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Commentary on Casswell et al. (2011): getting the full picture of alcohol's burden in the society.

Sally Casswell and colleagues [1] have conducted an important study on a topic that has a growing relevance for the alcohol policy debate. The reduced wellbeing and health of those with heavy drinkers in their lives is not a novel issue, but these problems have had little weight in the alcohol policy debate during the last decennia. Much of the debate around policies that aim to reduce alcoholrelated problems centres on whether it is appropriate for the state to influence someone’s behaviour for his or her own benefit. It has been common to argue that as long as the harms caused by alcohol are experienced by the drinker him/herself, everyone has a right to behave as they please and take any risks they want. Alcohol policy restrictions are thus refuted by referring to the freedom and rights of the individual consumer. In contrast, there is a general consensus that the state should intervene when someone’s behaviour causes harm to others. This is illustrated by the substantial impact that the findings around the health effects of second-hand smoke have on tobacco policies [2]. There are some examples of this line of thinking in the alcohol field too. Restrictions on an individual’s behaviour in traffic or at the work-place have become widely accepted. Good research can help in gaining a clearer picture of what exactly we are talking about here, and what the moral and practical implications could be. Quantitative studies such as the one written by Casswell et al. [1] are particularly useful as they lead to population-level estimates of the societal cost of the problems, and thus lead to policy arguments. Earlier studies have often been clinical or qualitative, providing an insight to the lives, resources and needs of significant others of alcoholics or drug users [3–5], typically conducted from the point of view of helping, from developing treatment and interventions to support the individuals. As the authors note, measures of the impacts of alcohol on others included in estimates of the global burden of disease have focused on tangible impacts, such as traffic crash data or fetal alcohol syndrome, and there are fewer data for many of the less tangible impacts. A full picture of the burden of alcohol on both the drinkers and others is very important in convincing the policy makers and community leaders that something has to be done to reduce the harmful use of alcohol. Casswell et al.’s paper [1] is also important because it takes the methodology of empirical research forward. The measurements for self-reports of heavy drinkers in their lives are innovative. Twenty-nine per cent of the sample reported that they had at least one heavy drinker in their life. Of the respondents who reported exposure to a heavy drinker, every fourth respondent was living in the same household. The results show an association between lower personal wellbeing and lower health status while controlling for demographic variables and the respondent’s own drinking. This study includes respondents aged between 12 and 80 years, and thus with different relationships to drinkers, and different needs and problems. In particular, those aged between 12–18 years are likely to have a different relationship to the drinker than the older respondents. The authors are to be congratulated for including minors in the data. It is important to listen to the opinions of under-aged victims of adults’ excessive use of alcohol. The coping mechanisms available to children and the interventions possible for helping them are different than for adults, and we know too little about these. Research on young people’s experiences and opinions is important, but seldom conducted [6,7]. The paper does not discuss the policy implications. It is certainly important for the research to just show the magnitude of alcohol-related harms on others. Such data can perhaps help to convince policy actors of the amount of social cost from alcohol, and thus act as an argument for general alcohol control policies. Research can have also other tasks in narrowing the gap between burden of alcohol and effective response, as Norman Giesbrecht [8] points out. First of all, this information needs to be introduced into the consciousness of those who manage alcohol policies and fund and implement prevention programmes relevant to different settings. Secondly, empirical research, which opens up the complex phenomena behind the words ‘harms to others’ can offer further support for public policies and community-based initiatives that look beyond blaming the victim or focusing exclusively on the individual. Population-level policies and offering screening and brief intervention services will benefit not only the highvolume drinker, but also his or her partners and family members. Research may help by making these phenomena better understood among various types of professionals, community activists and ordinary citizens. Open and rational discussion can unravel these problems from the taboos and ideological barriers that prevent action. Research can also empower the victims of other’s alcohol use into demanding their rights for personal safety and wellbeing. COMMENTARY