Eurostat. EHIS module on alcohol consumption. Grant September 2010

Transcription

1 Eurostat Improvement of modules for the European Health Interview Survey ImpEHIS II EHIS module on alcohol consumption Grant Part I Theoretical framework supporting the revision of the questionnaire September 2010 Jean Tafforeau Jean.Tafforeau@wiv-isp.be Lydia Gisle Lydia.Gisle@wiv-isp.be Hélène Mimilidis Helene.Mimilidis@wiv-isp.be Scientific Institute of Public Health

2 List of countries and abbreviations AT Austria BE Belgium BG Bulgaria CY Republic of Cyprus CZ Czech Republic DE Germany DK Denmark EE Estonia EL Greece ES Spain FI Finland FR France HU Hungary IE Ireland IT Italy LT Lithuania LU Luxembourg LV Latvia MT Malta NL Netherland PL Poland PT Portugal RO Romania SI Slovenia SE Sweden SK Slovak Republic UK United Kingdom CH Switzerland HR Croatia NO Norway IS Iceland TR Turkey EU European Union MS Member State CC Candidate Country 1 EFTA European Free Trade Association 2 EHIS European Health Interview Survey 1 Candidate countries: Croatia, Iceland, The former Yugoslav Republic of Macedonia, and Turkey. 2 EFTA countries: Iceland, Liechtenstein, Norway, and Switzerland

3 1. Introduction In order to prepare the second wave of the European Health Interview Survey (foreseen for 2014) some parts of the EHIS questionnaire considered as being problematic i.e. the modules pertaining respectively to physical activity, mental health, and alcohol consumption were placed under examination. Accordingly, a project (ImpEHIS II) was launched at the beginning of this year in order to improve and ultimately to provide a revised set of questions for each and every topic mentioned above and to be included in the next wave. In this context, the present document synthesizes the results of the first phase of the project regarding the revision of the module on alcohol consumption. For obvious reasons (in particular space constraints) the present document represents only a summary of all the material brought forward during the different working activities which have been undertaken in the framework of ImpEHIS II under the aegis of Eurostat, and provides only the main outcomes of all the discussions that had taken place and that still continue to feed the debate at the time of writing these lines. 2. Activities The methodological approach followed as well as the various activities carried out during the first phase of the project pertaining to the development of a revised set of questions on alcohol consumption are in line with the different steps agreed upon in the framework of the ImpEHIS II work packages and correspond to a large extent to the set of usual or standard scientific practices also described within the Handbook of Recommended Practices for Questionnaire Development and Testing in the European Statistical System (Brancato et al., 2006): Identification of problems encountered by Member States (MSs), EFTA Countries, and Candidate Countries during the 1 st round of EHIS implementation (questions on alcohol use) through an questionnaire. Review of experiences from European and international projects (e.g. SMART 3, AMPHORA 4, ECHIM 5, etc.) and examination of the scientific literature on specific aspects related to the study of alcohol consumption (i.e. the conceptual frame dimensions and indicators) and its measurement (i.e. operationalization aspects the use of different approaches to measurement each one encompassing an array of instruments). Identification of a series of known experts in the field of alcohol consumption measurement in population surveys, and organization of a two-day meeting aimed at discussing available instruments and at providing an alternative questionnaire. Follow-up by means of an expert consultation on the revised set of questions to be presented. 3 Standardizing Measurement of Alcohol Related Troubles: index.html 4 AMPHORA. Alcohol Public Health Research Alliance: 5 European Community Health Indicators Monitoring: See also: healthindicators.eu/healthindicators/object_document/o5873n28314.html - 3 -

4 The aforementioned expert meeting was organized in Brussels in July 2010 and brought together acknowledged specialists in the domain of alcohol measurement and population survey instruments. This panel was explicitly built bearing in mind that it should somehow reflect the inherent diversity characterizing the European context. The different experts contacted for the project are listed hereafter: Jacek MOSKALEWICZ Institute of Psychiatry and Neurology, Warsaw (PL) Paul LEMMENS University of Maastricht (NL) Gerhard GMEL Swiss Institute for the Prevention of Alcohol and Drug Problems SFA-ISPA, Lausanne (CH) Silvia GHIRINI Istituto superiore di sanita ISS (IT); Peter ALLEBECK Karolinska Institutet, Stockholm (SE); Kersti PÄRNA University of Tartu (EE). Some information was also kindly provided by Emanuele SCAFATO Istituto superiore di sanita ISS (IT); Pia MÄKELÄ National Institute for Health and Welfare THL, Helsinki (FI); and Ann HOPE Health Service Executive (IE)

