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2 Perspectives on Current Alcohol Policies The simplifying conceptions of alcohol policy presented in chapter 1 and the diverse avenues for affecting the problems outlined in chapter 2 provide a broad perspective on conceivable alcohol policies. It is useful to place current policies toward alcohol in this context to see how many of the conceivable alternatives are now being exploited and what pieces of the problem lie outside current efforts. CURRENT ALCOHOL POLICIES AND INSTITUTIONS Characterizing current alcohol policies with precision is no simple task; the very term "policy" is ambiguous. It may refer to publicly stated goals, to specialized institutions predominantly concerned with alcohol, or to the net effect of all institutions. Another difficulty is that in the complex institutional structure of the United States, many different policies are being pursued independently by many separate institu- tions each with independent purposes, resources, clientele, and au- thority. Still, a survey of the current institutional setting reveals three strategically important features. First is the heavy regulation of the production and distribution of alcohol. The federal government, operating through the Bureau of A1- cohol, Tobacco, and Firearms (BATE) of the Department of the Treas- ury, collects approximately $5 billion per year from taxes on alcohol. The 51 state ABC boards exercise substantial influence over the price and availability of alcohol in off-site premises and, through regulation, shape some aspects of the contexts of drinking in on-site premises. These 48

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Perspectives on Current Alcohol Policies 49 institutions exert influence on alcohol problems despite the fact that they are not now explicitly being managed for this purpose. The objec- tive of BATF's operation is largely to collect revenue and to ensure the legal and orderly operation of the commercial system for distributing alcoholic beverages. Thus, although substantial authority over the sup- ply of alcohol is vested in these institutions and they are both active and influential in shaping drinking practices (for good or ill), they are not now being managed for this purpose. The second strategically important characteristic of the current insti- tutional setting is the continued existence of powerful cultural beliefs and attitudes that tend to moderate drinking practices in the United States. It is easy to forget that one-third of the adult population of the United States is abstinent and another third drinks very little over the course of a year. These drinking practices, no less than the heavier drinking practices of the remaining third of adults, are created and sustained by powerful, deeply rooted cultural and family traditions. The majority disapprobation of immoderate drinking is still embodied in state and local statutes prohibiting drinking by minors, driving while drunk, and public drunkenness. These laws have recently been subject to liberalizing trends. Age restrictions on drinking have been lowered, convictions for drunken driving have been difficult to secure, and, in perhaps the most significant of the changes, public drunkenness has been widely "decriminalized." But the continued existence of these laws and the very moderate drinking practices of most of our population testify to the continued vitality of public intolerance of immoderate or reckless drinking. The third feature of the institutional setting pertaining to alcohol control policies is the National Institute for Alcohol Abuse and Alco- holism and the network of state agencies and treatment programs par- tially spawned and supported by NIAAA's most influential client groups. This institutional nexus is important in part because it absorbs a substantial volume of economic resources. Even more important, how- ever, NIAAA is the most prominent government agency concerned primarily with alcohol problems. It is therefore the primary institutional focus for conceiving, articulating, and, to a degree, managing the gov- ernment's explicit efforts to cope with alcohol problems. For broad and innovative thinking to be done in this area and for managerial efforts to be launched to exploit underutilized institutional capacities, NIAAA must be the lead agency. Since NIAAA is the primary custodian of alcohol policies at the level of goals and current understandings of the nature of the problem, it becomes important to know how NIAAA understands the problem and the appropriate responses.

