Project SMART

Minutes of the European Conference on Standardizing Measurement of Alcohol Troubles (SMART). Barcelona, 19 October 2010.

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The symposium of the conference devoted to alcohol survey methodology was held on 19th October 2010 in Barcelona. It brought together 31 participants from 19 European countries and even one presenter from Canada. Representatives of World Health Organization Head Quarters (WHO HQ) in Geneva and European Monitoring Centre for Drugs and Drug Abuse (EMCDDA) were also present.

After welcome made by Joan Colom on behalf of hosting institution Generalitat de Catalunya (GENCAT) and by Jacek Moskalewicz on behalf of the SMART project the floor was given to Dag Rekve (WHO HQ). He talked about the WHO Global Alcohol Strategy and role of research in monitoring its implementation.

Then, Ann Hope (Ireland) gave a brief presentation on an important product of the project which was review of the methodological literature on alcohol surveys. The review was assessed as a very comprehensive product which is currently ready for submission for publication.

Consecutive product of the project - EU Survey Review was presented by John Foster (UK). The review covered about 40 alcohol surveys carried out in more than 20 European countries.
The review benefited from the discussion which suggested replacement of research recommendations by summary and suggestions for future research.

Results of the pilot survey on alcohol consumption measures were presented by Janusz Sieroslawski (Poland). It was found that Beverage Specific Quantity Frequency (BSQF) method work well in all nine countries participating in the pilot offering in most countries higher estimates of annual alcohol consumption compared to Graduated Frequency and Last Occasion (LO) approach. Moreover, BSQF method offers similar estimations of annual frequency of drinking as generic Quantity Frequency method.

Results of the pilot survey which addressed standard instruments on alcohol abuse and dependency were shown by Ludwig Kraus (Germany). Three standard measures were used in the pilot: diagnostic instrument (M-CIDI) and screening instruments AUDIT and RAPS. The preliminary results showed that there was considerable variation across countries in the RAPS and AUDIT which raises questions on the pre selection cut-off points for these measures. More people were diagnosed using the M-CIDI than the 10% of heavy drinking in the sample. A comparison of the M-CIDI and AUDIT, showed good specificity (small number of false positives) however sensitivity was very low, in other words a large proportion were false negative. A comparison between M-CIDI and RAPS showed acceptable specificity (70.8%) and good sensitivity (89.6%). More detailed analysis is considered necessary. The conceptual mismatch between instruments raises the question of what is the purpose of this section of the questionnaire - screening or diagnosis?

The section on 'harm to others' presented by Jacek Moskalewicz as a result of someone drinking showed the proportion of known heavy drinkers were relatively similar across countries. However, those negatively affected differed across countries. The measures on impact of others drinking in the community showed as expected, the most common were of a less sever nature (annoyed, awaken at night) and the more serious (physical abused) less common. A factor analysis of the original 11 items were reduced to 9 items and showed three dimensions- factor one 'looking for trouble', factor two 'verbal level of abuse' and factor three 'public space'.

The section on public support for alcohol policies was presented by Jacek Moskalewicz. Public support for alcohol policies was measured using 12 statements. A factor analysis of the 12 items were reduced to 8 items which gave 3 dimensions- factor 1 (alcohol control measures), factor two (drink driving measures) and factor three (liberal attitudes). A question was raised as to whether the opposite phrasing of the items were also tested which could give different results.

Qualitative assessment of the SMART pilot instrument (Zsuzsanna Elekes and Alina Allaste) was undertaken through focus group discussions (18 focus groups) in six of the countries. The main purpose was to understand the cultural meaning of the major SMART concepts. People distinguished between alcohol consumption (any kind of alcohol use) and drinking (heavy drinking, social events) and the concept of what constitutes a 'drink' is more likely to be a social event or some mixed alcohol beverage like a cocktail. When speaking about a 'drink', people never see it as a unit alcohol and there are major differences across countries about the quantity of 'a drink'. Reporting on the frequency and quantity of drinking, people tended to see a year as too long, especially for those who do not regularly drink. In terms of quantity the 'usually' is what people report and rarely heavy drinking occasions. Drinking problems are associated with alcoholism and prevention measures for the general public are not seen as the solution. The social context such as better living conditions are seen as solutions to problems. People consider strict rules and regulations for reduce drinking among young people and to offer alternatives, thus change the motivation for drinking. Problems of drinking in the community are seen mainly as activity done by alcoholics.

The discussion that followed these presentations raised three main issues. Firstly, the translation issue where some words have no translation into certain languages, for example there is no German word for 'intoxication'. The conceptual choice of measuring problems was highlighted, diagnostic measures versus screening measures. Finally, the major challenge of how to measure a standard drink was discussed. Some argued that a standard drink is far from the reality of 10g drink. The market sizes are much bigger and stronger and so the possibility of underestimation is great. Some countries try to increase reliability by asking in the national glass sizes of the country and then translating into grams of alcohol later.

After discussing experiences of the pilot survey participants were divided into six working groups discussing consecutive sections of the questionnaire. Reports from the working groups were presented:

Measuring alcohol consumption (Kim Bloomfield):
With regard to question F-1, Janusz proposed deleting the frequency item as annual frequency estimated from the most frequently drunk beverage in from BSQF questions is very close to generic frequency question. Kim brought up the reason for having a generic frequency question, i.e., that one can then calculate annual consumption with it. The representative from Spain mentioned also that it can be used as a filter to determine drinking status.
There was also discussion of the phrasing drinking "even in small amounts". It was asked whether sips and trials should be included in the question according to WHO definitions of abstention. But others in the group were for keeping it in.
There was also discussion of collapsing frequency categories.
There was also a proposal to include a question about lifetime abstention which prompted a discussion of optional questions regarding starting and quitting drinking.
Another group member referred to the ECHIM health indicator project and the indicators used for it: alcohol-attributable deaths, total per capita consumption, hazardous drinking (women 20+ gr., men 40+ gr) and RSOD. The questionnaire should be in agreement with these indicators.

Drunkenness and RSOD (Allaman Allamani)
RSOD is based on quantity and frequency whereas drunkenness is a perception. Are they complementary? Also tolerance plays a role in drunkenness which can make people feel less drunk. Which of the two items is more clear to measure. Delete either AUD3 or the RSOD question. Time span: average of 3-6 hours for the occasion but a shorter period would be more critical. A context of RSOD was considered important.

Unrecorded consumption (Alina Allaste)
The group was satisfied with the questions. But there were a couple of problems: 1) people maybe are buying illegal alcohol without knowing it (but nothing can be done about this), 2) illegal activity: people don't admit to it. Maybe a question in the third person would be better. More questions were raised in the discussion, including an issue of competitive sources of information and existence of unrecorded supply in wine countries.

Alcohol abuse/dependence (Daniela Piontek)
Conceptual discussion: is it possible to have a measure of clinical dependence or should there be a broader measure? What is the purpose of the survey? Determine what you include. CIDI for dependence, abuse/general abuse should have another measure. Is DSM the gold standard? RE: AUDIT, RAPS, cut-offs would be different across countries. We cannot recommend an instrument since we have no real basis of psychometric testing. Depends on what you want to do, e.g., what population and what to measure. This is not a validation study. In the discussion it was suggested to add few more questions on individual harm in such life areas as health and finances. Ethical considerations of screening were also raised.

Harm to others (John Foster)
Harm to people who are known vs. harm to strangers. Relationship to heavy drinker. Take into account WHO global strategy. Technical report, page 64: other kinds of harm to be included, optionally. Frequency of harms vs. yes/no occurrence. In the discussion a distinction between nuisance problems and harm problems.

Public support (Ladislav Csemy)
Number of factors was reduced in a course of factor analysis. Those which remained consists in four consistent factors. No major revisions needed except for removing "random" from "random breath testing" and few more small revisions. The group recommends items 2, 4, 5, 6, 7, 8 and 11, some with modifications.

Two last presentations dealt with comparability of survey results across different countries. Kevin Shield presented a paper co-authored by Jürgen Rehm on prospects of standardizing alcohol consumption estimated in surveys by recorded or overall alcohol consumption. By modelling alcohol consumption using a gamma distribution, they developed new methodology to account for the undercoverage of alcohol consumption which was observed using other methodologies. This new method was developed as part of the ongoing Global Burden of Disease (GBD) Comparative Risk Assessment and the US Burden of Disease Study.

Robin Room in his presentation on cross-cultural applicability of alcohol survey showed a long tradition of comparative surveys reaching back to the 1960's. He recalled the WHO Community Response Study run in Zambia, Mexico, Scotland and California, in the 1970's. More recent traditions include WHO affiliated GENESIS study as well as World Mental Health Survey Initiative on mental health epidemiology which include also large section on alcohol. More recent studies include Nordic initiatives seven-country ECAS project, as well as EUROBAROMETER study sponsored by European Commission. There are also two studies targeting school children: ESPAD and HBSC.

Room pointed to methodological controversies in cross-national surveys including cultural incompatibility at the conceptual level, questions on translation, difficulties with diagnosis- based questions as well as dramatic fall in response rate. The presentation was followed by vivid discussion.

In the discussion on feasibility representative of all countries expressed their commitment to consider prospects of participating in a future comparative study and even to raise funds from national sources.

