The impact of programs for high-risk drinkers on population levels of alcohol problems

Addiction (2000) 95(1), 37± 52

RESEARCH REPORT

The impact of programs for high-risk drinkerson population levels of alcohol problems

REGINALD G. SMART & ROBERT E. MANN

Centre for Addiction and Mental Health, Addiction Research Foundation Division, Toronto,Ontario & Department of Public Health Sciences, University of Toronto, Toronto, Ontario,Canada

Abstract

Aims. Historically, treatment programs and related activities for alcoholics or high-risk drinkers have beenviewed as not relevant to efforts to prevent alcohol problems, and in particular population-based prevention

efforts. In this review we consider evidence that high-risk programs may have an impact on population or

aggregate levels of these problems. Design. We ® rst summarize recent reviews of the clinical impact ofprograms for high-risk drinkers, since some level of effectiveness at the individual level is necessary for these

programs to have an aggregate level impact. Following that, correlational evidence on the impact of high-risk

programs on aggregate problem levels is examined. Estimates of the potential impact of high-risk programs onaggregate problem levels, based on available information on the impact of these programs and the numbers

of individuals affected, are then considered, as are estimations of the comparative aggregate level impact of

high-risk and consumption reduction strategies. Findings. There is increasing evidence that high-riskprograms have bene® cial effects for individuals. Available correlational evidence supports the proposal that

increases in treatment and AA have contributed to the declines in alcohol-related morbidity and mortality

observed in some countries in recent years. Studies estimating the recent impact of increases in levels oftreatment and AA membership support that interpretation, and studies comparing estimated effects of

high-risk and population strategies ® nd similar potential for aggregate effects. Conclusions. Programs for

high-risk drinkers can have bene® cial aggregate-level effects and are thus a valuable component ofpopulation-based efforts to reduce alcohol problems.

Introduction

Traditionally, there has been a great divide be-tween programs for alcoholics or high-riskdrinkers and those for preventing such problemsin the ® rst place. Those providing treatment orself-help for alcohol abusers focus on the need totreat alcoholics and do little by way of preven-

tion. These efforts can be termed ª high-riskstrategiesº as they focus on reducing alcohol useand problems among high-risk users. On theother hand, those interested in prevention focuson broad educational approaches, communitydevelopment and government policy as themeans of preventing future alcohol-related

Correspondence to: R.G. Smart, Centre for Addiction and Mental Health, Addiction Research FoundationDivision, 33 Russell Street, Toronto, Ontario, Canada M5S 2S1.

Submitted for publication 20th July 1998; initial review completed 2nd November 1998; ® nal version accepted27th April 1999.

ISSN 0965± 2140 print/ISSN 1360-0443 online/00/010037± 16 Ó Society for the Study of Addiction to Alcohol and Other Drugs

Carfax Publishing, Taylor & Francis Ltd

38 Reginald G. Smart & Robert E. Mann

problems. These have been termed population-based strategies. In North America, few treat-ment agencies have any mandate to carry outprevention work in the community or take muchinterest in alcohol policies. Alcoholics Anony-mous, the largest self-help group, focuses almostexclusively on providing help to alcoholics and ittakes little interest in alcohol education orgovernment alcohol policy. Room (1997) spokeof ª the two models of alcohol problemsº , onemodel emphasizes treatment for individuals andthe other emphasizes prevention for the broadercommunity. One of the most prominent theoriesabout prevention, the Single Distribution The-ory, (Ledermann, 1956; Bruun et al., 1975; Ed-wards et al., 1994) posits a strong relationshipbetween per capita alcohol consumption andalcohol-related problems in the population, butmakes no reference to programs for heavydrinkers and how they might help in prevention.The Single Distribution Theory and relatedstrategies emphasize reducing alcohol problemsthrough restrictions on the availability of alcohol,e.g. through increased taxation or reduced hoursof sale.

High-risk strategies have high face validity.Heavy drinkers or alcoholics have the highestrates of alcohol-related problems such as cir-rhosis and motor vehicle collisions, and thussuccessful interventions with them shouldin¯ uence population indicators of problems.However, Moore & Gerstein (1981), Kreitman(1986) and others (e.g. Rose, 1992) estimatedthat light to moderate drinkers have the largestnumber of alcohol-related problems, eventhough the number of problems per drinker maybe far fewer. Because there are far more suchdrinkers, a reduction in their excessive alcoholconsumption should affect overall rates of prob-lems, perhaps by a larger degree than reducedconsumption among heavy drinkers or alco-holics.

Despite the usual distinction between high-risk and population-based strategies, recent re-search has begun to consider the impact thathigh-risk approaches may have on populationlevels of problems. This paper examines this newarea of research. It begins by de® ning programsfor high-risk drinkers, and then summarizes evi-dence from experimental and quasi-experimentalstudies on the effectiveness of these programs forindividuals. It then proceeds to review evidencefor impact at the aggregate level, by reviewing

changes in alcohol problems observed followingchanges in levels of high risk programs and esti-mates of the comparative impact of high-riskand population-based prevention programs. Itends with a consideration of data and researchissues.

What are programs for high-risk drinkers?

Programs for high-risk drinkers are those de-signed mainly to assist individuals to modify orstop their alcohol consumption when it increasestheir risk of adverse health, legal or social conse-quences, or when they are already experiencingthese consequences. Programs traditionallyde® ned as treatment are included; they may ormay not be formally incorporated within a socialor medical structure. Thus, programs in otherhealth-care services would be included, as wouldless formally constituted programs, in particularAlcoholics Anonymous or other self-help groupswith similar goals.