5 2.1. Description of the problems: experiences with EHIS implementation As underlined by Eurostat, 21 countries (18 MS + CH, NO, and TR) out of 32 participated fully or partly to the EHIS first round data collection (see Table 1) and most of them have implemented the survey in the years Table 1: EHIS 1 st wave status of implementation of the EHIS in the different countries EHIS fully implemented: 13 countries (12 MS + TR) BG, CY, CZ, ES, HU, LV, MT, RO, SI, SK, PL, EL + TR EHIS partly implemented: 8 countries (6 MS + CH, NO) AT, BE, IT, DE, EE, FR + CH, NO EHIS not implemented: 11 countries (9 MS + HR, IS) DK, SE, FI, IE, LT, NL, PT, UK, LU + HR, IS 6 Total 32 countries: EU-27 + NO, CH, IS, HR,TR In an attempt to collect information on experiences with the EHIS implementation (i.e. problems encountered, improvements that are deemed necessary, possible solutions and recommendations, etc.) a questionnaire was circulated in April 2010 by way of the Eurostat ESSNET on Health Statistics among the members of the Technical Group HIS (TG-HIS) and targeted at professionals in charge at national level. A total of 28 countries (25 MS + CH, HR, and TR) out of 32 sent an effective reply to the aforementioned questionnaire. Among these, all the countries that participated fully to the EHIS first round data collection that is 13 countries (12 MS + TR) shared their views by responding to the form. Besides 7 countries (6 MS + CH) out of 8 where the EHIS was partly implemented took part to the consultation while 8 countries (7 MS + HR) out of 11 where the EHIS was not implemented did so. Finally, it is worth mentioning that only 4 countries didn t take part to the discussions: FI, LU + IS (EHIS not implemented) and NO (EHIS modules partly covered). The 2 nd section of the questionnaire that specially focused on a feedback on questions of the EHIS allowed the collection of two types of information. First, a general assessment of each and every question (if it should be kept, removed, etc.), and secondly a more detailed account of the problems encountered with the instrument (or features thereof) as well as some suggestions that may have been considered (all this through a series of open-ended questions). The results obtained from this consultation are summarized hereafter: Before reviewing the questions in more detail, it s important to mention some general issues that have been addressed by a couple of countries and that pertain to the module as a whole. For example it was reported by ES that respondents hesitated to answer the questions on alcohol arguing that they don't drink regularly. For ES most respondents considered excessive the questions related to alcohol and needed some clarifications to complete them (unluckily, the types of clarification required by respondents were not further developed). Additionally, the questionnaire on alcohol was considered too long by BG, MT, and PL while for DE the EHIS instrument misses in its current form a series of questions on dependency and addiction. 6 According to Eurostat, in DK, LT, LU, and PT no health interview survey or a survey with a health component was performed since

6 Question AL.1 of the EHIS questionnaire: AL.1 During the past 12 months, how often have you had an alcoholic drink of any kind (that is beer, wine, spirits, liqueurs or other alcoholic beverages)? Never 1 GO TO QUESTIONS ON USE OF DRUGS Monthly or less 2 GO TO QUESTIONS ON USE OF DRUGS 2 to 4 times a month 3 GO TO AL.3 2 to 3 times a week 4 4 or 6 times a week 5 Every day 6 General assessment: A majority of countries that is 19 out of 28 (68%) consider that this question should be kept without any change. The revision of AL.1 either partly or totally is supported by 7 countries. In fact ES, SE, DK, DE stand in favor of keeping the question with some adaptations while AT, BE, EE indicate the need to change it totally. Among the countries that effectively replied BG and IT did not provide any answer. AL.1 - Review of experiences with EHIS implementation Should be removed 4 Should change totally Should be kept with some adaptation Should be kept without any change No answer 19 Comments received on AL.1 (via open-ended questions) concentrate mainly on two topics: the use of filters and the response categories. The use of filters: For SE and DK (that did not implement the EHIS) monthly or less drinkers should also answer to AL.2 on the quantities consumed as well as to AL.3 on binge drinking or risky single occasion drinking. For ES (full implementation of the EHIS) those who answer 2 to 4 times a month (this category includes those who drink once a week) should not jump to AL.3 (binge drinking), but should rather answer to AL.2 on quantities consumed. Finally, for EE (where the EHIS was partly implemented) it is argued that the best solution is not always to reduce the number of questions by asking many aspects of a specific phenomenon within one single question (in this case occurrence/prevalence, and frequency). Accordingly it is suggested to implement an introductory question (e.g. Do you drink alcohol? Yes/No If YES During the pas 12 months, how often do you...)

7 The response categories: According to SE (where the EHIS was not implemented) the category monthly or less should be replaced by once a month or less. Besides, it was highlighted by BE (EHIS partly implemented) that it remains cognitively difficult for respondents who drink once a week to convert or translate this practice into 2 to 4 times a month. Also, it is suggested that the response scale (the order of the categories) should be reversed (from every day to never and not the contrary). Finally it is recommended to adapt the response options so as to provide categories where weekly drinkers can be clearly identified (to obtain a clear vision on the proportion of the population that drinks at least once a week, and also to provide such a denominator for the construction of other indicators). Question AL.2 of the EHIS questionnaire: AL.2 How many drinks containing alcohol do you have each day in a typical week when you are drinking? Start with Monday and take one day at a time. Number of drinks in a 7x5 Table: Per day of the week, and By beverage type (beer, wine, liqueur, spirits, other local alcohol beverage) General assessment: The revision of AL.2 is supported by 18 out of 28 countries (64%). On the one hand it is the opinion of a couple of countries that this question should be kept with some adaptation. In point of fact 8 countries supported this alternative (IT, CZ, LT, DK, PL, SK + HR, and TR). On the other hand there are still 8 countries considering that AL.2 should change totally (BG, MT, CY, AT, LV, DE, EE + CH). A more severe position is hold by 2 MS for which it is clear that this question should be removed (EL and BE). Finally there are still 8 countries for which this question does not raise any particular problem and that think AL.2 should be kept without any change (ES, IE, PT, UK, SI, RO, NL, and FR). As mentioned hereunder, 2 countries were excluded from the analysis on the ground that they provided each two different answers to this assessment (SE, HU). AL.2 - Review of experiences with EHIS implementation 2 2 Should be removed 8 8 Should change totally Should be kept with some adaptation Should be kept without any change No answer 8 NB: SE and HU gave two different answers. These countries where therefore excluded from the analysis ( No answer )

