TORONTO DEPARTMENT OF PUBLIC HEALTH
Proposal for An
Alcohol Abuse Prevention Program
September 2, 1992
Origin: Board of Health, June
25, 1992 (c34hlth92084:133)
1. That the Department of
Public Health increase emphasis on alcohol in its health promotion and
public awareness campaigns to raise community awareness regarding alcohol
2. That the Department of
Public Health increase emphasis on alcohol in its school and community
educational programs and in individual counselling.
3. That the Department of
Public Health work with the Board of Health Subcommittee on Substance
Abuse, health professionals, the Addiction Research Foundation and similar
organizations to promote public awareness of the health, social and fiscal
costs of alcohol abuse.
4. That the Board of Health
request City Council to direct appropriate staff to review city legislation
and policies on alcohol issues (e.g., serving alcohol at civic functions
or on city property, rules for special occasion permits, and employee
assistance programs) to ensure that city requirements allow only low-risk
consumption of alcohol.
5. That the Board of Health
recommend that the federal government, within the context of a comprehensive
strategy integrating both environmental and individual risk factors:
(a) develop legislation
that will require all alcohol products to carry clear health warning labels
that include easily understood alcohol content descriptions and identify
the health risks associated with alcohol use;
(b) prohibit all advertising
of alcoholic beverages on broadcast media as approved by City Council
Report Number 1, Clause 16 (January 15, 1991), and further, to develop
mechanisms to limit advertising of alcoholic beverages in print media;
6. That the Board of Health
recommend that the provincial government, within the context of a comprehensive
strategy integrating both environmental and individual risk factors, develop
legislation that will require all places where alcohol is sold to post
clear signs that warn about a wide range of risks associated with alcohol
use. The Department of Public health will offer to work with the Province
to ensure appropriate content of such warning signs.
7. That the Board of Health
recommend that the provincial and federal governments use their powers
of taxation to:
(a) increase the cost to the
consumer of alcoholic beverages by tying alcohol taxes to the consumer
(b) implement a schedule of
regular tax increases over and above the rate of inflation; and,
(c) equalize the price of
different forms of alcohol according to pure alcohol content.
8. That the Board of Health
recommend that the Liquor Licence Board of Ontario develop mechanisms
to ensure mandatory server intervention/education programs in all licensed
establishments in order to improve enforcement of existing provincial
legislation prohibiting the sale of alcohol to underage and intoxicated
This report summarizes recent
information on alcohol consumption and its effect on individuals and communities.
It describes the variety of programs and activities underway and suggests
a new approach and related initiatives to reduce alcohol consumption to
a level of minimal risk.
At its meeting of June 25,
1992, the Board of Health requested a background paper on the topic for
discussion by the Board's Subcommittee on Substance Abuse; it forms the
basis of this report.
This report also stemmed from
discussions at the Board of Health on September 8, 1991 concerning the
possibility of developing a by-law requiring the posting of a health warning
sign in all licensed premises. This matter was brought to the Board's
attention by Councillor Kay Gardner in relation to Fetal Alcohol Syndrome
(FAS). At its September 8, 1991 meeting, the Board of Health received
a report, Proposal for a City of Toronto By-law to Make Provisions for
the Warning of Fetal Alcohol Syndrome, prepared by Department of Public
Health staff and heard deputations from concerned organizations and groups.
These discussions highlighted the need for a review of the City's alcohol
abuse prevention program and initiated the planning process for a comprehensive
health promotion approach to alcohol use which resulted in the attached
This report proposes a comprehensive
strategy to reduce alcohol consumption, utilizing a health risk continuum
model. The strategy builds on prior Board of Health actions and Departmental
activities. The Department of Public Health looks forward to continuing
to work with the Board of Health and its Subcommittee on Substance Abuse
to reduce the negative health consequences of alcohol consumption.
