Social Research Unit for Alcohol Studies, National Research and Development Centre for Welfare and Health (STAKES), P.O. Box 220, FIN-00531 Helsinki, Finland,
1 Nordic Council for Alcohol and Drug Research, Finland,
2 School of Slavonic and Eastern European Studies, University of London, UK,
3 Estonian Institute of Humanities, Tallinn, Estonia,
4 Department of Sociology, University of Stockholm, Sweden,
5 Institute of Psychiatry and Neurology, Warsaw, Poland and
6 Finnish Foundation for Alcohol Studies, Helsinki, Finland
Received 5 May 1998; in revised form 15 December 1998; )
ABSTRACT
The Baltic Sea region today is a scene of a double transition: the eastern transformation and the western integration. As a consequence, alcohol-related issues are undergoing extensive changes. As part of a study of prevalence and perception of social problems around the Baltic Sea (the Baltica Study), alcohol issues have been studied from four perspectives: official statistics, mass media, public opinion and views of influential groups. The Baltic Sea region contains countries from the top and from the bottom of the European statistics on alcohol consumption (Latvia and Sweden respectively). Alcohol has been an important political issue in the transition of many countries (Russia and Poland just before the transition, Sweden and also Finland in their processes of European Union integration). For the medically oriented alcohol research community, the most important finding is that the medical profession and medical and epidemiological arguments play a secondary role in most of the countries when it comes to the definition of the problem.
INTRODUCTION
It is relatively uncommon in the health-related discussion about problem drinking to pay extensive attention to non-medical aspects that underlie and parallel medical wisdom. In the comparative study of countries undergoing rapid social and political change, the non-medical aspects become unavoidably visible. This article provides an example of the complexity of alcohol issues in the European transition (Lehto and Moskalewicz, 1994; Lehto, 1995; see Simpura, 1997 on ex-socialist countries) on the basis of findings from a study in the countries around the Baltic Sea.
Alcohol-related issues have been much debated in the discussion of mortality changes in transitional Russia since the Gorbachev alcohol reforms in 1985 (see e.g. Leon et al., 1997; Shkolnikov and Nemtsov, 1997; Simpura and Levin, 1997). Evidently, the assumed crucial role of drinking in mortality changes in Russia has provoked much international medical attention to alcohol issues there. Much less attention has been paid to other transitional societies in the Baltic Sea region (Estonia, Latvia, Lithuania, Poland), although in some of these countries the level of alcohol consumption and the prevalence of alcohol-related harm may exceed that in the Russian Federation (Moskalewicz et al., 1997).
Also the northwestern countries around the Baltic Sea are undergoing changes that may influence the prevalence of problem drinking there. Denmark, Sweden and Finland must adapt themselves to the slowly proceeding European Union (EU) harmonization that applies also to alcohol sales and has thereby an effect on alcohol consumption and alcohol-related harm (Holder et al., 1995, 1998
). For Denmark, the adaptation has meant reduced alcohol taxes to meet the lower German price levels. Sweden and Finland are facing more fundamental challenges, as they have to remould their strict alcohol control policies and state monopolies to changing conditions. In the case of Finland, an additional important element is the opening of borders to the south (Estonia) and east (Russia) that has led to a rapid increase in tourist import of alcoholic beverages, contributing to a rise in aggregate alcohol consumption since 1995.
Around the Baltic Sea, only in the western German region of Schleswig-Holstein have alcohol-related issues remained relatively untouched in the transition of the 1990s. In Mecklenburg-Vorpommern, i.e. the northernmost region of the former German Democratic Republic, there have been some changes in alcohol consumption, availability and prices after the reunification of Germany (see e.g Kraus et al., 1994 for a comparison of western and eastern Germany; also Perkonigg et al., 1998). A very special case is the Kaliningrad region, where drugs and HIV have been a very visible issue. With respect to alcohol, that region may not, however, differ radically from other regions in northwestern Russia [see e.g. Hansen (1996), pp. 7173].
The Baltic Sea region (Fig. 1) includes some of the top countries in the unofficial world statistics on alcohol consumption (e.g. Latvia; see Strazdins et al., 1992), as well as one of the heaviest-drinking regions in the EU (northeastern Germany: see e.g. Reissig, 1991; Winter, 1991 on the time before the German reunification). Sweden is the country with the lowest alcohol consumption in the region, showing consumption levels that are also lowest in the EU. There is considerable variation in alcohol-related policies in the region, ranging from largely uncontrolled sales and only partly enforced taxation (e.g. Latvia, Russia) to strict systems of state alcohol monopolies and high alcohol taxes (Sweden, Finland). Similarly, the importance of alcohol as a political issue varies greatly between the countries and over time. It is very important to note that alcohol is certainly not always seen as a health policy issue, first and foremost, in these countries. Alcohol policies have been intertwined with more general political changes in a very complicated way (see, e.g. Moskalewicz, 1991, 1994; Moskalewicz and
wi
tkiewicz, 1995 on Poland; Tarschys, 1993; Gerner, 1995; White, 1996 on Russia). Even in the Nordic countries, the recent debate around reforms in alcohol policy has been more about ideological issues of the relations between individuals (or citizens) and the state (and market) than about evidence-based policies (Sulkunen, 1997; see also Edwards et al., 1994 on the evidence supporting the Nordic alcohol control policy).