While the target population and goals of theprogram are key factors in determining whetherit is considered here, the speci® c activities of theprogram are less important. For example, weinclude ª educationº programs aimed at high-riskpopulations. Although most authors distinguishbetween ª educationº and ª treatmentº , in prac-tice this distinction breaks down. Thus, treat-ment programs often include educationalactivities and education programs often includebehaviour-change procedures. For example,many educational programs for convicted drink-ing drivers assist participants in identifying andmodifying hazardous drinking behavior, e.g. self-monitoring of drinking, development of plans toavoid driving after drinking and relapse preven-tion training (e.g. Mann, Vingilis & Stewart,1988a). On the other hand, school educationprograms designed to prevent excessive con-sumption by students are not considered here,since the target populations are not primarilyhigh-risk drinkers. Deterrence programsmounted by police to reduce drinking-drivingmay detect many high risk drinkers. However,the goals of these programs are not to modify thedrinking behaviour of the individuals apprehen-ded, and thus these programs are not consideredhere. We also exclude solely pharmacologicalinterventions from this review, but studies whereit is dif® cult to disentangle pharmacological fromnon-pharmacological treatment are included.

Aggregate effects of high-risk programs 39

Treatment effects at the individual level

Programs for ª traditionalº treatment-seeking popu-lations

Many years ago, Gibbins (1953) identi® ed manyways to treat alcohol problems such as religiousconversions, prolonged institutionalization, elev-ation of blood sugar level, spinal drainage, con-vulsive therapy, serotherapy and hemotherapyand pharmacological measures such as ben-zedrine sulphate, atropine and/or strychnine,emetine, apomorphine and colloidal gold salts.Gibbins concluded that few, if any, of theseapproaches were of any use and this contributedto the general pessimism about the effectivenessof all interventions for alcohol abuse. Early treat-ment evaluations often found no evidence for theeffectiveness of interventions (e.g. Smart et al.,1967; Edwards, Orford & Egert, 1977). A dec-ade ago Riley and colleagues (1987) concluded,in a comprehensive review, that ª ¼ treatmentsfor alcohol problems with demonstrated endur-ing effectiveness do not exist, regardless of treat-ment orientations or treatment goalsº (p. 107).

Recently, however, the assessment of the im-pact of treatment has been changing and manystudies have supported the value of treatmentand related interventions for individuals withalcohol problems. Several in¯ uential and auth-oritative reviews have appeared over the years(e.g. Emrick, 1975, 1987; Miller & Hester,1986; Institute of Medicine, 1989; Holder et al.,1991; Bien, Miller & Tonigan, 1993; Finney &Monahan, 1996) which identify bene® cial im-pacts of treatment interventions, or point tocharacteristics of interventions or individualsassociated with better results.

Holder et al. (1991) reviewed the results of177 studies of the impact of treatment. Theynote several problems in this literature, includinglittle agreement on the ª activeº ingredients oftreatment, no accepted standard of effect, failureto recognize the homogeneous nature of thetreatment population and the wide variety ofactivities which could be considered treatment.Thus, their purpose was not to examine treat-ment effectiveness overall, but to consider therelative impact of different treatment modalitiesand their cost-effectiveness. Holder et al. (1991)reasoned that, since treatment was likely to con-tinue whether effective or not, the focus shouldbe on methods which are less expensive butdeliver the same result. This approach has alsobeen taken by Finney & Monahan (1996) in a

similar evaluation of treatments. Both groups ofauthors concluded that some forms of treatmentare more effective than others. For example,Holder et al. (1991) concluded that, among non-pharmacological treatments, such modalities associal skills training, self-control training, briefmotivational counselling and behavioural maritaltherapy were more effective than such modalitiesas confrontational interventions, educational lec-tures/® lms, general counselling, group therapyand residential milieu therapy. The most effec-tive non-pharmacological treatments identi® edby Finney & Monahan (1996) were communityreinforcement, social skills training, behaviouralmarital therapy and stress management training.The least effective were residential milieu ther-apy, confrontational interventions, general coun-selling and hypnosis.

Bien et al. (1993) reviewed the effectiveness ofbrief interventions for alcohol problems. Theseinterventions serve a variety of treatment-relatedpurposes, including facilitating referral andtargeting drinking directly. In 15 of the 16 stud-ies identi® ed with a no-treatment condition,brief intervention proved superior to no treat-ment. Bien et al. (1993) concluded that briefinterventions ª ¼ are usually signi® cantly moreeffective than no intervention, ¼ commonlyshow similar impact to that of more extensiveinterventions, ¼ and ¼ can enhance the effec-tiveness of subsequent treatmentº (p. 326).These interventions were effective in health-caresettings, among self-referred drinkers and inmore traditional treatment contexts. However,studies with an untreated control group primarilyinvolved groups which are not the ª traditionalºclients of treatment; that is, individuals solicitedthrough newspaper advertisements or patientsscreened in primary health-care settings for al-cohol problems.

Alcoholics anonymous and other self-help organiza-

tionsSelf-help organizations have probably been thesingle largest source of assistance for individualswith drinking problems over the years. Alco-holics Anonymous, the model for many self-helpgroups, was founded in 1935 by Bill W. and DrBob, to assist themselves and their friends to dealwith their own alcoholism (MaÈ kelaÈ et al., 1996).By 1990 AA had more than 92 000 groups


around the world (MaÈ kelaÈ et al., 1996). Othersmaller and less well-known self-help groupshave arisen, such as Women for Sobriety(Kaskutas, 1992), to meet the special needs ofparticular groups. Much has been written aboutAA and other self-help organizations over theyears both as sociological phenomena and as aresource for individuals needing treatment (e.g.Ogborne & Glaser, 1981; McCrady & Miller,1993; MaÈ kelaÈ et al., 1996). The success of theseorganizations, in particular AA, in terms ofgrowth public acceptance and the perceivedvalue to its many successful members is seen asa key factor in the acceptance of self-help strate-gies in other health issues, and health promotion(Lalonde, 1974).

