Portal de Periódicos da CAPES

France: alcohol today

2005; Wiley; Volume: 100; Issue: 10 Linguagem: Inglês

10.1111/j.1360-0443.2005.01207.x

1360-0443

MICHEL CRAPLET,

Wine Industry and Tourism

In France, public interest in alcohol problems began in the political climate following defeat in the Franco Prussian war in 1870 and the events of the Commune, the popular Parisian rebellion. The bourgeoisie took fright and pinpointed public drunkenness as responsible for the troubles and for the spirit of sedition. Since these fanciful notions, and in spite of a long history of real personal and social suffering due to alcohol consumption, France is often depicted as 'a country where the natives drink, sing and dance till the wee small hours of the morning without experiencing any problem'[1]. Although the industrial revolution began in the middle of the nineteenth century, France is still largely an agricultural country (where the richer farmers benefit most from European Common Agriculture Policy funds) where cultivated fields, orchards, and vineyards occupy 35% of the land. To many observers, France still looks like the Garden of Eden before the Fall and our traditional social drinking often appears to protect against the consequences of binge drinking—a pattern universally deplored. The above view of French drinking should be seriously reconsidered as many changes have arisen through modernisation and globalisation. Average consumption in France has decreased from 19 litres of pure alcohol per capita per year in 1960 to 10 litres per capita in recent years: that is to say over 1% per year for 40 years. Consumption has decreased especially in regard to daily consumption, and there has been a move from traditional beverages (especially common wines) to quality wines and international brands of beers and spirits. The main factor explaining the decrease of the average consumption is the change in living conditions with a rural-to-urban drift of the population and the change in patterns of consumption: alcohol is no longer drunk at every meal or even every day. Alcohol is drunk less during working hours and more during leisure time. As in northern Europe, it is becoming the drink of parties, football matches and rock concerts. It is less frequently used as a food, but more as a drug for its psychoactive effect. For these reasons, the consumption declined and the consequences changed. Young people and city dwellers are the main players in these changes as they are refusing to follow the habits of their parents and grandparents; this leads us to consider that they will create new patterns of drinking. We must also note that the consumption of cannabis, psychoactive drugs (tranquillisers and antidepressants) and tobacco (especially by women), has increased in recent years. Resulting from the decline in average consumption, we observe a decrease in mortality and morbidity related to alcohol but, following the new patterns, we can see an increase in social harm due to binge drinking. The mortality rate of chronic alcohol-related somatic diseases such as liver cirrhosis has decreased from 15 000 annual deaths in 1960 to 10 000 today. The decline in other medical complications (e.g. pancreatitis, polyneuritis) is also due to new drinking patterns. It is difficult to assess the consequences of the social harm resulting from drunkenness and addiction. If the number of addicts ought to have decreased due to the decline in average consumption, the present congestion of specialised detoxification centres is due to an increase in demand for help—especially by women—and not to an increase in the problem, as is usually stated in the press in order to awaken the attention of the readers, sometimes with the complicity of physicians looking for better working conditions. However, due to the growth of binge drinking, social harm is more likely to occur. We can illustrate this complexity by the example of traffic accidents. Once France's national shame, far ahead of other European countries in the table of road fatalities, the level of such accidents has shown recent decline. In the past three years 2500 lives have been saved, but alcohol responsibility in accidents is constant: one third of fatal accidents are still alcohol related. We lack data on the other consequences of drunkenness: assaults and violent crimes, child abuse and cases of domestic violence. Resulting from the social stigma concerning alcohol, many communities and families hide such private problems. In the French media, the role of alcohol in the death, in July 2003, of a famous French actress was hidden, just like in 1997, the intoxication of the chauffeur in Princess Diana's death. Again, we can say that the changes have resulted in a shift from one drug to another (cannabis and tranquillisers especially), from one harm to another, from one victim to another. There are also considerable variations in drinking patterns and consequences between France's different regions. Some 50 years ago, pioneers proposed housing alcoholics in general hospitals to show that alcoholism is a disease and in order to prevent relegation to psychiatric units. They stressed the need to take into account the drinker's personality (le 'sujet' in a psychological perspective) with its medical problems and social disorders. To tackle this complexity, most alcohologists