8 Comments received on AL.2 clearly form the bulk of all answers collected about the EHIS module on alcohol. It can be perhaps mentioned that countries concerns and problems listed hereafter are rather diverse in nature. In a way, this variety of opinions could be said to mirror to a certain extent the diversity of positions already illustrated above (in the general appraisal of the question) exemplifying perhaps the difficulty to provide an instrument that fits all purposes in a context characterized by a multitude of cultural settings, by various and for some, longstanding traditions in the design and implementation of surveys, etc. Layout: It was mentioned by BE that in self-administered format (paper-and-pencil), respondents tend to skip the question or tick the cells instead of indicating the amounts (or number of drinks) consumed. Wording: It was brought forward by a number of countries (SE, DK, SK) that when you are drinking should be deleted. A suggestion was also made by SK (EHIS fully implemented) to reword the question as follow: How many drinks containing alcohol do you have in a typical week? (the terms each day and when you are drinking are suppressed here). The response categories: For SE, if this table is meant to be kept, one more column that says 0 drinks needs to be added. Indeed, currently respondents have to answer 0 in all the columns for the days they had no drink (burdensome). Besides, BE highlighted a recurrent dilemma when using beverage-specific instruments that is the need to be specific in terms of types of beverage taken into consideration. In the particular context of BE it is felt that beer for example needs to be breakdown into 2 categories (light and strong beers) and that the categories of aperitifs, cocktails, and breezers/alcopops should be investigated separately. Timeframe and recall bias: SE pointed out that a typical week when you are drinking can be interpreted in more than one way (threaten the possibility of cross-country comparisons). BE shared somewhat of a similar concern arguing that by using such a frame we don t really know what we are measuring exactly. A couple of countries also brought forward that it s difficult for respondents (a great deal of a burden) to interpret and recollect a typical week in terms of drinking (HU, BE), and to calculate an exact number of drinks per day in such a typical week (HR, BE). In this context a suggestion was made by HU to use a weekly recall method (assessment of the last-week consumption) adding subsequently an extra question asking how typical the last week was in terms of drinking. Somewhat in accordance with what has been said above, BE shares the view that those drinking 2 to 4 times a month (includes those drinking once a week see AL.1) should answer AL.2 on quantities consumed. Nevertheless BE points out that it s difficult for occasional/irregular drinkers (whose drinking may be unsteady or uneven) to think about, and to process something like a typical week when they drink. BE goes even further by asking if such a week may exist at all. In this context asking for a typical-every-day consumption may be misleading (may give a distorted picture of real - 8 -

9 consumption), and may be more adapted to regular drinkers (those who drink on a weekly or daily basis). Concluding that AL.2 is too complex, a suggestion is made from BE to implement a question asking for an average amount per week. In addition it is important to note that IT and CY also share the particular view that AL.2 is too complex. Both countries argue that the question itself is confusing (recall bias?) and that it could produce unreliable results, especially for self-completed version of the questionnaire. For IT and CY it is clear that the question on amounts consumed shouldn t go into specific details about quantities ingested per beverage and days of the week (i.e. alcohol consumption questions could be improved by reducing the level of details asked). In this context, CY emphasized that AL.2 was especially difficult for respondents whose habit is to consume a large variety of drinks during the week. Accordingly a suggestion was introduced by IT which was also supported by PL and MT stating that more sufficient will be the use of two bands (aggregation of days) focusing on the number of equivalent drinks consumed during the week (Monday- Thursday), and the week-end (Friday-Sunday). Besides, according to DE asking for alcohol consumption by days in CATI mode proved unsuitable after a pre-test procedure. DE brought forward as suggestion that for the German Federal telephone survey (GEDA aktuell) the AUDIT C was adapted (a 12-months timeframe was added) and tested, and finally proved itself as satisfactory in CATI mode. Finally, in any attempt to revise AL.2 a reference period of 7 days is seen as too short for EE to select out population groups that have more risky behaviours than others. It is therefore suggested to give a specific reference period (e.g. 4 weeks) and to modify the questions so that presumably heavier drinking at weekends will be gathered without asking consumption day by day. Translation problems: According to SE the question cannot be translated in comprehensible Swedish and at the same time cover the concept. In fact SE mentioned without developing the issue at stake that it s necessary to split the question, and that the way of doing so will depend on the mode of data collection. Additionally BE briefly underlined that adding when you are drinking to the question is creating a lot of problems in the translation and at implementation stage. Unit of measurement ( standard drink ): BE pointed out that the indicator is expected to be expressed in grams of ethanol, but in practice, this becomes complicated when standard drinks are not defined at national level. According to CZ the typical national measures (amount of alcohol) should be observed. The standard units should be computed additionally since it s very difficult for respondents to compute them. EL warned that the serve sizes and/or container sizes differ from country to country and that this should be taken into account in a way or another. For LT the definition of a drink or a glass (guidelines) should include the approximate volume of each by kind of alcoholic beverage, this to allow for adaptation to common national measures and for recalculation in one uniform format after the survey. Finally following AT, the term drink was not used apparently considering that it does not - 9 -