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THE DIVERSITY OF THE BALTIC SEA COUNTRIES AND ITS INFLUENCE ON PERSPECTIVES ON ALCOHOL ISSUES
There is great variation between the Baltic Sea countries with respect to cultural, political, historical and economic ties. It would certainly be an exaggeration to describe the Baltic Sea region as an organically interlinked region. However, cooperation between the countries has been intense in past times, and continues to be so at present.
Including only the two northernmost Länder of Germany, the coastal regions of Poland and the city of St Petersburg with the immediately adjacent regions from Russia, the total population in the Baltic Sea region is about 45 million, living in an area ranging 2000 km from south to north and 1500 km from west to east, the land area being five times that of Britain. Of these, the largest population group are the Swedes (almost nine million), followed by roughly equal populations (five to eight million) of Russians, Danes, Finns, Poles and Germans. Of course, adding the total populations of Poland (36 million), Germany (80 million) and Russia (150 million) would radically change the ranking of the countries around the Baltic Sea. Some of the basic features of the countries are presented in Table 1.
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THE BALTICA STUDY: ALCOHOL ISSUES IN THE FIELD OF SOCIAL PROBLEMS
The Baltica study started in 1991 (see Simpura and Tigerstedt, 1992) and was completed in 1998. This article summarizes alcohol-related findings from the study. The overall aim of the study was to analyse the prevalence and perception of social problems in the countries around the Baltic Sea. Thus, four pictures of the field of social problems were produced in four sub-studies with different kinds of data as their bases: official statistics (Leifman, 1999), public opinion (Moskalewicz and Tigerstedt, 1998
), views of influential groups (Hanhinen and Törrönen, 1998
), and mass media debate (Lagerspetz, 1994; see also Lagerspetz, 1998). The sub-studies were mostly cross-sectional by nature, analysing the conditions around the mid-1990s, and in some cases providing data since the mid-1980s. Although the origins of the study are in socio-epidemiological research on alcohol and drugs, the study is not limited to these issues only. Actually, the main focus of the study is on the relationships between various social problem categories, and also on the similarities and differences between the views provided by the four sub-studies. The results on alcohol issues to be summarized below, then, do not come from a specifically alcohol-related study but from a setting where alcohol has been one of many topics. Potential social problems like unemployment, poverty, environmental deterioration, ethnic conflicts, crime, drug issues etc. were studied in tandem with alcohol issues.
The comparative setting in the study was not a straightforward mechanical comparison. It very consciously aimed at first studying the countries separately (countries as cases) and making international comparisons only afterwards. Thus it was hoped that the peculiar cultural, historical, political and economic contexts in each country can be properly accounted for. Such an approach was deemed appropriate in particular in the ex-socialist countries, where the framework for perceiving social problems was rapidly changing. Given the small number of countries studied, the setting certainly belongs to the class of small n studies in comparative research. Ragin (1989, pp. 6971) gave the following list of characteristic features of such studies: (1) their attention to cases as wholes, as configurations of parts (apparent similarities of results of measurement may be epiphenomenal); (2) qualitative outcomes (how causes fit together to generate qualitative change); (3) causal conjectures (causes rarely operate in a simple additive fashion); (4) causal heterogeneity (different combinations of causes may produce the same outcome); (5) deviant cases and concern for invariance [there is no such thing as (statistically analysable) error in small n studies].
The question in this article is not about what explains the epidemiological variation over time in the prevalence of various alcohol-related problems in the countries around the Baltic Sea. Rather, the question is about what factors other than epidemiological information shape the understanding of the seriousness of alcohol as a social problem in different countries. The comparisons will be those across countries, but at the same time also across problem categories. Many of the results illustrate the position of alcohol issues with respect to other problem issues in different countries in the early 1990s.
