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Alcohol Control Policy in the Nordic Countries (Denmark, Finland, Norway, Sweden, Iceland)

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Alcohol Control Policy in the Nordic Countries (Denmark, Finland, Norway, Sweden, Iceland) 6F Alcohol Control Policy in the Nordic Countries (Denmark, Finland, Norway, Sweden, Iceland) K. GUNNAR GOTESTAM AND OLA ROSTUM There are interesting similarities and differences in the alcohol control policies in the Nordic countries, which include the three Scandinavian countries, Denmark, Norway, and Sweden, plus Finland and Iceland. This opens up the possibility of a comparative analysis of regulatory policies in these countries, which in other respects have rather similar cultural settings. Finland, Norway, Sweden, and Iceland have similar types of alcohol legislation. Denmark has no special alcohol legislation, but has tried to include alcohol regulations in other laws. In addition, alcohol regulations in Denmark are more liberal as compared to the other countries. Several factors affect alcohol consumption. One of these, which has been considered very important, is legislation. Others include price policy, increased urbanization, increased leisure time, spread of prosperity, facili­ tated communications, enlarged youth populations, and augmented tourist traffic bringing more contact with drinking patterns in other cultures (Kom­ mittebetankande, 1978). High levels of alcohol consumption also increase the number of alco­ holics (Skog, 1980-81). Recent research has shown that an increase in the K. GUNNAR GOTESTAM • University of Trondheim, Ostmarka Hospital, Trondheim, Norway. OlA ROSTUM • Blue Cross Alcoholism Treatment Center, Trondheim, Norway. 213 P. M. Miller et al. (eds.), Prevention of Alcohol Abuse © Plenum Press, New York 1984 214 K. Gunnar Gotestam and ala Rostum total consumption by a factor of two increases the number of alcoholics by a factor of four (Bruun, Edwards, Lumio, Makela, Pan, Popham, Room, Schmidt, Skog, Sulkunen, & Osterberg, 1975; Skog, 1980-81). With an individual increase in alcohol consumption, the probability of liver cirrhosis is also increased (Skog, 1980, 1980-81) and, in several countries, a relation between increased alcohol consumption and higher death rates from liver cirrhosis has been shown (Bruun et a/., 1975; Skog, 1980). Other chronic health damages caused by alcohol also seem to follow increases in alcohol consumption (Skog, 1980-81). Although it seems appropriate to assume a causal relationship between the amount of alcohol consumed and the occurrence of other damages caused by alcohol (i.e., acute health damages and social defects), such a relationship has been difficult to document since factors other than alcohol consumption affect such damage. Cancer in the proximal part of tractus gastrointestinalis is dependent both on the amount and type of liquor con­ sumed, with the highest risk for strong spirits (Tuyuns, Pequignot, & Ab­ batucci, 1979; Skog, 1980-81). Much harm occurs from drinking in con­ nection with driving or working. There are also clear correlations between total alcohol consumption and injuries, such as damages in traffic accidents, criminality under alcohol influence, social damages at work and in the fami­ ly, and death by acute alcohol intoxication (Kommittebetankande, 1978). A natural hypothesis from present knowledge is that alcohol legislation affects the consumption of alcohol and this in turn affects the total damage caused by alcohol. Although this may be a feasible starting point for law­ makers, the causal relationship has been difficult to pinpoint. In this chapter, alcohol control policies in the Nordic countries are described from 1900 to 1980 for Finland and Iceland and from 1945 to 1980 for Norway, Sweden, and Denmark. Total consumption is then pre­ sented for these countries, from 1950 to 1980. Finally, available statistics for liver cirrhosis are discussed. Reports from national boards and committees were studied to provide a description of current legislation and changes in legislation during the last three decades. The findings are described for each country. From the same sources, the consumption pattern from 1950 to 1980 was also extracted, together with data on the occurrence of liver cirrhosis. Table 1 shows the current 1980 alcohol control policies in the Nordic countries. Although they are quite similar, Denmark has the most liberal policies. The different countries, however, have had rather different histories, part of which are revealed in Table 2, where changes in legislation from 1950 to 1980 are shown. In Figure 1 the total alcohol consumption, expressed as 100% alcohol Alcohol Control Policy in the Nordic Countries 215 Table 1. Comparison between the Current Alcohol Control Policies (1980) for the Different Nordic Countries (Except for leeland) Item Denmark Finland Norway Sweden Iceland Drinking age IS IS ISa/20 IS 21b Sale age 20 IS a/20 IS a/20 2l b State monopoly no yes yes yes yes Restrictions of sale few yes yes yes yes Taxation yes yes yes yes yes Advertisement reduced banned banned banned banned Alcohol driving prohibited yes yes yes yes yes "The lower figure indicates wine and beer, whereas the higher indicates strong spirits. bFor strong liquors and wine (more than 2.25 vol. % alcohol). YEARL Y ALCOHOL CONSUMPTION 13 12 Oenmark..