Addiction (2001) 96, 1093–1096

EDITORIAL

From Paris to Stockholm: where does theEuropean Alcohol Action Plan lead to?

Since a second European Alcohol Action Plan(EAAP)1 has been endorsed by the EuropeanHealth Ministers at the Stockholm conference, itis now worthwhile to look back at the outcomesand pitfalls of the past EAAP.

The European Alcohol Action Plan,2 1992–99, was developed with the aim to “create aconcerted and sustained European movement toprevent the health risks and social problems re-sulting from alcohol use and to improve thehealth of Europeans through an overall reductionof alcohol consumption”.3

To achieve a signi� cant reduction in thehealth-damaging consumption of alcohol, twomain strategies were proposed: a population-based approach reducing overall consumption,in accordance with target 17 of the EuropeanHealth for All policy (25% of reduction of al-cohol consumption in the period 1980–2000)and a high-risk approach targeting high-risk be-haviours.

The European Conference on Health, Societyand Alcohol held in Paris in 1995 was a keypoint for the development of the EAAP. HealthMinisters of all countries met there to approvethe European Charter on Alcohol.4 The Charterhas been translated into most of the Europeanlanguages and contains 10 strategies for alcoholaction, based on � ve ethical principles and goals.The ethical principles emphasize the right ofpeople to impartial information on alcohol andprotection against the negative consequences ofits consumption; the right to be safeguardedfrom pressures to drink; and the right to treat-ment for people with hazardous or harmful al-cohol consumption. The strategies for actiontarget speci� c issues such as drink-driving, al-cohol education, alcohol availability and accessi-bility to treatment and regulation of alcohol

advertising. It is important to note that thosestrategies were established on the basis of soundscienti� c evidence.

Raising awarenessThe fact that WHO has been able to raise aware-ness at the highest political levels in Europe inorder to promote the EAAP merits recognitionand must be recognized as an improvement onthe long road that leads to profound changes inpublic conceptions and attitudes towards al-cohol. However, apart from this general positiveoutcome, a more concrete evaluation would beneeded in order to identify which are the im-provements made and the barriers to be over-come. Scienti� c evaluation of political action is achallenge, and the EAAP is intended as a politi-cal action. Moreover, there are several barriersthat make evaluation an almost imposible task.Some of them are outlined below.

First, and probably most important, thetremendous heterogeneity of the WHO Eu-ropean Region makes comparisons almost im-possible. There is no doubt that alcohol-relatedproblems are far from identical in places such asSpain, Russia, Norway or Israel. Since the base-line is so different, the effects of the EAAP mustalso be expected to be very different. Some of thecountries have had alcohol policies for manyyears, while others have not been concernedabout this issue. Is it logical to put into the samebag a predominantly Muslim country such asTurkey and a wine-culture Christian countrysuch as Italy? Should we set the same targets forboth nations? Also, the end of the century hasbeen characterized in most of the central andeastern European countries by dramatic politicalchanges which no doubt have had a strong

Correspondence to: Dr Antoni Gual, Unitat d’Alcohologia de la Generalitat, Hospital Clinic, Villarroel 170,08036, Barcelona, Spain. e-mail: tgual@clinic.ub.es

ISSN 0965–2140 print/ISSN 1360–0443 online/01/081093–04 Ó Society for the Study of Addiction to Alcohol and Other Drugs

Carfax Publishing, Taylor & Francis Limited

DOI: 10.1080/09652140120060671

1094 Editorial

in� uence on social conditions and which makeevaluation of the EAAP enormously dif� cult.Our paper will focus on the European Union,since it offers homogeneity enough to conduct anoverall analysis. In so doing, we are aware thatvery important factors in the rest of the Eu-ropean Region are left aside (e.g. the alcohol-re-lated mortality increase in the former SovietUnion), but to describe in detail the whole pic-ture would far exceed the limits of an editorial.

EvaluationNo systematic external evaluation of the EAAPhave been conducted so far, and this must beconsidered a weakness in the EAAP. Neverthe-less, WHO has conducted an internal evaluationof the EAAP, presented at the National Counter-parts meeting in Firenze (1999), which shedssome light on the questions raised. The mainevaluation tool has been a review based on 12open questions, answered mainly by nationalcounterparts in the EAAP. Therefore evaluatorsmight lack impartiality and this has to be takeninto account, since most of the questions re-quired qualitative answers. Of 51 countries, 37(73%) replied. The questionnaire included itemson alcohol consumption, and also speci� c ques-tions on the development of alcohol policies.