Jacek Moskalewicz in his wrap-up stressed great contribution of all participants which make us think of improvement of the questionnaire itself but also of expansion of methodological context of a potential European comparative alcohol survey.

Despite certain amount of skepticism there is a need of comparative cross-European surveys as EU becomes increasingly more integrated and its alcohol strategy is very likely to be elaborated and need monitoring.

A question of non-response rates should be challenged in different ways. Major issue is not a low respond rate but to what extent dropouts are random. Therefore, careful attention should be given to those who dropout from the sample. Their social demographic characteristics as well as reasons for non-response have to be analyzed.

It seems beyond capacity and mandate of the project to produce final complete questionnaire. The project should rather propose a number of core questions whose implementation should not take more than 15 minutes and a series of optional questions.

LIST OF PARTICIPANTS (STANDARDIZED SURVEY GROUP)
Allaman Allamani – ASF – Azienda, Italy
Airi-Alina Allaste – Institute for International Social Studies, Tallin Univ., Estonia
Sharon Arpa – Foundation for Social Welfare Services, Malta
Kim Bloomfield – Arhus University, Denmark
Elin k. Bye – SIRUS, Norway
Andrei Botescu – Romanian National Antidrug Agency, Romania
Joan Colom – Generalitat Catalunya, Spain
Ladislav Csemy – NIPH - National Inst. Public Health, Czech
Zsuzsanna Elekes – Corvinus University Budapest, Hungary
Fernanda Feijao – Institute on Drugs & Drug Addictions (IDT), Portugal
John Foster – UK
Lydia Gisle – Scientific Institute of Public Health, Belgium
Ann Hope – Health Service, Ireland
Oyvind Horverak – SIRUS, Norway
Marke Jaaskelainen – The National Institute for Health and Welfare, Finland
Thomas Karlsson – National Institute for Health and Welfare, Finland
Ludwig Kraus – IFT, Germany
Paul Lemmens – University of Maastricht, Holland
Jacek Moskalewicz – Institute of Psychiatry & Neurology, Poland
Daniela Piontek – IFT, Germany
Dag Rekve – WHO Headquarters
Robin Room – SORAD, Sweden
Emanuele Scafato – Istituto Superiore di Sanita’, Italy
Lidia Segura – Generalitat Catalunya, Spain
Kevin Shield – CAMPH, Canada
Janusz Sieroslawski – Institute of Psychiatry & Neurology, Poland
Hana Sovinova – National Institute of Public Health, Czech
Alfred Uhl – Anton Prosksch Institut (API), Austria
Momtchil Vassilev – National Centre for Addictions, Bulgaria
Julián Vicente – EMCDDA

Minutes of the Mini-Seminar on Cost Benefit Analysis of Alcohol Policy.
(Barcelona, Emporda, 18-19 October 2010).

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1. Introduction

Governance of alcohol policy can be understood as the way in which a society or organization steers itself with regard to managing alcohol and its consequent harm. The harm done by alcohol cannot be reduced to biological phenomena; psychological, social, historical and economic factors influence the harm done by alcohol to individuals and to those around them. In the research field, these and many other themes have been investigated; however, there is still a gap in the way they can be linked in more comprehensive approaches that have important implications for the governance of alcohol policy.

Alcohol policy does not occur in a vacuum. One example of this is the impact of economic recessions on health and on alcohol-related harm; another example is the influence of the value that consumers place on drinking. Costs and benefits as well as the value of health and human life must be considered integral to alcohol policy.

A number of questions can be raised about the role of cost-benefit analysis (CBA), which inform governments about where to invest in resources, to reduce harms, particularly, but not only, to others. CBA is not an easy topic and there are different views about measurements, modelling and about how to incorporate issues like the ones described above in the analysis; in this sense, CBA for alcohol policy is work in progress.

A group of experts on CBA and governance of alcohol policy, convened by the Department of Health of Catalonia, met in Barcelona and the surrounding Emporda, 18-19 October 2010, as part of the activities undertaken in the SMART project - "Standardizing Measurement of Alcohol-Related Troubles". Their aim was to discuss the importance of undertaking cost-benefit analyses and its value for alcohol policy. The meeting was an opportunity to review CBA's technical issues, such as measuring the value of pleasure and the value of pain, to consider lessons learnt from avoidable burden studies, to re-examine policy, when including harm to others in the analysis, and to account the implications of economy, inequities, and social welfare. The group of experts also reflected on issues such as the role of the alcohol industry, and how better to realign incentives at all levels and in all sectors that lead to health gain from reduced alcohol intake. The research field was also discussed, considering recommendations for future studies, for policy and for alternative approaches, and for thinking of additional policies that could help consumers make healthier choices.

2. What is cost benefit analysis and what are we trying to do?

Alcohol is not an ordinary commodity. Health itself, productivity, pleasure, social networks, conviviality, advertising, industrial production, drinking and driving, health systems, crime, and many other things influence the way societies deal with alcohol and the harm done by its use. There are private and external costs and benefits due to alcohol. What is the best and most comprehensive way to manage all of these factors?

Economic analysis through different methodologies have provided important knowledge about the social and economic costs of alcohol (social cost studies), health and economic impact of policy measures (cost- effectiveness analyses), and assessment of alcohol policies (cost-benefit methodologies). These methodologies have different analytical perspectives and CBA, for example, has a societal one, taking into consideration health and non health dimensions that can be explored using a matrix (Table 1) where cost and benefits are considered. Cost and benefits can be primarily internal or external as described in Table 2. Through pathways of analysis, CBA aims to measure consumption of market goods/services (unrelated to health), consumption of market and non-market goods and services (unrelated to health), and economic welfare, through increases or decreases in consumption of health-related services and goods, in production of non-health market and non-market goods and in savings, assets and capital formation as consequences of a certain alcohol policy (WHO, 2010).

Table 1. The matrix of cost and benefits


When undertaking CBA, each component should be considered in a comprehensive way. The implementation costs of brief interventions, for example, are not only related to the cost of training personal and providers' maintenance to deliver the interventions (WHO, 2009), there is also a complexity involving the implementation with effects over time. Further, in some of the CBA calculations and estimates the results do not refer to "real manageable money", while policy makers have real money to manage.

Although reductions in alcohol use are likely to reduce labour and productivity losses (Lye & Hirschberg,
2010), studies approaching these issues are scarce, and more data is needed on alcohol's impact on absenteeism and work performance (how a reduction in consumption would enable the person to return to work).

Table 2. Cost and benefits described by being primarily internal or external

Source: WHO, 2010
Note: The costs caused by harms to others are all external, including costs for crime, health care, social services, research, prevention, social security, unemployment and retirement benefits, labour lost by the victims of accidents and crime, and nonfinancial welfare costs (including fear of crime).

The most common unit for measuring healthy life years is the quality-adjusted life-year (QALY). Health- related QALY evaluations follow a standard tradition in health economics: state valuations for each alcohol- related condition, and a health state for other conditions. For example, if a year living with alcohol dependence is assessed as having a QALY value of 0.6, this means that 6 years of perfect health are worth
10 years of alcohol dependence (WHO, 2010). Ethical issues are present when one attributes a fixed value to life, assuming that this could be applied in different contexts, times and places. Research has suggested that QALY valuations vary according to many factors like individual's wealth, age and family status, as well as baseline levels for a given risk, changes in the risk, moral responsibility for it and whether it is public or private (WHO, 2010). These differences impact the decision of which monetary valuation of a QALY to use in the analyses. In real world relationships, when policy makers make the case for health they are asked for money valuations. So, if the aim is to move the debate to a different level, it is important to find a way where these issues can be addressed, preferably something that looks at changes over time.

Another component to be considered is the impact of changes in policies to the alcohol industry. If regulation policies are implemented, what would happen to the alcohol industry? When evaluating whether particular services are affected by particular policies, there are transitional costs to be considered. Major transitions could impact on alcohol industry jobs. However, there are opportunity costs associated with transition, and on balance there are potential gains, with other jobs created in the economy as a whole. Media/marketing practices also influence transitional costs. Marketing messages are more powerful than education and directly affect drinking initiation. Sponsorship is critically important here. What would happen if advertisements were banned? How much is the industry currently infringing people's liberties through marketing?

3. Counting in alcohol's harm to others

The harms caused by someone's drinking to others can be quite small, quite severe, or even life- threatening, depending on the type of burden focused. Harms can vary from a spoiled holiday celebration, physical abuse, a child left stranded when a drinking parent fails to pick them up, or people's fears of being injured or even killed.

The reduced wellbeing and health status for those with heavy drinkers in their lives is under researched. Casswell et al. (submitted for publication) created an index of exposure to heavy drinking. The greater that people were exposed to a heavy drinker in their lives, the lower they reported satisfaction and well-being in life. Heavy drinking was defined by the respondents and the relationships found were similar to those reported on studies about exposure to people with disabilities. Conventional cost of alcohol studies mostly measure the costs to the drinker and to governments. Adding in costs to others matters, as, at least in Australia, this doubled the cost estimates (Room et al., 2010).