Emrick (1987) summarized the research onthe treatment effectiveness of AA and identi® ed44 relevant studies. He noted an absence ofª hard, empirical dataº on the effectiveness ofAA, but found substantial correlational or quasi-experimental data. He cautioned that the impactof AA may not always be bene® cial, and that AAis not suitable for everyone. Despite thesecaveats, he noted that AA has led to many al-cohol-dependent individuals achieving absti-nence, more so than for professional treatment,while professional treatment more often led tothe achievement of reduced drinking goals.Among alcoholics who become long-term mem-bers, 60± 68% improved at least somewhat and40± 50% had periods of total abstinence lastingseveral years. In a subsequent meta-analysis in-volving 107 studies, Emrick et al. (1993)con® rmed the observation of a positive relation-ship between AA involvement and several mea-sures of treatment outcome.

In the most recent meta-analysis of the effectsof AA, Tonigan, Toscova & Miller (1996)identi® ed 300 research citations of which 74were studies with suf® cient methodological in-formation for inclusion. They noted that theliterature on AA is weak experimentally, withinfrequent use of random assignment. Clearly,random assignment would strengthen estima-tions of the effects of AA, but for understandablereasons its members may object to it. Tonigan et

al. (1996) noted that outcomes were heteroge-neous, and existing studies typically lackedsuf® cient sample sizes to detect meaningful rela-tionships. However, in general patient involve-ment with AA was associated with betteroutcomes. This ® nding was stronger in studies

with better research designs and those involvingoutpatient than inpatient samples.

Rehabilitation programs for convicted drinkingdrivers

Interest in developing rehabilitation programs forconvicted drinking drivers was stimulated byearly work which demonstrated their high fre-quency of alcohol problems. (e.g., Smart &Schmidt, 1961; Selzer, 1971). Reports evaluat-ing these programs appeared in the early 1970s(e.g., Nichols et al., 1978) and have continued tothe 1990s (e.g., Donovan et al. 1990). Theseevaluations have emphasized the impact ontraf® c safety measures, most notably reconvic-tions for a drinking-driving offences (recidivism)and alcohol-related collisions (Mann et al.,1983). Several early reports presented the para-doxical ® nding that individuals in these pro-grams had higher rates of recidivism andalcohol-related collisions than individuals in con-trol conditions (e.g., Preusser Ulmer & Adams,1978; Hagen, Williams & McConnell, 1979).Other researchers have noted that the introduc-tion of rehabilitation programs for drinking driv-ers had the potential to have a large adverseimpact on the alcohol treatment system (Weis-ner, 1986; Institute of Medicine, 1989). Sub-sequent investigators were strongly in¯ uenced bythese observations and recommended against theuse of these programs (e.g., Klajner, Sobell &Sobell, 1984). Certainly, this controversy stimu-lated closer evaluations of these remedial pro-grams.

Most early observations of deleterious effectsof these programs occurred in studies where areduction or waving of the license suspensionwas used as an incentive to attend a rehabilitativeprogram (e.g., Preusser et al., 1978). Licensesuspensions are an effective measure to reducerecidivism and collisions (Homel, 1980; Mann etal., 1991). Thus, comparisons of groups whoreceive rehabilitation with no license action togroups who receive a licensing action with norehabilitation constitute a confounded examin-ation of the rehabilitation effect.

More recent reviews, where this methodologi-cal confound is controlled for, have concludedthat rehabilitation programs signi® cantly reducerecidivism and alcohol-related collisions (e.g.,Mann et al., 1988a; Peck, 1991; DeYoung,1997). The most comprehensive evaluation was


the meta-analysis published by Wells-Parker et

al., (1995) with 215 studies of the impact ofrehabilitation programs on recidivism and al-cohol-related collisions. The meta-analysis por-trayed a literature with many methodologicalstrengths: for example, the median sample size inthese studies was 1145, and untreated controlconditions and random assignment to conditionswere frequently employed. Additionally, Wells-Parker et al. (1995) rated the methodologicaladequacy of the studies and repeated their analy-ses on the strongest subset of studies. Theyconcluded that these programs demonstrated asmall but statistically signi® cant bene® cial effecton recidivism and alcohol-related collisions(about a 7± 9% reduction). However, when typesof treatments were examined, larger impactswere suggested in programs which combinededucation and therapy. Additionally, these ef-fects were found even in research where groupswho receive rehabilitation with no license actionwere compared to groups who receive a licensingaction with no rehabilitation, thus suggestingthat the effects in the meta-analysis may beconservative. Mann et al. (1994) compared themortality experience of convicted second offend-ers randomly assigned to rehabilitation or un-treated control conditions. Over a follow-upinterval ranging between 8 and 13 years, those inrehabilitation had 30% less mortality than theuntreated control group.

Interventions in primary health care

The systematic use of alcohol-related interven-tions in primary health care settings is a relativelynew development arising from a number of ob-servations. First, screening for alcohol problemsin these situations identi® es many individualswith alcohol-related problems not receiving anyalcohol-related intervention (Babor et al., 1986).Secondly, levels of alcohol use lower than thoseamong alcoholics in treatment still result insigni® cant problems for individuals and society(e.g. Moore & Gerstein, 1981). Thirdly, briefinterventions (even simple advice) administeredin primary health-care settings can in¯ uencehealth-related behaviour such as smoking (e.g.Russell et al., 1979). Finally, research ® ndingssupport the value of screening for alcohol prob-lems and brief interventions in these settings(Kristenson et al., 1983; Skinner et al., 1986;Antti-Poika et al., 1988; Babor & Grant, 1991;

Bien et al., 1993; Israel et al., 1996). Reviews ofthis work are uniformly positive about the impactof interventions in primary health-care settingsand showed reductions in drinking behaviour.