According to this evaluation, alcohol con-sumption has decreased in 41% of the reportingcountries and increased in 35% of them. Na-tional Alcohol Action Plans have also been de-veloped in 57% of the reporting countries (41%of the WHO European Region). Also, eventhough there seems to be a clear trend in thedirection of enforcing drinking and driving poli-cies and restricting alcohol availability to adoles-cents, one-third of the reporting countries haveexperienced a reduction in alcohol taxation. Therole of the alcohol and hospitality industry inpreventing alcohol-related problems is seen asinsuf� cient or non-existent by a majority ofcountries, and alcohol promotion through adver-tising has not been evaluated. If changes in poli-cies are to be considered as intermediateobjectives of the EAAP, the partial data availableseem to show that while policies dealing withhigh-risk situations can be implemented success-fully, those addressing decreasing overall alcoholconsumption have failed to be approved.

Apart from internal evaluation, some of theavailable external criteria might shed light on the

evolution of alcohol consumption and alcohol-related problems in Europe over the past 5 years.It is remarkable that, according to the Health forAll Database,5 alcohol consumption in the WHOEuropean region has decreased by an average of14.4% in the period 1985–97. The EU (exclud-ing Germany data) has experienced an evenlarger decrease (18.3%) in the period 1980–97,approaching the target of 25% of reduction thatwas set in the European Health for All policy.That is good news, but it can also be argued thatthis decreasing consumption trend appearedlong before the EAAP was launched. In fact,during the period 1992–97 alcohol consumptionin WHO Europe has remained almost stable(from 7.8 to 7.9 litres per head per year) and hasdecreased 4.9% in the European Union (from9.9 to 9.4 litres).

What has caused the trends in consump-tion?Within the EU trends in consumption seem farmore in� uenced by a tendency towards homoge-nization rather than by decrease. While most ofthe southern countries have experienced import-ant decreases in their consumption since 1980(Italy 39%, France 27%, Spain 26%), most ofthe northern countries have raised their alcoholconsumption (UK 6%, Denmark 9%, Finland11%, Ireland 23%). In fact, for the period 1980–97, alcohol consumption in the EU (excludingGermany) has decreased from 11.5 6 2.7 litres ofalcohol per head annually to 9.4 6 1.7. From astatistical point of view the decrease in the stan-dard deviation is far more surprising than thedecrease of the mean consumption: this againcon� rms the idea that homogenization, not dim-inution, is the underlying main trend (Fig. 1). Itcould be argued that this homogenization mightbe more in� uenced by marketing strategies ofthe beverage industry than by Member States’policies on alcohol, since the replacement ofwine by beer is one of the main reasons for thedecline in alcohol consumption experienced bysouthern countries.6

It would be unrealistic to expect the EAAP tohave a direct and swift in� uence on per capitaalcohol consumption. Even though the homo-genization tendency has been shown clearly7

changes are slow to develop,8 and even the mostrecent data suggest that there are still largedifferences between countries within the EU.

Editorial 1095

Figure 1. Trends in per capita alcohol consumption in the European Union (1992–97). Source: Health for All StatisticalDatabase, Copenhagen, World Health Organization Europe.

To make � gures even more complicated, al-cohol consumption and alcohol-related problemsdo not always follow similar patterns in thewhole WHO European Region. While consump-tion has decreased in both EU and Central East-ern European countries, the latter haveexperienced a rise in alcohol-related mortalityper 100 000 people from 123 in 1980 to 138 in1997. Meanwhile, within the EU alcohol-relatedmortality has decreased from 118 to 84 duringthe same period of time.

Policy changesIf changes at the consumption level should notbe expected in the short term, changes at policylevel should be expected immediately after theapproval of the EAAP. At a national level atendency to act on drinking and driving and alsoto restrict the availability of alcohol to adoles-cents are the only relevant achievements. At aninternational level WHO is seen by one-third ofthe countries as in� uencing positively the devel-opment of an international alcohol policy, whilecriticisms directed at the EU focus mainly ontwo interwoven facts: alcohol taxes have beenlowered and the alcohol industry has increasedits activity. In the policy area, the issue of alco-pops is an example of how interested the EU hasbecome in alcohol issues. It is also a good exam-

ple of how limited is its ability to react at a policylevel in the face of the market movements.9

Even accepting the pitfalls and limitations ob-served, it has to be stated that the EAAP hasbecome a useful tool to move European societytowards a more sensible approach to alcohol-re-lated problems. Recent studies in Canada andthe United States10 show that public opinionseems mainly to agree with policy measures thatprovide information or focus on the heavydrinker and high-risk situations, while those thatcontrol physical or economic access to alcoholare not supported as strongly.

Certainly, politicians are very dependent onpublic opinion, and even though there is evi-dence that high-risk strategies have some impacton population levels of alcohol consumption,11

the fact is that population-based strategies havedisappeared as a speci� c strategy in the EAAP2000–05 endorsed at the Ministerial Conferencein Stockholm. This should be a cause of con-cern, since taxation of alcohol has decreased inone-third of the countries and consumption isstill increasing in 35% of them.

