the effects of increasing the retail prices of alcoholic beverages, say by 10%.

Introduction

The Legal Sanctions Subsystem reflects the community's use of police powers to respond to and control alcohol-involved behaviors and events that are defined as illegal. Along with the Formal Control and Regulation Subsystem, the Legal Sanctions Subsystem is also involved in detecting and punishing those who violate specific rules concerning the possession and use of alcohol. The purpose of enforcement is not only to punish those who violate the laws or rules, but also to deter or prevent such behaviors or events through the threat of punishment.

Behaviors and events subject to enforcement within the Legal Sanctions Subsystem can include public intoxication or public drinking, alcoholinvolved violent behavior, illegal sale of alcoholic beverages, drinking in places where it is prohibited (such as parks or beaches), and driving under the influence of alcohol (DUI). This chapter first briefly summarizes enforcement considerations in each of these areas. The rest of the chapter focuses primarily on drinking and driving, which is the dominant concern of this subsystem in many industrialized communities. The discussion of drinking and driving provides a detailed example of how the Legal Sanctions Subsystem functions and interacts with other subsystems in all aspects of enforcement.

Areas of enforcement within the subsystem

A common function of the Legal Sanctions Subsystem is detection and deterrence of public intoxication. Even where alcohol sales and consumption are legal, many communities in industrialized countries have defined intoxication in public view as illegal. As a result, the offense of public intoxication can consume considerable police time and court resources.

Introduction

Alcohol is consumed in most of the world's industrial cultures and in many non-or pre-industrial cultures. Some cultures have formal bans on alcohol, but in many, consumption of alcohol is a part of routine community life. Although the proportion of people who elect to abstain from alcohol varies across communities and cultures, alcohol is likely to be consumed in some form by a significant percentage of the population where it is not forbidden. In a community system, drinking is manifested in the Consumption Sub-system.

Each member of a community can be described according to his or her patterns of drinking (including abstention), characterized by quantity and frequency of alcohol consumption and by rates of intoxication. Across the community as a whole, these individual drinking (or abstinence) patterns in the aggregate form consumption categories or distributions, which make up the Consumption Subsystem. Alcohol use within the community differs by age, gender, marital status, religious preference, and racial or ethnic heritage. Men usually consume more alcohol on average than do women. Youths, young adults, adults, and the elderly exhibit distinct patterns of alcohol use. People from religious groups that prohibit alcohol use (e.g., Muslims, Mormons, or Southern Baptists in the US) consume less alcohol than do people from religious groups with no such proscriptions. Within the US, whites, African-Americans, and Latinos differ in their drinking patterns.

The Consumption Subsystem is dynamic. Over time, people move from one consumption category to another, changing both frequency and quantity of alcohol consumption.