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In an open letter to Addiction, Michel Craplet (2006) is both sceptical and unhappy about recent publications (Babor et al. 2003; Room et al. 2005) that have called into question the assumed effectiveness of education and persuasion as primary preventive approaches to reduce alcohol-related harm. Craplet suggests a different and more differentiated approach to the issue and argues for a more benign interpretation of the cumulative evidence for several reasons: (a) some interventions have had positive results and (b) we lack evidence about the effects of long-term and intensive interventions.

While the current evidence has methodological limitations (Foxcroft et al. 2002, 2003), it is coherent in the sense that no firm positive conclusions about the effectiveness of educative interventions in the short- and medium-term are possible. This is a strong statement, made after more than 50 controlled studies had been evaluated in a standardized Cochrane review (Foxcroft et al. 2002). Together with the finding that many studies showed ineffectiveness, the conclusion drawn in such publications as Alcohol: No Ordinary Commodity (Babor et al. 2003) seems justified.

What does this mean for education and persuasion activities as a means to reduce alcohol-related harm, and for those engaged in such activities? First and foremost, there seems to be evidence, particularly from the United States, that educational and other persuasive activities, such as media campaigns and warning labels, have not been effective. For much of the world, including most of Europe, there has been no research on effectiveness at all, although this is a case where no news is unlikely to be good news. The results of the reviews do not mean that all future activities will necessarily be ineffective, especially if they are guided by different theoretical principles and more intensive implementation. In this respect the example of tobacco control efforts is instructive. The overall picture on school-based programmes to prevent tobacco use is as pessimistic as that for alcohol (Thomas 2002), but the research on media persuasion campaigns is more promising, with one important caveat: the advertisements need to portray hard-hitting attacks by government on the tobacco industry, suggesting, for example, that ‘they are not in business for your health’ (Sly et al. 2002; Hersey et al. 2005). This underlines the importance of identifying boundary conditions, beyond which persuasion and education could be successful. It seems that primary preventive interventions could be successful if they are more intense, more professional and are carried out in the context of larger social movements (e.g. the current anti-tobacco movement and historically, for alcohol, the temperance movement), which are not focused solely on young people. Unfortunately, these conditions do not apply well to current alcohol education and persuasion efforts. Globally, we have not seen any hard-hitting government campaigns against the alcohol industry, and alcohol control does not seem to be a popular focus of current social movements. This may explain the lack of effectiveness of current education and persuasion interventions in the alcohol area.

What can we conclude from Michel Craplet's plea to reconsider alcohol education and persuasion strategies? Contrary to Craplet's portrayal of the evidence we have reviewed, we believe that there is a role for education and persuasion, mainly in conjunction with evidence-based control measures (e.g. taxation, drinking-driving laws, etc.; see Babor et al. 2003). Primary prevention activities can create a social climate of better acceptance for effective measures. However, given the current state of knowledge, they are unlikely to reduce alcohol-related harm alone, i.e. without other control measures.

Of course, the above conclusion may be misused by governments to cut primary prevention efforts in situations where there is no public or political support for more effective control measures. Because there is no convincing evidence that education and persuasion measures alone can reduce alcohol-related harm, public health advocates should insist on other interventions for which there is much more promising evidence of effectiveness. After all, the global net health impact of alcohol equals that of tobacco (Rehm et al. 2003), which is a compelling argument for reducing this harm. A good place to start is with alcohol marketing. One working hypothesis is that alcohol education and anti-alcohol persuasion activities are futile when they have to compete directly with well-financed and aggressive marketing campaigns aimed at the same audience. Alcohol education may work better in populations where restrictions on marketing alcohol to young people are enforced systematically. If all the good will, money and energy invested in alcohol education and persuasion strategies could be channelled into more effective interventions, perhaps our pessimistic and (for some) demoralizing conclusions about lack of effectiveness will have served a useful purpose.

References

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  2. References
  • Babor, T., Caetano, R., Casswell, S., Edwards, G., Giesbrecht, N., Graham, K. et al. (2003) Alcohol: No Ordinary Commodity. Research and Public Policy. Oxford and London: Oxford University Press.
  • Craplet, M. (2006) Open letter to my friends and colleagues. Addiction, 101, 450452.
  • Foxcroft, D. R., Ireland, D., Lister-Sharp, D. J., Lowe, G. & Breen, R. (2003) Longer-term primary prevention for alcohol misuse in young people: a systematic review. Addiction, 98, 397411.
  • Foxcroft, D. R., Ireland, D., Lowe, G. & Breen, R. (2002) Primary prevention for alcohol misuse in young people. Cochrane Database of Systematic Reviews, 2002, CD003024.
  • Hersey, J. C., Niederdeppe, J., Ng, S. W., Mowery, P., Farrelly, M. & Messeri, P. (2005) How state counterindustry campaigns help prime perceptions of tobacco industry practices to promote reductions in youth smoking. Tobacco Control, 14, 377383.
  • Rehm, J., Room, R., Monteiro, M., Gmel, G., Graham, K., Rehn, N. et al. (2003) Alcohol as a risk factor for global burden of disease. European Addiction Research, 9, 157164.
  • Room, R., Babor, T. & Rehm, J. (2005) Alcohol and public health: a review. Lancet, 365, 519530.
  • Sly, D. F., Trapido, E. & Ray, S. (2002) Evidence of the dose effects of an antitobacco advertising campaign. Preventive Medicine, 35, 511518.
  • Thomas, R. (2002) School-based programmes for preventing smoking. Cochrane Database of Systematic Reviews, 2002, CD001293.