The theory of collectivity of drinking cultures: how alcohol became everyone's problem

In 1985, Ole-Jørgen Skog published “The collectivity of drinking cultures: A theory of the distribution of alcohol consumption”, in which he outlined his influential theory of population drinking. Skog argued that there is a strong collective component to population drinking so that when the mean consumption changes drinkers across the entire distribution will move in concert. The implication—that there is a collective drinking culture—has formed a cornerstone of the public health approach to alcohol problems, because it provides a link between per-capita consumption and rates of harm. His work has thus contributed to fundamentally reshaping both alcohol policy and alcohol research, shifting the focus from dependent or heavy drinkers to more universal preventive efforts. With increasing availability of better data and advanced statistical methods, today's researchers should re-examine and re-evaluate this pivotal theory. In a broader sense, Skog's work should also inspire us to theorize about the objects of our research and develop new theories of drinking. “If certain structural requirements are fulfilled, nearly everybody will influence and be influenced by nearly everybody else, either directly or indirectly. In this case, the population will tend to behave as a collective. Therefore the population might be expected to move in concert up and down the consumption scale, thereby creating a close connection between the general level of consumption in the population and the prevalence of heavy use.” (1: p. 97) The story of collective drinking cultures, however, starts out with the French researcher Sully Ledermann's observation of a correlation between per capita alcohol consumption and cirrhosis mortality. Ledermann was baffled by these results and could see no plausible reason for why they would occur. Drinkers from the normal population did not die from cirrhosis of the liver, those suffering from alcoholism did, and in the 1950s, the predominant idea was that the drinking of the general population and the problematic drinkers was inherently different. Ledermann therefore sought an explanation for the correlations observed. What he proposed was that the distribution of drinking in a population was always the same. If the mean then changes, the levels across the entire distribution will follow suit. This is an oversimplified brief overview of what is usually referred to as the single distribution theory 2. “A society can be conceived as an enormous social network—i.e. a system of actors tied together by different types of social relations which tend to produce a co-ordination of their behaviour. Each actor is influenced by a fairly small number of co-actors, but he is indirectly tied to a very large number of others (possibly all members of the society) by common friends, by common friends of friends etc. In effect, one can argue that each actor is influenced, directly or indirectly, by practically every other member of his culture.” (1: p. 88) “Therefore a drinking culture should not be conceived as an aggregate of independent individuals, but rather as a highly organized system of independent actors. The descriptive parameter ‘mean consumption’ therefore has a socio-cultural content which goes far beyond its technical content” (1: p. 91) It follows, then, from this conclusion, that we can reduce alcohol related harm through efforts directed towards reducing the mean consumption in the population, because this will also reduce drinking among the heaviest drinkers and by extension rates of harm. This was in contrast to the prevailing (medical) paradigm of the time that we should only treat the drinkers with problematic use and in even starker contrast to policy responses like the rationing system in use in Sweden between 1919–1955 aimed particularly toward regulating and controlling the problematic drinkers 3. Skog's theoretical development sparked a large body of empirical work demonstrating a link between per capita alcohol consumption and a wide range of harms 4-6. These associations have become so well established that they today are largely taken for granted. This evidence combined with the idea of a collective drinking culture formed the cornerstones of the argument for a broader shift towards a public health approach driven by Bruun and others 3 that fundamentally reshaped alcohol policy in many countries. This perspective, launched by a group of sociologists and public health researchers, advocated the use of universal alcohol control policies to reduce drinking in the entire population. Policy-makers and researchers in many jurisdictions gradually shifted their focus from dealing solely with heavy or dependent drinkers and aimed instead at changing population consumption via broad measures like taxation or availability restrictions. This was especially true in places like the Nordic countries, with cohesive populations and strong collective social welfare systems. To those of us who have entered the field of alcohol research more recently the theories of Ledermann and Skog have come back into focus following observations of a disconnection between levels of drinking and rates of harm in the early 2000s 7, 8. These patterns ran counter to expectations and raised some fundamental questions about Skog's theory. If rates of harm increase while per-capita consumption declines, then perhaps consumption trends were not linked across the entire population. Indeed, some researchers suggested a potential polarization of consumption where the trends among the heaviest drinkers would be at odds with those in the broader population 9. This has renewed the field's interest in Skog's work, with a series of recent papers examining the distribution of consumption and scholarly debate around the definitions and interpretations of collective shifts 9-20. The theories of Ledermann and Skog thus continue to inspire and provoke scholars some 50 years after they were first outlined and are most relevant still. Ledermann and Skog did not have ideal empirical data available to test and develop their theories. Skog made a serious attempt to provide an empirical base to test and support his theoretical assumptions. His empirical observations were, however, based on multiple cross-sectional surveys from several countries and widely varying populations, and it is only recently that studies have examined if changes within the same population are collective 16. This is perhaps mostly relevant to the mechanisms proposed in Skog's collectivity theory where the central agent for producing and spreading change is via social contagion. A proper test of this mechanism requires advanced network data with the participants drinking and interconnections across time. Even though some work has been done along these lines 21, until today, these kinds of data have been almost impossible to compile. With new technology and data collection techniques emerging, this will perhaps provide opportunities to collect the complex data necessary. “an increase in mean consumption would be expected to lead to a larger rate of increase in the consumption of light and medium drinkers than among heavy drinkers. As a result, the relative dispersion of the distribution of alcohol consumption seems to be a decreasing function of the mean consumption” (1: p. 90) “Rather than postulating mathematical distribution functions, a theory of the distribution of alcohol consumption ought to be based on hypotheses about the factors influencing human drinking behaviour. These hypotheses may in turn produce some predictions about the mathematical properties of factual distributions, but a realistic set of hypotheses will probably not predict rigid distribution laws.” (1: p. 84) Skog's continuing influence is a reminder of the dearth of other theories concerning population drinking, and how it changes, within the field of alcohol research. Incorporating all drinkers, even the heaviest, into one collective distribution of drinking guides us in our work trying to understand the harms caused by alcohol on a societal level. This central assumption is where the theory started once upon a time and why it is still used today. We think contemporary addiction scholars should re-visit and read Skog's Addiction classic, The collectivity of drinking cultures, because this played a major part in making alcohol everyone's problem. The argument for a shift toward population drinking also implied a shared responsibility for the harms caused by alcohol, because all drinkers were included in the collective drinking culture. Skog's work should serve as an inspiration for us to think more deeply about the ways that population behaviours change, and to theorize and scrutinize our ideas with empirical data. None Jonas Raninen: Conceptualization; formal analysis; writing-original draft; writing-review formal analysis; writing-original draft; writing-review & editing.