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SHAPING A MODERN ALCOHOL POLICY: A RECENTLY DISCOVERED CHALLENGE

  1. Top of page
  2. SHAPING A MODERN ALCOHOL POLICY: A RECENTLY DISCOVERED CHALLENGE
  3. THE PRESENT SITUATION AND TRENDS IN ALCOHOL USE AND ALCOHOL-RELATED DISORDERS
  4. PREVENTION AND TREATMENT PROVISION
  5. THE RESEARCH BASE
  6. THE FUTURE
  7. Acknowledgements
  8. References

Drug policy is a well-known term in the German language, because for more than 30 years it has been a prominent focus of public and health political debate. Alcohol policy, on the other hand, is a concept discovered only recently, the impetus for which was probably increased scientific evidence for the prevalence of alcohol-use disorders in the German population (see Bühringer et al. 2002), following the publication in 1997 of the German edition of Alcohol Policy and the Public Good (Edwards et al. 1994) and the political pressures of the WHO Alcohol Action Plan 2000−05 (WHO 2000). Some early signs of action can also be found: in 2003, for the first time, the reduction of the national per capita consumption of alcohol was formulated as a political target of the Federal Department of Health, in order to reduce alcohol-related morbidity and mortality. Related actions, however, have rarely occurred and are limited predominantly to demand reduction (e.g. school-based prevention programmes; see Die Drogenbeauftragte der Bundesregierung 2003). One exception is a youth protection law, which was passed in 2004 to reduce explicitly the consumption of ‘alcopops’ (a mixture of alcohol—mostly spirits—and sweetened juices) by increasing the sales tax on them. In spite of some small developments, Germany is still a customer-friendly country for the hazardous drinker. For example, youth protection laws forbid the purchase and consumption of beer and wine by those under 16 years of age and spirits by those under 18, but the regulations are not enforced and test purchases by minors have shown that control mechanisms are lacking. Alcoholic beverages are widely available (all food shops and restaurants sell alcohol) 24 hours a day (e.g. in petrol stations), and they are relatively inexpensive. However, we pay a price for this liberal approach.

THE PRESENT SITUATION AND TRENDS IN ALCOHOL USE AND ALCOHOL-RELATED DISORDERS

  1. Top of page
  2. SHAPING A MODERN ALCOHOL POLICY: A RECENTLY DISCOVERED CHALLENGE
  3. THE PRESENT SITUATION AND TRENDS IN ALCOHOL USE AND ALCOHOL-RELATED DISORDERS
  4. PREVENTION AND TREATMENT PROVISION
  5. THE RESEARCH BASE
  6. THE FUTURE
  7. Acknowledgements
  8. References

Youth and adult representative national surveys have been carried out regularly since 1973 and 1980, respectively, and treatment utilization data from monitoring systems have existed since 1978 (for a brief review and further references, see Bühringer et al. 2002). Some of the major findings from the last adult population survey conducted in 2003 on 18–59-year-olds are as follows: 16.9% were abstinent, the majority of whom had been abstinent during the last 30 days; 71.1% described themselves as being low-risk drinkers (fewer than 20 g and 30 g for woman and men, respectively), but 12.1% drank hazardous daily amounts; 12.9% had four or more occasions of binge drinking (five standard drinks or more of alcohol consecutively) in the last 30 days, and 22.7% of the entire adult population (34.7% males) had an Alcohol Use Disorders Identification Test (AUDIT) cut-off score for hazardous use (≥ 8; Augustin & Kraus 2005). The national per capita consumption of alcohol reached a maximum of 12.9 litres in 1980, and then declined gradually to 10.2 litres in 2003. This places Germany continuously in the top group of alcohol-consuming countries (Meyer & John 2005).

Alcohol use early in adolescence is associated with higher alcohol-related problems in adulthood (Kraus et al. 2000). Some highlights from recent youth surveys are as follows: minors aged 12–15 years had a life-time prevalence of 72% for alcohol use. The average weekly consumption of absolute alcohol for this age group increased from 14.1 g in 2001 to 20.9 g in 2004 (an increase of 48%); 5% had a weekly consumption of more than 120 g; 8% reported 1–2 days of binge drinking in the last 30 days; 3% binged weekly and 1% did so approximately twice per week; altogether, 12% of this age group binge-drank. The respective binge percentages for the 16–19–year-olds were 26%, 12% and 6%. Their weekly consumption of absolute alcohol increased from 65.5 g to 97.5 g (an increase of 49%) during the same period (Bundeszentrale für gesundheitliche Aufklärung 2004).

The high levels of alcohol consumption and of problematic use patterns are not without consequences. The Diagnostic and Statistical Manual version IV (DSM-IV) prevalence estimates for alcohol dependence and alcohol abuse in the adult population are 2.6% each (Kraus & Augustin 2001). Approximately 42 000 people die each year of causes attributable to alcohol consumption (amounting to 4.8% of all deaths, 7.5% deaths of males and 2.4% deaths of females). For 1995, alcohol-related direct and indirect costs were calculated to be €20.7 million (Bühringer et al. 2002). The total per capita consumption has decreased gradually by about 15% during the last 20 years, but problematic alcohol use among adolescents and young adults (early onset of alcohol use, early regular and heavy alcohol consumption, early binge drinking) showed a sharp increase.