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so REPORT OF THE PANEL The answer to this question is difficult to pin down. In the articulated aspirations of representatives of NIAAA and in its organizational struc- ture, there is a variety of conceptions and approaches. At the level of agency operations, however, it seems clear that the prevailing underlying assumption is that the general alcohol problem is largely one of alco- holism and that the most effective way of dealing with it is to locate and successfully treat alcoholics. Of course research on alcoholism may well throw useful light on drinking problems of a less intensive or less chronic nature, but most of NIAAA's funds, institutional apparatus, and man- agerial attention have been devoted to treatment delivery, not research programs. NIAAA searches for more effective modes of treatment and broader methods for identifying and recruiting "problem drinkers" or those likely to become alcoholics. Thus, it has tended both to reflect and sustain the governing idea that alcoholism is a disease for which treatment is the most appealing policy. The overall institutional picture, then, is one in which a few major institutions play important but largely unintentional roles in shaping drinking practices; and in which the government institution that is most responsible for shaping our social response to alcohol problems reflects the current conception of the problem as largely one of alcoholism. The juxtaposition of this institutional setting with the analytic conception of the problem developed in chapter 2 prompts an important question: Is full advantage being taken of the current institutional capacity to cope with the diverse aspects of alcohol problems, or is the current concept of alcoholism narrowing our conception of the appropriate objectives of alcohol policy and diverting society from some important policy al- ternatives? More specifically, the question is whether the regulatory apparatus and cultural commitments to temperate drinking could be utilized more effectively to ameliorate alcohol problems, and if so whether current policies (and conceptions of the problems) should be diversified to take better advantages of these institutional opportunities. THE PRIMA FA CIE CASE FOR PREVENTION We believe that a significant opportunity for diversifying current policies does exist. Specifically, there is both a need and an opportunity for alcohol policies to be diversified to prevent alcohol abuse and problems in the general population of drinkers. This argument rests on three observations. First, as chapter 2 indicates, there are clear limits to what treatment policies can accomplish by themselves. Treatment policies can be jus- tified by a humanitarian commitment to care for the casualties of drink- ing and by the contribution (whatever its size) that treatment makes to

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Perspectives on Current Alcohol Policies 51 prospects for recovery. But it is also clear that bad consequences of drinking are strewn so widely among the general population of drink- ers including many for whom treatment would be entirely inappro- priatethat treatment alone could at best deal with only a portion of the important social consequences of drinking. Second, the analysis of existing institutions suggests that while there is little institutional focus for prevention efforts, there is a surprising amount of institutional capability. The regulatory apparatus governing commercial availability remains intact but underutilized for the preven- tion of alcohol problems. Social sentiment in favor of moderate drinking remains strong and ensures a supportive climate for broadly targeted efforts to shift drinking practices in desirable directions. Thus, much of the institutional basis for prevention programs already exists. Third, it seems clear that treatment and prevention can be seen as complements to one another rather than competitors. There is ample evidence indicating that the number of chronically dependent drinkers is not a fixed number and is importantly influenced by general drinking practices and opportunities (Bruun et al. 1975~. Moreover, efforts to protect lighter drinkers from the worst consequences of occasional ep- ~sodes of drunkenness could also protect heavier drinkers in their more frequent drinking episodes. In effect, prevention efforts might usefully supplement treatment efforts by decreasing the size of the population needing treatment and by shielding the treatment population in ways that treatment could not accomplish. Furthermore, treatment and pre- vention programs do not seem to compete for resources. Most preven- tion programs do not cost the government a great deal of money. They involve taxation, regulation, and the design of persuasive communica- tions that could be used over and over again. While not all of these things are inexpensive to the society as a whole, most of them are relatively inexpensive in federal budget terms. Besides, the possibility of important positive interactions between treatment and prevention would make it wise to invest in both, even if they were equally expensive. Thus, it seems sensible to consider diversifying alcohol policies by exploiting a variety of opportunities to prevent drinking problems in the general population. Note that in considering diversification, we are thinking, not of an abrupt shift, but of an incremental addition of new capacities that can be enlarged if they turn out to be successful in han- dling some aspect of the problem. As discussed below, existing evidence about the efficacy of prevention policies is not so strong and compelling as to justify "great experiments," yet, opportunities for dealing with alcohol problems through prevention programs seem sufficiently at- tractive to merit close investigation. In the second part of the report, we look at the available empirical evidence about the efficacy of pre-

