Sweden—is alcohol becoming an ordinary commodity?

Sweden has a long history of restrictive alcohol policy, although the forms have varied. The background to this restrictive policy should be seen as a response to the high levels of consumption and concomitant problems in the late 19th century. In 1920 a ration-book system was implemented on a national level, a programme devised by a young physician, Ivan Bratt. People over 20 years of age (except married women) could be granted an allowance of 1–4 litres of spirits per month. The allowance depended mainly on the individual’s income and social stability. From the outset, there was strong opposition against the rationing system from the temperance movement. In their view the system was an obstacle for prohibition, which was their primary goal; further, they beleived that it encouraged rather than prevented drinking because people were reluctant to have their allowances frozen. Due much to the strong influence of the temperance movement in various alcohol political committees, and increasing popular resentment, the rationing system was abolished in October 1955. The efficiency of the rationing system became obvious once it was abolished. During the course of a few years there was a dramatic increase in various forms of alcohol-related harm; for example, public drunkenness, rates of alcoholism and alcohol psychosis approximately doubled between 1954 and 1956. Even though per capita consumption increased by about 15% during this time period, the main explanation seems to be that there was a redistribution of consumption. Analyses of survey data on alcohol intake before and after abolition indicate that it was mainly heavy drinkers who increased their consumption, while the intake of moderate and light drinkers changed little [1]. In order to dampen consumption alcohol taxes were gradually increased, to the effect that by 1958 the real price of spirits—the dominant beverage—had increased by almost 50%. High alcohol prices became a key instrument in the evolving alcohol policies, but other vital elements from the rationing period were also retained, most importantly the overarching principle of minimizing the private profit motive. One expression of this is the state monopoly for imports, production and retail sales (as well as wholesales to restaurants) of wine, beer and spirits. In addition, other measures were implemented to reduce the availability of alcohol, e.g. in 1982 the closing of monopoly stores on Saturdays. The public health perspective, as presented by Bruun et al. [2], was in fact influential on the formation of alcohol policies from the late 1970s. These policies were also relatively successful; Sweden had (and still has) one of the lowest levels of per capita consumption and alcohol-related harm in western Europe. In the mid-1990s the conditions for Swedish alcohol policies changed radically. All state monopolies in the alcohol field—except for retail sales—were abolished in connection with the European Union (EU) membership negotiations in 1994. This paved the way for a large number of commercial actors, particularly in the wholesale trade. EU membership (1995) further reduced the Swedish national sovereignty to maintain an independent alcohol policy. Alcohol taxes had to be adjusted to the effect that, e.g. beer prices decreased by about 20% in 1997. However, the most important change concerns the quotas for private importation of alcoholic beverages from other EU countries. The quotas have been adjusted upwards gradually so that, after 1 January 2004, in practise there is no upper limit for what a traveller can import, given that the goods are for private use. Because alcohol prices are lower in Denmark and Germany, this has led to a marked increase in the private importation of alcohol. Between 1996 and 2004 legal imports almost trebled and illegal imports quadrupled, as estimated from survey data. This, in turn, has led to political pressure to lower Swedish alcohol taxes. A recent Government Commission thus suggested a 40% cut in the spirits tax [3], although it is still not clear whether this will be realized. It is of interest to note that complete abolition of the quotas was not foreseen as a likely scenario by the time Sweden entered the EU in 1995. For instance, the issue is not treated in the report from an expert group [4] that analysed potential consequences on consumption and harm of the Swedish EU membership. Another cornerstone in restrictive Swedish alcohol policies, that of limited availability, has also eroded. To maintain public support for the retail monopoly, Systembolaget, there has been a marked increase in the number of alcohol shops as well as in opening hours. Saturday opening was implemented in 2001, which led to an estimated 4% increase in sales [5]. Also the number of restaurants licensed to sell alcohol has increased (up 25% during the last decade). The gradual dismantling of the restrictive Swedish alcohol policy has been accompanied by a steep increase in per capita alcohol consumption, from 8 litres in 1996 to 10.4 litres in 2004 (including estimated unregistered consumption). Increasing traveller’s alcohol imports have played a major role in this increase, rising from one-tenth of per capita consumption in 1996 to almost one-third in 2004. Sales at the retail monopoly stores also increased, but due to rising overall consumption their market share has actually fallen to less than 50%. Survey data suggest that men and women as well as most age groups have increased their alcohol consumption. There is some evidence, however, of a more significant increase among women above the age of 50 years, which has been ascribed to the introduction of ‘bag-in-box’ wines in 1996. This package, assumed by some to encourage frequent drinking, has been a huge success in Sweden and today represents more than half of the wine sales at Systembolaget. Practically the entire recent rise in consumption is due