are continuing along that route [2]—caring for all aspects of the character and life of the patient—even though simplistic statements on miracle methods are regularly pronounced. Such was the case of disulfiram, psychoanalysis, opioid antagonists—or other wonder drugs—and the cognitive-behavioural therapies of today. The pioneers—knowing how difficult it is to live as an abstainer in an 'alcoholised' society—developed partnerships with self-help groups of recovering alcoholics. Besides Alcoholic Anonymous, many French national or local groups (Vie Libre, Croix d'Or, Croix Bleue) bring this mutual help and support in welcoming sessions. There is no central administrative structure in the organisation of the treatments which are proposed in various institutions. Out-patient centres—for the time being called Centres de Cure Ambulatoire en Alcoologie (CCAA)—were established during the years 1970–90. By now, there are about 220 specialized centres. Care is free of charge for the patient. Residential care can be programmed in general hospitals (with a few specialised unités d'alcoologie), psychiatric wards, and private clinics. Specialized professionals and institutions have good experience in treatment. They have placed their comprehensive approach on the bio-psychosocial model for all alcohol related problems. As there were no other caring professionals, they had to deal with all problems from drunkenness to its medical consequences and addiction. For a long time, general practitioners have behaved just like ordinary citizens, oscillating between feelings of impotence, doubt and rejection when facing alcohol problems. We hope things will change with the training of GPs—for example through the WHO programme 'Less is better' ('Boire moins c'est mieux' in its French translation)—and the dissemination of brief intervention programmes for heavy drinkers. Pioneers in the field of prevention policies have, for a considerable time, seen the need for a comprehensive approach. They were led to this broad view by taking into account at the same time the common medical consequences of the convivial consumption of wine, found in all Mediterranean countries, and the social consequences from binge drinking of northern European countries. This global approach has been pursued only by a few solitary experts and non-governmental organisations not bound by the consequences of prevention on alcohol marketing. With a Latin way of not facing the problems by hiding one's head in the sand, this economic reality explains why alcohol prevention has been difficult to implement in France especially regarding control policies. Fortunately, some licensing laws were passed during the 1950s. They prevent the opening of premises in inappropriate locations, for instance near schools, and set a maximum density of outlets in newly urbanised areas. The number of establishments authorised to sell alcohol declined from 250 000 in 1960 to 170 000 today. Local authorities determine restrictions on permitted hours. The restrictions are, however, not alcohol specific but related to the nature of the establishment. Alcohol sales from vending machines are not allowed but regretfully the sale of alcohol is allowed in petrol stations during the day (6 am to 10 pm). The Code de la Santé Publique forbids all minors under the age of 16 to enter a bar unless accompanied by an adult. Purchase of spirits is prohibited to persons under 18 years of age while the purchase of wine and beer is allowed from 16 years, but only for off-premises consumption. If the legal age-limits are fairly well enforced for on-premise sales, it is not, regarding off-premise sales. Taxation has never been used as a tool of prevention. When compared with the Consumer Price Index, it is clear that the real value of excise duties on all alcoholic beverages has decreased or stabilised from 1970 to 2000. The real price index for all alcoholic beverages in France has been quite stable or has decreased by a few percentage points [3]. This is the success story of alcohol policy in France. A law (loi Evin [4]) was passed in 1991 in order to control advertising of alcohol. This law is very strict for a country where alcohol control is so lax. It forbids advertising on television and controls the message where advertising is authorised, on radio, in the press and on billboards. The adverts must show only the products: the use of images of drinkers is not allowed. Since 1991, many advertisements infringing the law have been condemned by the French courts of justice. As a consequence, we can observe a real change in alcohol advertising: the law has modified the language of advertising making it lose most of its seductive character. Of course, the law has been regularly criticised and attacked but it resisted the pressure of Anheuser Bush during the 1998 Football World Cup in France. The law was threatened by an active wine producers lobby during the year 2004. Thanks to the struggle of public health experts, only small changes were made in January by the French parliament and the law remains one of the most severe in Europe. This change introduced the possibility of talking about the objective characteristics of the products (including colour, smell, taste). Moreover, the European Court of Justice ruled in 2004 (C-262/02) that the law is compatible with the European treaties and