4. The avoidable cost of alcohol

Australian and Canadian studies have provided important evidence about the avoidable costs of alcohol to society. For example, in Canada, Rehm et al. (2008) reported that by implementing effective policies some portion of alcohol-attributable burden and its costs could be avoided. Under conservative assumptions and using interventions which are generally supported by public opinion, one billion dollars per year could be saved (7% of the total social cost). The largest impact would come from comprehensive interventions affecting the overall level of drinking such as increased implementation of brief interventions and increased taxation.

5. Modelling the costs and benefits of increasing alcohol prices

What can impact alcohol policy? How do changes to prices affect consumption in the population? And how do changes to the consumption of alcohol affect outcomes?

The Sheffield Alcohol Policy Model (Purshouse et al., 2009) is the closest approach to a cost-benefit analysis and could supply data on implementation costs, health and welfare costs, costs to industry, labour and productivity losses, costs to pleasure and non-financial welfare losses. The overall concept of a model developed by the University of Sheffield is the distribution of prices, the distribution of patterns and the distributions of alcohol attributable outcomes. It is a pragmatic approach modelling the impact of feasible policy options.

Estimates found that a 10% price rise would reduce alcohol consumption by 4% and premature deaths by
13%, with a total value of harm reduction of ?5.9 billion over 10 years. When prices rose, consumers spent more on alcohol, even though they reduced their drinking. A 10% price rise was associated with an overall increased spend of €1.2 billion per annum, some 5.3% of the total consumer spend on alcohol.

6. What is the value of a human life?

What economists define as "value" may not reflect people's feelings and beliefs in the real world, or what they might consider gains or losses about their health. One concept introduced in economic analysis is the value of a statistical life (VSL) that can be thought of as a convenient way to summarize the value of small reductions in mortality risks (Suhrcke et al, 2005). It is not meant to be applied to the value of saving the life of an identified person (i.e., the value of changing the risk of mortality from one to zero). In order to study this concept researchers have investigated how much individuals are willing to pay for an extra year of life, observing wealth-risk trade off and using direct surveys. It is assumed that people tend to maximize
'utility' subject to budget constraints, and that life is a trade-off between fun ('consumption') and risk ('mortality risk'). So, the idea behind willingness to pay analyses is that people want to maximize happiness. Different values and different individuals lead to different models. There is not a stable value for life to be incorporated in the model. Different values for different risks in different countries should be discussed.

7. Mitigating the impact of economic recessions on the harm done by alcohol

Economic recessions lead to job losses that can impact on health. Stuckler et al. (2009) investigated how economic changes have affected mortality rates over the past three decades in countries members of the Organization for Economic Cooperation and Development (OECD), and found that a more than 3% increase in unemployment had a greater effect on suicides at ages younger than 65 years and deaths from alcohol use disorders, supporting the notion that short-term negative effects of unemployment mainly affect psychological distress. Moreover, younger populations were more sensitive to the negative health effects of rising unemployment than were those older than 60 years.

Stuckler et al. (2010) also found that active labour programmes that kept and reintegrated workers in jobs could mitigate some of the adverse health effects of economic downturns. Increased overall social welfare spending was significantly associated with reduced mortality from diseases related to social circumstances (such as alcohol related deaths), even though health care spending was not. More research is needed to understand the effect of different types of social spending and the implications of economic policies for health.

8. Discussion - implications for the governance of alcohol policy

What would a policy maker expect from researchers in terms of translating evidence and technologies that could help to improve policy decisions and change behaviours? Is it more important to a policy maker to have satisfied citizens or to save some Euros? Or, a mix of both? One could say that a good start in terms of research could be by providing a comprehensive tool to help identify the costs and benefits of specific interventions and the political consequences of the policy implementation, taking into account issues like the value that consumers place on drinking and the spending costs needed to manage the alcohol-related harms that will appear.

CBAs have demonstrated to be an informative tool to offer to policy makers. However, important constraints of this type of analysis can be identified. An example is when economists talk about the value of a statistical life. How far are we from real life relationships? People attribute different meanings to the way they drink according to the cultural background they have. In the same way, people can react differently to an increase in alcohol prices, changing their patterns of drinking accordingly. Pleasure and happiness are concepts with different meanings that are also culturally influenced.

To the extent that pleasure can be translated into a utility/expenditure, one could consider that it is already included in CBA. However, the pleasure people get from drinking goes beyond what they pay for it. Increased prices decrease consumers surplus, a cost that considers pleasure as a stable item (the same bottle of wine will always provide the same pleasure). But from a psychological point of view this is not true; people can have different pleasures from different beverage types. Pleasure in CBA is measured as a cost, but in real life it is not tangible. Alcohol is not a common good and from the individual side, pleasure could be considered as not a business of the state, but rather a private affair. The role of the state could be considered as preventing harm. Further, alcohol is a drug and an intoxicant. The relationship between alcohol and pleasure is complex as people may enjoy its use, for example in the evening, but regret it the following morning. People's pleasure could be enhanced by getting them to drink less; however, more research is needed on this issue. How do we shift the cultural perception of pleasure?

Alcohol policies are consequences of historical, economic, social, and cultural factors. There are costs and benefits from governments' perspectives and from the society perspective. Science has the role to inform the public debate, translating research evidence into technical decisions. Analysis should not be reductionist. For example, morbidity is very important, but is just one point of the equation. Longitudinal approaches are also necessary, seeing the phenomena from different perspectives.

The starting point of the public debate about alcohol policy is still, much of the time framed as a negative, individualized and restrictive. However, alcohol is not only an issue of individual level; it also has to do with societal perceptions and interactions. Individualizing approaches can have the negative consequence of labelling people. Apart from dubious effectiveness, these types of policy contribute to social inequity, as the stigmatized ones will be the poorer drinkers (Room, 2005). Aggregate-level interventions have the great advantage of not singling people out, as well as being effective. When moving the focus to the harm caused to others, there is a potential risk of stigmatizing people who drink, although this could be considered a desirable outcome, as with drink driving. To cost elements of stigma is a challenge for economists.

One could argue that different perspectives using more positive and comprehensive narratives that demystify moral perspectives and that account for the benefits of drinking as well as the costs, could attract a better social support to change policy into more cost-effective approaches that support healthier behaviours. One of the benefits of this approach would be to provide an environment in which people are freer to make healthier choices.

10. References

Casswell S, You RQ, Huckle T. Alcohol's harm to others: reduced wellbeing and health status for those with heavy drinkers in their lives. Submitted for publication

Lye J and Hirschberg J. Alcohol consumption and human capital: a retrospective study of the literature. Journal of Economic Surveys 2010; 24: 2, 309-338. doi: 10.1111/j.1467-6419.2009.00616.x

Purshouse R, Brennan A, Latimer N, Meng Y, Rafia R, Jackson R, Meier P. Modelling to assess the effectiveness and cost-effectiveness of public health related strategies and interventions to reduce alcohol attributable harm in England using the Sheffield Alcohol Policy Model version 2.0. Report to the NICE Public Health Programme Dvelopment Group, 2009

Rehm J, Gnam WH, Popova S, Patra J, Sarnocinska-Hart A. Avoidable cost of alcohol abuse in Canada 2002. Report, 2008

Room R, Ferris J, Laslett AM, Livingston M, Mugavin J, Wilkinson C. The drinker's effect on the social environment: a conceptual framework for studying alcohol's harm to others. International Journal of Environmental Research and Public Health 2010; 7: 1855-1871. doi: 10.3390/ijerph7041855

Room R. Stigma, social inequality and alcohol and drug use. Drug and Alcohol Review 2005; 24: 143-155

Suhrcke M, McKee M, Arce RS, Tsolova S, Mortensen, J. The contribution of health to the economy in the
European Union. Luxembourg: Office for Official Publications of the European Communities, 2005

Stuckler D, Basu S, Suhrcke M, Coutts A, McKee M. The public health effect of economic crises and alternative policy responses in Europe: an empirical analysis. Lancet 2009; 374: 315-23. doi: 10.1016/S0140-6736(09)61124-7

Stuckler D, Basu S, McKee M. Budget crises, health, and social welfare programmes. BMJ 2010; 341: 77-79

World Health Organization (WHO). Evidence for the effectiveness and cost-effectiveness of interventions to reduce alcohol-related harm. WHO Regional Office for Europe, Denmark 2009

World Health Organization (WHO). Best practice in estimating the costs of alcohol - Recommendations for future studies. WHO Regional Office for Europe, Denmark 2010

11. Acknowledgements

We thank the European Commission and Generalitat de Catalunya (GENCAT) for co-financing the SMART
project (Standardizing Measurement of Alcohol-Related Troubles). We thank GENCAT for hosting the "Expert workshop on cost-benefit analyses and governance of alcohol policy". Michaela Bitarello do Amaral Sabadini prepared the notes of the meeting and Peter Anderson edited them.