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52 REPORT OF THE PANEL vention programs. It is first necessary, however, to become more precise about what we mean by prevention policies. THE DEFINITION OF PREVENTION POLICIES The general idea of a prevention policy toward alcoholism and alcohol abuse is at once too narrow and too broad for our purposes. It is too narrow because it focuses attention on the harms to be limited and obscures the fact that benefits of alcohol use exist and should be pro- tected. It is too broad because all instruments of alcohol policy can be understood as devices to prevent some bad effects of drinking. Treat- ment programs, for example, can be understood as devices for pre- venting cirrhosis from reaching terminal proportions, forestalling sui- cides, and preventing accidents by motivating chronic alcoholics to reduce their alcohol use and change other aspects of their lives. To serve our purposes, then, we need a more precise definition of how we mean prevention policies to be understood. Perhaps the most convenient way to develop the concept of prevention policies is to distinguish the policies we have in mind from clinical al- coholism treatment programs. From our point of view, such programs (as a class) have two important characteristics. First, they operate through a continuing face-to-face relationship with discrete, identified individuals. Individualized attention begins at intake, when a detailed client history is taken; continues with a treatment plan calling for con- tinuing, intensive involvement; and becomes the basic mode of operation as the progress of a client is continuously monitored on a variety of dimensions. The services and supervision that operate within this in- dividualized relationship are the heart of treatment programs. Second, treatment programs tend to be directed at the relatively small proportion of drinkers who have experienced the most severe problems with their drinking and have either asked for or been referred to treatment. This concentration occurs in part because treatment is sufficiently expensive that its use is reserved for those who are in the most serious trouble. The distinctive features of treatment, then, are individualized services and a focus on drinkers who are already in trouble. One can logically imagine extending such individualized services to people who are on some grounds thought destined for trouble as well as those who are already in it. Examples of such at-risk or high-risk populations are those beginning to experience problems on the job or in school related to excessive or ill-timed drinking; young populations that are just starting to drink but have sufficient problems in other areas of their lives (for example, an alcoholic parent) to induce concern about

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Perspectives on Current Alcohol Policies 53 their futures; and demographically defined groups (for example, native Americans) that have previously shown especially high rates of clinical or other problems with alcohol. Such programs do in fact exist, and are generally called early detection and intervention, occupational program- ming, or preventive services. Moreover, they do have a preventive aspect in that they are directed at populations that are not yet deeply in trouble with alcohol. On the whole, however, these are really treatment pro- grams with different kinds of outreach mechanisms. They still depend on personalized services. Although not confined to people who are already in severe trouble related to or dependent on drinking, the ability of such efforts to reach people who may be potentially at risk will be strongly limited by reliance on personalized services that are expensive, vaguely defined, and demanding of the client and on detection capa- bilities that are still at the basic research stage (Institute of Medicine 1980). The prevention policies on which this report focuses are different from either treatment programs or preventive services. They include: taxes on alcohol, regulation of the availability of alcohol, liability rules that would make bartenders or hosts more responsible for the safety of their guests, improved enforcement efforts against drunken driving, ed- ucation programs that present a view of unsafe drinking practices and encourage bystanders to comment on unsafe practices, and the design of workplaces and homes to make them safe for people who are intox- icated. This is a very heterogeneous set of policies, but they are all alike in the following respect: They are all policies that operate in a nonper- sonalized way to alter the set of contingencies affecting individuals as they drink or engage in activities that (when combined with intoxications are considered risky. In effect, they are designed to manipulate conditions that will influence either patterns of drinking or the consequences one can expect from any given drinking practice. The differences between these programs and treatment are three. First, the prevention policies operate on a fundamentally nonpersonal basis. None of these policies depends on a continuing personalized re- lationship between a program and a drinker. Instead, they operate through the remote manipulation of a relevant set of incentives and contingencies: the terms and circumstances under which alcohol is avail- able, the attitudes of people surrounding the drinkers, and the benignity of the physical and social environment toward drunkenness. Second, the programs operate generally throughout the society. The incentives and contingencies are established for everyone. They become activated when one begins drinking or engaging in behavior that would be risky if one had been drinking. Thus, drinkers in many patterns of