EK/sm David J. McKeown, MDCM,
MHSc, FRCPC, FACPM
Acting Medical Officer of
City of Toronto Department
of Public Health
ALCOHOL ABUSE PREVENTION
David J. McKeown, MDCM, MHSc,
FRCPC, FACPM Acting Medical Officer of Health
PROFILE OF ALCOHOL USE
Recent statistics suggest
a general decrease in the prevalence, frequency and amount of alcohol
use. Nevertheless, alcohol is the most widely-used drug in Toronto and
all Canada. A 1989 national survey reported that approximately 78% of
Canadians, 15 years of age and over, are current drinkers, and an additional
16% are former drinkers (1). The Community Health Survey, 1988, found
that 85% of Toronto residents aged 15 and over do drink. According to
an earlier Community Health Survey, 85% of Torontonians also drank in
A positive association has
been found between alcohol consumption and income and education; language
spoken at home, employment and marital status are other factors that affect
alcohol consumption (3). Gender and age are also important. At all ages,
men are more likely to drink than women. According to a 1989 Ontario survey,
81.9% of men 18 years of age and older used alcohol in the past year,
with 68.2% occasionally consuming five or more drinks at a single sitting
and 13.3% using alcohol daily. The corresponding statistics for women
are 76.9%, 40.9% and 6.7% respectively (4). The 1991 Ontario Student Drug
Use Survey found that 66.2%, or 1.7 million, highschool students used
least once in the year preceding
the survey and 23.9% of this group had consumed five or more drinks on
one occasion. In the four weeks before the survey 16.6% of students had
been drunk (5). In 1990, Toronto street youth aged 13 to 24 were surveyed
to learn about alcohol and other drug use. Ninety-five percent of street
youth contacted had used alcohol at least once in the year before the
study and 63% reported consuming five or more drinks at a single sitting
in the four weeks directly preceding the survey (6).
In the Community Health Survey,
1988, 11% of Toronto drinkers surveyed in 1988 drank heavily (2) (defined
by the Ministry of Health as more than 12 drinks/week (7). Health, social
and legal problems mainly occur with heavy drinking. For instance, 30%
or more of violent crimes are alcohol related and about 20% of Canadians
have been assaulted by someone who has been drinking. Furthermore, an
estimated one-third of child abuse cases involve alcohol. In Canada, approximately
one in ten deaths is the result of alcohol (8). (See Appendix 1 for more
detail on the health and social consequences of alcohol abuse.)
Alcohol abuse is one of the
most significant substance abuse problems of the 1990s (1) and a major
public health concern. The chronic problems caused by alcohol abuse continue;
individual, family, societal and fiscal costs have not diminished. Prevention
efforts must be comprehensive and based on a solid understanding of the
current patterns of alcohol use and the associated consequences, and on
the popular beliefs that underlie alcohol use. Given the recent report
of the House of Commons Subcommittee (9), it is timely for the Board of
Health and the Department of Public Health to recommit to alcohol use
The mission of the City of
Toronto Department of Public Health is ". . .to enable all people
in the City of Toronto to be as healthy as they can be" (10). The
Ontario Ministry of Health mandates the Department of Public Health, under
the direction of the Board of Health, ". . .to improve the health
of the population by reducing the abuse of substances that pose a risk
to health" (11). The Healthy Toronto 2000 report (12), which forms
a blueprint for the Department of Public Health for the 1990s, is congruent
with the province's mandate. The report directs the Department to produce
a comprehensive, data-based substance abuse prevention strategy to address
root causes, plan community-based programs, and encourage inter-agency
and intersectoral cooperation.
In 1985 the Department proposed
a formal approach to alcohol abuse prevention (13). A 1987 report to the
Board of Health (14) detailed an enhanced educational program, just beginning
to be implemented, which aimed to promote knowledgeable decision-making
about alcohol use through focused activities such as school-based education
for children, community-based support, advocacy and health promotion,
and inter-agency and inter-sectoral cooperation. The program's goal was
" . . .a low health risk use of alcohol by Torontonians that would
result in no preventable deaths or disability from the use of alcohol"
(14). The program was designed as part two of the comprehensive Substance
Abuse Prevention Program. Part one, dealing with tobacco issues was already
well-established, and part three, dealing with licit and illicit drugs,
was, in the mid-80s, in the planning stages.
Increasing knowledge about
HIV and AIDS in the 1980s meant that the Department and Board drew attention
from other programs, including alcohol, to start-up appropriate HIV-related
interventions. More recently, community and political concerns regarding
the use of illicit drugs led to the swift development of the Department's
Drug Abuse Prevention Program (DAPP). This program generally follows the
outline of a comprehensive, multifaceted, community-based program consistent
with part three of the Substance Abuse Prevention Program. The acute problems
that the rise in illicit drug use brings to individuals, families and
communities has led to an increase in resources and publicity for the
Drug Abuse Prevention Program.
has proceeded as an integrated component of the day-to-day work of staff
in their roles as counsellors, educators, health assessors, promoters
and advocates. Advocacy actions have related to alcohol content and sales
of stomach bitters and low alcohol content beverages, pricing of alcohol,
hours and locations of alcohol sales, and advertising of alcoholic products.