Originally, the Baltica Study was planned to cover all the countries around the Baltic Sea. The first introductory report on the study (Simpura and Tigerstedt, 1992) included contributions from all the nine countries. For various reasons, however, the study could not be completed in the two northern German Länder (Mecklenburg-Vorpommern and Schleswig-Holstein), and also the Danish participation was finally restricted to the mass media sub-study only (see Laursen, 1994). Thus, although consumption and mortality data are given also for Denmark and those two Länder, the results below concern at most seven countries: Russia (St Petersburg) the three Baltic countries that are all ex-Soviet republics (Estonia, Latvia and Lithuania), the ex-socialist Poland and two Nordic countries (Finland and Sweden).
A BRIEF REVIEW OF ALCOHOL ISSUES AROUND THE BALTIC SEA
As shown in the last two columns of Table 1, the Baltic Sea countries have remarkably different experiences with respect to alcohol-related issues. In Finland and Sweden, alcohol has been an important policy issue for more than a century, and the temperance movement was a central part of the rise of modern political institutions (see Mäkelä et al., 1981; Nycander, 1996). Both countries have applied a strict alcohol control policy with state alcohol monopolies, and Finland also had a 13-year period of prohibition (19191932). Recently, a central issue has been the fate of these policies after Sweden and Finland became EU member countries in 1995. In terms of alcohol-related harm, both countries showed an increasing trend in alcohol consumption and alcohol-related harm in the mid-1990s. Contrary to most stereotypical beliefs, the dominant beverage type here is not distilled beverages: beer is clearly the most popular alcoholic drink in Finland, and beer and wines together dominate in Sweden (see e.g. Nordic Alcohol Statistics, 1998). The era of spirits drinking as a dominant feature in the Scandinavian countries ended in the 1960s. This statement hides, however, the fact that spirits drinking did not disappear only its relative position became weaker. New beverages (beer, wine) came as additions to, not as substitutes for, the traditional beverages.
Denmark has a quite different tradition of policies on alcohol-related harm, compared to the other Nordic countries. Even there, however, the link between the per capita level of alcohol consumption and alcohol-related harm has been clearly demonstrated over this century (Thorsen, 1990). Still, this country has no elements of the centrally administered alcohol control policies familiar in Sweden and Finland. The Danes drink more than the Finns and the Finns drink more than the Swedes (Nordic Alcohol Statistics, 1998
). Stereotypically, Denmark is a beer-drinking country, but still in the early decades of this century it was very much like any other Scandinavian country with distilled beverages as the dominating type. Germany, again, is a quite different case, with its high alcohol consumption (higher than in any Nordic country, with per capita figures similar to those of France; see World Drink Trends, 1997) and lack of almost any national preventive alcohol policies. In a few studies from the 1990s, it has been shown that drinking in the two northeastern German Länder is as great or even greater than in the rest of Germany (e.g Kraus et al., 1994; Perkonigg et al., 1998), with the popularity of distilled beverages (Schnapps) as a feature distinguishing this region from predominantly beer- and wine-drinking regions of Germany.
The southeastern banks of the Baltic Sea all belong to the realm of vodka today. The challenge of beer and wine has been weak so far. Detailed analyses of changes in alcohol consumption are available only from Poland (Moskalewicz and wi
tkiewicz, 1995
). The results give a picture of relatively strong fluctuations in alcohol consumption in Poland, with an increasing trend in the mid-1990s. The level of alcohol consumption in Poland is between the German and Danish levels. In the three Baltic countries and in Russia, data from the 1990s on alcohol consumption and alcohol-related harm are scattered and inaccurate. Various indirect procedures have been used (see, e.g. Simpura and Levin, 1997 for a discussion), showing that, very probably, the level of alcohol consumption in Russia and Latvia is even higher than in the traditionally high-consumption countries like France. The Estonian figure seems to be lower than that for Latvia, and Lithuania is an intermediate case closer to Latvia than Estonia (see also Table 2). Specific regional studies (e.g. Jyrkinen-Pakkasvirta, 1997 on the northernmost parts of northwestern Russia) give a dramatic picture of the conditions of problem drinkers.
As for drinking patterns, representative studies are few, but they support the picture of relatively high alcohol consumption in this part of the Baltic Sea region [e.g. Simpura and Levin, 1997 about Russia; scattered information on the Baltic countries can be found in the Norbalt living conditions studies (Aasland, 1996; Grøgaard, 1996
; Knudsen, 1996
)]. Also, they show that the variation in drinking patterns by socioeconomic variables is very similar to that found in more Western countries. The picture is partly repeated in a recent comparative study of adolescent drinking patterns (Hibell et al., 1997; the ESPAD study), showing that Denmark has the highest prevalence of heavy drinking among adolescents, followed by Poland, the Baltic countries, Finland and Sweden. Unfortunately, the countries in the region with probably the heaviest drinking (Latvia, Russia and Germany) were not included in the ESPAD study.