Babor (1995) included interventions in pri-mary health-care settings in a review of earlyinterventions and secondary prevention pro-grams and noted that such interventions arefeasible, and also that reduction of alcohol con-sumption can reduce almost all adverse conse-quences of excessive alcohol use. He concludedthat the results of controlled trials of these inter-ventions show bene® cial effects.

Public health authorities, who previously con-cluded that treatment had little relevance to ef-forts to reduce population levels of alcoholproblems (Bruun et al., 1975), now point to thesubstantial bene® ts from brief interventions foralcohol problems in medical practice (Edwards etal., 1994). There is now broad recognition of thevalue of screening and intervention carried outby primary care physicians (Edwards et al.,1994), including efforts to increase attentionpaid to these issues in medical school curricula(Ashley et al., 1990).

Methodological issues and summary

Evaluations of treatment for alcohol abuse oftencompare two or more treatments without anuntreated control group. Here, there are often nosigni® cant differences in outcome betweengroups (e.g., Edwards et al., 1977). Recently, thelargest and most carefully conducted evaluationof treatment of alcohol abuse reported a complexset of ® ndings on the impact of three differenttypes of treatment intervention that do not per-mit simple interpretation (e.g., Project MatchResearch Group, 1997, 1999). These observa-tions have been interpreted erroneously by someas casting a negative light on the effects of treat-ment. However, the Project March ResearchGroup point out that all treated groups showedsubstantial improvement over the course of treat-ment (e.g., Project Match Research Group,1999). These studies do not address directly thebasic issue of treatment effectiveness but suggestinstead that there is as yet little empirical basisfor matching clients to treatments.

A related problem is the tendency to acceptthe null hypothesis in a no-difference study, andthen to recommend that the less expensive treat-


ment be preferred (e.g., Holder et al., 1991; Bienet al., 1993). Although there are many no-difference results in studies comparing differenttreatments, many suffer from methodologicalshortcomings which preclude accepting the nullhypothesis, such as small sample sizes (Bien et

al., 1993). Accepting the null hypothesis in thissituation, when there are recent quasi-experimental data suggesting that longer treat-ment is associated with reduced mortalityemploying sample sizes of 20 000 or more (Bunnet al., 1994; Moos, Brennan & Mertens, 1994),may be a hazardous practice.

In summary, the growing consensus is thattreatment is effective in reducing excessive al-cohol consumption and related problems. Ofcourse, every treatment does not work for everyindividual and at present there is little infor-mation allowing the selection of speci® c treat-ments that are more effective for an individual.Expert opinion among researchers seems to rec-ommend less intensive treatment options, atleast initially. As well, the strongest evidence forthe effectiveness of treatment arises from non-traditional populations, such as impaired driversand those provided in primary health-care set-tings. It is easier with these groups to carry outmethodologically rigorous research with no-treatment control conditions, random assign-ment to conditions and large sample sizes.ª Traditionalº treatment and AA both appear tohave bene® cial impacts, at least with some typesof individuals.

Treatment effects at the aggregate level

Changes in alcoholism treatment levels associated

with changes in alcohol-related problems

Many countries experienced a large increase inalcohol consumption and related problems in thedecades after World War II (Bruun et al., 1975;Smart, 1989). However, in the period 1975± 80declines in alcohol consumption were observedin many countries (Smart, 1989) along withdeclines in problems such as liver cirrhosis (e.g.,Mann et al., 1988b). RomelsjoÈ ® rst suggested(1987) a link between changes in aggregate levelsof alcohol problems and treatment levels. Heobserved declines in alcohol-related problems forStockholm in the 1970s and 1980s, includinghospital admissions for liver cirrhosis, pancrea-titis, alcoholism, alcoholic psychosis and alcoholintoxication. He attributed these declines pri-

marily to decreased alcohol consumption andnoted that the numbers of daily doses ofdisul® ram, an anti-alcohol drug, increased by81% over the same period, suggesting a substan-tial increase in treatment for alcohol abuse.

Initial con® rmatory evidence of a possible rolefor treatment in problem level declines camefrom Ontario (Mann et al., 1988c) where therewas a large increase in the number of alcoholicstreated in the years between 1975 and 1982 (thenumber of alcoholics treated increased by 76%over that time). However, there were large varia-tions across the province; in some areas theincreases were very large and in others there waslittle change. Mann et al. (1988c) found thatincreases in treatment levels were signi® cantlyassociated with declines in liver cirrhosis morbid-ity rates across areas of the province. Per capitaconsumption measures were stable over thattime and no signi® cant associations with cir-rhosis morbidity levels were observed.

A subsequent study by Smart & Mann (1995)in Ontario reported changes in alcohol problems,alcohol consumption, availability of alcohol(price and numbers of alcohol outlets), treat-ment and prevention levels and AlcoholicsAnonymous membership for the years 1975± 92.Per capita alcohol consumption declined byabout 19% while problem measures such as hos-pital admissions, liver cirrhosis mortality andalcohol-related accidents declined by a muchlarger amount (32± 66%). This occurred at atime when the relative price of alcoholic bever-ages was stable and the number of on-premiseoutlets for alcohol had increased substantially.Changes in treatment levels and prevention ac-tivities were more consistent with recent declinesin alcohol use and problems than changes inavailability measures in Ontario. However, thestudy was descriptive and no formal analysis ofthe data was presented.