10 have the same meaning in all countries (depends on national habits). According to AT the calculation of standard glasses would improve cross-country comparisons. Question AL.3 of the EHIS questionnaire: AL.3 During the past 12 months, how often did you have 6 or more drinks on one occasion? Never 1 Less than monthly 2 Monthly 3 Weekly 4 Daily or almost daily 5 General assessment: A majority of countries 17 out of 28 (61%) consider that this question should be kept without any change (15 MS + HR, TR). Change is nonetheless supported by 10 countries. On the one hand 5 countries think it should be kept with some adaption (ES, LT, SE, EE + CH) while on the other hand 4 countries consider it should change totally (AT, CY, BE, BG). One MS expressed a more strict position arguing that AL.3 should be removed (EL). Finally while responding to the questionnaire one MS didn t provide any answer (IT). AL.3 - Review of experiences with EHIS implementation Should be removed Should change totally Should be kept with some adaptation 5 Should be kept without any change No answer 17 The wording: It is proposed by BE to change the wording of the question. A suggestion is made to use the question developed by EMCDDA: How often do you drink 6 glasses or more of an alcoholic drink on the same occasion? The cut-off level: According to ES and CH the cut-off level of 6 or more drinks should be adapted for women and men 7. In this context it is suggested by ES to use 6 or more drinks for men and 5 or more drinks for women. 7 According to ES an obvious reason is the smaller mean body volume of women. Additionally it is mentioned that an alcohol concentration on blood of 0.08% or over is considered to cause effects on health

11 The response categories: BE suggests to use EMCDDA response categories (i.e. daily or almost daily, every week, every month, less than once a month, never). This means to reverse the order of the response scale and to adapt the wording of the categories e.g. to use less than once a month instead of less than monthly. Besides it is argued by EE that the frequency scale does not seem to be balanced when keeping in mind the reference period of 12 months. Accordingly a suggestion is made to insert some response categories between never and monthly. Translation problems: BE reports the conceptual ambiguity surrounding the response categories at least for the French translation. More specifically a clarification is needed for BE as to whether the category monthly means every month (in this case it is argued that respondents may binge for example several times in a month) or if the category should be understood as once a month (here also it is argued that respondents may for example binge twice a month). In any case, BE highlights a possible overlap of response categories (between monthly and weekly ) or a nonexhaustiveness of possibilities. The latter point stands somewhat in accordance with the issue addressed above by EE (see the point on response categories ). Timeframe & recall bias: The reference period (the past 12 months) is seen as too long for SE and BE. It is argued that such a timeframe may distort estimations or that it will most likely entail some memory bias. In this context BE suggests to use a shorter reference period e.g. the past month (4 weeks) which is considered as a more manageable timeframe for respondents. Accordingly answer categories will then need to be changed. Unit of measurement: LT briefly mentioned that the guidelines should include the definition of a drink or glass expressed as the approximate volume (serving or container size) of each per beverage. Additionally LT advised against giving a beverage-specific example in the question among others because confusion can be cast over respondents (one type of beverage effectively consumed may not exceed the limit indicated in the question). The need for additional information: ES points out the need to collect data on the number of episodes of binge drinking in the last month (not only the past 12 months) and on the the amount drunk on the last occasion. Literally it is mentioned that this question, or additional ones, should allow for the calculation of the number of episodes of binge drinking in the last month, and also the amount drunk on the last occasion. These amendments to the questionnaire would provide according to ES important information on the health effects of binge drinking, and on the impact of specific regulatory measures

12 2.2. Literature review: concepts and indicators From the outset discussions surrounding the study of alcohol consumption (assessment of levels of intake) tended to concentrate on three characteristic dimensions or components: frequency of drinking, quantity per drinking occasion, and variability of alcohol intake (Alanko, 1984; Room, 1990; Dawson, 1998a; Rehm, 1998; Gmel & Rehm, 2000 and 2004; Greenfield & Kerr, 2008). If it is clear that quantity and frequency of alcohol intake are crucial variables for determining health problems and estimating health risks (WHO, 1999). More and more evidence however suggests that volume of drinking (usually operationalized by an indicator of average quantity per week or day, typically derived from multiplying together frequency and average-quantity questions) is not in itself sufficient to fully understand the various mechanisms that typically relate consumption to alcohol-related outcomes and consequences (Gmel & Rehm, 2000). Clearly, the assessment of alcohol consumption can no longer be restricted to an evaluation of volume alone (Rehm, 1998). Figure 1: Model of Alcohol Consumption, Intermediates Outcomes, and Long-Term Consequences (Rehm et al, 2006) 8 In point of fact, it has been clearly demonstrated (Rehm et al., 2006; Anderson & Baumberg, 2006; WHO, 2004) that the way alcohol consumption relates to acute (or short-term) and chronic (or long-term) health and social outcomes should be envisaged as schematizing a rather complex and multidimensional network of relationships (see Figure 1). Still, following the demonstration of Rehm et al. (2006), it is possible to distinguish two major dimensions pertaining to the study of alcohol consumption that is volume of consumption (involving as components frequency and quantity) and drinking patterns 8 -