FINDINGS: FOUR PICTURES OF ALCOHOL ISSUES AROUND THE BALTIC SEA
In the following section, we restrict ourselves to comparisons between countries and between the four arenas for defining alcohol-related problems, i.e. official statistics, newspapers, public opinion, and influential groups.
Statistics on alcohol consumption and alcohol-related harm
When it comes to the extent and accuracy of statistics on alcohol consumption and alcohol-related harm, the Baltic Sea region contains almost the extreme ends of the worldwide scale. The Nordic countries, and Finland and Sweden in particular, provide a most detailed set of statistical data, with uninterrupted time-series from almost a century. This is also true for Denmark (see, e.g. Thorsen, 1990), although alcohol does not enjoy such a special position in the official statistics as in those of Finland and Sweden. In Germany, the data base is much more scattered, as alcohol-related issues do not appear as a separate domain in the production of statistics. In a longer time perspective, the statistics on the former GDR may be problematic, although no detailed analysis of their quality is available. In Poland, alcohol issues have often had great political importance, and therefore some alcohol-related statistics have been widely used and well developed (see, e.g. Moskalewicz and wi
tkiewicz, 1995). The three Baltic countries and Russia share a common heritage in the Soviet official statistics. Serious doubts have been presented on the reliability of those statistics on alcohol consumption and alcohol-related harm (see, e.g. Simpura and Levin, 1997; Treml, 1997), and some recalculations have been made afterwards to correct falsifications. Still today, the scope of alcohol-related statistics is somewhat limited in these four countries.
Alcohol statistics generally cover registered consumption and alcohol-related harm indicators. The real problems in alcohol statistics are the unreliability of consumption statistics and the attribution of various health and social problems to drinking. As for the consumption statistics, unrecorded consumption (home production, illegal industrial production, tourists' imports and exports, smuggling, use of surrogates) poses serious problems in all countries, as its volume can be only crudely estimated. Even in the least problematic cases of Finland and Denmark, it is probably impossible today to arrive at an error margin of less than ±5% (for Finland, see Simpura et al., 1997). In Sweden, serious efforts have been made recently to estimate the volume of unrecorded consumption, but still the degree of inaccuracy is remarkably high (Norström, 1997; Kühlhorn et al., 1999
). An extensive Swedish study (Kühlhorn et al., 1999
) was based on self-reported alcohol consumption questions from a representative national sample of more than 10 000 respondents and is probably the most comprehensive project aiming to estimate the actual alcohol consumption in a single country. Telephone interviews were conducted throughout a whole year, covering all 365 days from 1 March 1996, to the end of February 1997, with detailed questions on the respondents' consumption of different alcoholic beverages on the day before the interview. Special attention was paid to the problem of high non-response among problem drinkers: telephone interviews were conducted with a special sample of alcohol abusers (in this case, chronic drunken drivers, randomly selected from a crime register). The accuracy of survey-based consumption estimates could be improved to some extent, but still the degree of uncertainty remains high. This means that survey-based estimates are very likely to be seriously biased in all countries.
In Germany, the whole issue of actual (i.e. recorded and unrecorded) alcohol consumption is largely ignored in scientific debate, as the single distribution theory with its emphasis on the per capita consumption (or total consumption: see, e.g. Edwards et al., 1994) has been unimportant in the political debate about problem drinking there. The same is to a certain extent true for Denmark. In Poland, the proportion of unrecorded alcohol consumption has evidently varied a lot in the 1990s, partly due to very liberal laws on private imports of alcoholic beverages (see Moskalewicz, 1994). In Russia as well as in the three Baltic countries, the gap between the official recorded per capita consumption level and various alternative estimates has been wide indeed. In Russia, for instance, the official figures for the early 1990s varied around 6 l of pure alcohol per capita per year (see, e.g. Rossiiskij Statisticheskij Ezhegodnik, 1996, pp. 142, 321 and 325). Indirect measures based on the number of certain alcohol-related deaths have given estimates between 13 and 15 l per capita (Nemtsov, 1995; Shkolnikov and Nemtsov, 1997
; Treml, 1997
). In addition, similar indirect estimation of the total consumption in Latvia indicates that the country would occupy the top ranking position in the world's alcohol statistics with a figure of more than 15 l per capita (Strazdins et al., 1992
; Strazdins, 1995
).