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54 REPORT OF THE PANEL consumption are affected, in addition to people who may become clumsy and inattentive as a result of drunkenness, fatigue, senility, or anger. Third, with the one exception of education programs directed at drink- ers themselves, the programs that we focus on do not operate by seeking major changes in the personalities and orientations of drinkers. Instead they seek to alter the set of opportunities, risks, and expectations that surround drinkers in society. To be sure, the orientations of individuals may change as they adjust their attitudes to the altered conditions sur- rounding drinking, but the attitudes and drives of drinkers are not the immediate target. Prevention programs seek to avoid the intrusions associated with therapy and concentrate on managing the set of external contingencies that operate on drinkers as they drink, pair their drinking with other activities, and accept a variety of risks associated with their drinking from the external environment. In fact, even education pro- grams avoid the most penetrating kinds of intrusions simply because, although they carry personal significance for drinkers, they do not seek out specially identified individuals and track their behavior. Thus, the prevention programs that are the focus of our study avoid sustained personalized efforts to alter the individual attitudes and drives of indi- vidual drinkers. These characteristics seem to give the prevention policies described above some important advantages. First, because they operate imper- sonally without a continuing relationship between an agency and an identified individual, they do not create the problems that may arise from "labeling" individuals as deviants. To be sure, a drunken-driving arrest is an adverse personal effect, and encouraging third parties to help regulate the drinking of others may exacerbate social conflict over drinking (as similar efforts have done in the area of smoking). Yet prevention programs involve many fewer of society's explicit labeling activities than treatment programs do. Second, because these programs broadcast their effects generally throughout society, they may be a low-cost way of reaching the general population of drinkers. A tax increase affects all drinkers in proportion to their consumption. An effective media program can help educate large numbers of people at low per-capita costs. Safer highways protect everybody who drives whenever they are driving not just a few problem drinkers. Of course, the fact that large numbers of people can be reached at a relatively low per-capita cost does not necessarily make such pro- grams valuable. If they produce no important changes in the pattern of drinking or in the set of consequences that result from any given pattern of drinking, the lower unit cost is hardly a virtue. If, however? as we think the arguments and evidence of chapter 2 warrant, it is important

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Perspectives on Current Alcohol Policies 55 to reach a large population of drinkers, these kinds of programs rep- resent an inexpensive way to start. The question of whether any of them are likely to produce any important, beneficial results is the dominant focus of the second part of this report. Before looking at this question, however, it is important to consider some basic normative and pragmatic arguments against such broad ef- forts to shape drinking practices. Unless these basic objections can be overcome or at least placed within limits pending the receipt of evidence, the attractiveness of these general prevention policies is in jeopardy. OBJECTIONS TO PREVENTION POLICIES The most fundamental objection to the idea that government should seek to shape drinking practices is that such action may violate common understandings about the proper role of government in a free society. In this view, government may place constraints on individual liberty only when one person's actions materially affect the welfare of another who is unable to protect himself or herself *om the unwanted intrusion; voluntarily assumed personal risks are beyond government bounds. Moreover, our legal system is designed largely to restrain government from acting until after the fact of intrusion has been established, not on mere presumption or potential. Since drinking produces adverse exter- nal effects only occasionally, general drinking practices seem for the most part inappropriate matters for official concern. Thus, any govern- mental effort to influence drinking practices may be seen as an inap- propriate paternalistic restriction on freedom irrespective of how gentle or heavy-handed the intrusion. One can disagree with this conclusion at several points in the argu- ment. First, individual freedom is not the only premise defining the proper role of government. There are other (equally venerable) notions of politics in which the government is called on to enhance the general welfare, promote the spread of knowledge, and encourage civil behavior among its citizens as well as guarantee various liberties. Alternatively, one could cite the extent of harmful, irreversible, external effects of drinking practices that clearly do warrant government interference (e.g., reckless drunken driving or piloting a plane while under the influence of alcohol). Thus, the basic principle that government should constrain private conduct only when that conduct affects others in important ways need not be, and has not been, an absolute bar to governmental efforts to shape drinking practices. Beyond this fundamental normative issue, several more pragmatic issues arise. The most important rest on the judgment that a repre-