13 (which introduce a sense of variability generally in reference to the volume of intake 9 ). Definitely and using the authors own words: The relation between alcohol consumption and acute and long-term (chronic) health and social consequences largely depend: on the two main dimensions of alcohol consumption (average volume of consumption and patterns of drinking) and on various mediating mechanisms (toxic and beneficial biochemical effects, intoxication, and dependence) (Rehm et al., 2006) More specifically (and adding to the present description), it is currently recognized that for each potential health or social outcome, various dimensions of consumption may have different relationships (Rehm & Gmel, 2000; Bondy, 1996; Rossow, 1996). Thus, both volume of drinking and drinking patterns are to be conceived as essential dimensions (Moller, ) that need to be considered, and of course, placed under scrutiny through their inclusion in the EHIS. Volume of consumption: As mentioned before, the volume or average volume of consumption can be considered as the archetypical measure of exposure in the field of alcohol research (Rehm & Gmel, 2003). Regardless of patterns, [it] certainly remains the most important single characterization of a person's drinking in sociological and epidemiological studies (Greenfield, 2000). As such, it has been related to numerous categories of illness/disorders and was principally found to increase the risk for the following major chronic diseases: mouth and oropharyngeal cancer, oesophageal cancer, liver cancer, breast cancer, unipolar major depression, epilepsy, alcohol use disorders, hypertensive disease, hemorrhagic stroke, and cirrhosis of the liver (Rehm, Room, Graham et al, 2003). One aspect of uttermost importance is that for most diseases, there is a dose-response relation to volume of intake, with risk of the disease increasing with higher volume (Room, Babor & Rehm, 2005). In view of this dose-response relation, follow-up should effectively focus on tracking and mapping heavy consumption behaviours prompt to alter health and to cause negative social outcomes. By this means it also becomes clear that monitoring should somewhat focus on depicting alcohol misuse (rather than simply alcohol use), and particularly heavy drinking behaviours such as hazardous consumption and/or harmful consumption (that can be both considered as potential indicators for follow-up in relation to the specific dimension pertaining to volume of consumption ). Following the results of the ECAS project in an area focusing on establishing Community health indicators (Leifman et al., 2002) and considering the outcomes brought forward by the ECHIM project 11 aimed at developing and implementing health indicators in Europe 9 Measures pertaining to patterns of consumption are commonly and primarily used as a first-order correction applied to the person's volume (Greenfield, 2000). 10 See : 11 See:

14 and at supporting an EU-wide health information system, it is clearly considered to establish an indicator relating to hazardous alcohol consumption (see ECHI shortlist 12 ). In this frame, following the Communication from the Commission establishing an EU strategy to support Member States in reducing alcohol related harm (EC, 2006) as well as the WHO Lexicon of Alcohol and Drug Terms (WHO, 2010), and the framework developed in the course of the PHEPA project 13, hazardous alcohol consumption can be defined as: A level of consumption or pattern of drinking that is likely to result in harm should present drinking habits persist (Babor, Campbell, Room, Saunders, 1994) [ ] however, there is no standardized agreement on the level of alcohol consumption that should be regarded as hazardous drinking. A pattern of substance use that increases the risk of harmful consequences for the user. Some would limit the consequences to physical and mental health (as in harmful use); some would also include social consequences. In contrast to harmful use, hazardous use refers to patterns of use that are of public health significance despite the absence of any current disorder in the individual user. The term is used currently by WHO but is not a diagnostic term in ICD-I0. As opposed to harmful drinkers i.e. those drinking above medically recommended levels for low-risk consumption with evidence of concomitant alcohol-related harm, hazardous drinking [can be described as] drinking above medically recommended levels for low-risk consumption but without current evidence of alcohol-related harm. Following the same WHO Lexicon of Alcohol and Drug Terms (WHO, 2010), harmful drinking can be regarded as: A pattern of psychoactive substance use that is causing damage to health. The damage may be physical (e.g. hepatitis following injection of drugs) or mental (e.g. depressive episodes secondary to heavy alcohol intake). Harmful use commonly, but not invariably, has adverse social consequences; social consequences in themselves, however, are not sufficient to justify a diagnosis of harmful use. The term was introduced in ICD-I0 and supplanted "non-dependent use" as a diagnostic term. The closest equivalent in other diagnostic systems (e.g. DSM-IV) is substance abuse, which usually includes social consequences. We have already acknowledged that volume of consumption is usually operationalized by an indicator of mean amount consumed during a specified period (i.e. the average quantity consumed in a week or day, typically derived from multiplying together frequency and average-quantity questions). Problems however arise when it comes to circumscribe the average amount per day/week needed to define for example hazardous drinking. Indeed as already mentioned above there is no standardized agreement on the level of 12 See: 13 PHEPA - Primary Health Care European Project on Alcohol: phepa/html/en/du9/