A recent study using data from Alberta haslargely con® rmed the results seen in Ontario.Smart & Mann (1998) used data from 1980 to1992 on alcohol consumption and problems, aswell as data on numbers of people treated and onalcohol controls such as price and the physicalavailability of alcohol. Increases in treatmentwere signi® cantly related to declines in liver cir-rhosis mortality but not to changes in alcohol-re-lated road fatalities. In both Alberta and Ontario,declines in liver cirrhosis rates were associatedmore closely with increased levels of treatment


than with changes in availability measures overthe time period examined. Holder & Parker(1992) replicated the results found in Canada.They utilized monthly data from North Carolinaand were able to perform a methodologicallymore sophisticated multivariate time± series analy-sis. They found that treatment had a signi® cantshort-term lagged effect on cirrhosis mortality,with an increase in treatment being followed 3months later by a decline in cirrhosis mortality.However, alcohol sales and unemployment rateswere not related to cirrhosis mortality.

Two cross-sectional studies using data fromthe United States failed to ® nd a relationshipbetween declines in alcohol related problems andincreased treatment for alcohol problems. Mannet al. (1991) found that changes in liver cirrhosisdeath rates between 1974 and 1983 were notrelated to changes in treatment rates acrossstates. Similar results were found in a study byMann, Smart & Anglin (1996) where drinking-driving fatality rates were the outcome measure.Alcohol abuse treatment levels for 50 states andWashington, DC did not relate to state by stateor trend differences in alcohol-related or totalfatalities. The authors noted that fatally injureddrivers, especially those in alcohol-related acci-dents, are often younger than the average al-coholic clinic patient (about age 40± 44), anddemographic factors may moderate the aggre-gate-level impact of different interventions. Onepossible explanation for the failure to ® nd animpact of treatment rates in the United States onproblem rates (Mann et al., 1991, 1996) was thatthe measures of treatment used from the Na-tional Drug and Alcoholism TreatmentUtilization Survey (e.g., National Institute onAlcohol Abuse and Alcoholism, 1982) werepoint-prevalence estimates; that is, estimates ofthe number of clients in treatment on a particu-lar day during the year. Since the day selectedvaried over surveys, these estimates could alsore¯ ect important seasonal differences, in ad-dition to differences between years. To test thissuggestion, Smart et al. (1996) examined theimpact of a different measure of change in treat-ment and change in alcohol consumption onchange in cirrhosis mortality death rates forAmerican states between 1979 and 1989. In thisanalysis, the measure of treatment activity se-lected was the states’ per capita spending ontreatment in the year in question. Across states,larger increases in treatment funding were

signi® cantly associated with larger declines incirrhosis mortality. However, changes in per cap-ita consumption were not signi® cantly related tocirrhosis mortality changes.

A follow-up study of data from Stockholm wasreported by Leifman & RomelsjoÈ (1997) usingtime± series techniques to analyze quarterly datafrom 1980 to 1994. The dependent variableswere mortality and morbidity from liver cirrhosisand from a combined measure of alcoholism,alcohol psychosis and alcohol intoxication(AAA). As independent measures they employedalcohol sales and also two measures of treatmentactivity. The ® rst measure of treatment activitywas the simple rate of sales of anti-alcohol drugs(disul® ram and citrated calcium carbamide) andthe second was a lagged weighting of this mea-sure. Sales signi® cantly and negatively predictedmortality and morbidity from cirrhosis, but notfrom AAA. Interestingly, the treatment measureswere signi® cantly related to all dependent mea-sures. However, the relationship for the twomeasures were in opposite directions, with thesimple rate of sales being positively related andthe lagged and weighted measure negatively re-lated. Leifman & RomelsjoÈ (1997) suggestedthat the former relationship was due to the sim-ple rate of sales of anti-alcohol drugs re¯ ectingthe level of alcohol problems in the population,while the latter relationship revealed thebene® cial effects of treatment on alcohol prob-lems.

So far, no studies involving treatment datafrom several countries have been reported.Corrao et al. (1997) studied the relationshipbetween alcohol consumption and cirrhosis in22 European countries. They noted that thelag between declines in consumption andcirrhosis deaths varied greatly from one countryto another. For about half the countries thelag was 0 or 1 year, suggesting an almost im-mediate impact of declines in drinking on cir-rhosis rates. Corrao et al. (1997) suggested thatin countries with short lags improved alcoholismtreatment was a possible explanation, but unfor-tunately did not have the data to test thishypothesis.

Most of the studies reviewed have observedthat decreased rates of alcohol problems such asliver cirrhosis were associated with increases intreatment levels. However, not all did, and thereasons for the discrepancies are not entirelyclear. All involved correlational procedures or


simple inspection of trends, and thus could besubject to a variety of sources of bias.

Changes in Alcoholics Anonymous membership andchanges in alcohol problem levels

AA tends to attract a different type of alcoholicfrom that seen in clinics and hospitals. At theAddiction Research Foundation less than half(46%) of patients report attending AA regularly.Ogborne & Glaser (1981) concluded thatª af® liates of AA are more likely to be men over40 years of age, white, middle or upper class,and socially stableº . AA af® liation has been asso-ciated with binge drinking, physical dependenceon alcohol and loss-of-control drinking.

Smart et al. (1989) noted that in Ontario thenumber of persons in AA was 75% of the num-ber treated in clinical facilities. In many areas thenumbers of alcoholics treated in clinics and thoseattending AA meetings are probably not verydifferent. In isolated areas there may often be anAA group where no clinical treatment is avail-able. Because AA attracts heavy-drinking, oldermales, successful membership might lower livercirrhosis and other health risks, in individualsand at the aggregate level.

Smart et al. (1989) examined the relationshipsamong changes in AA membership, cirrhosisrates, drinking-driving charges and liquor actoffences for the 10 provinces in Canada in 1974to 1983. There was no signi® cant associationbetween AA membership and cirrhosis ratechanges. However, AA membership interactedwith consumption changes so that, at higherlevels of consumption increases, changes in AAmembership and drinking-driving offences werenegatively related. This effect is consistent with apreventive impact of AA on drinking-drivingrates, although of course many other potentialexplanations exist.