12. List of Participants

Professor Peter Anderson, Catalonia, Spain, Public Health Consultant
Ben Baumberg, United Kingdom, LSE
Dr. Michaella Bitarello do Amaral Sabadini, Catalonia, Spain, Barcelona University
Dr. Peter Burge, United Kingdom, RAND Europe
Professor Sally Casswell, New Zealand, Massey University
Dr. Dan Chisholm, WHO
Dr. Joan Colom, Catalonia, Spain, Generalitat Catalunya
Dr. Brian Easton, New Zealand Independent Scholar
Dr. Antoni Gual Catalonia, Spain, Fundació Clinic
Dr. Priscilla Hunt, United Kingdom, RAND Europe
Dr. Eva Jané Llopis, Catalonia, Spain, World Economic Forum
Dr. Johan Jarl, Sweden, Lund University
Silvia Matrai Catalonia, Spain, Fundació Clinic
Professor Petra Meier, United Kingdom, SCHARR, University of Sheffield
Esa Osterberg, Finland, THL
Dr. Svetlana Popova, Canada, CAMH / University of Toronto
Dr. Robin Purhouse, United Kingdom, University of Sheffield
Professor Robin Room, Australia, Turning Point
Dr. Kevin Shield, Canada, CAMH / Univerity of Toronto
Dr. David Stuckler, United Kingdom, Oxford Universtiy
Professor Marc Suhrcke, United Kingdom, University of East Anglia

SMART Project's Meeting in Conjunction with the KBS Annual Symposium
(Lausanne, 1 June 2010).

DRAFT MINUTES        < PDF document >

1. Introduction
The meeting was conveyed in conjunction with the KBS Annual Symposium held in Lausanne on 31 May - 4 June 2010. It was held as a regular workshop scheduled in the KBS Symposium programme on Tuesday 17:15 till 19:00 and was eventually prolonged until 19:30. The workshop was attended by eight participants representing six out of ten participating countries, including Estonia, Finland, Germany, Hungary, Italy and Poland (list of participants attached).

The agenda (attached) was adopted. It covered recent news, progress up-to-date in recent activities in both qualitative and quantitative approaches, publications and coming alcohol conference in Madrid which offers an opportunity to disseminate results of our study.

Extension of the project
Of major concern was a question of extension of the project by two months as a formal end of the project is 31 August 2010 which implies that the project's final European conference will have to be held during high summer time season. Such a timing may reduce participation of important experts to a very low level, affecting therefore dissemination work package of the project and in particular consensus seeking process towards standardisation of measurement of alcohol consumption and related problems at the EU level. First request for extension was sent early this year and draft amendment submitted in March 2010. It has not been approved yet despite numerous communications including a face-to-face meeting with a new project's officer in Luxembourg.
In 20 month of project's life, it has got three consecutive project's officers at Executive Agency on Health and Consumers (EAHC). Since April this year our project's officer is Hristina Mileva who is very co-operative doing her best to get approval of the extension.

Tentatively, three alternative dates of the final EU conference to disseminate SMART products were adopted:

• 30-31 August 2010
• 18-19 October 2010
• 25-26 October 2010

It was agreed that a gender ratio should be taken under consideration while selecting participants of the conference.

Co-ordination SMART-EHIS
Jacek Moskalewicz reported about his meeting in Brussels with Hél?ne MIMILIDIS from Belgian National Institute of Public Health which is charge of drafting alcohol questions for European Health Interview Survey (EHIS). EHIS is co-ordinated by EUROSTAT and by 2014 it will become obligatory for all Member States. Current draft has three questions only focusing solely on alcohol consumption:

• consumption questions only
• generic frequency taken from AUDIT
• average consumption each day from Monday to Sunday
• frequency 6+ drinks

No attempts are foreseen to estimate annual consumption of those questions. In July an expert meeting will be organised to discuss details of the alcohol section of EHIS. Some experts from the SMART project are likely to be invited. Final version of the alcohol section of EHIS is expected by October 2010.

Irish national survey
In June, a national alcohol survey will be held in Ireland based on experiences of the SMART pilot survey. Ann Hope circulated her draft questionnaire requesting comments. It was difficult to comment as analyses of the SMART pilot survey was not completed. Nevertheless, it was accepted that Jacek Moskalewicz and Janusz Sieroslawski will draft comments and send them to assist Ann Hope in her task.

Progress in qualitative work
All countries but Spain provided their country reports from the pilot survey. Reports summarised pilot experiences, including qualitative assessment of the questionnaire and its individual sections made by respondents and interviewers right after completion of the interview.
Five countries - Czech Republic, Estonia, Hungary, Italy, Poland and UK completed focus group discussions on relevance of the basic concepts used in the questionnaire. All but Czech Republic provided the focus group reports.
As lack of focus group data from three countries - Finland, Germany and Spain would mean a serious gap for the project both content- and financial-wise Finland and Germany will consider possibilities to carry out focus group discussions and provide relevant reports by June. No declaration was given from Spain as its representative was not present.
Interest in further comparative analyses of qualitative data was confirmed by Zsuzsanna Elekes and Jacek Moskalewicz; commitment with this regard had been earlier expressed by Alina Alaste and Betsy Thom.

Progress in quantitative analyses
Data base consisting of about 2000 questionnaires from nine countries is completed and cleaned. Utility of three consumption measures was tested. Beverage-specific quantity-frequency (BSQF) measure proved to estimate significantly higher level of annual consumption compared to graduated frequency (GF) and last occasion (LO) measures. BSQF was superior in this regard in six out of nine countries. In Estonia, Finland and Poland LO measure gave slightly higher estimates compared to BSQF but that difference was not statistically significant. BSQF offered also relatively good prediction of alcohol abuse and dependency as measured by DSM-IV questions, AUDIT and RAPS. All ROC curves indicated good specificity and sensitivity with area under curve surpassing always 0.7. High predictive value of BSQF for AUDIT scores looks encouraging but it may be related to the fact that AUDIT contains consumption measures similar to BSQF. Therefore, further analyses are planned to control for AUDIT's consumption questions. Further analyses of "outliers" are also intended to consider their impact on final results. Removal of outlier cases from the data base may also be considered.

Factor analyses were carried out to understand better a nature of community problems and meaning of support for different alcohol policy measures. Number of items in both areas was then substantially reduced.

Publication of research papers
It was confirmed that first results of the project will be published in the Open Addiction Journal as a "Hot Topic Supplement". At this stage the following articles are considered:

• Literature review on drinking survey methodologies
• Review of drinking survey experiences across EU/EEA countries
• Application of the standardised alcohol survey methodology in nine EU countries - results of the pilot survey
• Meaning of basic concepts applied in alcohol surveys - results of the focus group discussions from nine EU countries
• Literature review on cost-benefit analyses of alcohol policies and proposal of standardised methodology
• Literature review on public support for alcohol policies

The papers should be submitted consecutively, between July and October this year as to be published by the end of year.


Alcohol conference in Madrid

On 14-16 June 2010 a conference will be held in Madrid: "WHO meeting of National Counterparts for Alcohol Policy in the WHO European Region and the AMPHORA Expert meeting". Persons responsible for co-operation with WHO as regards alcohol will attend from over 40 countries in addition to dozen or so researchers from the largest alcohol research project in EU. Jacek Moskalewicz was invited to give a half-an hour presentation "What does SMART project have to say about standardised methodologies for surveys?". The presentation should contribute to dissemination package of the project. It was agreed that the presentation will focus on methodological aspects of the pilot survey.


ATTACHMENT

SMART PROJECT'S MEETING IN CONJUNCTION WITH THE KBS ANNUAL SYMPOSIUM. LAUSANNE 1 JUNE 2010

LIST OF PARTICIPANTS:
Estonia: Maarja Kobin
Finland: Esa Õsterberg and Thomas Karlsson
Germany: Ludwig Kraus
Hungary: Zsuzsanna Eleles
Italy: Allaman Allamani
Poland: Jacek Moskalewicz and Janusz Sieroslawski


SMART PROJECT'S MEETING IN CONJUNCTION WITH THE KBS ANNUAL SYMPOSIUM. LAUSANNE 1 JUNE 2010

AGENDA
ADOPTING AGENDA 17:15 - 17:20
RECENT NEWS 17:20 - 17:40
 EAHC: AMENDMENT STILL PEDNING
EUROPEAN HEALTH INTERVIEW SURVEY (EHIS)
IRISH NATIONAL SURVEY 17:40 - 17:50
PROGRESS TO DATE IN QUALITATIVE REPORTS 17:50 - 18:10
PROGRESS TO DATE IN QUANTITATIVE 18:10-18:50
PUBLICATION OPEN ADDICTION JOURNAL 18:50-19:00
MADRID CONFERENCE 19:00-19:15

SMART: MEETING IN BARCELONA (Barcelona, 29-30 March 2010)

MINUTES OF THE MEETING      < PDF document >

Monday 29th. March:

The morning sessions were devoted to a general discussion how the survey was received and implemented in individual countries. Jacek presented brief quantitative summary. The pilot survey was completed in nine participating countries and the data entered except for 12 last interviews from Germany. The questionnaire was in general well received. However, 13% of the interviewers admitted that it was difficult to convince respondents to participate. This varied from country to country. It seems that respondents from the new EU countries were more difficult to convince to participate in the survey than respondent from the old EU. Most countries applied face to face paper and pencil approach but at least two used CAPI which worked well too.