At an area level, teaching continues at elementary schools as part of
our Substance Abuse Prevention Program, currently being evaluated. The
Eastern Health Area also is piloting a classroom-based program for grades
7 and 8. Currently, a multidisciplinary committee is developing a strategy
to link education for adolescents about drugs, alcohol and sexuality.
The Ministry of Health's report,
Ideas for Action on Alcohol, released in 1990, is consistent with Board
of Health philosophy and Department programming. It includes a framework
(see Appendix 2) that provides a practical and concrete tool with which
to reassess and organize our alcohol abuse prevention programming. Certain
approaches that have been identified as priorities by the Department of
Public Health but not by the Ministry framework (such as cultural sensitivity,
strengthening communities and addressing inequities in access to the basic
health prerequisites) must be integral components of our alcohol abuse
prevention program. Congruency with the Department's program focus initiative
is also required. An alcohol component should be included in healthy parents/healthy
children, healthy children/healthy adolescents and healthy adults/healthy
A CONTINUUM APPROACH FOR DEPARTMENT
From 1930 onward, the disease
concept of alcoholism dominated popular thinking. (See Appendix 3 for
an overview of this concept.) Current thinking on alcohol use and alcohol-related
problems has, however, moved from a concentration on the "alcoholic"
to the realization that many health, social, legal and economic problems
relating to alcohol use are caused by drinkers who are not alcoholics
or "alcohol-dependent", but who have drunk heavily and/or inappropriately.
This has led to a change in strategies for dealing with alcohol problems.
The focus has shifted from fixating on the alcoholic individual to a more
complex and comprehensive approach with strategies also aimed at the agent
(alcohol) and the social, cultural, legal, political and economic context
in which drinking occurs.
A simple and graphic way of
looking at the main cause of alcohol problems (i.e., alcohol consumption)
is to use the Risk Continuum Model (see Appendix 4). This model associates
increased risk of health, social, legal and economic problems with increased
amounts of alcohol consumed. Using a continuum indicates that there is
no definite point at which alcohol consumption changes from harmless to
harmful. Drinking is a dynamic situation, dependent on the physical, emotional
and mental state of the individual and the context in which drinking occurs.
However, looking at categories of relative risk is useful for program
The risk continuum makes it
possible to define a series of program and service categories into which
any population can be separated. Four categories are identified: no-risk,
low-risk, moderate-risk and high-risk. For planning purposes, each can
be considered a separate target group characterized by its relative level
of risk. Programs and services can then be developed in line with each
category and shaped by a distinct set of objectives and strategies.
Most Department of Public
Health activity will lie within the health promotion end of the continuum,
ranging from preconception and prenatal education to school-based programs
and communitybased health promotion activities. Minimal intervention activities
such as promoting self-help materials, brief assessment and referral programs
could also be included. A continuum of programs would attempt to move
people from high-risk to low or no-risk. Legislative, educational and
community support initiatives are having an influence on alcohol consumption
as attested to by recent Ontario statistics that show that people are
beginning to drink less (1); this should give momentum to the City's programs.
Society has long recognized
the need to control alcohol use by developing codes of behaviour, or by
passing laws governing production, sale, and use. In the early 1900s the
Temperance Movement in Canada blamed alcohol for almost all crime, divorce,
poverty, prostitution and family problems. In Ontario, prohibition began
in 1916 and lasted until 1923. However, although illegal, alcohol was
soon available from underground sources for all who wanted it. Since the
end of prohibition, the production, distribution, sale, and use of alcohol
have been controlled by the federal and provincial governments. Many restrictions
were removed in the 1960s and liberalization has continued (15,16).
Recently, a number of Canadian
cities and municipalities have begun to develop alcohol management policies.
In Ontario, 11 communities have officially adopted alcohol control policies
(17). These include: Guelph, Simcoe, Thunder Bay, Sault Ste. Marie, Elliot
Lake, Walden, Chapleau, Schreiber, Sturgeon Falls, and Tehkummah and Manitowaning
on Manitoulin Island. Other Ontario communities, such as North Bay, Mattawa,
Moosonee and Moose Factory, are in the process of developing similar policies.
