European drinking survey: Technical challenge or expression of European integration. Lessons from the SMART project

The history of population surveys on alcohol in Europe varies from country to country and across its geographical regions. To understand this variation one has to see alcohol surveys not just as an academic exercise, but as an expression of interest and concern on the one hand, and attempts to reduce alcohol related problems on the other. The first surveys were initiated in Finland in the late 1940's (Kuusi, 1948) where the interwar period witnessed alcohol prohibition followed by an alcohol monopoly system after its repeal. Sweden and Norway where alcohol monopolies were also installed were next to undertake alcohol surveys in the 1950's. Poland, a country famed for heavy drinking, established an alcohol monopoly after World War I and reinstalled it after World War II and launched its first population survey on drinking in 1961 (Święcicki, 1963). At the same time the UK and a few other countries ran their pioneering work on alcohol surveys. By the 1980's alcohol surveys had spread to the Mediterranean region where alcohol had become a matter of concern relatively late. Finally, in the 1990's, eastern European countries which emerged from the Soviet Union started alcohol surveys of their own reflecting their concern about the health and social crisis which to a large extent could have been attributed to the high tide of drinking during the first decade of political and economic transformations (Bobadilla, Costello, & Mitchell, 1997; Moskalewicz, Wojtyniak, & Rabczenko, 2000).

Currently, alcohol surveys with focus on alcohol consumption and related problems are carried out in most of the European countries. Despite serious efforts and substantial spending, however, comparison of their results across countries is difficult, perhaps impossible, due to the variety of methodologies applied which reflects different survey traditions and different approaches adopted in their first alcohol surveys. After launching their first survey, individual countries were interested in replicating its questions in attempts to secure comparability across time and without much regard to achieving international comparability.

This individual country perspective on alcohol dominated at European Union (EU) level. For decades alcohol was perceived in the European Commission (EC) as a regular commodity which brings substantial trade surplus for the EU and secures decent profits and employment in agriculture, alcohol production, hospitality and advertising industries. However, enlargement of the EU eventually included European countries which were more concerned with the serious health and social problems related to alcohol consumption. This pressure in combination with increased evidence of the relationship between consumption and harm levels (Anderson & Baumberg, 2006; Babor et al., 2003) convinced the EC to work out and then adopt the first ever European alcohol strategy in 2006 (European Commission, 2006). Soon it was realized that it's monitoring and evaluation required member states to adopt a standard survey instrument.

Against this background, the EC within its public health programme called for the development of a standardized comparative survey. In response to that call, a project proposal entitled Standardizing Measurement of Alcohol Related Troubles (SMART) was submitted by the Institute of Psychiatry and Neurology and received funding to undertake research from 2008 till 2010 (SMART, 2012). Prominent academic and research centres participated from ten EU countries including the Czech Republic, Estonia, Finland, Germany, Hungary, Ireland, Italy, Poland, Spain and UK. The countries were purposively selected to represent a wide variation of different drinking cultures and levels of economic development. Among participants we had Mediterranean countries with their wine culture; Nordic countries whose benchmark drink used to be vodka and where, as in Estonia and Poland, beer has become a beverage of choice; we had the biggest beer consumers – the Czech Republic, Germany, Ireland and the UK. “Old” “middle aged” as well as “new” EU countries participated providing an appropriate sample of countries to develop and then pilot-test a standardized survey instrument which could also respect the cultural and social particularities of European countries.

The major aim of the SMART project was to develop a standardized survey instrument on alcohol use, including unrecorded supply, heavy drinking, binge drinking, drunkenness, the context of drinking, alcohol dependence and alcohol related problems as well as public support for alcohol policy measures.

To achieve this aim, the project undertook several preparatory steps including a comprehensive literature review on alcohol survey methodologies reported in international journals; its purpose was to learn from others about the advantages and shortcomings of different survey instruments for measuring alcohol consumption, risky drinking, alcohol abuse and dependence, social consequences and harm to persons other than the drinker. This review is summarized in the first article of this special focus (Bloomfield, Hope, & Kraus, 2013). After reviewing major review papers and more than seventy other sources, the authors recommend applying beverage specific quantity-measures to estimate levels of alcohol consumption using a reference period of one year; this offers the possibility of linking consumption levels with related problems. To investigate frequency of risky drinking, the authors recommend asking about single consumption episodes surpassing 60–70 g of ethanol rather than about frequency of drunkenness whose definition may vary in different drinking cultures within individual countries and across countries. As for alcohol dependence/abuse, application of either the Rapid Alcohol Problem Screen (RAPS 4) or Alcohol Use Disorders Identification Tests (AUDIT) is recommended for screening purposes while relevant section of the Composite International Diagnostic Interview (CIDI) – is recommended for diagnostic ones.