The data base consisted of 1877 interviews which gives close to 210 interviews per country. Mean and median length of the interview was 35 minutes and only 10% of respondents considered it too long. Taking under consideration that the pilot questionnaire had to be much longer compared to its final version it may be estimated that the average length of the final questionnaire will last not longer than 20 minutes. Vast majority of respondents found the questionnaire clear and well below 10% only considered it fairly unclear or very unclear. Beverage-specific quantity-frequency (BSQF) approach alongside with last occasion (LO) approach were found much easier and better describing respondent's consumption pattern compared to Graduated Frequency (GF). As for individual problems measures RAPS4 and DSM-4 questions were considered much easier compared to AUDIT. Only 6% of respondent found RAPS4 most difficult to respond compared to two other measures (DSM - 15%, AUDIT - 24%).

Representatives of individual countries offered their qualitative feedback and assessments. A number of issues arose for discussion:

• Some countries had found difficulty persuading people to participate. This may have been because of suspicion of authorities/ use of the research, people feeling 'over-researched' or the subject of the survey (alcohol). Suspicion of research seemed to be a feature in 'new' EU countries.
• There was quite a difference between countries in length of time to complete the interview - a mean of 23 minutes in Spain and 45 minutes in the Czech Republic. Reasons for the difference were unclear.
• There were some problems with translation of some sections and concepts. This recurred as an issue later on as well. Countries will look at this carefully and some data may have to be excluded.
• Concepts such as 'drunkenness' and 'illegal' production and 'unrecorded' consumption were discussed throughout the meeting and clearly presented problems in cross national research. In relation to 'unrecorded consumption', it was mentioned that this is useful in getting an estimate of the accuracy of population statistics/ market movements/ taxation but not so useful for measuring individual drinking patterns. So, we need to be clear about the purpose of this question. These issues will be examined further in the qualitative write up of the data.
• Researchers described their research procedures and methods, indicating a considerable variation in the way the data had been collected - 'random walks', snowballing, 'networks' of friends and acquaintances etc. Heavy drinkers were also recruited in different ways. However, all countries complied with the guidelines regarding quotas - gender and age groups.
• It was emphasised in this session and throughout that the country samples could not be regarded as representative and that the data could be used only for examining optimum measurement tools and procedures etc. It was not suitable for a comparative analysis of consumption patterns.
• Questions of cultural sensitivities were raised e.g. in Hungary 'drinking' means heavy drinking, especially for women, possibly making them reluctant to participate; policy questions were not well received in some cases as in some countries drinking is still seen as a personal issue; etc. There are cultural issues around measuring 'drinking occasions' and 'heavy drinking' e.g. does 6 drinks measure a level of 'risk'? It was suggested that we might look at drinking patterns across Europe rather than within culture - broken down by characteristics such as age/drinking patterns/ other factors.
• It was reported by several participants that the GF was not liked while he BSQF was generally accepted by most as performing well across Europe.
• The question of how meaningful it is to use the concept a 'standard drink' was raised as in most countries a concept of 'standard drink' sounds artificial. It was suggested that different levels of measurement might be needed.
• It was questioned whether 12 months was too long a period to expect good recall (but everyone did not agree on this).

Two afternoon sessions were given over to presentation and discussion of some preliminary quantitative findings from the questionnaires, led by Janusz as regards consumption and three major problems scales. He explained how he had conducted necessary conversions to categorise the data. His presentation and discussion that followed indicated the following:

• There may still be coding problems and each country needs to clean and check their data.
• There are big differences between countries in results achieved so far which can partially be distributed to different sampling procedures. Nevertheless, BSQF does give the highest estimate of annual consumption for the whole nine-country sample while LO and GF seem to be inferior with this regard. There are, however, three exceptions namely in Estonia, Finland and Poland where LO offers slightly higher estimates.
• In consequence, standard deviation of annual consumption is clearly higher in BSQF which may suggest that that method covers the widest spectrum of consumption levels.
• BSQF shows also the highest dispersion around the median as measured by the range between the first and the third quartiles.
• Preliminary analysis of variance suggests that BSQF approach is more universal while LO method is more country-specific.
• Three problem measures applied, namely DSM-4 questions, AUDIT and RAPS have not given consistent results within individual countries.
• To assess a predictive value of different consumption measures as regards alcohol problems a decision tree analysis was applied controlling for country. Preliminary results suggest that the best prediction is offered by two consumption measures: GF in combination with AUDIT allocating correctly 94% of "normal" drinkers (AUDIT score lower than 8) and 65% hazardous drinkers followed by BSQF: 86% of "normal" drinkers and 75% of hazardous drinkers. A utility of AUDIT in this context has its limitations, however, as AUDIT itself has two items measuring consumption which to some extent implies assessing predictive value of one consumption measure by another consumption measure. If AUDIT is put aside, a predictive value of both GF and BSQF gives decent results with RAPS: 85% "sensitivity" versus 55% "specificity" and 85% versus 52%, respectively. A predictive value of LO for all three problem scales is much weaker and a predictive value of all consumption measures as regards DSM- 4 questions is clearly poorer.
• ROC curves calculated for all three consumption measures on AUDIT showed very similar curves for GF and BSQF and much "worse" curve as regards sensitivity and specificity of LO. This relation holds for all gender and age groups except for youngest respondents (18-24 years) where all three consumption measures show almost identical ROC curve on AUDIT.
• Question was asked whether an analysis should be done without the 'extra' heavy drinkers.
• Could differences in sample size between countries be a factor in the differences found between countries regarding the measures?
• The usability of DSM in general population samples was raised.
• The point was also made that we have no external criteria - no 'gold standard' against which to measure and decide which is the best instrument.
• Next steps in data analyses were suggested including application of item response theory

Last afternoon session discussed preliminary results of sections on individual and community problems. Small corrections were proposed in individual questions which in general measured what they were intended to measure. Factor analysis of attitudes towards alcohol policy showed four factors: alcohol availability control (4 items), advertising control (2 items), drunken driving (two items) and liberal attitude (3 items). Reduction of a number of items was discussed.



Tuesday 30th, March

The morning sessions were devoted to more in-depth examination of the different measures; discussions were held as a whole group and in smaller working groups.

Group reports

Group on consumption measures (Ladislaw Csemy, Esa Österberg - rapporteur, Lidia Segura, Janusz Sieroslawski)

We first wanted to look at conclusions that could be made based on the analysis made thus far, and what kind of analysis has to be made in the future. It was noted that similar questions are not necessarily similar in all countries, and that the effects of rotation should be studied. Last occasion questions seem not to be working in Spain which calls for checking the data also in other countries. The question was then raised, what kind of variables could be used in cross-checking. Differences in sampling techniques should be taken into account as well as translation process because of different cultural meanings. Checking the data was seen important because it could save some respondents who otherwise were to be eliminated because their answers were not logically acceptable. Each country should do a consistence control for their own dataset and proposals for deleting some cases and propose some rules how to treat them.

Heavy drinkers and normal drinkers should be analysed separately. Differences of results of heavy drinkers with regard to consumption level according to different methods were felt to be smaller than with regard to normal drinkers. Older population have more regular drinking habits and therefore QF gives for them higher consumption level than last occasion method whereas among younger people the three consumption measurement methods give more similar results. The time of the last occasion should be checked to reveal if it was a time of a special event (New Years Eve; Christmas). For instance in Poland last occasion usually gives the highest consumption estimate, this time the lowest. Holidays have different effects because Czech people for instance are clearly more secular compared to still religious Polish people.

Also algorithms behind has an importance like an assumption as regards the number of days in a year if people have been drinking almost every day. It was also discussed to use data from different studies to control SMART pilot study data.

At the moment the last occasion method seems to be the worst one but after checking data for internal consistence these result may change.

Age should be used more as a controlling variable. The question was also raised if countries could be used more as variable in order to reveal cultural differences.
We were reminded that our basic task in SMART project is to find the best method for all countries. Janusz reminded us that the criteria for finding the best method were dealt in previous meeting (coverage; comparison to recorded consumption figures). In SMAR pilot study the consumption figure is per drinker 15+ (not per capita nor per 15+). The European Health Survey 2013 puts pressure on SMART project to find the best instrument.



Group on problems section (John Foster - rapporteur, Antoni Gual, Ann Hope, Ludwig Kraus)

It was recommended to identify inconsistencies across individual items - with particular reference to ordering of questionnaires. There are a number of items that are repeated- "eg remorse after drinking." Establish what is the "gold standard"/reference point by which to make comparisons.

A question was discussed of forthcoming DSM-V in 2011-2012 probably relating to wording of abuse criteria.

Following questions were discussed as regards AUDIT/DSM/RAPS:

• Correlate data from first 2 AUDIT items with BSQF, AUDIT 3 with RSOD, AUDIT Dependency subscale with DSM, AUDIT 5,6, 7, 8 with RAPS.
• Identify hazardous, harmful drinkers, risky drinkers?
• There is scope for repetition- elimination of items?
• Compare: Order of severity items- across countries after plotting of curves.

Discussion on section on Adverse Social Consequences (ASC) raised number of questions:

• Is there an overlap with DSM-IV abuse items?
• Is there an overlap with AUDIT- 7,8,9,10?- is AUDIT a gold-standard for alcohol-related problems?
• Does ASC provide additional data - are there gender and age effects that justify its inclusion in addition to AUDIT?

