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1 This article was downloaded by:[källmén, Håkan] On: 30 January 2008 Access Details: [subscription number ] Publisher: Informa Healthcare Informa Ltd Registered in England and Wales Registered Number: Registered office: Mortimer House, Mortimer Street, London W1T 3JH, UK Nordic Journal of Psychiatry Publication details, including instructions for authors and subscription information: Alcohol habits in Sweden during measured with the AUDIT Håkan Källmén a ; Peter Wennberg b ; Anne H. Berman c ; Hans Bergman b a Department of Psychology, Uppsala University, Uppsala, Sweden b Section for Addiction Research, Magnus Huss-clinic, M4:04, Karolinska Hospital, Karolinska Institute, Stockholm, Sweden c Division of Forensic Psychiatry, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden Online Publication Date: 01 January 2007 To cite this Article: Källmén, Håkan, Wennberg, Peter, Berman, Anne H. and Bergman, Hans (2007) 'Alcohol habits in Sweden during measured with the AUDIT', Nordic Journal of Psychiatry, 61:6, To link to this article: DOI: / URL: PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: This article maybe used for research, teaching and private study purposes. Any substantial or systematic reproduction, re-distribution, re-selling, loan or sub-licensing, systematic supply or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material.

2 Alcohol habits in Sweden during measured with the AUDIT HÅKAN KÄLLMÉN; PETER WENNBERG; ANNE H. BERMAN; HANS BERGMAN Källmén H, Wennberg P, Berman A, Bergman H. Alcohol habits in Sweden during measured with the AUDIT. Nord J Psychiatry 2007;61: Oslo. ISSN This study aimed to describe changes in Swedish alcohol habits during a period of harmonization with European Union alcohol policy. Three random samples collected during the years 1997 (n997), 2001 (n893) and 2005 (n914) were compared. Alcohol habits and hazardous consumption was measured with the AUDIT (Alcohol Use Disorders Identification Test) distributed to the respondents by post. Results were somewhat diverse, but significant changes in alcohol habits occurred among two subgroups of the population: for women and the age group between 28 and 60 years, AUDIT scores peaked in The results are discussed in relation to the changes made in Swedish alcohol policy during the investigation period. Alcohol habits, Alcohol policy, Hazardous consumption. Håkan Källmén, Section for Addiction Research, Magnus Huss-clinic, M4:02 Karolinska Hospital, Karolinska Institute, S Stockholm, Sweden, hakan.kallmen@ comhem.se; Accepted 24 November Since the 1950s, the basic aim of Swedish alcohol policy has been to reduce the demand for alcoholic beverages by high taxation (1). The assumption behind this high taxation level is based on single distribution theory, where the level of overall consumption determines the extent of negative consequences. However, consumption is less elastic for high consumers than single distribution theory would predict. Thus, high prices should also be complemented by restrictions of the availability of alcohol (2). Since Sweden joined the European Union (EU) in 1995, several political decisions have been taken to liberalize the alcohol policy in accordance with EU standards (Table 1) (3). These measures have increased the availability of alcohol, which has been shown to be associated with a higher consumption (4). According to the Centre of Research on Alcohol and Drugs in Sweden, the per capita consumption of alcohol has increased from 8.8 litres of 100% alcohol in June 2001 to 10.5 litres by October However, from October 2004 to June 2005, consumption was reported to show a downward tendency (10.1 litres) (5). These predictive estimates of consumption are based on calculations of alcohol sales, alcohol imported from other countries, self-reports and an implicit assumption that all measured available alcohol is consumed during the month it was purchased. Bergman & Källmén (6, 7) have described hazardous or harmful alcohol habits in Sweden based on surveys using the AUDIT (Alcohol Use Disorders Identification Test). This was done in representative samples of the Swedish population on two different occasions*1997 and The first study was performed at the beginning of the Swedish EU membership process, and the second after a partial harmonization to the norms and rules of the European Union. A third study was performed in 2005, after full harmonization. The overall objective of the present study is to show how the alcohol habits have changed over the 9-year period, during which alcohol policy has changed and alcohol regulations have been liberalized. More specifically, we address two issues: (a) AUDIT score trends in the whole population and in subgroups of gender and age over the 9 years, and (b) 9-year trends in changing proportions of risky or harmful alcohol consumption among the entire population and in subgroups. Our hypotheses are that average AUDIT scores have increased unremittingly over the 9 years and that the prevalence of hazardous or harmful drinkers should have increased accordingly. Method AUDIT The AUDIT questionnaire is recommended by the World Health Organisation (WHO) and is used internationally to screen for problem drinking. The Swedish version of the test has been described earlier by Bergman &Källmén (6). Although the AUDIT was constructed as # 2007 Taylor & Francis DOI: /

3 ALCOHOL HABITS IN SWEDEN DURING EU MEMBERSHIP Table 1. Political decisions in Swedish alcohol policy connected with harmonization to following EU membership Abolishment of the import monopoly on alcohol Reduction of the tax on beer with high alcohol content 1999 Abolishment of duty-free purchases of alcohol within the EU 2000 First marginal increase in duty-free allowances when crossing Swedish border 2000 Trial Saturday alcohol sales by the retail monopoly 2001 Permanent Saturday alcohol sales by the retail monopoly 2001 Second increase in duty-free allowances when crossing Swedish border 2002 Third increase in duty-free allowances when crossing Swedish border 2003 Permission to commercially advertise beverages with low alcohol content 2003 Fourth increase in the duty-free allowances when crossing Swedish border 2004 Full harmonization of duty-free allowances in accordance with EU rules a screening instrument for hazardous or harmful alcohol habits, it has been shown that it also screens for alcoholrelated social problems, alcohol-related health problems and dependency (8). For these reasons we considered it appropriate to use the AUDIT to estimate changes in Swedish alcohol habits. The AUDIT consists of 10 items; eight items have five response alternatives on a scale from 0 to 4 and two items have three response options (0, 2, 4). The maximum score on the test is 40 points. The AUDIT was constructed with the ambition that it would be useful in countries with differing alcohol habits and cultures. Various cut-off points for hazardous or harmful habits have been suggested. For the purposes of the present study, the cut-off for hazardous or harmful alcohol habits among men was set at the recommended 8 points (9) and the cut-off for women was set at 6 points (7). A higher cut-off, 15 for men and 13 for women, has been used to identify more severe alcohol-related problems. This higher cut-off was suggested by Babor et al. (10) but has not yet been well established. For AUDIT respondents, a drink is defined as 12 g of 100% alcohol. This quantity is exemplified on the form according to various types of drinks (e.g. beer, wine or spirits). According to a previous study (6), alcohol habits at the population level were fairly stable over the ages 2860, and for this reason study participants were grouped by age into three groups: 1727 years, years and 6171 years. Respondents Data were collected by Infodata Direkt AB. A systematic random sample of 1250 individuals was drawn from the Swedish population for each year of the study from a official register including all persons having an address registered in Sweden (Dafa-Spar). Half of the respondents sampled were men and half women. The response rate was nearly 80% in 1997 (n997), 72.5% in 2001 (n 893) and 74.5% in 2005 (n914). In total, 2804 persons were tested during all three surveys (a total response rate of 74.8%). An analysis of non-responders showed that men under 40 were over-represented and their response rate decreased (and their dropout increased accordingly) from 2001 to 2005 (Table 2). Since we had no information about ages in the samples, the expected number of respondents was calculated on basis of the population data. The proportion of non-responders was estimated by dividing the number of observed responders by the expected frequency in each stratum, and subtracting this proportion from 1. Since it is well known that younger men have higher alcohol consumption rates than the general population, it is reasonable to assume that many heavy consumers did not complete the questionnaire. Thus, the mean AUDIT scores and prevalence of hazardous and harmful alcohol habits on the population level are underestimated. However, among women and older men our estimations are probably more valid. Procedure The questionnaire was posted together with an introductory letter and a stamped addressed envelope to the respondents. In the letter, they were asked to participate anonymously in a screening of Swedish