-. Norway ......... 11 Sweden o--a Finland 10 Iceland 9 8 a: w 7 ...:::; 6 OLL--____~ ______~L- ______L_ ______ L_ ______ ~ _______U 50 55 60 65 70 75 60 YEAR Figure 1. Mean yearly consumption of alcohol (calculated as pure alcohol) per inhabitant over 15 years in the Nordic countries in the period 1950 to 19S0 (data from Om alkoholpolitikken, 19S0-S1, reprinted with permission). In the data from Iceland, an approximation of the data for a population above 15 years has been made for 1950-63, as only figures for the total population were available. Table 2. Comparisons between the Different Legal Systems and Changes in Them in the Period 1950 to 1980 in the Five Nordic Countries Year Denmark Finland Norway Sweden Iceland 1954 The Bratt system abol- Spirit monopoly; adver- ished; establishment tisement ban of state monopoly 1957 Liberalization for hotels 1958 Liberalization of restric- tions on restaurants 1965 Introduction of medium beer 1967 Liberalization of retail sale 1968 New alcohol act (medi- um beer. rural prohi- bition abolished) 1971 Individual purchase control abolished 1973 Spirit monopoly abol- Liberalization of sale ished (EEC) 1975 Advertisement ban 1977 Advertisement ban Medium beer with- drawn; advertisement ban 1978 Increased local control Alcohol Control Policy in the Nordic Countries 217 LIVER CIRRHOSIS DEATHS 12 11 Denmark (1olal) ..-. .... Denmark (alcoholic) 0-0 '"z 10 Norway ........ « Iceland ......... .... 9 iii « 8 J: ~ 7 0 0 0 6 0 5 ~ II: 4 w II. 3 ....J: « 2 w c 0 1965 1970 1975 YEAR Figure 2. Annual mortality rate per 100,000 inhabitants from liver cirrhosis in Denmark, Norway, and Iceland in the period 1963 to 1978 (data partially from Prytz and Skinh¢j, Alcoholic and nonalcoholic cirrhosis of the liver, reprinted with permission from Ugeskrift for Laeger, copyright 1981). The data from Iceland have a great variability (from 0 to 7 deaths per year), and therefore are presented as floating means per three-year period. For Finland, see text. per inhabitant above 15 years of age, in the period 1950 to 1980, is shown. Both Table 2 and Figure 1 are discussed in relation to the descriptions provided for each country below. In Figure 2, the death rate in liver cirrhosis per 100,000 inhabitants is shown for Denmark, Norway, and Iceland for the period 1963 to 1978. These and other aspects of damages also are discussed under each section below. DENMARK LEGISLATION In Denmark, there is no special alcohol law, since regulations regarding alcohol have been covered in laws governing taxation, hotels and restau­ rants, traffic, and primary schools. In 1917, a high alcohol tax was intro­ duced. It has been gradually increased, but not as rapidly as wages. When Denmark was admitted to the European Common Market (EEC) in 1973, the Danish spirit monopoly was abandoned. Danish and foreign products became equal with regard to price regulation and taxes, and the real price since has been reduced, especially for wine. There are no special regulations 218 K. Gunnar Gotestam and ala Rostum on the sale of alcohol, apart from the rule that it must only be sold during regular opening hours of stores. Hotel and restaurant laws include regulations regarding the serving of alcohol, prohibiting service to drunken persons and persons under the age of 18. Traffic laws prohibit drunken driving and determine sanctions when the law is violated. The primary school law requires that information on alcohol use and abuse be given in the first nine school grades. Some increase in alcohol taxes is foreseen, as well as some restrictions on alcohol advertisement, although it will not be totally banned, as in the other Nordic countries. PROPHYLAXIS AND ATTITUDES TOWARD ALCOHOL The use of price policy and taxes has been regarded in Denmark as the main means of restricting total alcohol consumption. In 1917 such steps resulted in an abrupt decrease in total consumption and cases of delirium tremens. However, illegal import and home distillation tend to increase when price is increased. In general, there has been a relatively liberal atti­ tude regarding the use of alcohol in Denmark (Kontaktutvalget, 1980). CONSUMPTION In the period between 1950 and 1980, consumption has increased by three times, with a continuous development during the period (see Figure 1). After liberalization of the legislation in 1958 (see Table 2) the sharpest increase has been seen. Denmark also has the highest consumption among the Nordic countries. This may depend not only on relatively liberallegisla­ tion, but also on liberal attitudes toward alcohol use in the population (Danmarks Statistik, 1980; Stortingsmelding, 1980-81). DAMAGES CAUSED BY ALCOHOL The death rate from liver cirrhosis increased 29% in the period be­ tween 1963 and 1978. Alcohol-dependent liver cirrhosis has been responsi­ ble for most of this increase (see Figure 2). It is evident that the death rate from alcohol-dependent liver cirrhosis increased seven times during the period (Danmarks Statistik, 1980; Prytz & SkinhS1.lj, 1981).
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