As for the section on heavy drinkers (HD) in your life opinion was expressed whether this relates to alcohol-related social problems? Context is doubtful. Does this fit within the aims of the SMART study? There is likely to be a link to community problems section (COM). Recommend - do not use HD items.

Suggestions for Further Analysis:

• Item response.
• Factor analysis using consequence data.
• Cross country analysis.
• Separate effects re heavy drinkers v others - i.e consumption levels.
• Factor Analysis COM data.
• General elimination of weak items throughout.- insufficiently exact e.g what is a family problem- e.g severity? - time scale, attributable to alcohol?

Group on sections on community problems (COM), alcohol policy (AP) and socio-demographic (Alina Allaste, Allaman Allamani, Kaisa Kaha, Jacek Moskalewicz, Esa Österberg, Betsy Thom - rapporteur)

The cultural sensitivity of these questions was raised again and it was suggested that some questions could be added on the positive aspects of drinking. Finnish examples (6 questions) were suggested as a model. These questions could be an option for each country.

It was agreed that the COM questions need to be refined. COM 2/ 4/ 5 are very similar and can be reduced. Factor analysis could be undertaken to see which questions might be eliminated.

Factor analysis would also be useful on the AP questions. Agreement was reached regarding the omission of some items.

Socio-demographic: Apart from adding 'separated' to the 'divorced' category, this was felt to be OK as it stands.


The afternoon session focussed on planning what needed to be done now. The suggestions included:

1. Each country should examine their data for consistency - but we need some criteria for deciding on consistency. Countries should detect any possible errors in their own data set; clean their own data (looking for "wrong cases", "checking for reasons for outliers." Is there a defect in the questionnaire wording- translation?

2. We need to end up with the same data set (co-ordinated by Janusz) for everyone to share.

3. The above should be completed in April.

4. Final versions of all country reports should be submitted by mid-April.

5. During May, more sophisticated analyses will be conducted for the meeting in June at KBS.

6. The KBS meeting will be used to review the situation and suggest the next steps.

7. The final questionnaire and report will need to be completed well before end August (unless a project extension is granted)

8. The final conference will take place at the end of August (unless an extension is granted)

9. Publication of results in a journal special issue. Drafts to be submitted early autumn and hopefully published by end December 2010. Following division of labour was agreed:

• Elaboration of Kim Bloomfield's paper Methodology of survey research. Ann to collaborate.
• Review of European surveys. Janusz and John to collaborate.
• Literature review - Public support for alcohol policy. Jacek, Esa and Thomas to collaborate
• Methodology paper from this survey. Janusz, Ludwig and Antoni to collaborate
• Qualitative data/ focus groups - concepts: Zsuzsanna, Airi-Alina, Kaisa and Betsy to collaborate.

Notes by Betsy supplemented by Esa, John and Jacek

SMART Meeting (Florence, 28-29 September 2009)

MINUTES OF THE MEETING       < PDF DOCUMENT >

Main Points from SMART Meeting- Florence 28-29 September 2009

Delegates present: Airi-Alina Allaste, (AAA) (Estonia), Kim Bloomfield (KB) (project's expert), Ladislaw Csemy (LC) and Hana Savinova (HS)(Czech Republic), Zsuzsanna Elekes (ZE) (Hungary), John Foster (JF) (UK), ( Ann Hope (AH) (Ireland), Esa Österberg (EO) (Finland), Daniela Piontek (DP) (Germany), Jacek Moskalewicz (JM) and Janusz Sieroslawski (JS) (Poland), Lidia Segura,(LS) (Spain), Allaman Allamani (AA) and Karin Panzer (KP) (Italy)

Apologies: Peter Anderson (project's expert), Joan Colom and Antoni Gual (Spain), Ludwig Kraus (Germany), Betsy Thom (UK),

Main agenda items included discussion of a literature review on survey methodology prepared by KB, EU surveys review report by JS and then extensive discussion on consecutive parts of the pilot questionnaire, implementation plan, focus group themes to assess utility of the survey instrument, first proposal of statistical analyses and finally administrative and financial issues.

Literature Review
Literature review was discussed and felt to be very helpful to the SMART project. The main concerns were around table 3 on recommended drinking limits as there appeared to be a number of inaccuracies. Delegates were requested to email updated information to Kim.
It was also felt that the review should include some discussion of the RAPS. Finally KB stated that the SMART team needed to consider a unique angle for this review with a view to publication.

Survey Review
The latest draft of this was presented by JS. This will be distributed to the delegates for further comments. It was felt that attempts should be made to check that the information/interpretation is correct. If checking is not possible a rider with this regard should be added to the report.

There is still some missing data from Sweden and Denmark amongst others (EO will attempt to obtain this).

KB suggested that perhaps some of the GENACIS data in Lausanne could be used. Finally before the report was approved there needed to be a number of collective recommendations made.

On the final day KB suggested that there was a need for more tables and less text- e.g. in relation to what country had used which approach and measures of dependence and abuse. A good approach would be to focus upon areas where confusion exist- e.g. P13 Table 4- Spain, Holland, Estonia etc.
Each country was asked to read the report and feedback if there are any obvious errors.


Pilot survey instrument

Questions on Alcohol Consumption and Drinking Context:
JS led this discussion. There was a feeling that there was a need to avoid interviewer fatigue and confusion and it was agreed to drop questions relating to the last 30 days . However it was also decided to introduce a filter question - along the lines of "Have you drunk any of the following during the past 12 months." The word "alcohol" will not be used as this is culturally specific in some countries e.g. wine is not considered alcohol. JS will distribute the finalised version shortly. Following the sending of the final version, when training the interviewers please ensure that the consumptions methods (i.e. graduated frequency or last occasion) are presented in random order.

Unrecorded Consumption
Following discussion a number of suggestions were made to shorten this part of the questionnaire and to ensure consistency between purchase and consumption. JS will distribute final version shortly

Heavy Consumers and Problems
The state of play following the Copenhagen meeting was fed back. After some discussion it was decided to keep CIDI dependence scale but to amalgamate the CIDI abuse items into a social problems section of the questionnaire. LS questioned the veracity of using DSM-IV related items for a general population survey. Thus the RAPS and AUDIT (full version) have been added to this part of the measure to test their psychometric effects. When the survey is administered these should be presented in random order.
The drunkenness items were accepted though the question should be worded to avoid a double negative. "Binge drinking" was also accepted in principle, though for RSOD_2 it was suggested that time intervals were used.
"Alcohol Harm to Others"- AH raised concerns about altering the items from Robin Room's questionnaire. Items H1-11 will be included in the final version, and a number of "Attitudes to Alcohol Policy" questions will be included in the final version.
AH will circulate the final version shortly.

Implementation of the Pilot Study
All interviews will be face to face and interviewers will have to be trained and a protocol will be sent to ensure consistency.
It will be necessary to keep some record of the numbers of refusals (e.g. record gender and make an estimate of age). The pilot survey will apply to individuals who have drunk within the past 12 months only and a filter question will be employed. The aim is to perform a household study (i.e. knock on doors) and for the main study recruit 180 individuals- (90 from urban areas, 90 from non- urban areas). The aim is a 50% gender split in the following age bands 18-29-30-49, 50-74 (these categories may be changed in the final protocol.) Again if viable these should be related to census data so that it reflects the age and gender spilt of the general population. If possible there should be a class/education spread.
There will also be a survey of a further 20 heavy drinkers (10 urban/10 non-urban)- these can either be snowballed from the original sample or taken from alcohol treatment centres or similar. The final protocol will define how "heavy drinker" is to be assessed.
Re-Qualitative data: A protocol will be developed to add this and a number of semi-structured questions will be asked as part of the interview. The interviewer will take notes and then be asked to write a short reflection on each interview. At the end of this process each country will write a global report concerning the experience of completing these questionnaires etc.
The final English version of the questionnaire and protocol should be distributed before the end of October. Where relevant the survey tools will have to be translated into the native tongue, this is likely to take 1-2 weeks. The aim is to complete collection of the pilot data before Xmas.

Focus Groups
The aim is conduct three focus groups that reflect the age ranges that will be set out in the final protocol and a group of heavy drinkers. It may be possible to select the heavy drinkers with reference to their replies to the consumption questions. All participants will be asked in the pilot study (above) if they are willing to participate in further focus groups. The interview will also provide the interviewer with a chance to assess the suitability of the participant for the focus groups (i.e. do they understand the concepts sufficiently and are they able to articulate their thoughts to provide valuable data). It will be up to each country to find the best way of conducting these in their chosen environments and it is unlikely there will be need for full taping and transcription. It may be best to consider them as group discussions. The key will be taking full notes of the main points raised in the discussion and that the interviewers are trained and understand the concepts being discussed. It may be helpful to tape the groups as this will aid subsequent note taking. The final protocol and the questions will be distributed at the end of October by the Polish team.

Cost- Benefit Analysis
Peter Anderson's draft report was distributed at the meeting and feedback was requested. However as PA was not able to be present at the meeting there was no further discussion.