More recent Canadian studies further examinehow AA membership changes relate to changesin alcohol-related problems. Data for Ontariohave been examined for the years 1975± 93(Smart & Mann, 1995). This descriptive studyshowed that as AA membership levels increased,alcohol-related problems such as alcohol depen-dence, liver cirrhosis deaths, driving while im-paired charges and drinking-driving fatalitiesdecreased. This happened when treatment levelsand prevention programs also increased, sochanges in AA levels were only one of many

potentially bene® cial trends. Very similar resultswere found in Alberta during about the sametime (Smart & Mann, 1998). However, bothstudies only involved reporting of trends, with nostatistical analysis of the relationship between AAdata and problem levels due to the small samplesize.

Two reports have examined AA and alcoholproblem data from the United States with largersamples. Using regression analysis, Mann et al.

(1991) examined data for 50 states and theDistrict of Columbia for the period 1974± 83, atime when AA membership increased greatly. Asigni® cant negative relationship between changesin cirrhosis mortality rates and AA membershipwas observed, and a 1% increase in AA member-ship was associated with a 0.06% decrease incirrhosis mortality.

The second study also involved data from 50states and DC and examined the relationshipsbetween AA membership levels and both totalaccident fatalities and alcohol-related traf® c fa-talities for 1982 and 1990. For each year, AAmembership rates were negatively related totraf® c fatality rates; that is, states with higher AAmembership rates had lower alcohol-related andtotal collision fatality rates. However, there wasno signi® cant relationship between changes overyears in AA levels and in the fatality measures.The authors suggested that these mixed resultscould have been due to several factors, includingpossible masking by strong consumption effects,and the differing demographic characteristics ofAA members and individuals most likely to beinvolved in a fatal collision.

Only one international study of AA member-ship and changes in alcohol problems has beenreported. Smart et al. (1998) examined AA lev-els, per capita consumption and liver cirrhosisdeath rates in 33 countries for 1965 and 1991.Four regression analyses with cirrhosis deathrates as the dependent measure were reportedand in all four AA membership rates were nega-tively associated with the dependent measure.However, these effects were modest and onlytwo approached signi® cance (0.05 , p , 0.10).There was also a suggestion of a lag effect sincethe negative relationship involving the 1965 AAmembership rate and 1991 cirrhosis mortalityrate was stronger than that between 1991 AAand cirrhosis data. Several issues were notedwith the data. Any relationship between AA andhealth problems such as cirrhosis mortality is


likely to be modest and thus susceptible to mask-ing where sample sizes are restricted and otherpowerful predictors such as per capita consump-tion are present. As well, almost all the AAtrends were upward. This restriction in rangelimits the utility of the data in correlationalanalyses.

Are recent changes in treatment populations and

Alcoholics Anonymous membership large enough tomake a difference?

In the research literature, estimates of the impactof treatment on drinking behaviour (e.g. Emrick,1974; Polich, Armor & Braiker, 1980), theamount of alcohol it is necessary to consume toincrease risk of cirrhosis (e.g. Lelbach, 1974)and the drinking behaviour of alcoholics enteringtreatment (e.g. Schmidt & Popham, 1968) areavailable. Two studies have combined these esti-mates with data on increases in treatment andAA membership to generate estimates of thepotential impact of those increases on the num-bers of individuals who develop or die fromcirrhosis.

Smart & Mann (1990) estimated the effects ofchanges in treatment and AA levels for 1975± 82in Ontario and 1979± 82 in the United States.Those were periods when alcohol consumptionwas relatively stable in both geographic areas.Increased treatment and AA levels could poten-tially have accounted for all of the cirrhosisdeaths and 87.7% of the hospital discharges foralcoholism in Ontario, given conservative esti-mates of the effectiveness of both alcoholismtreatment and Alcoholics Anonymous member-ship. Data for the United States indicated thatincreased treatment and AA membership couldhave accounted for 85.8% of the reduction incirrhosis deaths and 60.8% of the reduction inhospital discharges for alcoholism. A later study(Smart & Mann, 1993) used the same methodwith a longer series of years (1979± 87 for On-tario and 1975 and 1986 for the United States).Changes in treatment and AA levels could ac-count for all the declines in cirrhosis deaths andhospital admissions in Ontario. In the UnitedStates the same factors could account for all thedeclines in cirrhosis deaths and about 40% of thedeclines in hospital admissions.

Although these studies are supportive of otherssuggesting that alcohol problems are affected bytreatment and AA membership, they have limita-

tions. They cover a short span of years and donot take into account changes in drinking pat-terns. An attempt was made to take account ofthe overlap between treatment and AA member-ship. However, this is based on estimates, as arethe numbers of individuals treated and in AAmembership. It would be useful to repeat thesestudies in other geographic areas.

Comparisons of population and high-risk strategiesThe impact of population and high-risk strate-gies has been simulated using existing epidemio-logical and survey data. NorstroÈ m (1995)compared two different strategies for preven-tionÐ a reduction of 25% in per capita alcoholconsumption and a decrease in the consumptionof heavy drinkers (the highest 5%) to achieve thesame reduction in consumption (about 36%).NorstroÈ m observed that the high-risk strategywould be more effective in reducing cirrhosisand the population strategy best for reducingaccidents and suicide, but the high-risk strategywould also achieve these aims. He concludedthat ª neither of the two strategies appear asclearly superior to the otherº and both have theirgreatest effect on the groups on which they fo-cus. This approach is based on several assump-tions. The data are drawn from surveys anddeath statistics for Sweden as well as assump-tions about risk functions from French liver cir-rhosis deaths and it is unclear whether the sameresults would be predicted if performed else-where.