In addition to the literature review, a search for survey instruments currently in use in Europe was undertaken to identify what methodologies and instruments are applied most often across Europe and to select those which are methodologically sound and commonly used. The results of this survey of European drinking surveys are presented in the next article (Sierosławski, Foster, & Moskalewicz, 2013). The review, which obtained data from 22 countries out of 29 which were approached, confirmed great variation in survey methodologies, including variation in sampling, age ranges, composition of questionnaires, formulation of questions, reference periods, the thresholds adopted. Particular differences were found with respect to measures of alcohol consumption, risky drinking, dependence/abuse instruments as well as negative social consequences. Questions relating to harm to others are rare and in the early stage of development. Nevertheless, analysis of these variations helped to identify the most important priorities in working towards standardization of alcohol measures across Europe.

The third article published in this special focus approaches the issue of the level of public support for alcohol policy measures which was also covered within the SMART project (Moskalewicz, Wieczorek, Karlsson, & Österberg, 2013). The need for social support for policy change is crucial in all countries, not only in democratic societies; top-down alcohol reforms are often, or strongly, resisted; they may produce unintended side-effects, and their sustainability is limited – as documented by the failure of American prohibition in the 1920's–1930's and the short-lived success of the Soviet anti-alcohol crusade of the mid-1980's. The literature review showed that the level of public support for restrictive policy measures, including affordability and availability of alcohol, tends to decline. Nevertheless, despite the growing wave of economic liberalism, relatively large proportions of society in developed countries are still in favour of alcohol control policies and are satisfied with the existing status quo regarding national regulations. Policies which aim at reducing drunken driving, including random breath testing, enjoy even higher support.

Finally, the last paper discusses the results of qualitative analyses conducted within the SMART project; the aim here was to contribute to better understanding of the meanings of various drinking terms and concepts which are used in alcohol surveys (Thickett et al., 2013). Concepts such as drinking, a drink, heavy drinking and drunkenness were explored in the course of focus groups run in four SMART countries. Significant variation in the understanding of these concepts within and across participating countries was found in this study, a finding which has far-reaching implications for constructing a standardized survey instrument to be applied in Europe. A major lesson to be learned is that identical questions do not imply their identical understanding in different cultural contexts.

Despite methodological reservations, the SMART survey instrument which emerged after its pilot-testing in nine countries seems to be meeting increasing demand for a standardised survey approach to study trends in alcohol consumption and problems as well as attitudes towards public policy on alcohol in a comparative manner across Europe. This demand is a must as stated in the recent WHO publication. ‘Perpetuating the status quo in this field, that is, spending resources on hundreds of national alcohol surveys which offer limited scope for international comparisons, is neither cost-effective nor helpful for monitoring progress towards common aims such as those of the EU strategy to support member states in reducing alcohol-related harm. A move towards the use of common instruments, such as the questionnaire developed in the SMART project, would be crucial to advance methodology in this field and would, over time, reduce the costs of monitoring at both national and international level. An EU-wide or European drinking survey to gather comparable baseline information would be a necessary first step to encourage Member States to adopt a common methodology’ (Anderson, Møller, & Galea, 2012, p. 116). In 2013 the European Union launched its Joint Action on Alcohol whose crucial element is a comparative survey. So far 20 European countries have declared their participation and offered 50% national contribution, including non-EU countries such as Iceland and Norway (see Figure 1). Good prospects exist to include also Russia or its northern regions within the frame of a Northern Dimension Partnership in Public Health and Social Well-being, as well as Serbia supported by the European Monitoring Centre for Drugs and Drug Addiction.

Figure 1. Coverage of the SMART survey in Europe funded within Joint Action on Alcohol and from other sources

Declaration of interest: No conflict of interest exists.