These communities have worked closely with the Addiction Research Foundation
to negotiate and draft alcohol control policies. Principally, these policies
focus on municipally-owned facilities where alcohol use is not permitted
and those facilities where alcohol use is permitted under Special Occasion
Permits. The City of Toronto Department of Parks and Recreation is preparing
a report for City Council about control of alcohol consumption on City
As a consequence of the constitutional
division of powers, the federal government has jurisdiction over advertising
and labelling of alcohol, whereas provincial governments control licensing
of establishments and regulation of all aspects of the selling and serving
of alcohol. Laws controlling the advertising of alcoholic beverages are
currently under discussion. Presently, liquor (distilled spirits) advertisements
are not allowed on television, but beer and wine ads are permitted. Advertisements
are restricted in that they must highlight the product, not the consumer.
The report of the Subcommittee on Health Issues of the House of Commons
Standing Committee on Health and Welfare entitled Foetal Alcohol Syndrome:
A Preventable Tragedy, released in June of this year, recommends a complete
ban on lifestyle advertising of alcohol products on television and radio
(9). A complete TV and radio advertising ban was called for by the Canadian
Medical Association earlier this year (18).
The Subcommittee report also
recommends the institution of health warning labels on all alcohol sold
in Canada. Health and Welfare Canada is currently planning pilot projects
to test warning labels on alcohol in certain jurisdictions. The United
States has already enacted laws requiring producers of alcoholic beverages
to put health warning labels on all their products. Some state and local
jurisdictions have also passed legislation requiring warning signs where
alcohol is sold. This strategy was brought to the Board of Health's attention
in early August 1991 by Councillor Kay Gardner. On September 8, 1991,
the Board of Health received a report, Proposal for a City of Toronto
By-law to Make Provisions for the Warning of Fetal Alcohol Syndrome, considering
the development of a by-law requiring proprietors of all premises licensed
to sell alcoholic beverages to post a sign
warning of the dangers of
drinking alcohol during pregnancy. A number of deputations were made to
the Board at this meeting. This issue highlighted the need for a review
of the City's alcohol abuse prevention programs and initiated the planning
process for a comprehensive health promotion approach to alcohol.
The federal Subcommittee on
Health Issues recommends that the federal government initiate discussions
with the provinces to require warning signs in establishments serving
or selling alcohol. The Subcommittee recommendations about warning labels
and signs are specific to fetal alcohol effects and fetal alcohol syndrome.
The Addiction Research Foundation, which has also called for warning labels
and signs, recommends a more comprehensive program dealing with warnings
about a range of ill effects of alcohol use (19).
ALCOHOL ABUSE PREVENTION PROGRAM
Alcohol will be recognized
as a drug and addressed as part of the Substance Abuse Prevention Program.
It will be acknowledged that alcohol, like tobacco, plays a leading role
as a gateway drug to illegal drug use. Alcohol is the drug of choice for
the majority of citizens; it is crucial that Department programs reflect
this. The Department's alcohol abuse prevention efforts can build upon
the successes of the Smoking Prevention Program, the Drug Abuse Prevention
Program and ongoing alcohol abuse prevention initiatives.
Simple, clear, health-based
guidelines for alcohol consumption and low-risk drinking practices will
be developed and disseminated. It will be emphasized that not drinking
alcohol is always an option. Not drinking is advised for youth, pregnant
women, people operating vehicles or machinery and people with health problems
that alcohol might exacerbate.
A comprehensive program is
needed to address the complex social, cultural, medical and economic factors
involved in alcohol use and public health. It will incorporate individual
counselling; group education; mass media campaigns; policy and legislative
initiatives at the City level; advocacy for provincial and federal legislation;
community-based projects; coalition building and developing partnerships
and programs with family physicians, the Addiction Research Foundation
and other organizations working on substance abuse prevention.
HEALTH AND SOCIAL CONSEQUENCES
OF ALCOHOL ABUSE
Alcohol and Health
Alcohol affects the brain
and the central nervous system. Many people use alcohol because the short-term
effects make them feel less nervous, more confident and socially competent,
but the after-effects often leave the drinker up-tight, irritable and
anxious. The effects of alcohol on other parts of the body are not immediately
apparent to the drinker. Yet, alcohol use affects blood pressure, the
digestive system, the liver, and the endocrine and immune systems (20).