The problem of inaccuracy only gets worse when time-series data are used. In many of the countries around the Baltic Sea, it is probable that the volume of unrecorded alcohol consumption has varied during the 1990s. In recent years, in Sweden and Finland, the unrecorded amount of alcohol has increased due to EU membership and thereby increased permissible legal import quotas for alcohol. In Sweden, this means that, whereas the registered consumption statistics indicate a drop in overall consumption by 5% between the years 1994 and 1996, the actual consumption appears to have been stable. Therefore, any statistics on alcohol should be accompanied with detailed accounts on what is included in the statistics, how estimates have been produced and what is the accuracy each year. In an ideal case, the semi-official international alcohol statistics (e.g. World Drink Trends, 1997) should be complemented with crude estimates of unrecorded consumption and accuracy. An attempt has been made to do this in Table 2 for the ex-socialist countries participating in the sub-study on statistics in the Baltica Study (Leifman, 1998).
During recent years, the uncertainty of what officially registered alcohol consumption really indicates has allowed various interpretations of the real development. In Sweden, for example, the government reduced taxes on strong beer as of January 1, 1997, because of a claim, mainly from the alcohol industry, that the amount of legally privately imported strong beer brought from Denmark to Sweden had reached such proportions that it threatened the efficiency of the existing policy, and thousands of jobs in the brewing industry and in related industries. This claim, based on surveys ordered by the Brewery Association, later turned out to be a gross exaggeration.
Also, in Russia, and in the three Baltic countries, the uncertainty about the factual per capita consumption and its development is high. This has contributed to the wide debate around the role of alcohol in the increase of death rate among Russian males in the 1990s (see e.g. Leon et al., 1997; Treml, 1997). Those claiming that the most important cause of the fall in male life expectancy is the increase in alcohol consumption, mainly draw their conclusions from indirect sources, such as changes in the statistics on consequences of drinking. However, statistics on alcohol-related harm also suffer from a high degree of uncertainty, not least in the countries that belonged to the former Soviet Union. In the Soviet era, these statistics were generally not available, but they were collected and available, non-falsified, for a restricted group of officials. During and after the Gorbachev anti-alcohol campaign, such data started to become available, and were actually used as an efficient weapon in political battle.
In international comparisons, the most common general indicator of alcohol-related harm is liver cirrhosis mortality (see Table 3). This, too, carries a number of problems, beginning from the difficulties in distinguishing between alcohol-related and non-alcohol related cases and ending at changes in recording practices (see Edwards et al., 1994, ch. 1 for a discussion; see also notes in Table 3
). Still, the values in Table 3
mostly make sense in so far as they reflect differences between countries in per capita consumption and national consumption trends.
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Despite all the shortcomings in alcohol statistics, some conclusions can be drawn by studying the trends over the past 1015 years. Six countries or regions (Estonia, Latvia, Lithuania, St Petersburg, Finland and Sweden) finally participated in the sub-study on statistics. In many respects these countries can be divided into two groups. One group consists of the three Baltic countries and St Petersburg, the other of Finland and Sweden. In the first, ex-Soviet, group, consumption appeared to have been fairly stable from 1980 to 1985. Then followed a period of a substantial drop, mainly due to the Gorbachev anti-alcohol campaign, reflected both in the official statistics on consumption as well as in different indicators of alcohol-related problems (see, e.g. the country reports by Leifman, 1999). From the late 1980s onwards, however, the consumption increased once again, and especially so in the 1990s at the same time that alcohol control has more or less vanished. In the Baltic countries, the situation appears to have become more stable in the mid-1990s. There, too, no one really knows the true level of alcohol consumption. The indicators of alcohol-related harm, though, show no increase during the past 23 years.
In Finland and Sweden, there has been a gradual increase in the availability of alcohol at least for the past 1015 years (see, e.g. Holder et al., 1995, 1998), and especially after the countries entered the EU in 1995. The unrecorded alcohol consumption has also increased in both countries, due to an increase in both legal private imports and smuggling.
The production and use of alcohol statistics in the countries around the Baltic Sea nicely demonstrates how statistics can be seen as social constructions. Decisions about what statistics will be produced and how they will be used are not merely technicalities. Particularly in a case where many of the statistics are of dubious quality, leeway is left for the use of statistics as constructs and as ways of constructing reality. We would therefore like to illustrate how misled one can become by putting too much faith in internationally published semi-official country statistics. World Drink Trends (latest edition 1997) has recently included a number of new countries in its tables, among them Estonia and Russia. Also recently, the publishers of these trends have started giving estimates of the reliability of the statistical information, ranging from one star (less reliable) to three stars (very reliable). In the 1997 publication, Russia and Sweden both receive one star, Finland and Poland two stars, and Germany, Estonia and Denmark three stars. This very much contradicts our experience from the Baltica Study. We would rather say that the data are quite reliable in Denmark and Finland, less reliable in Sweden and even less so in Germany, and quite unreliable in Poland, Estonia and Russia.
