Local alcohol prevention in Sweden : construction of a prevention index and assessments of prevention effects on consumption and harm

Abstract: Background: Over the past 15–20 years, local alcohol and drug prevention has developed substantially in Sweden. This has largely been a planned strategy from the national level with channels through to the regional level and down to the local level, which should be seen as a reaction to Sweden joining the European Union in 1995. Following that event, the restrictive import quotas on alcohol from other member states were gradually abolished. This led to greater availability of cheaper alcohol in Sweden and alcohol consumption increased in the following years. This, in turn, put increased pressure on the restrictive Swedish national alcohol policy, especially to reduce the taxation of alcoholic beverages. Thus, the government searched for alternative prevention approaches, e.g., strengthening local alcohol and drug prevention. Aims: The aim of this thesis is two-fold: 1) to develop a composite measure (index) for monitoring local alcohol prevention, and 2) to investigate the effects of an increase in local alcohol prevention efforts on alcohol consumption and alcohol-related harm in Sweden, 2006–2014. Methods: A composite measure of local alcohol prevention, Alcohol Prevention Magnitude Measure (APMM), was constructed based on a systems model for alcohol prevention and community action. APMM was validated by comparing the change in APMM score in community intervention municipalities (where previous evaluations pointed at increased prevention) with that in non-intervention municipalities (studies I–II). Fixed effects models were used to analyse the prevention effects of a community intervention called LUMA and of APMM on consumption and harm (studies III–IV). Results: Studies I–II. Initially, indicators and data sources for monitoring alcohol development in Sweden were identified. An APMM was constructed with 37 indicators of local alcohol prevention. These indicators were divided into five main categories of prevention. Categories were scored with a maximum of 20 points each (i.e., maximum total 100 points). The validation of the APMM indicated that it reflected changes in local alcohol prevention. Another result was that local alcohol prevention, measured using APMM, increased among Swedish municipalities between 2006 and 2010. Studies III–IV. Findings revealed increased prevention activities in the LUMA municipalities compared with control municipalities. Positive developments for alcohol consumption and several alcohol-related harm indicators were found. When a weighted version of APMM (WPI, a combination of a direct and a lagged prevention effect of one year) was analysed in relation to consumption and harm, the main results suggested that an increase in APMM (WPI) by 1 percent yielded a decrease in alcohol-related mortality by 0.26 percent. However, the estimated effect of APMM (WPI) on alcohol consumption was very small, -0.02 percent. Unlike mortality, most of the effect estimates on morbidity revealed no effects of prevention. Implication and conclusion: This thesis has shown how a prevention index for monitoring local alcohol prevention can be constructed and applied. Furthermore, the findings suggested that the increased efforts on local alcohol prevention in Sweden have had some effect on alcohol consumption and related harm. However, given the identified limitations of the measures of local prevention, consumption, and harm, the results must be interpreted with caution. Additional studies on the effectiveness of local alcohol prevention are needed to assess the generalizability of the current findings.