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56 REPORT OF THE PANEL sentative government is unable to exercise any independent influence on drinking practices. This argument appears in varied forms. Some- times it is argued that government influence on drinking can do nothing more than reflect prevailing practices. When we observe a change in government policy, it is not because someone has decided on rational grounds that a change is desirable, but because large cultural forces are at work. Government actions are corks bobbing in great cultural tides. If by some chance a government policy were established at odds with prevailing practices, it would work substantial mischief making de- viants or criminals of the large groups in the population who stubbornly refused to alter their habits, fueling the development of illegal operations to meet the needs of those who are now outlawed, and generally sac- rificing the legitimacy and effectiveness of government. But then, the policy would shortly collapse in the face of continued private intransig- ence. The implication of these judgments is that since government policy must mirror prevailing practice, it is fruitless to rely on the government to shape those practices. Such efforts will be at best redundant and at worst self-defeating. A slightly less extreme view holds that government may indeed in- fluence current drinking practices, but in unexpected and potentially dangerous ways. Since current drinking practices are supported by in- formal but nonetheless strong and long-standing networks of beliefs, relationships, and other social practices, and since drinkers will seek to maintain their current patterns against both new inconveniences and the risks of deviance, the best the government can hope to accomplish is to set in motion many modest but unpredictable changes in actual drink- ing practices. It is certain that at least some people will try to maintain centuries-old practices against new prescriptions and will suffer incon- venient and painful losses in some dimensions of their lives as a result of the new policies. With such an uncertain (and potentially bad) result, it is foolish for the government to act. The central insight in these views is that informal social controls are much more powerful in shaping collective drinking practices than the government could ever be and that it is dangerous to have government conceptions of drinking be wildly at odds with the drinking practices that emerge from the informal system. Clearly, there is wisdom in these views. But the general observation nevertheless implies that properly chosen governmental actions could be valuable. It leaves open the pos- sibility, for example, that government prescriptions that were slightly more constraining than current practices, that put a gentle brake on dangerous shifts in current practices or accelerated favorable trends, might operate to shape drinking practices in a positive way without

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Perspectives on Current Alcohol Policies 57 doing much harm. Moreover, to point out that some drinkers will prob- ably be made worse off by a particular policy does not eliminate the value of the proposed policy: it depends on how many people move in what directions in response to the policy. It is by no means obvious that the largest effect will be for drinkers to remain intransigent and therefore suffer. It is also possible that over time the informal controls will change under consistently applied pressure, and drinkers will adapt as though things had "always been this way." A final pragmatic objection is that prevention efforts cannot effec- tively alter drinking practices at low cost. Instead, to be effective such policies would have to "over-deter": to penalize and restrain drinking behavior that is not or would not be troublesome, interfering with the long-standing use of alcohol as a pleasant accompaniment to occasions of relaxation and festivity, far out of proportion to whatever bad be- havior and undesirable consequences are averted. Certainly, in sizing up the effects of policies, it is essential to look closely at the untrou- blesome, beneficial conduct that might be discouraged and-disrupted, to see how much good behavior might be suppressed along with the bad. But this is an empirical judgment, and it is best to let the available evidence speak for itself. In summary, the strongest objections to governmental efforts to shape drinking practices are not insurmountable barriers. Instead, they suggest useful principles to recognize in considering whether and how govern- ment policies should be formed. The pragmatic objections point to the subtlety with which specific policy instruments must be chosen and em- ployed: they must be sensitive not only to the consequences of given practices, but also to the kinds and degrees of support for prevailing practices. Interestingly enough, because the vast majority of the pop- ulation drinks safely most of the time, the government, if it did nothing more than reflect prevailing practices back to the population, would be exercising an important moderating influence. The normative objections suggest a second important principle: We should be aware of who and how many people are the intended bene- ficiaries of certain kinds of prescriptions and select the particular policy instruments accordingly. It is of great importance to recognize commonly understood lines that divide ideal or appropriate areas for government interference from less appropriate or inappropriate areas. Proportion- ality must be maintained between the coerciveness of the measures used and the extent to which policy goals are consistent with prevailing prac- tices and common ideologies about state intervention. A line defended by criminal statutes must command wider compliance (i.e., admit more of current drinking practices) and be focused on behavior that produces