The risk of health damage
from alcohol, as from any other drug, depends on the dose and the characteristics
of the person taking it. Generally, the amount and frequency of any drug
consumed directly relates to the harmful effects. This is true for alcohol.
Alcohol is highly toxic (poisonous) in very high doses. Heavy long-term
drinking (five or more drinks per day) has been linked to liver disease,
heart disease, some cancers, brain damage, a weakened immune system and
a host of other potentially fatal health problems (20,21). Children born
to mothers who drink heavily during pregnancy are more likely to show
fetal alcohol effects or to have fetal alcohol syndrome. Mental retardation,
growth problems, head and facial deformities, joint and limb abnormalities
and heart defects are, in differing degrees, characteristic of these conditions
Heavy consumption can result
in major problems of dependency and disruption of life. Twelve percent
of current Canadian drinkers have experienced a physical health problem
at sometime in their life due to their drinking. An estimated one in ten
deaths in Canada is the result of alcohol (24). In Ontario, alcohol is
believed to indirectly cause an estimated ten percent of cancer deaths
(or 1,740 deaths/year) and five percent of deaths due to heart disease
and stroke (or 1,510 deaths/year). Alcohol is a major contributor to accidents
that result in injury and death because it modifies behaviour, alters
perceptions, judgement, and response time. Alcohol plays a role in at
least 50% of traffic fatalities and 30 to 40% of falls, drownings and
fires. In 1985, 6,506 deaths were directly or indirectly caused by the
use of alcohol (25).
Drinking and Driving
In Ontario in 1987, 18,737
car crashes involved drinking drivers. Where car crashes involved driving
under the influence, drivers were predominantly male and young (16-34
years old). Research has shown that the more people drink, the more likely
they are to drink and drive (26). Thirty-three percent of Toronto drivers
drive after drinking. The practice is more common among men than women,
38% versus 24% (27).
Seven percent of Canadian
drivers drink and drive frequently. More than one-third of Canadians have
been passengers in a motor vehicle (car, truck, motorcycle, all-terrain
vehicle, boat or snowmobile) with a drunk driver. Drinking drivers place
themselves, their passengers and the people around them at risk of death,
injury and physical disability. Drinking drivers face criminal charges
that can lead to higher insurance fees, high legal fees, jail time and
fines. With a criminal record, they may lose job opportunities and have
trouble travelling outside Canada (28,29).
Alcohol and Society
Alcohol use has become pervasive
in our society with strong cultural, economic and recreational components.
The social costs of heavy alcohol use can be seen at the individual, family
and community levels.
Roughly 30% to 50% of violent
crimes are alcohol-related. About 20% of Canadians have been assaulted
by someone who had been drinking (29). An estimated one-third of child
abuse cases involve alcohol (28). Children of alcoholic parents pay in
yet another way. They are more likely to become alcohol or drug dependent
and adopt high-risk patterns of drinking. Children of alcoholics are also
seen at an increased risk for a variety of reasons including, genetic
or other physiological factors, psychological and social factors (30).
Seven percent of Canadians
report that drinking has affected their happiness at some time. Six percent
feel that it has harmed their marriage or home life; one in six divorces
is associated with heavy alcohol use. About one-fifth of Canadians have
had family problems because of others' drinking. Eleven percent of Canadians
report that alcohol has caused problems with friendships or social life,
and 16% of Canadians have lost friends. More than half of adult Canadians
have been insulted by someone who has been drinking, and nearly half have
been disturbed by loud parties or the behaviour of people drinking at
a party (31).
In Ontario in 1981, alcohol
abuse cost society approximately $1.8 billion a year in extra health,
law enforcement and social welfare services (32). Alcohol abuse reduces
productivity, increases absenteeism, lowers morale and causes accidents
at the workplace. Employers who require licensed drivers have gone bankrupt
due to crashes caused by impaired employees. Four percent of Canadians
believe that alcohol use has caused harm to their work-related abilities,
employment or studies. Similarly, five percent report that their drinking
has harmed their financial position, and three percent have had financial
difficulties because of others' drinking. Eight percent of Canadians have
had property vandalized, yet another cost to society (29).
A FRAMEWORK FOR ACTION ON
An effective plan for action
on alcohol consists of three APPROACHES carried out in six SITES aimed
at many TARGET GROUPS (35).