According to the supposedly very reliable statistics in World Drink Trends on Estonia, the per capita consumption was 1.9 l of pure alcohol in 1993 and 1994, 2.9 l in 1995 and 2.3 l in 1996. A parallel and of course also problematic data set that is available from the WHO files (WHO Health for All Database) gives a value of 6.7 l for 1993, and no later values for 19941996. The WHO value is 252% higher than that given by World Drink Trends. In 1990, the registered consumption in Estonia amounted to 6 l of 100% alcohol per capita. From the beginning of the 1990s, the registered sales statistics have become very unreliable. The author of the Estonian report of our sub-study on statistics wrote: Since 1992, it is not possible to describe developments in alcohol consumption on the basis of official statistics due to the rapid liberalization of sale conditions and large quantities (by expert opinions) of illegally imported alcohol' (Ahven, 1999).
However, consumption most likely has not declined since 1990. None of the available alcohol-related medical indicators has declined, but, rather, increased. The mortality rate from liver cirrhosis, for instance, had more than doubled from 5.6 deaths per 100 000 inhabitants in 1990 to 13.9 in 1995.
Alcohol-related issues in newspapers
If official statistics only rarely are treated as social constructions, newspapers and other media appear as the most visible battlefield where social problems are constantly redefined. The constructionist focus on collective definition processes implies that the study of mass media will lie at the very heart of social problems research. The Baltica sub-study of mass media (Lagerspetz, 1994) was a comparison of analyses of newspapers from six of the nine countries and regions around the Baltic Sea: Finland, St Petersburg, Estonia, Poland, Denmark and Sweden. The aim of the study was to compare the press attention given to different putative social problems, and the supposed causes and proposed solutions to these problems.
However, the design of the study was not of the variable-oriented type (Ragin, 1989), where the research setting is identical in all countries involved. This traditional comparative approach proved impossible because of different interests and resources of different researchers, and also because of the heterogeneity of the available materials themselves. Here, we refer to differences in the structure of the mass media in the countries and regions involved, and also to differences in journalistic genres (the newspapers of the former Soviet Union, for example, lacked such a genre as the Western editorial). Because of these problems, we decided to make a variable-oriented comparison between two countries only; in the other countries, the work was based on more freely chosen research methods and research problems. These other country studies were included in the comparison on the basis of their conclusions, not on the base data. The two countries compared directly were Finland and Estonia. This choice of countries had the benefit of treating one country from either side of the former Iron Curtain, which at the same time had much in common with the other Nordic and Baltic countries, respectively.
The comparison shows that the so-called traditional social problems (poverty, unemployment, cime) received only slight attention in the editorials and comment articles. In all societies, most attention was given to economic and political concerns. Other problems received more prominence only when they became politically burning issues for one reason or another. This was the case with alcohol problems in the Soviet Union during Gorbachev's campaign against alcoholism, and with environmental problems in Estonia (and other Central and Eastern European countries) in the later 1980s. In both cases, the problem in question came to be associated with other, more thorough attempts to change the society: the former with perestroika policy, the latter with the national and political emancipation of peoples in the socialist countries. The problems became testing-grounds for each society's potential for change. As such, these problems carried symbolic value. This position they owed primarily to the limited opportunities for public expression of other politically important issues. By way of contrast, the Nordic press tended to discuss social problems mainly with reference to reasons and solutions on the institutional level. Here, alcohol-related problems were an important exception, as in the Nordic countries, too, their solutions were connected with deeper political changes (see also below).
In the Nordic countries, it is commonplace to speak of a crisis of the Scandinavian welfare state model. In practice, the crisis is represented by a challenge to adjust this model to that of the EU. As noted in one of our country studies, an article on the discussion of alcohol problems in Sweden (Olsson, 1994), the discrepancy between the two models is clearly visible in the field of alcohol policies. This has heightened the interest of the mass media in alcohol issues. Furthermore, alcohol policy is a field where the ideology of the welfare state clashes very concretely with the principles of free trade. The Nordic model is built on the idea of a collective responsibility for the well-being of all citizens; market liberalism stresses individual sovereignty. Public health and private pleasure seem to be competing for primacy (cf. Sulkunen, 1992, pp. 147162).
Great and sudden changes in the mass media's treatment of social problems seem to occur only in times of profound political change. It seems also that alcohol and alcohol problems have a curious potential to become carriers of connotative political values, sometimes greatly exceeding their more direct (financial or health-affecting) role in society. This fact is caused by alcohol's penetration of all layers of society, economic, social and symbolic. Firstly, alcohol issues are connected with, e.g., taxation, foreign and domestic trade, costs of health care and labour effectiveness. Secondly, alcoholic drinks and their positive and negative consequences are parts of the everyday life of most people living in modern industrialized societies. Thirdly, they are connected with morality, aesthetics, identity and other cultural values. This social polyvalency makes alcohol issues one of the few visible channels that directly connect distant and abstract political decisions with the everyday life and moral values of the people affected by them. For this reason, the Gorbachev anti-alcohol campaign could be presented as simultaneously fighting economic ineffectiveness and moral deterioration. For the same reason liberal alcohol policy in the Nordic countries could become a leading symbol of European free trade.