Statistical Analysis
JS introduced his tentative ideas for statistical analysis based upon the principles of General Linear Modelling. One of his aims is to look at the predictors of problems/troubles and to do this he will aim is to minimise the interaction between countries and control for individual differences. It is likely he will collapse the countries into three or four groups and use any of the following either alone or in combination- cluster analysis, multi-dimensional scaling or factor analysis. Other aims will be to get an estimation of consumption levels and test the sensitivity/specificity of the troubles measures- i.e DSM-IV/CIDI, RAPS and AUDIT).
One of the main concerns of the delegates was to ensure uniformity of data collection and coding. JS will design a data set with coding instructions. Each country will then enter this and send it on to JS.

Financial Reports
JM stated that were still some financial reports outstanding and requested they be sent to him by Wednesday 7th October.

Web-Site
JS presented the web-site, links and the number of hits etc. A list was made of those individuals who should be added to the list of participants. Each institution was asked to send a web link and to provide a web link to the SMART web-site.

Next Meeting
A data has not been fixed for the next meeting. However it will be held at some point March/April 2010 following analysis of the pilot data.

Rapporteur: John Foster

SMART First Expert Meeting (Munich, 12 -13 March 2009)

Minutes of the meeting (PDF document)
Introduction
A review of the main activities that have been undertaken since Barcelona meeting was made. They included "homework" from three working groups on three topics:

• Heavy drinking, binge drinking, drunkenness, dependence and problems,
• Consumption, unrecorded consumption, drinking context,
• Survey administration, sampling, quantitative and qualitative methods.

In addition, two instruments on literature review and survey review were elaborated and circulated among participants for piloting and comments

Discussion on the literature review and survey review including review instruments
Presentation on initial literature search based on two key words (alcohol survey, drinking survey) was pre-circulated. Following questions were raised in the discussion:

• Are the keywords sufficient and appropriate to identify the kinds of publications we need? The databases and keywords miss publications in languages other than English. Government sponsored documents (many of the national surveys) are not available in the published (journal) literature but are published in report format or available electronically.
• The list of papers generated by the search is in English (majority of American studies) and a much wider European literature base needs to be identified.
• What is the purpose of the literature review? Are we looking at methodological approaches/ discussions, instruments used/ results? Would we get the kind of information we need from conducting a literature review? Two papers were considered as possible outcomes of the literature review:

A review of the surveys - methodology and measures (accepted as related to the main focus of the work).
A review of the results (the viability of this was questioned, especially to make comparisons across countries).

Following decisions were taken to:

• At this stage priority should be given to the review of alcohol surveys in Europe at the expense of overall literature review.
• It was agreed that the instrument for survey review itself worked quite well. A final version after cosmetic revisions would be circulated before we carry out further reviews
• Each partner should review (published) national population surveys
• Partners undertake to contact experts in other European countries aiming at completion alcohol surveys review in all EU countries
• Jacek to produce a standard letter to experts from non-SMART countries explaining the SMART project and asking for assistance (partners can personalise this)
• Consider how we can best acknowledge the help provided by outside experts
• The review of surveys should cover the survey methods and procedures, measures and results - using the questionnaire - which might be modified after further consideration.
• At country level, we look at the wider (mainly European with some wider international) literature to provide context for the review of surveys.

Development of the questionnaire. General issues, survey administation
Over the course of the morning, a number of issues were raised concerning the development of the population survey instrument and the survey methodology. Issues raised:

• What will be the outcome measures of pilot survey carried out in 9 participating countries?
• Again the question about how far we could compare countries.
• Should we aim to produce a set of 'core' questions and 'optional' questions which countries could include or not, depending on resources, interest etc.?
• Should we aim to produce an instrument for insertion into a more general survey (as many existing national surveys are of this type) or for use as an alcohol specific survey?
• Should we produce an instrument AND a methodology which describes best practice and provides recommendations?
• Should the questionnaire be administered face-to-face or by self-completion?

After long discussion it was agreed that relevance or feasibility of different consumption measures in the pilot survey will be assessed against three major criteria:

• comparing several annual consumption measures ("the higher the better")
• comparing predictive qualities of different consumption measures "the higher association with problems the better"
• comparing consumption distribution "the more similar between countries the better"

A decision was also taken that the output would be a common best methodology and a common instrument for an alcohol specific survey.

It was hoped that this would complement current policy directions by providing an appropriate methodology and instrument should member states be required to conduct alcohol specific national surveys.

The question of whether to have a core set of questions and other optional sets was not finally decided but combination of a core set and optional questions respecting cultural specificity seemed to be the most appropriate.

It was agreed that the questionnaire would be administered face to face for the pilot. If this form of administration will be advised for general population use is to be decided based on existing literature. Discussion highlighted the expense of this option but the advantage in terms of response and completeness of data.

It was repeatedly stressed that a general population survey should not be too long (30-40 minutes) and it was acknowledged that countries would differ (for cultural as well as other reasons) in the length of questionnaire/ type and number of questions on alcohol which would be seen as acceptable and/or likely to be used.

Development of the questionnaire. Four methods of measuring consumption
Four alcohol consumption measures were presented. Their advantages and disadvantages were considered and discussed.

• FxQ method - last 30 days, than last 12 months
• FxQ method separately for weekdays and weekend days - last 30 days, then ordinary FxQ last 12 months
• Exact review of last week and then preceding last 3 drinking episodes
• Frequencies of drinking occasions x quantity for last time of each occasion

It was suggested that graduated quantity/frequency measure could be considered as an extra option, even though it is difficult to respond
The difficulty to capture by one measure the irregular consumption patterns as well as the regular ones was noted.
Respondents in FxQ report a mode consumption intake rather than average which leads to underestimation.
Two important questions were raised:

• What is the evidence for using one or other of the 4 methods?
• Is it worth testing the methods? -What are the chances that countries will adopt/ implement a new set of questions as there are many reasons why they may prefer to use existing measures.

It was felt that the survey/literature reviews would help to address the issue of evidence and that which methods to test would be finally decided taking account of the reviews.
The number of methods which should be tested was also considered and it was suggested that, taking account of country contexts, it might be more useful to test 2 options plus a country specific method (a method already in use in the country). This latter suggestion was adopted as optional.
Context questions might be identified by looking at available sets of questions e.g. GENASIS. This should be discussed at the next meeting.

Q/F will be used as one method but the precise format is still to be decided.

Decisions taken:

• To test no more than 2-3 methods - 2 'global' and one national consumption measure (the latter one - optional).
• The questionnaire will be structured.
• A qualitative approach will be used to examine understanding of concepts and experience of completing the questionnaire.
• The questionnaire should take no more than 40 minutes to administer

Measures of Binge drinking / Drunkenness / Problems
Presentations on binge drinking and drunkenness indicated the problems of defining and measuring these concepts and offered some alternatives for consideration.

Binge drinking: It was suggested that:

• The term 'risky single occasion drinking' might be adopted by SMART.
• We should adopt the measure of 60+ grams in a single occasion as a measure of 'binge' drinking (The decision should depend on evidence emerging from the literature review).
• The time period needs to be added: 2 hours / 6 hours / or a continuous - 2,3,4,...etc. hours.
• The qualitative work could ask about whether the cut off point (risk) was meaningful for people.
• We might possibly include a body weight question.

Drunkenness:
It was agreed that although this is a subjective measure and open to wide individual and cultural variation, it would be worthwhile including a question(s) and possibly look at this measure in relation to the measure of binge drinking.

The problem of attribution was discussed especially when questions included attribution as part of the question. It was suggested that perhaps questions could be asked without mention of the relationship to drinking - but this was not decided.

It was agreed that qualitative questioning could be used to examine what respondents meant by 'drunk'. It was also suggested that we could ask, 'How many drinks it takes you to get drunk?' The measure still has to be decided.

Other health and social problems
A list was circulated showing measures used in a sample of European surveys for different domains of problems - dependency, chronic, acute, social.
It was felt that existing measures (e.g.DSM4) were available for chronic alcohol related conditions.
Harm to self and harm to others were suggested as two important dimensions for inclusion.
Both frequency and severity of harm should be considered.
Again attribution needs to be considered.
Acute problems needed to be included and the best indicators identified.
One suggestion was to choose indicators of harm in line with EU and/or WHO priority areas e.g. children, workplace, injuries etc.

Social problems - again there is a long list of possibilities and Group 1 was asked to circulate a proposal for measures of acute harm/ harm to third party / social harm.
The questions in this section should take no longer than 7 minutes to administer. Time frames of 30 days and the last 12 months were suggested as suitable.
In qualitative pilot assessment, respondents could be asked open questions re: what they think are alcohol-related problems and what they think are harms to others resulting from alcohol.


Administration of the piloting survey
The questionnaire is intended to pilot and test different methods of acquiring data on alcohol consumption and drinking patterns. The intention is to find a common instrument to get the best data.
Some suggestions for sampling were circulated - 200 interviews per country; 30% 'problematic' drinkers/ 70% 'regular' drinkers; urban/ rural; 50% age 18-39/ 50% age 40-64; 100 women/ 100 men; abstainers to be excluded.
Discussion centred on the scientific rigour of attempting to do this with so many variables and on the practicalities of sampling and administering the pilot questionnaire.

