This thread started in the ADDICT-L-group by my abstract of a population study I made in the Oslo population. In his reply, Ron Roizen confirmed that "this abstract very economically retells the story that survey research started telling us in the late 60ies". I replied that one of the most consistent findings in population studies is that alcohol problems to a large extent are caused by drinkers who may not be labeled addicted and never seek alcoholism treatment. Seen together with the close relationship between per capita consumption and the extent of problems, I maintained that it seems hard to avoid the conclusion that reduction alcohol problems most effectively is done by reducing per capita consumption. I also pointed to the embarrassing fact that comparing Norwegian counties, we find a strong correlation between alcoholism treatment facilities and rates of death from alcohol. Treatment is fine, but society's degree of "wetness" is the main factor behind both the demand for treatment and the deaths related to alcohol. Ron Roizen has given a thorough answer in 13 numbered paragraphs, aimed at explaining why the findings should not lead to the conclusion that per capita alcohol consumption should be reduced. Here, I will argue that I do not see that his 13 paragraphs leads to this conclusion. In his first 5 paragraphs, Ron gives very knowledgeable and interesting historical remarks on the evolution of the conceptualizations of alcohol problems in general populations. In paragraphs 6 and 7, Ron states that from early findings, Jellinek and Keller used the phrase "the alcohol problems" (in plural form), referring to the variety of problems related to alcohol, instead of the phrase "the alcohol problem" associated partly with the temperance movement. I do not believe the diversity of alcohol problems may have been unknown to the temperance movement, and none of the terms may be called erroneous. Thus, Jellinek's phrase does not reflect new research findings, but mainly reflects his wish to demonstrate a distance to the temperance movement and rhetoric, as Ron implies in paragraph 8. In paragraphs 9 and 10, Ron argues that he and "even Robin" (Room) has written about other preventive efforts than reducing per capita consumption, i.e. making the world safer for heavy drinkers or refrain from drunk driving. Who are you arguing against, Ron? Of course, all prevention agencies do such things - this does not contradict the fact that per capita consumption is the main factor determining the extent of alcohol problems. The very variety of alcohol problems limits the potential to "make the world safe for the heavy drinker" - drunkenness and heavy drinking remains a risk factor. In the 80ies, ARF in Toronto was asked by the state authorities to propose initiatives to reduce drunk driving. The first paragraph in ARF's answer was the statement that the most important factor is the per capita consumption. After that, other initiatives were proposed. In paragraph 11, Ron argues that not everything called "alcohol problems" really must be seen as alcohol problems. His example is that "spending too much money on drinking" may as well be called a budgeting or income problem. I agree in the example, and if he could not drink, he might have wasted his money on gambling. So what? In paragraph 12, Ron refers to Genevieve Knupfer's notion that the persons reached in population surveys do not "really represent clinical alcohol dependence". I agree that very heavy drinkers are probably over-represented among drop-outs in population surveys. But my clinical experience tells me that alcoholism treatment populations are not THAT different from many respondents, although the patients usually enter treatment after their most extreme binge periods and therefore leaves a rather dramatic impression. In studies like the one I presented, with a respondent rate of 77 %, we get a considerable number with large problems. In paragraph 13, Ron mentions that the book "Alcohol and the Public Good" presents a more complicated history than I presented in my posting. Of course. But in summary, Ron, I think your posting mainly show that reducing per capita consumption is not the ONLY way to reduce problems, and it most certainly is not. But the limitations of harm reduction while maintaining the same per capita consumption seem rather obvious to me. So the basic question may be - if the population is made aware of the importance of the general "wetness" of society upon problems and deaths - do they think the advantages outweigh the sufferings? In a Norwegian survey ten years ago, 80 % answered "no" to this question. But this is a question of values, not a specific topic for professionals. Hans Olav Fekjaer ------------------------------------------------------------------- Hans Olav Fekjaer MD, psychiatrist. mailto:[log in to unmask] Chief Medical Officer, Agency for Alcohol and Drug Problems, P.O.B. 4662 Sofienberg, 0506 Oslo, Norway. http://www.rusinfo.no/rusinfo/ Work (47) 222-03-600. Home (47) 669-12-654. Fax (47) 221-11-429 -------------------------------------------------------------------