The approaches used to reduce
alcohol use and influence behaviour are:
- EDUCATION: A first step
in this approach is to give people facts on alcohol use and problems.
Information makes people more aware of the issue, increases knowledge
and changes attitudes towards alcohol. A second step in the EDUCATION
APPROACH is skills development. People need to learn skills to change
or avoid high-risk practices. Skills and information are both necessary
for behaviour change to occur.
- POLICIES: Health-oriented
policy measures, such as restricting the supply of alcohol, place barriers
in the way of risk drinking and make it easier to engage in no/low-risk
- ENVIRONMENTAL SUPPORT: This
approach creates opportunities and an environment that supports healthy
behaviours. It includes programs and services, access to information and
services, promotions and advertising, and the existence of self-help and
support groups as well as related interest groups.
Action to reduce alcohol problems
must take place in many settings. Community projects should include programs,
activities and policies in many sites:
- Community-at-large: Media,
both small (e.g., neighbourhood newsletters, posters, flyers), and mass
(e.g., radio, television, print), community organizations such as youth
clubs, social service agencies, and community facilities such as recreation
facilities and parks are all places where alcohol messages can reach large
numbers of people.
- Home: People spend more
time at home than anywhere else, and drinking behaviour is often shaped
by practices and attitudes in the home.
- Educational settings: Statistics
show that young people begin to experiment with alcohol very early. Programs
in elementary and secondary schools, community colleges and universities
may help students develop low-risk drinking habits and responsible attitudes
- Health-care settings: Offices
of physicians, dentists and other health professionals (e.g., pharmacists,
chiropractors, therapists), hospitals, emergency departments, visiting
nurses, community health centres and public health units are all places
where people turn for health information.
- Workplaces: An effective
place to reach adults is the workplace. As employers pay a high price
for problem drinkers (e.g., lost productivity), they are likely to be
receptive to workplace programs on alcohol.
- Licensed Premises: Places
that serve alcohol for consumption on-premise can have a strong impact
on people's drinking habits. They can be used to encourage low-risk drinking.
THE DISEASE CONCEPT OF ALCOHOLISM
AND RECENT CONCEPTUAL CHANGES
Chronic heavy drinking was
first connected with ill health in the late 1700s. In the 19th century,
Matthew Huss, a Swedish doctor, coined the word "alcoholism"
to describe the chronic health effects of continual heavy drinking. In
the 1930s, Otto Jellinek, an American physician, promoted a new disease
concept of alcoholism. He defined alcoholics as people whose dependence
on alcohol interfered with their health, social functioning or economic
well-being. Jellinek's work had tremendous influence on medical, scientific
and popular thinking about alcohol use, and in 1952 the World Health Organization
adopted this definition (33).
Whereas early ideas focused
on "the demon alcohol", the disease concept saw the problem
as lying not so much in the alcohol as in the person, or in certain people
who had developed a disease called alcoholism which made them unable to
control their drinking. This disease concept was politically and commercially
acceptable because it allowed alcohol to be portrayed as beneficial for
most people, apart from those who were afflicted with "alcoholism".
It also removed the moral stigma from drunkards: they were neither bad
nor evil, but sick. In a landmark 1960 paper, Jellinek defined alcoholism
in terms of harm to the individual and to society. Jellinek's ideas underlie
the belief that alcoholism is a chronic disease and that the sole treatment
is to abstain. General acceptance of Jellinek's ideas led to the success
and world-wide spread of Alcoholics Anonymous. Originating in the United
States, this self-help initiative is based on the belief that alcoholism
is an incurable disease that can be controlled by abstinence, spiritual
awareness and fellowship (34).
Recent conceptual changes
have been accompanied by changes in terminology. People who are physically
and psychologically reliant on alcohol are now described as "alcohol
dependent", and "alcohol abuse" is used to describe the
behaviour of people who experience health or social problems because of
their alcohol use habits. A further classification is made up of "social
drinkers" or "alcohol users": people who drink, but have
no serious health or social consequences. It is now recognized that people
do not fit neatly into one category and that individuals who are usually
social drinkers may, on occasion, be involved in accidents or incidents
related to a single occurrence of heavy drinking and risk-taking behaviour.
Thus there is no clear line
delineating alcohol use, alcohol abuse and alcohol dependence. There is
no evidence of an inevitable sequence of behaviour and systems leading
from one classificati