In conclusion, compared to many other social problems, claims about alcohol-related problems can easily be used to further more general political striving. Discussions on alcohol policies tend to have wide political relevance, and their contents tend to be related to the overall political atmosphere, rather than to the (epidemiological) developments of the alcohol situation itself.
Public opinion on the seriousness of problem drinking
The third picture arises from a general population survey on views about social problems, carried out in seven countries (see the country reports and a general summary in Moskalewicz and Tigerstedt, 1998). Since public opinion polls may have a strong impact on the social definition of a problem, they can be considered an important element of claim-making processes. The role of public opinion polls in the construction of social problems is a complex one. Results of polls are often used to increase concern about a social problem or, for example, to support more repressive legislation or relax restrictive alcohol policies. The selection of issues to be investigated, or the formulation of questions to be posed, and the context of the questionnaire are very likely to shift the attention of the public from one problem to another, to sharpen the focus on one issue and to neglect another one. Finally, opinions expressed by respondents may also be regarded as their individual claims on social problems or as one avenue for expressing collective claims of the social class or group to which they belong.
In the Baltica questionnaire, a core list of 12 problems was adopted for investigation, including drunkenness, alcoholism, drug abuse, problems caused by smoking, environmental pollution, poor population health, poverty, unemployment, crime, family violence, prostitution and ethnic problems. The survey attempted to explore their perceived prevalence, opinions regarding the threat posed by them as well as the priority or urgency of solving them. Thus, the concept of social problem was disaggregated into three dimensions, and the respondents were asked to assess the prevalence and threatening nature of each problem using a 9-point scale, and then to select those three problems which most urgently require solution. In addition, in most countries the separate assessment had to be made at the country level and at the respondent's residential community level. Finally, a question was posed on the prevalence of the investigated problems in the late 1980s, that is, just before the transition in the socialist countries.
Consequently, problem drinking and drunkenness had to compete in public opinion with a number of problems having a crucial impact on the lives of respondents and their families, especially during a sudden decline in living standards in all participating countries, acute deterioration of the population's health in the three Baltic countries and ethnic conflicts in the beginning of the 1990s.
In the previous decade, alcohol used to be a problem of major concern around the Baltic Sea, particularly in Finland, Sweden, the Soviet Union and Poland. This finding is confirmed in the 1994 1995 Baltica survey (Table 4). In their retrospective answers, respondents in all participating countries were of the opinion that alcoholism and drunkenness belonged to the most prevalent problems just before the current transitions. It was considered the most prevalent problem in Lithuania, Latvia, Estonia and St Petersburg, the second one in Poland and the third one in Finland. Also, at the community level, it occupied either the first or second position. In most countries alcohol used to share its high position with other problems of significance for public health, e.g. with smoking and environmental pollution.
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Alcoholism and drunkenness belong to the group of problems perceived as the most threatening, along with crime, unemployment and poverty in all countries, with the notable exception of Sweden where alcoholism appears among the four least threatening issues. Currently, the Swedes seem to be much more concerned with crime, violence, drug abuse and economic problems. Less concern with alcohol may also be a reflection of growing neo-liberal sentiments in a society that is reconsidering its traditional support for a restrictive alcohol policy.
As for the priority of solution of the problem, alcohol ranks high, but in some countries clearly lower than on prevalence and as a threat. The need for a solution to alcohol problems was emphasized at the community level in particular. Between 30 and 50% of the respondents selected alcohol among problems that require immediate solution in all the five countries where the community level was investigated. There was more variation in priorities at the country level. In Poland, Lithuania and Latvia, roughly 30% of respondents perceived alcohol problems as a priority at the country level, while the respective proportions were about or below 20% in St Petersburg, Estonia and Finland.
On the basis of the three dimensions of prevalence, threat and priority of solution, a five-class typology was constructed (highly developed, developed, potential, marginal and highly marginal problems; see Moskalewicz and Tigerstedt, 1998 for details). Alcoholism and drunkenness appeared to be either highly developed or developed in all countries where sufficient information to construct the typology was available at the country level. That is, alcohol problems were regarded as very prevalent, more threatening than most other problems, and requiring more immediate solu-tion than many other problems. In all countries but Sweden alcohol problems are perceived as being as serious as unemployment, poverty and crime.