15 alcohol consumption that should be regarded as hazardous drinking (EC, 2006). In practice, several definitions exist (see Table 2 for an example) depending on the thresholds (average drinking levels) established to assess the intensity of health-risks related to certain drinking behaviours e.g. hazardous, harmful, or high-risk drinking (see English et al., 1995; Rehm et al., 2004; Rehm et al., 2006; Anderson & Baumberg, 2006). Table 2: Risk levels and selected criteria, an example (Gual, Anderson, Segura, & Colom, 2005) Risk level Low-risk drinking Hazardous drinking Harmful drinking Criteria < 280 g/week men (< 40 g/day) < 140 g/week women (< 20 g/day) AUDIT-C < 5 men AUDIT-C < 4 women g/week men ( g/day) g/week women ( g/day) AUDIT-C 5 men AUDIT-C 4 women AUDIT g/week men ( 50 g/day) 210 g/week women ( 30 g/day) Presence of harm AUDIT High (alcohol dependence) ICD-10 criteria AUDIT 20 In order to provide a standard definition for the indicator to be used it seems somewhat reasonable to draw on the classification agreed upon in the framework of the ECHIM project where hazardous alcohol consumption is defined as an average rate of consumption of more than 20g of pure alcohol daily for women and more than 40g daily for men (Kilpeläinen, Aromaa and the ECHIM Core Group, ). It is worth mentioning that this classification is also presented as a working definition of the World Health Organization. One positive feature of using such definition is that it may contribute to change the understanding of alcohol-related problems to include lesser degrees of severity and the recognition of hazardous consumption as being of concern (Heather, 2006). Nonetheless considering that this definition goes beyond the monitoring of hazardous consumption alone (it includes de facto harmful drinking ) the use of such a label might cast some confusion over the debate. In fact the ECHIM definition somewhat parallels the criteria endorsed by Rehm et al. (2006) in an attempt to circumscribe high-risk drinking (which includes both hazardous and harmful drinking). Nevertheless, using a term such as high-risk drinking or risky drinking in order to provide a denomination to this indicator may also be confusing considering for example that risky-single-occasion drinking (RSOD) expresses a quite different phenomenon. Finally, after examination of the literature it may be noticed that a slightly different definition for the indicator has also been proposed defined in gender-specific terms as drinking 20 grams per day or more of pure alcohol on average for females and 40 grams per day or more of pure alcohol on average for males (Rehm et al., 2006; Rehm, Room, Monteiro et al. 2004). 14 See: (page 111)

16 Patterns of consumption: Not only the usual or average volume of consumption over time, but also patterns of drinking (i.e. the way alcohol is consumed), and especially irregular heavy drinking, have been shown to determine the occurrence of unfavourable health consequences (Room, Babor & Rehm, 2005). As mentioned by Greenfield (2000) it is appealing that even with respect to all-cause mortality, drinking pattern, beyond volume, remains a significant predictor. Particularly, patterns of drinking have been linked to two broad categories of detrimental health and social outcomes: short-term or acute effects of alcohol use (for instance accidental and intentional injuries: WHO, 2007; WHO, 2004; Gmel & Rehm, 2003) and cardiovascular outcomes (principally coronary heart disease and stroke: Rehm, Sempos & Trevisan, 2003; Bondy, 1996). In practice, attempts to capture the variability in individuals drinking patterns have driven most of the advances in measuring alcohol intake (Dawson, 1998a). As a concept the term has however been used to illustrate a multitude of aspects related to alcohol consumption (Anderson & Baumberg, 2006). Patterns of drinking are therefore more difficult to depict than the volume of alcohol intake, especially because there is not one single element that univocally defines the term. As a result drinking patterns keep being measured in a variety of ways, and many different indicators are effectively used in practice (EUPHIX, 2009). Rehm, Ashley, Room et al. (1996) for example have provided a negative definition of the term, defining drinking patterns as all aspects of alcohol consumption that are not covered by the term volume of drinking. For these authors such aspects incorporate primarily high-risk drinking occasions, heavy episodic drinking or binges (Gmel, Rehm & Kuntsche, 2003; Bondy, 1996). But also temporal variations in drinking (Dawson, 1996), settings, activities, and circumstances associated with drinking (e.g. drinking during/outside meals, drinking in public settings: Rehm et al., 2004; Rossow, 1996), some personal characteristics of drinkers and drinking partners (Demers, 1997), and types of beverages consumed (Rogers & Greenfield, 1999; Goldberg, Hahn & Parkes, 1995). As mentioned by Rehm and Gmel, (2003) some aspects related to patterns of drinking have recently gained increasing attention, in particular, heavy drinking occasions, drinking with meals, or beverage type. According to Anderson & Baumberg (2006) while the type of beverage makes little difference to the level of alcohol-related harm, drinking context, frequency and particularly drunkenness (intoxication) are of importance from a public health perspective. Without a doubt, the most widely examined aspect of drinking patterns has been risky single-occasion drinking (RSOD) also called heavy episodic drinking or binge drinking 15. Basically, the idea behind studying binge drinking is to investigate drinking occasions leading to drunkenness or intoxication (i.e. a state of functional impairment due to drinking) and is particularly important given its link to a number of health and social problems (Anderson & Baumberg, 2006). 15 The term heavy episodic drinking might be problematic considering that heavy drinking spells may be routine and not sporadic and/or irregular has might be inferred from the given denomination. Beside, the term binge drinking is also criticized for its normative nature, but may nevertheless help to establish a clear distinction with heavy drinking (considering that binge measures are sometimes confused with high volume of consumption)