A similar study by Dawson, Archer & Grant(1996) used data from the United States. Theirstudy examined the impact of three types ofreduction in alcohol consumption amounting toa 25% decline in total: a 25% reduction by alldrinkers, the same reduction by drinkers whoseconsumption occasionally or usually exceeds amoderate level, or a reduction by those whosedrinking usually exceeds a moderate level. Re-ductions in the prevalence of alcohol abuse ordependence would be almost identical with thethree approaches. It was assumed that the re-duction in consumption would be achieved byreducing the number of drinks per day, ratherthan the number of drinking days or types ofbeverages consumed. Although the two studiesdiffered in the procedures used, it is interestingto note the convergence in results. BothNorstroÈ m (1994) and Dawson et al. (1996) re-]


port that the choice of high-risk or population-preventive methods makes very little differenceto the outcome.

Data issues and needs

Several issues exist with the data available forthis ® eld of research. Alcohol consumption data.typically expressed as per capita consumption,are based on of® cial sales ® gures and neglect avariety of beverage sources such as illicit pro-duction, out of country sales and duty-free sales.These sources may have contributed as much as28.2% of the total alcohol consumed in Ontarioin recent years (Macdonald, Wells & Giesbrecht,1999). Also, per capita consumption ® gures donot take account of changes in drinking patterns,such as increases in numbers of heavy drinkerswhen overall consumption is decreasing or sta-ble. Changes in drinking patterns may be im-portant signs of the impact of (or need for) highrisk programs, but aggregate-level data onchanges in consumption patterns are rarely avail-able.

There are also problems with AA and treat-ment data. First and most importantly, onlylimited amounts of these data are available. Bothtreatment and AA data may be subject to bias.For example, AA membership numbers arebased on estimates made by group leaders.Treatment data for places such as Ontario comefrom a census of all alcohol treatment centres(Rush & Timney, 1988; Rush et al., 1995).However, they leave out treatment by privatephysicians, and treatment centres may not re-spond fully. Portions of the treatment data forthe United States have been based on a 1-day(point prevalence) census (e.g., National Insti-tute on Alcohol Abuse and Alcoholism, 1982).The day for that census has changed so thatseasonal variations as well as yearly changes maybe re¯ ected in such data.

In addition to the need for more informationon aggregate levels of treatment activities, thereis also a need for information on the characteris-tics of people affected by treatment activities,including the characteristics of people affectedby changes in the levels of treatment. An in-crease in treatment or AA membership, for ex-ample, may in¯ uence a segment of thepopulation that is different from the segmentoriginally receiving services. The impact couldthus be different than an increase which affected

only those with the same characteristics as previ-ously. For example, if an increase in treatmentservices involved primarily larger numbers ofyounger individuals, the impact on cirrhosismortality might tend not to be immediate, butinstead spread out over a longer period of time.

Currently, good estimates of the cost-effectiveness of many population-based andhigh-risk programs are not available. Such esti-mates have been made for some types of treat-ment programs. Several reviewers haverecommended cost-effectiveness analyses forprevention programs (Holder, 1997; Wallace etal., 1998) or have presented useful paradigms(Plotnick, 1994; Kim et al., 1995). However,there are few estimates for legislative changes, foreducation programs, drinking driver rehabili-tation programs or primary health care programsfor problem drinkers. Mitchell et al. (1984)showed that a school education program wasable to reduce drinking levels in religious stu-dents for a cost of $68 per pupil. Miller, Gal-braith & Laurence (1998) showed that a sobrietycheckpoint saved $6 for every $1.30 spent on theprogram. It is interesting to speculate that AAprograms will be the most cost-effective sincethey require no public funding. At present, weare unable to say whether population-based orhigh-risk programs are more cost-effective.

Research issues

There is a long history of caution in interpretingresearch on aggregate indicators of health due tothe complex nature of aggregate data (Wilson &Drury, 1984). It is important to remember thatmany factors can in¯ uence aggregate data, andthat research on aggregate measures is alwayscorrelational in nature. These two limitationsmean that no single study will ever conclusivelydemonstrate causation, and also that the resultsof any single study can be due to several poten-tial causes. Even the use of increasingly sophisti-cated analytical procedures cannot obviate thisconcern, and could even impede progress if theyprovide a false sense that individual studies arefree from the caveats of correlational research.

A further limiting factor is the nature of thedata available, as described previously. In par-ticular, aggregate indicators of treatment andother prevention activities are relatively new, andlarge databases involving these measures arerare. Thus, the ability to apply many analytical


techniques that require larger databases is cur-rently restricted, and is likely to remain so for thenear future at least. This does not mean that theuse of less comprehensive databases should notoccur, but rather that we recognize that limita-tions on individual studies will remain with us.

Several studies in this area have involved sim-ple inspection of trends (e.g. RomelsjoÈ , 1987;Smart & Mann, 1995). In others sample correla-tions between measures have been examined(e.g. Smart & Mann, 1998). Regression ap-proaches involving cross-sectional data at onepoint in time, cross-sectional data involvingchanges between two points in time, and timeseries data from a single location (Holder &Parker, 1992; Leifman & RomelsjoÈ , 1998; Mannet al., 1996, 1988) have been the predominantanalytical strategies. These regression ap-proaches have thus proved to be of substantialvalue in this area of research. A related analyticalstrategy which in principle should be useful insituations where there are not enough datapoints for analysis of a single time series is thecross-sectional time-series analytical model (e.g.Her & Rehm, 1998), where ecological sets oftime-series are combined in a single analysis.