When looking at the alcohol issue from south-ern Europe, it is clear that the EAAP has con-tributed to the reduction of alcohol-relatedproblems, but many people living further northmight disagree. Even if we disagree on whetheror not improvement has taken place, we all con-

1096 Editorial

cur that there is much still to be done, and thatWHO cannot do it alone. As pointed out by thenational counterparts, one of the main obstaclesin the implementation of Alcohol Action Plans isthe lack of response from governments, and thisis the real challenge to be overcome. It is obviousthat governments should invest considerablymore resources in the EAAP if it is expected tobe something more than a big � reworks displayevery 5 years. It is also true that politicians tendto view alcohol issues with an eye to carefullyobserving public opinion and alcohol industryreactions. There can be no doubt that the sci-enti� c community still has a low impact ongovernment policies.

In the light of recent data,12 which clearlyprove which how the tobacco industry has benusing illegitimate tactics to undermine WHOanti-tobacco initiatives, there are some lessons tobe learnt. As Godle13 states, “In any area ofcommercial interest there will be activities thatfall below good corporate practice.” This is truefor both tobacco and alcohol. In fact, there areso many commonalities between alcohol and to-bacco, both from an economic and a publichealth viewpoint, that the Framework conven-tion for tobacco could even be used as a model.The EAAP 1992–99 has been a step forward.Careful attention should be paid to the develop-ment of the EAAP 2000–05. The fact that popu-lation-based strategies have been forgotten is areal cause of concern from a public health per-spective: when looking carefully at the most re-cent data made available by the producers,14 ittranspires that world production of beer hasincreased 2.6% and wine production has experi-enced a 6.1% increase between 1995 and 1997.Even more intriguing is the fact that, within thesame period, in the European Union beer pro-duction has remained stable and wine pro-duction has increased a dramatic 9.4%. Thequestion is, who is drinking it?

ANTONI GUAL

Alcohol Unit, Hospital Clõ nic,Generalitat de Catalunya,Barcelona, Spain

JOAN COLOM

Direccio General de Drogodependencies i Sida,Health Department, Generalitat de Catalunya.Barcelona, Spain

References1. WORLD HEALTH ORGANIZATION (2000) European

Alcohol Action Plan 2000–2005 (Copenhagen,World Health Organization), available fromURL: http://www.who.dk/adt/aaction.htm

2. WORLD HEALTH ORGANIZATION (1993) EuropeanAlcohol Action Plan, EUR/ICP/ADA/035 (Copen-hagen, World Health Organization).

3. KICKBUSCH I. Personal communication.4. WORLD HEALTH ORGANIZATION (1995) European

Charter on Alcohol, EUR/ICP/ALDT 94 03/CN01(Copenhagen, World Health Organization).

5. HEALTH FOR ALL STATISTICAL DATABASE (2000)(Copenhagen, World Health Organization Eu-rope), available from URL: http://www.who.dk/country/country.htm

6. GUAL, A. & COLOM, J. (1997) Why has alcoholconsumption declined in countries of southernEurope? Addiction, 92 (Supplement 1), S21–S31.

7. EDWARDS, G., ANDERSON, P., BABOR, T. F., CASS-

WELL, S., FERRENCE, R., GIESBRECHT, N., GOD-

FREY, C., HOLDER, H. D., LEMMENS, P., MAKELA,K., MIDANIK, L. T., NORSTROM, T., OSTERBERG,E., ROMELSJO, A., ROOM, R., SIMPURA, J., SKOG,O.-J. (1994) Alcohol Policy and the Public Good(New York, Oxford University Press).

8. HUPKENS, C., KNIBBE, R. & DROP, M. (1993)Alcohol consumption in the European Com-munity: uniformity and diversity in drinking pat-terns, Addiction, 88, 1391–1404

9. SUTTON, C. & NYLANDER, J. (1999) Alcohol pol-icy strategies and public health policy at an EU-level. The case of alcopops, Nordic Studies onAlcohol and Drugs, 16, 74–91.

10. GIESBRECHT, N. & GREENFIELD, T. K. (1999)Public opinions on alcohol policy issues: a com-parison of American and Canadian surveys, Ad-diction, 94, 521–531.

11. SMART, R. G. & MANN, R. E. (2000) The impactof programs for high-risk drinkers on populationlevels of alcohol problems, Addiction, 95, 37–51.

12. COMMITTEE OF EXPERTS ON TOBACCO INDUSTRY

DOCUMENTS (2000) Tobacco company strategiesto undermine tobacco control activities at theWorld Health Organization (Geneva, WorldHealth Organization), available from URL: http://www.who.int/home/reports.html

13. GODLEE, F. (2000) WHO faces up to its tobaccolinks, British Medical Journal, 321, 314–315.

14. PRODUKTSCHAP VOOR GEDISTILLEERDE DRANKEN

(1999) World Drink Trends (Henley-on-Thames,NTC Publications Ltd).