A fairly different perspective emerged from a series of open-ended questions on the most serious problems at the country, community and family levels (see the top row of Table 4). These questions were asked at the very beginning of the interview. Importantly, the formulation of the questions stressed problems, not social problems. This formulation was aimed to encourage the respondents to mention those issues that were really their foremost concerns. As expected, economic questions dominated in the answers to the open-ended questions. Poverty, unemployment and declining standards of living as well as unsuccessful economic policy and inflation were mentioned by large numbers and in many cases by the majority, of respondents. Also, the question of crime was often indicated among the most serious issues. After these top concerns, a category of less serious problems followed, with less than 25% of respondents mentioning them. In most countries, alcohol issues belonged to this group. The Estonians were the ones most concerned about alcohol issues: as many as 11% and 17% of them mentioned alcohol problems at the country and the community levels, respectively. The least concerned were the Finns, among whom only 1% mentioned alcohol problems as the most important issues in the country.
The apparent discrepancy between the responses to open-ended and to fixed questions suggests that people in the time of transition, associated with acute economic crisis, are occupied with economic problems of everyday life. Another important issue was the increased level of crime, posing a threat to personal safety. Some other traditional social problems, including alcoholism and drunkenness, then become of a secondary concern, but they will rise to the surface as soon as claims are raised that can make use of their political potential as problem issues.
Views of influential groups on alcohol issues
Finally, a fourth picture of alcohol-related problems as a social issue can be drawn from materials collected in group interviews with influential professions, that is, journalists, businessmen and civil servants. This material is available from Estonia, Latvia, Lithuania, Finland, St Petersburg and Poland. The Russian and Polish data could not yet be included in this preliminary comparison (see, however, Hanhinen and Törrönen, 1998). Also, the existing analysis of the Latvian data did not allow a detailed summary and is excluded from Table 5. The groups consisted of members with varying professional interests in alcohol problems. The selection of groups was deemed worthwhile as in none of the countries did any professional group (e.g. the medical profession) have a decisive role in the public debate around alcohol issues.
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The results provided an interesting, although fairly confusing, picture. First, it is evident that differences between countries are not larger than differences between various respective groups within countries. Secondly, the dimensions along which the position of alcohol problems are defined may still be fairly different between the countries. Thirdly, the models of thinking about alcohol issues are sought from very different directions, in particular in the ex-socialist countries where local traditions for dealing with alcohol issues may be lacking or have become seriously devalued.
In Finland, the groups could easily define the alcohol issue as a policy issue, thanks to the long history of specific alcohol policy arrangements in that country. Even those Finns who are critical towards existing policy practices easily recognize the link between alcohol policy and welfare and health policies. This is not clearly the case in the other countries. Lacking the tradition in alcohol-related health and social policies, these professions have conspicuous difficulties in placing alcohol issues in more general political contexts. The notorious Gorbachev alcohol reform, a common experience of Russia and the three Baltic countries, could be one explanation for these difficulties. It was, however, not mentioned very often in any of the discussions in the four countries. Thus the general interpretation would be that alcohol issues are still largely looking for a place in the new political, social and economic configuration in the transitional societies. Certainly alcohol is not seen as a clear-cut health issue, but carries also aspects of public order, social relationships and perhaps even productivity.
Another interesting common feature in the transitional countries is the fact that many of the influential groups produced fairly explicit views regarding social groups that are particularly prone to suffer alcohol problems. In most cases such groups were found at the margins of the society, either among the unprotected (children, adolescents) or among the excluded. There was a regional aspect involved (peripheral regions), and in some cases, but certainly not in a dominating way, also an ethnic and cultural component. In Estonia and Lithuania, the latter did not necessarily refer to differences between different ethnic groups resident in the country now, but rather to the experience of cultural change during the SovietRussian occupation.
Finally, models for dealing with alcohol issues were sought from different paradigms. In the Baltic countries, civil servants were ready to consider even the experience of the Nordic countries, even though the Nordic alcohol policy models appeared to be too restrictive and politically unrealistic for transitional conditions. Businessmen and journalists were less interested in state policies and regarded alcohol issues as a secondary question that should be addressed only after some more important issues are first solved. These more gen-eral issues seemed to relate to the functioning of economic and political systems in general. So, the reluctance to raise alcohol-related harm to the level of political debate is not only an indication of anti-statist or liberalistic political attitudes, but also reflects the uncompleted development of basic political and economic institutions in the countries.
GENERAL DISCUSSION AND COMMENTS: LESSONS FOR HEALTH-POLICY INTERESTS IN ALCOHOL ISSUES
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FOOTNOTES
* Author to whom correspondence should be addressed.
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