The majority of studies to date have reporteddata from North America and Sweden. Reportsfrom other parts of the world should be encour-aged, even if they are largely descriptive. Casestudies of different jurisdictions have in the pastproved useful in the evolution of the publichealth approach to alcohol problems (MaÈ kelaÈ etal., 1981) and can continue to do so, particularlyin this area.

Most studies have employed cirrhosis mor-tality or morbidity rates as an outcome measure,with some exceptions (Mann et al., 1996; Lief-man & RomelsjoÈ , 1998). The use of additionaloutcome measures would provide valuable addi-tional information, and it may be possible todevelop hypotheses which predict differential ef-fects on different outcome measures. For exam-ple, the introduction in a jurisdiction of amandatory requirement that all convicted drink-ing drivers complete a rehabilitation program,where previously very few did, might have adetectable impact on alcohol-related motor ve-hicle fatality rates, but not on cirrhosis mortalityrates.

Lag effects may be important in understandingthe relationship between per capita consumptionand cirrhosis mortality rates (Skog, 1980;

NorstroÈ m, 1987; Corrao et al., 1997; Corrao,1998). It would be reasonable to expect that theeffect of treatment on cirrhosis morbidity andmortality would not be solely immediate, or thatit might have both an immediate and a delayedimpact demonstrated as a lag effect. Some dataalready suggest that this might be the case(Holder & Parker, 1992; Leifman & RomelsjoÅ ,1997). Any speci® cation of the relationship be-tween treatment levels and problem levels wouldclearly bene® t from the ability to understand lageffects more fully.

It is also worth noting that population andhigh-risk strategies may affect subgroups of thepopulation differently, and thus differentially af-fect the characteristics of the population whomanifest an alcohol-related problem. For exam-ple, one population-based strategy is to controlthe price of alcohol, in order to make itsuf® ciently expensive so that excessive consump-tion is reduced (Seeley, 1960; Popham, Schmidt& deLint, 1978). People may be differentiallyaffected by this policy based on their socio-economic status, and thus the policy would bemost effective for those with lower incomes. Thepopulation of cirrhotics, for example, would thenbe over represented by those at high incomelevels. Terris (1967) observed that this was thecase in examining cirrhosis mortality in Englandand Wales in the period 1949± 53, and suggestedthat pricing policy was responsible. On the otherhand, policies which included equitable access totreatment services, such as is the case in Ontario,would tend to reduce socio-economic bias.These predictions may be testable in compari-sons of jurisdictions which employ different pre-vention policies.

Although it is not possible to achieve any formof experimental control in aggregate or popu-lation-level studies, such control might be poss-ible in comparative community-level studies.Although some community studies have at-tempted to include treatment as a form of inter-vention (e.g. Giesbrecht, Pranovi & Wood,1990), most have focused on policy-based orearly prevention approaches and none have per-mitted a comparison of high-risk and populationapproaches. Before such studies could be mean-ingfully undertaken, several conceptual andmethodological issues would need to be ad-dressed, such as contamination between sites,identifying appropriate outcome measures andselecting a suitable time-frame. In spite of the


dif® culties, however, these comparative com-munity studies seem to promise the best chanceof bringing some degree of experimental controlto research in this area.

Summary and conclusions

In general, the results of this review can besummarized as follows:

(1) Both traditional treatment and AlcoholicsAnonymous are associated with bene® cialimpacts on some types of individuals withalcohol problems.

(2) Non-traditional programs for drinking driv-ers and those in primary health care settingshave signi® cant bene® cial effects on alcoholabusers.

(3) Follow-up studies of alcoholism treatment,Alcoholics Anonymous members and otherhigh-risk interventions indicate that substan-tial proportions of those treated improve orbecome abstinent.

(4) In most but not all studies decreased rates ofalcohol problems such as liver cirrhosis areassociated with increases in treatment levelsand in Alcoholics Anonymous membership.

(5) The recent changes in numbers of peopletreated and Alcoholics Anonymous member-ship may be large enough, in at least somejurisdictions, to have a considerable impacton hospital admissions and deaths from livercirrhosis. Such changes could potentially ac-count for all of the reduction in cirrhosisdeaths in Ontario and the United States, allthe reduction in hospital discharges in On-tario and 40% of the reduction in hospitaldischarges in the United States.

(6) Comparisons of high-risk and populationstrategies indicate that these strategies canachieve similar outcomes and that no clearsuperiority of one over the other exists.However, these comparisons are based onprojections and assumptions using availabledata.

These results suggest that high-risk ap-proaches to prevention are a reasonable compo-nent of strategies to reduce alcohol-relatedproblems. Their effects have been large enough,in principle, to achieve substantial reductions inalcohol-related problems. In some countries itappears likely that they have already achievedsuch results. This does not mean that high-risk

approaches are superior to population ap-proaches or to be preferred over them. Availableevidence suggests that they may be similarlyeffective and the best advice would seem to bethat they be used together rather than separately.

Despite the apparent value of high-risk ap-proaches, there are many important areas forfurther research. Inconsistencies in the researchhave been observed, and efforts to understandthem should be encouraged. Studies examiningthe impact of high-risk approaches on alcohol-re-lated problems such as domestic violence, sui-cide and homicide would be valuable. Also, thereis a need for research from a wider variety ofcountries. Most of the current studies come fromCanada, the United States and Sweden, al-though liver cirrhosis rates are falling in manycountries (Corrao et al., 1997). At present, onlycorrelational and trend data are available, andexperimental comparisons of high-risk and popu-lation-based strategies at the community levelwould be very useful. Finally, it is important toreiterate that research on the aggregate effects ofhigh-risk programs is based on correlational pro-cedures and is at an early stage of developmentin comparison to research on population-basedstrategies. Thus, the evidence in this area bearscontinued monitoring.

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The impact of programs for high-risk drinkers on population levels of alcohol problems