The Stanton Peele Addiction Website, September 5, 2010.

Open letter to Jürgen Rehm

From: Stanton Peele
Sent: Sep 3, 2010 2:05 PM
Subject: Open Letter to Jurgen Rehm


To: Jurgen Rehm,
C/o Dr. Emanuele Scafato
Direttore, Centro Natzionale Epidemiologia


Dear Professor Rehm,

I recently presented on a program with Dr. Emanuele Scafato, at Forum droghe/Fuoriluogo, in Impruneta, on September 2-3. I took issue with some of your attitudes, centering around presentations you have made at Alcohol Prevention Day, in Rome.

Dr. Scafato corrected me for taking on your positions with you not being present. When I asked him, then, if I could be invited to present alongside you in the next Alcohol Prevention Day, Dr. Scafato asked as a prerequisite that I first alert you to my criticisms in a letter. I publicly agreed to do so. Here they are.

I began my presentation by noting that the European Comparative Alcohol Study (ECAS) for the first time certified what had long been claimed about cultural differences in drinking styles, and that Northern European cultures – specifically Nordic and English-speaking (which Harry Levine has group together as Temperance cultures) display a high-level of binge drinking, unlike Southern European societies. ECAS found that, on 40% of drinking occasions, British men binge drink, as do 33% of Swedes and 29% of Finns, compared with 13% and 9% of Italian and French men.

These conflicting styles in drinking have a great impact on the degree of alcohol-related harm experienced in these cultures. This includes not only social drinking problems, but actual alcohol- related mortality (ARM) as measured in ECAS. In Northern European cultures grouped by ECAS, there were 18 ARMs per annum per 100,000 males, compared with 3 per 100,000 for Southern European cultures. This exact 6:1 ration carried over for Northern and Southern European women (3 v .05).

I then noted that, despite this apparent Southern advantage in drinking styles and health consequences, alcohol policy for Europe is being formulated primarily in the very Temperance cultures whose drinking norms were so negatively skewed! For example, of the 17 authors listed for Alcohol Policy and the Public Good (Edwards et al., 1994), 16 were from so-called temperance cultures (the exception being Paul Lemmens, from the Netherlands). This was followed by Alcohol: No Ordinary Commodity (Babor et al., 2003), 14 out of 15 of whose authors are likewise temperance-nation nationality. Of course, as you know, you were the one exception – although I understand you are now fully employed by a temperance nation.

And so I was particularly intrigued when I learned that you were the invited expert to lecture in Italy on the best means for encouraging healthy alcohol consumption there. I found your presentation here:

In your presentation I saw that you found the Italian alcohol situation compared favorably to Europe’s as a whole in your group’s landmark work on the global burden of alcohol costs. That is, Italy’s deaths due to alcohol computed as @ 5% of the country’s total mortality, compared with @12% for Europe as a whole (QALYs). You commended the audience for Italian’s positive performance comparatively in relation to “intentional” and “unintentional” accidents. But you then undercut any pride this might inspire in Italy by asserting, “However, with the increase of binge drinking in Europe among youth and young adults, this picture may change.”

I need to digress briefly here. Franca Beccaria was also on the program just before me. She presented data from two research projects in Europe tracking youthful drinking, as well as a study she has recently participated in comparing Italian and Finnish drinking. Dr. Beccaria showed considerable gaps in drunkenness and binge drinking persisted between Northern and Southern European youth along the lines already discussed here. The Finnish-Italian comparison likewise showed that Italian youths, despite a notable change in drinking settings from prior generations, still maintained a largely moderate style of drinking, begun in the home, which contrasted with the Finnish style of initiation of drinking outside the home at a somewhat later point among peers that was strongly characterized by drunkenness; both of these styles of drinking were recalled by older respondents, residues of which continued into their adulthood.

As a result, I found your explanation that the Italian culture needed correction from a Northern perspective unconvincing. Nonetheless, you proceeded to recommend that Italy should raise its drinking age (potentially to 21!) since raising age limits produced drops in accidents in temperance nations (like Canada and Sweden).

Here again, I must digress. I find the European Charter on Alcohol remarkably contradictory. For, at the same time that this document states that ”Appropriate public-health-oriented alcohol policy interventions may differ for different parts of Europe,” it also says, “The earlier young people begin drinking, the worse the consequences are likely to be.” And, Dr. Scafato informed the audience, this statement had been operationalized as a goal that no parent should give a child 15 years or younger any alcohol! (Dr. Beccaria’s Italian subjects had been exposed to alcohol at much earlier ages on average.)

What most offended me about your presentation was the confidence that allowed you to come to a culture which had measured superior drinking outcomes in both ECAS and Global Burden, as well as in tracking studies of youth drinking, without displaying any curiosity about how this was achieved, and to dive in immediately to tell Italians how they should be drinking, and learning to drink. This is especially true given Dr. Beccaria’s analysis, which suggests such learning is at the heart of the moderate drinking experience. Frankly, the whole thing reeks to me of colonialism.

Lastly, since I am expressing my disappointment so frankly, I should say that I found your approach particularly puzzling given your contribution (with Fisher), “Harm reduction in an open and experimenting society,” to the 2010 EMCDDA volume on harm reduction, where you say: “patterns and practices of drinking predominantly influence the alcohol-related harm experienced” (which once again raises the question about your lack of curiosity about how some societies achieve this so much more readily than others), and also “accepted truths of the field (that is, that higher availability of alcohol leads to more harm under all circumstances) have been empirically challenged (example: Sweden has experienced much higher availability of alcohol in the past years, but not necessarily higher consumption or alcohol-attributable harm),” which would seem to undercut the very sorts of recommendations you were making in Rome.

I hope the penitence I have done through this letter will allow Dr. Scafato, by his promise, to allow us to meet to discuss these issues directly in Rome. Why, perhaps, Dr. Scafato might even see fit to invite an Italian (like Dr. Beccaria) to join us in such a discussion!

Stanton Peele

P.S. I am copying this to the KBS listserv since I hope the issues raised here have some greater importance to the field of epidemiologic and policy research.