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58 REPORT OF THE PANEL more adverse external effects than a line defended by weaker measures such as economic incentives, civil sanctions, advisory educational pro- grams, or exemplary actions by government. This suggests that one might want to establish a variety of lines with varying degrees of force. Criminal statutes should be sparsely used to discourage only the rarest and most dangerous conduct. Other programs could be used more lib- erally and establish somewhat more controversial goals. CATEGORIES OF PREVENTION POLICIES The objections to prevention that we have just reviewed and the prin- ciples of selection to which they lead indicate that prevention policies must be fashioned from a variety of materials. We need therefore an orderly way to identify the different approaches that are available, in order to judge their suitability for the normative climates and practical occasions for which they might be used. The conception of alcohol problems presented in chapter 2 invites a sorting of prevention policies according to how they seek to ameliorate the problems (cf. Bruun 1971~. First are those policies that, by regulating the terms of commercial availability, operate primarily on the dimensions of alcohol consump- tion. These include taxes, restrictions on the number of outlets and hours of sale, limits on the kinds and quantities of alcohol sold, etc. Of course, many of these policies react to the contexts of drinking as well as the quantities of alcohol consumed. Relative proportions of on-prem- ise and off-premise drinking might be importantly influenced by com- mercial regulation as well as many details of on-premise drinking, such as location, activities paired with drinking, and so on. But the dominant and most important thrust of policies regulating commercial availability is to shape broad patterns of consumption over time with the manage- ment of contexts as an important additional factor. Second are policies that seek to influence drinking practices directly by suggesting (with varying degrees of force) what are unsafe or inap- propriate practices. Such policies can be written into law (such as laws against public intoxication or drunken driving). They can be conveyed through explicit educational programs. Or they can emerge implicitly from the accumulated actions of government. The particular vehicle used is important, of course. Sensitive issues about proper relationships between the state and private drinking conduct are raised in choosing one vehicle over another. It is equally true that the force and precision of a control is influenced by the forms through which it is disseminated. Perhaps the most interesting thing at stake in the choice of vehicle is

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Perspectives on Current Alcohol Policies 59 the enthusiasm with which the public can be mobilized to change their customary drinking practices. The clearer the message, the stronger the government's commitment to it, and the closer the conception is to widely shared private attitudes toward drinking the greater will be the effort made by millions of private individuals to promote compliance. If images of unsafe drinking patterns can be persuasively communicated, they may begin to influence observable drinking practices and their consequences. Third are policies that are designed to make the external environment less hostile to drinkers to make the world a safer one in which to be drunk or similarly impaired. This set of policies involves changes in both the physical and the social environments. Changes in the physical en- vironment could include safer structures, consumer products, and ma- chines. Changes in the social environment could include more effective emergency medical services or more sensitive police reponses to do- mestic disturbances. Note that there is an important interaction between policies designed to reprove a specific drinking practice and policies designed to influence the social environment of drinkers. It is perhaps impossible to motivate individuals to refrain from a given way of drinking but to be perfectly tolerant of others who continue to drink in that way. Thus, extensive reliance on policies promoting certain conceptions of drinking will guarantee greater problems for those whose behavior is not consistent with the conception. SUMMARY AND CONCLUSION When current alcohol control policies are viewed in the context of the current institutional setting and against the backdrop of the analytic conception of the problem developed in chapter 2, an interesting op- portunity appears. It may be desirable to diversify our policies in the direction of prevention programs that operate on the general population, through the management of contingencies that affect drinking, the con- texts commonly paired with drinking, and the general features of the environment that make drinking in given contexts more or less risky. At a minimum, these policies may succeed in reaching a population that is having trouble with drinking, but would be unlikely to be involved in (and for the most part would be unsuitable subjects for) treatment. Beyond this aim, however, these prevention policies may be effective measures for reducing the number of clinical alcoholics. In the remaining chapters of this report, we take a closer look at the available evidence about the efficacy of these prevention policies, fol- lowing the lines of inquiry suggested in chapter 2. In chapter 4, we

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60 REPORT OF THE PANEL examine the potential of policies influencing price and availability. In chapter 5, we look at the potential for trying to shape drinking practices directly through laws, education, and symbolic action. In chapter 6, we consider what could usefully be done to make the environment safer for drinkers (and others). At the conclusion of the second part of the report, we shall have a more sharply defined view of the potential of what are here described as prevention policies.