alcohol habits and informed that they would receive 50 Swedish crowns (equivalent to about US$7) if they revealed the identification number that was printed on the forms. Two reminder letters were sent to non-responders. Less than 10% of the respondents chose to receive the money. The Karolinska institute ethical review board authorized the methodology (Dnr 95101). Statistics The analyses were performed using SPSS 11.5 software. Although it seems reasonable to assume a skewed distribution of AUDIT scores, a normal approximation (comparison of means) was used in concordance with earlier research about AUDIT. A univariate analysis of variance (ANOVA) was used to test the hypothesis of equal AUDIT means. Chi-square tests were used to identify significant difference between the numbers of persons in each condition (positive or negative). NORD J PSYCHIATRY VOL 61 NO

4 HKÄLLMÉN ETAL. Table 2. Drop-out rate by sex and age group ; expected frequencies and dropout All Age class Men Exp. freq Drop-out, % Women Exp. Freq Drop-out, % Results Average AUDIT scores Table 3 shows the mean scores on the AUDIT at the three points of data collection. As shown in Table 3, there were significant differences in women s alcohol habits between the three measurements. Post-hoc pairwise comparisons between groups, using Scheffe s method, showed that women scored higher on AUDIT in 2001 than in 1997 (P 0.048). There was also a tendency among women (although not significant), towards higher average scores in 2005 compared with 1997 (P 0.066). The average AUDIT score for men and women aged 2860 also differed between the three measurements. In the year 2001, scores were higher than in both 1997 and Prevalence of hazardous and harmful consumption As Table 4 shows, only alcohol habits defined as alcohol abuse among respondents in the 2860 age group differed between the three measurements. This indicates that high alcohol consumption in 2001 was significantly more prevalent than in both 1997 and 2005 for this age group, implying that lower alcohol habits (social drinking) seem to have been rather stable among this investigated period. Table 3 and 4 both show differences between the years measured for the 2860 age group. Table 3 shows higher AUDIT mean scores for the year 2001 and Table 4 shows higher prevalence of risky drinking but not more severe alcohol abuse. There is, however, an incongruity in that Table 3 shows heavier alcohol habits for women in the years 2001 and 2005 compared with 1997 but no differences among women are found in Table 4. The lack of differences regarding women s alcohol habits over years, according to chi-square testing, can be due to a lower power in non-parametric tests than in their parametric equalities. Discussion Our explicit hypotheses in this study were not confirmed*neither the hypothesis that the Swedish alcohol habits would show an unremitting increase over the whole period was supported, nor the hypothesis that the prevalence of risky or harmful habits would increase. Rather there seems to have been an increase that was restricted to the period between 1997 and 2001, while consumption seem fairly stable between 2001 and This pattern was most clear among women and for the 2860-age group. The phenomenon that women are gradually approximating men s alcohol habits is in accordance with the convergence hypothesis (11) that suggests that increased social equality for women leads to heavier alcohol habits. Another possible reason 468 NORD J PSYCHIATRY VOL 61 NO

5 ALCOHOL HABITS IN SWEDEN DURING EU MEMBERSHIP Table 3. Means and standard deviations for total AUDIT scores, by gender and age groups during the three years sampled (n997) 2001 (n893) 2005 (n914) Analyses of variance Total sample 3.77 (3.96) 4.12 (3.92) 3.93 (4.12) F1.81, df2, P0.165 Women 2.71 (2.81) 3.18 (2.97) 3.15 (3.31) F3.89, df2, P0.021 Men 4.94 (4.66) 5.17 (4.55) 4.82 (4.78) F0.59, df2, P0.556 Age (5.35) 6.32 (5.41) 6.51 (5.52) F0.44, df2, P0.647 Age (3.50) 3.96 (3.47) 3.55 (3.65) F3.16, df2, P0.042 Age (2.49) 2.37 (2.54) 2.93 (3.37) F2.51, df2, P0.083 Table 4. Proportion of individuals with hazardous or harmful alcohol habits according to the AUDIT (814 points for men/612 points for women) or with alcohol abuse (13for women and 15for men) (n997) 2001 (n893) 2005 (n914) x 2 test Total sample 13.2%/2.6% 15.1%/2.9% 13.6%/2.7% ns/ns Women 11.4%/1.1% 13.4%/1.5% 12.7%/1.4% ns/ns Men 14.9%/4.0% 16.8%/4.3% 14.4%/4.0% ns/ns Age %/8.0% 29.8%/9.3% 35.4%/7.4% ns/ns Age %/1.7% 13.6%/3.6% 9.3%/2.0% PB0.05/ns Age %/0.0% 3.1%/1.5% 2.0%/1.4% ns/ns for heavier alcohol habits is the liberalized policy following EU harmonization. Although we cannot assume that increased alcohol consumption results