17 Indeed from a public health perspective RSOD poses a wide range of problems and has been associated with the occurrence of various categories of harmful consequences and even mortality from the side of those who drink, but also for others (third party harm). These consequences consist of augmented risk of negative social consequences (Klingemann & Gmel, 2001), alcohol dependence and reduced work performance (Anderson, 2008), injuries (Gmel & Rehm, 2003), drunk driving accidents (WHO, 2007), sexually transmitted diseases, coronary heart disease (Rehm, Sempos & Trevisan, 2003; Bondy, 1996), and a series of neurobehavioral deficits to the unborn child (Anderson, 2008). Relationships between RSOD and short-term or acute consequences have been particularly apparent (Astudillo et al, 2010). Considering the high level of negative consequences related to binge drinking or RSOD in terms of health and social outcomes, it becomes clear that this aspect of drinking patterns is a major facet to be monitored, especially for public health and policy purpose. Actually, according to Gmel, Rehm and Kuntsche (2003) and from a conceptual point of view, the meaning of the term binge drinking has changed over time: Previously, the term was more related to a clinical definition of a drinking behaviour subtype of alcoholics that is a pattern of heavy drinking that occurs in an extended period of time set aside for the purpose [this definition is also used in the WHO Lexicon] or an extended episode of abusive drinking and usually defined in population surveys as having more than one day of drinking at a time. Nowadays, most descriptions consider this aspect as a shorthand for drinking to intoxication 16 and give a broader definition to the term. Binge drinking is therefore depicted as a pattern characterized by an episodic absorption of large amounts of alcohol (sufficient to cause inebriation) in a relatively short period of time [or in a single drinking session]. [It is useful to note that] both traditions share the idea of measuring heavy occasional intake to be differentiated from usual or average intake. Here also many different operational definitions (indicators) exist for RSOD and can be used in practice in order to guide measurement. A possible classification that might help to quickly describe approaches in the definition of binging is the one that distinguishes between objective and subjective definitions: The subjective approach focuses on the feeling of intoxication as experienced by individuals and deals with feelings of drunkenness, which cannot be measured other than from expressions of the subjects themselves (Gmel, Rehm & Kuntsche, 2003). This approach uses a variety of criteria such as drinking enough to feel (really) drunk, to feel the effects, to feel intoxicated, to feel high, to feel unsteady on one s feet, etc. in order to grasp information on episodes of drunkenness (without any reference to some kind of drinking guidelines or cut-off level); 16 It is nevertheless argued that RSOD constitutes only an imperfect measure of intoxication mainly because the speed of drinking and the constitution of drinkers are not taken into account. In this respect it is often claimed that BAC (blood alcohol concentration) represents a closer measure of intoxication

18 The objective approach which specifically focuses on drinking guidelines and cut-off levels (i.e. quantifiable binge measures such as maximum amount per occasion, and measures allowing atypical quantities per occasion to be assessed) also lacks some standardized definitions. For example, the quantification of the length of the drinking episode (a day 17, a single occasion, one sitting, X drinks in a row, two hours, etc.) and of the amount of alcohol ingested (5+drinks, 6+drinks, etc.) remains highly variable across countries or studies. Nevertheless as mentioned by Astudillo et al (2010) if definitions of binging vary among studies, RSOD tends clearly to be defined as 50, 60 to 70 g of pure ethanol consumed on a single occasion (sometimes less for women). Considering on the one hand that subjective definitions such as the number of drinks to feel drunk may change over time and seem to heavily depend on culture (Greenfield & Kerr, 2008) ambiguity may somewhat corrupt the meaning of the concepts used threatening cross-country and sub-groups comparisons and on the other hand that a definition expressing the cut-off level in terms of X+ drinks seems to be problematic, because drink sizes vary across countries (Gmel, Rehm & Kuntsche, 2003), it may be more reasonable to define RSOD or binge drinking in terms of X-grams of pure alcohol ingested per drinking occasion and to use the country-specific definitions of a standard drink to compute the corresponding numbers of drinks consequently. Therefore in an attempt to provide a suitable definition allowing for the monitoring across countries of crucial aspects pertaining to drinking patterns that is binge drinking or risky single occasion drinking it is plausible, according to the information gathered, to disregard to a certain extent the definition developed in the frame of the ECHIM project [ men/women having at least X-times 6 or more drinks on one occasion during the past 12 months 18 ] and to draw rather on the results achieved in the framework of the AMPHORA 19 research project concerning the development of a system of indicators for alcohol consumption and attributable harm which is based on information derived from ongoing international efforts by WHO and the EU and which can be implemented quickly in all EU countries and used as an over-time monitoring tool at the country level as well as for comparisons between countries (Rehm & Scafato, ). In this frame, and as mentioned by Rehm and Scafato ( ) the frequency of drinking 60g pure alcohol or more in one occasion has been identified as a good indicator for this dimension as it integrates several aspects: an aspect of volume, and another linked to heavy episodic drinking occasions [ ] If people drink continuously heavily, this corresponds to the volume effect of alcohol. However, there is also a detrimental effect of heavy episodic drinking when the overall drinking is light to moderate. 17 There is an implicit assumption in most surveys that there can be only one drinking occasion in any given day. However, this may not always be true (drinking with lunch and also in bar in the evening, for example), particularly on non-working days, and the difference between speaking about drinking occasions and drinking days should be borne in mind (Anderson, 2006) AMPHORA. Alcohol Public Health Research Alliance: 20 Article to be published

