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Book Forum: ALCOHOLISM   |    
Alcohol and the Community: A Systems Approach to Prevention
REMI J. CADORET, M.D.
Am J Psychiatry 1999;156:1463-1464.
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by Harold D. Holder. New York, Cambridge University Press, 1998, 173 pp., $64.95.

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This book proposes a community systems dynamic perspective to provide a paradigm for understanding and ultimate prevention of alcohol-related problems, such as medical complications and social consequences (divorce and job loss, for example). The community systems model of alcohol use and its resulting medical and social consequences contains six elements or subsystems: 1) community alcohol consumption that influences and in turn is influenced by 2) social, economic, and health consequences to the individual and 3) community legal sanctions. Further influences on alcohol consumption are 4) social norms for drinking behavior, 5) formal state and local laws controlling accessibility of alcohol, and 6) retail alcohol sales. Relations among these factors are often two-way, as for example between consumption and social norms, a relationship that is being scrutinized today in discussions about so-called binge drinking (defined as five or more drinks at a single setting). In addition to these six community factors and their interrelationships, there are two exogenous factors that are postulated to influence consumption—economic trends and changes in population.

The six subsystems and their relationships are described in detail in chapters 2 through 7. The chief message is that, because of the mutual influence of the factors, the system has a mechanism to make adjustments that can maintain the status quo (explaining why some social interventions into drinking behaviors result in little or no change) or produce a desired change (such as lowered availability of alcohol resulting in less liver cirrhosis). The final chapter, on alcohol problem prevention at the community level, describes how the model can be used to plan interventions in drinking behaviors by helping identify effective measures to cause change in the system, resulting in the desired outcome on community consumption. The author describes a computer-based simulation model, Sim Com, which is general enough to apply to alcohol use in any community and robust enough to give specific outcomes when provided with local community data. Examples of Sim Com’s use are given in chapter 8.

This modeling approach to alcohol consumption depends on the validity of the model (are all essential variables and their relationships depicted in the model?) and how reliable and valid the measures of the model’s variables are. The latter consideration is most important, especially in models involving trends where changes in definition of crime and its reporting may give a false estimate of an outcome such as drunk driving (e.g., lowering blood alcohol definitions of drunk driving from 0.10 to 0.08). Other measurement problems are also formidable, such as lack of suitable data to measure a variable, especially when measurement of a publicly available variable is itself influenced by public policy (number of drunk driving arrests, for example, which are related to police priorities).

The community approach explored in this book is enticing because of the generalizability of its models and, to some extent, the availability of public data to support the models (records such as arrests, tax on substances, etc.). The model demonstrates a wide range of variables that influence alcohol consumption and may be influenced, in turn, by consumption. However, the fact remains that most of the alcohol consumed is accounted for by a relatively small number of consumers. This fact and the individual differences in consumers that account for early life involvement with substances and serious breaking of the law while under the influence (as with antisocial alcoholics) are not considered in a community model because of the difficulty in factoring in such variables, which may not be available in public records (how many drunk drivers are also antisocial personalities?). Individual considerations of this sort are not a part of the community model, but that should not lead us to neglect individuals and their needs and their contribution to community statistics.

All in all, this book provides a short but well-written comprehensive view of drinking behavior from a community and systems perspective. It summarizes an approach that should be useful for social and community planners and policy makers. It also directs the reader to a computerized version of the system, which would permit a more quantitative approach to determining the feasibility of a specific approach to intervention.

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