from the liberalized alcohol policy, the heavier alcohol habits among women and the age group can be related to some political measures. The initial increase in alcohol habits could be explained by the introduction of duty-free allowances for returning tourists as well as the trial of selling alcohol on Saturdays. After habituation to the increased availability of alcohol, small and insignificant changes in alcohol habits occurred, in contrast to what Whitehead (4) found in the 1970s. The stable alcohol habits between 2001 and 2005 that are shown in Table 3 are in accordance with other statistics presented (5). According to these statistics, the main reason for the downward trend is that tourist purchases abroad, which peaked during the December 2003January 2004, were nearly 20% lower in April At the same time, retail alcohol sales by the Swedish government monopoly were nearly stable. This is probably the reason for our finding that alcohol habits did not change after Our conclusion is that the initial increase reported above between 1997 and 2001 was probably due to the increased availability of alcohol but when people became accustomed to this level of availability, consumption declined. Turning to the methodological aspects of the study, we found two main limitations. First, the response rate varied between the measurements (72.580%). Although the response rate is high compared with many similar studies, the variations in response rate suggest the need for caution due to systematic bias. Second, the measurements constitute snapshots made at three different points of time with little control of oscillations during the years between the measurements (including seasonal changes). Another drawback is that because we did not measure on the same individuals, it is possible that the different cohorts in the same age group at the three measurements had different but stable alcohol habits, so we cannot conclude anything at the individual level. Our results should only be interpreted on a population level. Acknowledgement*The authors would like to thank the The Swedish alcohol retail monopoly s council on Alcohol Research for supporting this study. References 1. Rosén M. Price and health policy in Sweden*A critical review. Health Policy 1989;/12:/ Cook PJ, Moore MJ. The economics of alcohol abuse and alcohol control-policies. Health Affairs 2000;/21:/ Swedish National Institute of Public Health. Gränslös utmaning* alkoholpolitik i ny tid (Boundless challenge*alcohol policy in new times). Stockholm; Whitehead PC. Effects of liberalizing alcohol control measures. Addict Behav 1976;/1:/ Ramstedt M. Alkoholkonsumtionen i löpande 12-månadersperioder. Uppdelat på typ av dryck och anskaffningssätt (Alcohol consumption in rolling 12-month periods. Divided into type of beverage and way of acquisition.). SoRAD; Bergman H, Källmén H. Alcohol use among Swedes and a psychometric evaluation of the alcohol use disorders identification test (AUDIT). Alcohol Alcohol 2002;/37:/ Bergman H, Källmén H. Svenska kvinnor har fått mer riskfyllda och skadligare alkoholvanor. Undersökning av förändringar i svenskarnas alkoholvanor åren (Swedish women show more hazardous and harmful alcohol habits. Investigation of changes in Swede s alcohol habits during the period ). Läkartidningen 2003;/100:/ NORD J PSYCHIATRY VOL 61 NO

6 HKÄLLMÉN ETAL. 8. Hradilova Selin K. Alcohol Use Disorders Identification Test (AUDIT): What does it screen for? Performance of the AUDIT against four different criteria in a Swedish population sample. Substance Use Misuse. Forthcoming. 9. Saunders JB, Aasland OG, Babor, De la Fuente JR, Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption*iii. Addiction 1993;/ 88:/ Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG. AUDIT, the Alcohol Use Disorders Identification Test*Guidelines for use in primary care, 2nd edition. Geneva: World Health Organization, Department of Mental Health and Substance Dependence; Neve RJM, Drop MJ, Lemmens PH, Swinkels H. Gender differences in drinking behavior in the Netherlands: Convergence or stability? Addiction 1994;/91:/ Håkan Källmén, Associate Professor, Department of Psychology, Uppsala University, Uppsala, Sweden. Peter Wennberg, Associate Professor, Section for Addiction Research, Magnus Huss-clinic, M4:04, Karolinska Hospital, Karolinska Institute, S Stockholm, Sweden. Anne Berman, Ph.D., Division of Forensic Psychiatry, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden. Hans Bergman, Professor Emeritus, Section for Addiction Research, Magnus Huss-clinic, M4:04, Karolinska Hospital, Karolinska Institute, S Stockholm, Sweden. 470 NORD J PSYCHIATRY VOL 61 NO

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