proportional to its objective. Since 1959, drink driving has been an offence. The authorised blood alcohol concentration (BAC) declined from 1.2 to 0.8 and is today set at 0.5. Random breath testing has been legal since 1978. Since 2003, the law has been more strictly enforced with more frequent tests and penalties have became harsher so that offenders would face, in addition to a fine and imprisonment, a licence suspension of one to three years, after which time a new licence would be issued only after a medical examination. However, as public health and road accident expert Professor C. Got maintains, 'there are still too many differences in the quality of preventive and dissuasive detection (between French regions)'[5]. As in other Mediterranean countries, the emphasis is put on strategies of information and persuasion. From time to time, media campaigns are launched by official bodies co-ordinated by the Institut National de Prévention et d'Education pour la Santé (INPES). These campaigns ought to be followed by local programmes to be really effective. Much of this grassroots prevention work is done, with few financial means, by the Association Nationale de Prévention en Alcoologie et Addictologie (ANPAA), a non-governmental organisation established in the nineteenth century. The lack of support from public agencies leaves the floor open to the alcohol producers. They organise campaigns—for example on road safety by designated driver programmes—the effectiveness of which are not assessed; and they disseminate information on harm reduction which is not always compatible with a comprehensive approach to prevention. In 1979, Pierre Fouquet founded the Société Française d'Alcoologie [6] in order to develop contacts between members and organisations of various disciplines concerned by the alcohol question. In recent years, this society has brought together much clinical work publishing conference papers and practical guidelines [7,8]. Many sectors of research remain undeveloped in France such as social and biomedical studies. Looking at the lack of interest in public laboratories for alcohol problems, we can understand that sociologists and biologists turn to funding by the alcohol industry. In their work, these researchers are not confronted by people suffering from the unethical efforts of the producers to increase alcohol availability and consumption. France had to wait until the 1950s to see the beginning of a coherent public alcohol policy underpinned by an interministerial committee answerable to the Prime Minister, the Haut Comité d'Etudes et d'Information sur l'Alcoolisme (HCEIA). It was set up by a brave politician: the left wing Pierre Mendès-France, in 1954, and continued by the right wing Michel Debré in 1959. At the same time, a demographist, Sully Ledermann published the study which led to the general consumption model. However, the policy recommendations of Ledermann were only implemented in northern Europe and were known in France only through Nordic publications. No one is a prophet in his own country. The HCEIA lost the high protection of the Prime Minister in the 1980s and its responsibility narrowed. Important changes have appeared only lately during the 1990s when politicians have, at last, allowed the experts to define a new health policy in which the problems linked to alcohol consumption have found their rightful place amongst other addictions. La Mission Interministérielle de Lutte contre la Drogue et la Toxicomanie (MILDT), an agency answerable to the Prime Minister, was asked to add alcohol, tobacco and psychotropic pharmaceutical drugs to its programme (Plan triennal de lutte contre la drogue et de prévention des dépendances). Unfortunately, indications are that alcohol consumption benefits from the new political majority, elected in 2002, using French traditional references to art de vivre which are always linked to alcohol. The new right wing leaders stress the problems arising from illegal drugs, placing their hopes more on repression than on education, and forgetting again the alcohol problem. Without a strong political impulse, the co-operation of the different public and private agencies is often difficult. The ambivalence of French authorities can be explained by the economic aspect, as the production and the marketing of alcohol account for 10% of the GDP. But the irresponsibility of this attitude is clear in a country where the medico-social cost of the consequences of alcohol abuse is 1,2 billion Euros per annum [9]. Thomas Babor wrote recently: 'Concerning alcohol problems, France stands in an interesting position in the middle of Europe. Frenchmen drink all kinds of beverages and experiment with different patterns leading to various problems and hesitate between several responses: alcohol control policies to lower the provision of alcohol—as in the Anglo-Saxon world—and health education to reduce the demand, as in Mediterranean countries. This is why it is important that Frenchmen should disseminate better their experience'[10]. Following this advice, French specialists—alcoologues and addictologues as they call themselves—could contribute to help mankind on this everlasting problem: how to go on living, with the conscience of our mortal being, often struggling with bad living conditions and without making the acquaintance of dangerous toxic substances.