PREVENTION AND TREATMENT PROVISION

  1. Top of page
  2. SHAPING A MODERN ALCOHOL POLICY: A RECENTLY DISCOVERED CHALLENGE
  3. THE PRESENT SITUATION AND TRENDS IN ALCOHOL USE AND ALCOHOL-RELATED DISORDERS
  4. PREVENTION AND TREATMENT PROVISION
  5. THE RESEARCH BASE
  6. THE FUTURE
  7. Acknowledgements
  8. References

Over a period of nearly 100 years, the traditional and sole professional approach to alcohol-related problems in Germany was in-patient, long-term treatment in addiction speciality centres for severe alcohol dependence. Major changes in this concept resulted in a dramatic reduction in treatment duration, from 6–8 months to 1–4 months, and a continuous increase in out-patient treatment. Rehabilitation after detoxification is financed by the public pension-insurance scheme. The rationale is that rehabilitation will enable addicted individuals to return to work, continue to make contributions to the pension scheme and avoid receiving an early pension. There is a legal right to be treated without cost, and there is no shortage of places where treatment can take place. In 2004 almost 95 000 cases were treated as out-patients and almost 41 000 cases on an in-patient basis (personal calculations, based on Sonntag & Welsch 2004a,b).

Demand-reduction activities as part of primary prevention have been developed only in the last 20 years, but are highly elaborate and are carried out all over the country. Kindergartens and primary schools can choose between several different programmes (e.g. improving life skills; Kröger & Reese 2000; Botvin & Griffin 2001), most of which are based on up-to-date scientific knowledge. The Federal Centre for Health Education provides information pamphlets, prevention guidelines and manuals for the general public, specific target groups and professionals who work with children and adolescents. Based on recent survey data in medical settings (e.g. private practitioners, internal medicine and surgical hospital wards), showing high rates of alcohol-related problems, programmes for early detection and early intervention have been developed and evaluated (e.g. John, Hapke & Rumpf 2002) using motivational interviewing and alcohol-use moderation techniques, and are being slowly implemented.

THE RESEARCH BASE

  1. Top of page
  2. SHAPING A MODERN ALCOHOL POLICY: A RECENTLY DISCOVERED CHALLENGE
  3. THE PRESENT SITUATION AND TRENDS IN ALCOHOL USE AND ALCOHOL-RELATED DISORDERS
  4. PREVENTION AND TREATMENT PROVISION
  5. THE RESEARCH BASE
  6. THE FUTURE
  7. Acknowledgements
  8. References

In 1891, the first German speciality journal for alcohol and other addictions was founded, which was the predecessor of the current journal Sucht. At that time, research was limited to treatment-outcome studies and cross-national comparisons of alcohol use and its negative consequences. During the 1930s and 1940s, eugenic issues increasingly dominated alcohol research in Germany, and the scientific community contributed to the ideology and crime of national socialism (for additional details see Bühringer & Watzl 2003). The first major post-World War II alcohol research group was established by Feuerlein in approximately 1970 and published, among other topics, the following: (1) treatment and follow-up data and factors that moderated outcome from a large, multi-site field study that included 21 centres and 1410 patients (Feuerlein & Küfner 1989) and (2) the alcohol screening and diagnostic instrument Munich Alcoholism Test (MALT; Feuerlein et al. 1980), which has now been translated into seven languages.

Systematic long-term funding by the Federal Ministry of Education and Research for all types of addiction research started in 1990, with approximately €24 million available until 2001 and another €20 million until 2007. Currently, four research networks and their associated research groups are engaged in alcohol research (for further information, see the following websites: http://www.bw-suchtweb.de; http://www.medizin.uni-greifswald.de/epidem/forschung/intervention/earlint.html; http://www.suchtforschungsverbund-nrw.de and http://www.asat-verbund.de)

THE FUTURE

  1. Top of page
  2. SHAPING A MODERN ALCOHOL POLICY: A RECENTLY DISCOVERED CHALLENGE
  3. THE PRESENT SITUATION AND TRENDS IN ALCOHOL USE AND ALCOHOL-RELATED DISORDERS
  4. PREVENTION AND TREATMENT PROVISION
  5. THE RESEARCH BASE
  6. THE FUTURE
  7. Acknowledgements
  8. References

Linkages between research and health policy are rare. For a small group of scientists, shaping the concept of a national alcohol policy is still at the kindergarten level. There is no public debate about the contents of a possible German alcohol policy, and—even worse—possible concepts for such policies do not exist in the political arena. It is unclear whether we will continue to move toward the action phase in developing and implementing a national alcohol policy or whether we will relapse to earlier stages. In this regard, a German State Minister of Finance suggested recently lowering the VAT for beer from the normal level to the reduced level for food, because ‘beer is food like bread and milk’.

Acknowledgements

  1. Top of page
  2. SHAPING A MODERN ALCOHOL POLICY: A RECENTLY DISCOVERED CHALLENGE
  3. THE PRESENT SITUATION AND TRENDS IN ALCOHOL USE AND ALCOHOL-RELATED DISORDERS
  4. PREVENTION AND TREATMENT PROVISION
  5. THE RESEARCH BASE
  6. THE FUTURE
  7. Acknowledgements
  8. References

This paper was written within the framework of the Addiction Research Network ASAT (Allocating Substance Abuse Treatments to Patient Heterogeneity). For further information contact: asatkoordination@mpipsykl.mpg.de (http://www.asat-verbund.de). ASAT is supported by a grant from the Federal Ministry of Education and Research (no. 01 EB 0140-0142). The author thanks C. Metzner, L. Kraus, H. Küfner and H.-U. Wittchen for support and critical comments and M. Cox for assistance with the language.

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  1. Top of page
  2. SHAPING A MODERN ALCOHOL POLICY: A RECENTLY DISCOVERED CHALLENGE
  3. THE PRESENT SITUATION AND TRENDS IN ALCOHOL USE AND ALCOHOL-RELATED DISORDERS
  4. PREVENTION AND TREATMENT PROVISION
  5. THE RESEARCH BASE
  6. THE FUTURE
  7. Acknowledgements
  8. References
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