19 Synthesis of discussions: Three key aspects are usually considered for the assessment of alcohol consumption in health surveys: frequency of drinking and quantity per drinking occasion (for calculating volume of pure alcohol consumed) and variability of drinking (also referred as drinking patterns ). A large number of indicators exist that relate to these aspects. Nonetheless, they should be kept to a sensible minimum in the framework of repeated cross-sectional general health surveys used for comparison at international level. During the expert meeting held in Brussels in July 2010 and in line with the scientific evidence drawn from various projects, articles and reviews (e.g. ECAS, AMPHORA, recommendations from the Kettil Bruun Society in Dawson & Room, 2000; Dawson, 2003; Sobell & Sobell, 2004), it appeared that from a public health perspective the following basic set of dimensions and indicators should be addressed in EU member states through the EHIS questionnaire on alcohol consumption: Dimension Drinking status Volume of pure alcohol consumed Patterns of drinking Indicator Level of abstention separated in: Lifetime abstainers: people who have never had an alcoholic drink (lifetime abstention) Former drinkers: people who have had a drink some time in their lives but not in the year preceding the interview (12-months abstention) Current drinkers: people who have had at least one drink in the past year. Past drinking behavior of the last 12-months abstainers is of major interest from a public health perspective. People for instance might be recent abstainers after a period of heavy drinking which endangered their health. Accordingly, if this aspect is not considered, distorted conclusions may possibly be drawn on certain aspects related to the health of the population or sub-groups thereof. Nonetheless detailed questions investigating about alcohol use in former drinkers are left to the decision of national HIS leaders. The point is to estimate "hazardous consumption" defined for the purpose of the EHIS in gender-specific terms as an average rate of consumption of more than 20g of pure alcohol daily for women and more than 40g daily for men (Kilpeläinen, Aromaa and the ECHIM Core Group, ). This indicator involves accounting for a series of variables such as the frequency of intake and the usual quantity of drinking (all alcoholic beverages considered together, or per beverage type). Frequency of risk drinking, binge drinking, or risky single occasion drinking : The frequency of drinking 60g pure alcohol or more in one occasion has been identified as a good indicator (Rehm & Scafato, ). There is another dimension of alcohol use that can be considered of importance in health interview surveys, namely, alcohol dependence. This aspect, though of high interest, was nevertheless not retained as part of the minimal set of indicators, leaving the decision to each country to investigate (or not) this particular dimension. 21 See: (page 111). 22 Article to be published

20 2.3. Survey instruments for measuring alcohol consumption: a review of the literature on a selected set of methods It is well established that alcohol consumption is a complex behaviour that can vary substantially over time (Alanko, 1984). Several (types of) approaches and measures are currently available (self-reports, objective measures such as blood alcohol concentration (BAC), and aggregate level methods). Considering that the topic of interest lies explicitly in measures based on self-reports the issue now remains to assess and to list some advantages and limitations related to a set of available methods and instruments potential candidates to be used for the purpose of the EHIS that have been described in the alcohol literature and that have been also brought forward during the expert meeting held in Brussels in July 2010 (see tables pp.22-27). From a very general point of view, there are a series of factors which can influence estimates of consumption variables and may constitute sources of measurement error (Sobell & Sobell, 2004; Dawson, 2003; Rehm, 1998; Lemmens, Tan & Knibbe,1992): the sample design; response rates among respondents (and non-response bias); the mode of data collection (CAPI, CATI, PAPI, etc.); the measurement instrument in use 23 (e.g. the questionnaire design and question wording); the presence of assumptions concerning drink strength, container sizes and serving sizes (for obtaining standard drinks ); errors in procedures for calculating total consumption; errors attributable to the respondents (underreporting or failure to recall details of the past drinking events); etc 24. As far as measurement instruments are concerned and as underlined through the alcohol literature there is currently no consensus regarding the best way to measure alcohol consumption (Graham et al., 2004). As a result there is not one single best instrument for assessing alcohol intake (there is no flawless measure). Therefore several aspects need to be considered when selecting specific alcohol questions. Indeed, according to Sobell & Sobell (2004) several factors are to be scrutinized in order to select an appropriate instrument: The population under study. How the information will be used. 23 According to Dawson (2003) and Rehm (1998), numerous methodological issues have an influence on the measurement of alcohol consumption: the reference period (exact recall for a short or recent period vs. a summary of the drinking behaviour over a longer period); the approach used to measure alcohol consumption (commonly used approaches are e.g. quantity/frequency or QF, and graduated frequency or GF approaches); beverage-specific vs. overall questions; the specific form of questions (exact wording, openended vs. categorical responses); the measurement of standard vs. actual drink sizes; features of the survey design (e.g. mode of interview, computerized survey instruments); and the context of the assessment (alcohol specific survey vs. survey about nutritional intake with some questions on alcohol included). 24 As mentioned by Lemmens, Tan & Knibbe (1992) some factors are less easy to manipulate than other. For instance, the degree of forgetting in surveys that collect retrospective data can be minimized by limiting the length of the recall period; however, only at the expense of losing information on individual behavior patterns, of requiring an enlarged sample size and, consequently, higher costs