Agreed that we need to:
1. Pilot the instrument to identify optimum design and measures
2. Examine qualitatively individual responses and experiences to completing the questionnaire - interviewer keeps notes and discusses understanding of concepts/ experience of completing the questionnaire etc. with a sub-sample of respondents
3. Discuss with a group of respondents - this raised questions regarding the viability of this exercise - Is it practical? What will we achieve by way of information? Would it be more useful to use a group of 'experts'? The decision was left up to individual teams/

A screening method or instrument was considered to identify appropriate respondents before completing the questionnaire.

Economic Impact of Alcohol Policies
A paper was pre circulated and Peter Anderson presented this work package. It was agreed that development of the cost/benefit analysis should take into account work completed or in progress (e.g. CHOICE/ AMPHORA project). Three possible models were presented and discussed:
1. Cost-of-illness studies
2. The CHOICE model
3. Avoidable burden of disease/illness

The third one was likely to be used for SMART but other options were also under consideration.

The importance of considering the impact of different policies on different social groups was discussed as well as looking at the unpredicted costs of different policy options. It was agreed that this should be taken into account.

It was suggested that some questions be added to measure public support for different alcohol policy options. Measures will need to be developed.

Short report from the EC Committee on Data Collection, Indicators and Definitions
Following indicators of alcohol-related harm were suggested:

• Total consumption of alcohol - per capita or per population aged 15+, beverage specific sub-categories.
• Harmful pattern of consumption - 60 grams or more on one occasion, monthly or more often in the past 12 months - same for men and women.
• Alcohol-related harm - alcohol-attributable years of life lost based on WHO attributable years lost due to chronic disease and injury.

Website
Points raised:
– Fully active members of partner teams could be named in a section on the country teams.
– Partners to send Jacek additional appropriate links for the website.
– Partners to send information (if available) on how to count 'hits' from different countries.

Other issues - organisational etc.
A timetable for completion of the work was discussed. It was agreed that collection of the data may take longer than expected and should start this Fall.
Partners need to complete time sheets. Reporting period is Sept.2008 - end August 2009.
External evaluation has been arranged.
Agreed that a final version of the survey reviews would be available by end May 2009 for discussion at KBS meeting.

Next meeting will be in Florence end Sept./ early Oct., most likely 5-6 October - to be confirmed.

SMART Kick-off Meeting (Barcelona, 10-11 November 2008)

MINUTES OF THE MEETING

1. Introduction
The meeting began with an overview of the project from Jacek Moskalewicz (IPIN), Co-ordinator of the SMART Project. The discussion that followed emphasized two main points. Every effort should be made
to co-ordinate with the other EU alcohol related projects and the survey methodology of the SMART project should try to link with the EU Health indicators division and the World Health Organisation to enhance compatibility.

ATTACHMENTS

• Participants List (attachment 1)
• Agenda (attachment 2)
• Report from Work Group 1 (attachment 3)
• Report from Work Group 2 (attachment 4)
• Report from Work Group 3 (attachment 5)
• Cost-benefit Methodology (attachment 6)

All of the partners in the project (attachment 1) introduced themselves and briefly outlined their expertise in alcohol surveys. The provisional agenda of the meeting was agreed with some minor changes (attachment 2). Three working groups were to be established to discuss survey methodology, each with a specific focus
Group 1 - Heavy drinking, binge drinking, drunkenness, dependence and problems
Group 2 - Consumption, unrecorded consumption, drinking context
Group 3 - Survey administration, sampling, quantitative and qualitative methods.
The three groups were asked to

• Review existing methodology
• Identify methods most feasible/promising for comparative purposes
• Identify further steps to be taken to elaborate on a standardized survey instrument
• Continue their work until next project's meeting.

Participants were invited to join one of the three groups.

2. Work package 1 - Co-ordination of project
Co-ordination of the project was presented by Jacek and discussed by the group. Main points were that every 5 to 6 months each country should report on work progress in terms of time allocation and tasks undertaken. The Institute of Psychiatry in Poland (IPIN), co-ordinator of the project, is to be the sole institute to liaise directly with the Executive Agency on Health and Consumers (EAHC) which execute the project on behalf of the DG SANCO. If anyone has issues or wishes to communicate with the EAHC they must go through Jacek who will bring it to the attention of the EAHC. SMART, through Jacek, will also liaise with other EU alcohol related projects - Building Capacity, FP7 AMPHORA project and the Committee on Data Collection, Indicators and Definitions established as a part of the EU alcohol strategy. There are several projects that have aspects of cost benefit analysis and it was suggested that each project could take different aspects to allow for a more comprehensive examination of this topic and avoid duplication.

3. Work package 2 - Dissemination of results
The proposed plan for dissemination of the project results was presented by Janusz Sieroslawski (IPIN). The main points discussed were the website, materials to be produced and scientific articles to be published. Suggestions were that the web name should be kept short, to try and buy domain name with link to the IPiN website and link SMART website to other relevant websites. In relation to the production of materials, it was felt that a short survey manual should be produced that would allow for translation. It should include the survey methodology and definitions of key terms and a set of core questions that all Member States would be encouraged to use. Materials to go on the SMART Website should be circulated to partners for approval, with a 10 day lag time. The extent of details of collaborating partners and contracted experts was at the discretion of the individual.

It was too early in the process to identify specific scientific articles to be published by the project. Among numerous options, the idea to publish in an open-access electronic journal was considered as time between submission and publication in open-access journals offer is short. It was decided to have a publication issue as an agenda item for the next and subsequent meetings.

4. Work package 4 - Survey methodology
Each partner was invited to give a summary of alcohol survey methodology in their country. In almost all the countries discussed survey data was collected using either face to face or telephone interviews, although mixed methods was also used. Sampling procedures involved random, stratified or quota methods. Definitions varied widely in terms of a standard drink (amount of pure alcohol), heavy drinking and episodic heavy drinking. Drinking context and alcohol problems were measured by some countries. The country presentations illustrated the need for a common core set of definitions and measurement of the key concepts, one of the objectives of the SMART project.

The three working groups as mentioned above were then asked to review existing methodology, identify possible methods for this project and a strategy to work through tasks.

Feedback from Group 1 on heavy drinking (attachment 3) suggested that the concept of drunkenness was difficult give its strong cultural context and may be too difficult to devise a valid measure. The term 'binge drinking' should not be used and a more appropriate term should be devised for the moment it would be called episodic heavy drinking (EHD). The key points for EHD were the volume of alcohol consumed, frequency, and time frame. Body weight should also be measured to estimate level of EHD or intoxication. Many surveys measure it as drinking over a defined number of drinks on a single occasion. However, the group suggested that rather than have a cut-off point ( as currently) ask for max quantity consume on the EHD occasion. Alcohol problems should include measures on acute, chronic and social problems and alcohol dependence.

The feedback from Group 2 on volume of consumption (attachment 4) suggested the best measures as beverages specific with quantity and frequency. An additional question could ask on quantity/ frequency of consumption in last week or last drinking occasion. In relation to drinking context a problem identified was that alcohol and drinking context has a different function in different cultures. While a standard drink was useful for analysis it was defined differently in countries and was not understood by the public in general. The duration of the drinking context was also seen as important. Unrecorded consumption usually refers to alcohol purchased while abroad. However, in some countries such as Italy or Poland and Estonia it can reflect the alcohol consumed from unrecorded sources within the country.

Group 3 examined survey administration (attachment 5) and identified three key issues - sampling (random or quota), questionnaire administration (face to face interview and/or self administration) and type of survey (alcohol specific survey or lifestyle survey with alcohol questions. The group recommended that the final survey manual should include how to analyse the data collected. Group 3 suggested, as part of the literature review, to collect national studies from each of the 27 Member States with a preference for alcohol specific but if not available lifestyle surveys with alcohol questions. It was also suggested the European wide alcohol surveys should be included. Each partner was allocated two to three countries to follow up and check for survey instruments.

The methods for the SMART project pilot survey was discussed - should it be quantitative or qualitative or both, how big/small the sample size, random, quota or purposeful. It was agreed that these questions could not be fully answered until clearer outcomes are defined. This would be the priority of the next meeting.

5. Work package 5 - Cost-benefit methodology
The aim of WP5 is to standardize methodology to undertake cost-benefit analysis of alcohol polices. Peter Anderson (GENCAT) presentation what is already known and what methodologies have been undertaken. He outlined the plan for moving forward on this work package (attachment 6).

6. Work package 3 - Evaluation
Evaluation of the project will be undertaken by STAKES or by an institution that emerges from a merge of STAKES and Public Health Institute. Esa Österberg gave a brief outline of the evaluation plan.

7. Financial Issues
The final part of the meeting discussed financial issues. The Commission was providing 60% of the total cost of the project. The Commission has given the first instalment (30%) of the eligible amount. It was emphasised that each institution must record the allocation of the 40% put forward by each institutions for the project. It is important to review eligible costs. Travel and accommodation must be paid for by each institution from their its individual budget. If the research experts were to change institutions then this would require an official amendment to the contract and would have to be notified and approved by the EAHC which is a lengthy and labour-intesive process.

8. Next meeting
It was agreed that the next meeting would take place on the 12/13 March 2009 in Munich.

Rapporteur - Ann Hope