to increased wine and beer consumption, whereas the intake of spirits has remained stable. This means the acceleration of a long-term change in Swedish drinking patterns which had already started in the 1950s, where spirits have gradually been replaced by beer and wine. While spirits comprised about 70% of total consumption in 1955 it was only approximately one-fourth in 2004, easily overtaken by both wine and beer. One might expect that the increasing importance of weaker alcoholic beverages would correspond to a less intoxication-orientated drinking style among Swedes. However, recent data suggest that the frequency of heavy drinking occasions have actually increased since 1996 [3]. In fact, Swedish drinking patterns stand out in international comparisons, with few drinking occasions but a high frequency of heavy drinking occasions both in the adult population [6] and among young people [7]. It is not customary to consume alcohol during ordinary weekdays, and most of the drinking in Sweden takes place during weekends. Sweden also has certain national holidays when the frequency of heavy drinking is notably high, the Midsummer celebrations being the most distinct example. These festivals are accompanied by peaks in alcohol-related harm, particularly alcohol poisonings and alcohol-related violence. The low level of per capita consumption has been the main reason for the fact that Sweden ranks low in international comparisons of alcohol-related diseases, e.g. liver cirrhosis [8]. A distinguishing Swedish experience is, however, an unusually strong relationship between per capita consumption and alcohol-related harm. Several studies have demonstrated that an increase in consumption by 1 litre per capita is associated with larger increases in various forms of alcohol-related mortality (liver cirrhosis, accidents, suicide, homicide and all-cause mortality) in Sweden (as well as in Finland and Norway) than in other western European countries [9]. There is as yet no convincing explanation for this Swedish anomaly, but the detrimental Swedish drinking style is one possible candidate. Given the strong link between population drinking and harm, a marked increase in harm rates should have been expected in response to the increase in consumption during the last decade. However, the available data hardly confirm this expectation; most forms of alcohol-related mortality have remained fairly stable between 1995 and 2003 (the last year available) [10]. There is probably no single explanation for this unexpected scenario. One hypothesis is that it is moderate rather than heavy drinkers whose consumption has increased. The premise underlying this hypothesis is that a good half of the increase in consumption is due to imports by people travelling abroad, a category which is more likely to be dominated by moderate drinkers. In a similar vein, there might have been a shift in drinking patterns in the way that the increased consumption is spread more evenly over weekdays. Yet another explanation is improved medical treatment (liver transplants) and the introduction of new medicines that reduce the craving for alcohol. However, all these possible explanations are little more than speculations that are difficult to test against hard data. It should also be noted that some harm indicators have increased as expected, for instance assaults and fatal accidents for men. Both these indicators are, however, influenced by many other factors than alcohol. Alcohol consumption, and the potential harms arising from it, maintains a major concern in Sweden although policy makers have to adjust to the new situation where traditional tools, such as the price instrument, have become inapplicable. Thus, in the current national action plan for alcohol initiated in 2001 there was a clear shift in emphasis towards developing preventive measures at the municipal level and to promote international cooperation. The title of the recent governmental commission with focus on problems connected with private imports is actually a good illustration of the new Swedish situation: ‘Borderless challenge—alcohol policy in a new era’[3]. Swedish alcohol policy is still very restrictive in an international perspective. For instance, Sweden has one of the strictest drinking and driving regulations in the world with a legal blood alcohol concentration (BAC) level of 0.02%. Further, the retail monopoly is still in existence and has support both at political and public levels. Recent polls from 2005 even suggest that the popularity of the monopoly was strengthened after a decline associated with a scandal revealed in 2003, where shop managers were accused of taking bribes from suppliers. Keeping the monopoly implies continuous restrictions in opening hours and sales to minors, and not least a symbolic reminder of the fact that alcohol should not be defined as an ordinary commodity. There are also some recent proposals in a restrictive direction, for example to increase the drinking age to 20 years in licensed premises and to limit opening hours in licensed premises. It is, however, uncertain whether public support will suffice to keep the last Swedish alcohol monopoly in a world where free trade is the dominant ideology. Internet trading with alcohol has become a new legal dispute and has been brought to the EU court. A decision will be given in the spring of 2006, and is of crucial importance for future Swedish alcohol policy. If this decision implies that alcohol purchased over the internet would not be taxed in Sweden, internet trade will suddenly make it easy for Swedes to order cheap alcohol from other countries and have it delivered to their homes. Obviously, such a change would further weaken the effectiveness of remaining restrictions on availability and price. In fact, if a more restrictive alcohol policy is not realized within the EU, for instance regarding alcohol taxes, there will be further pressure towards lower alcohol prices in Sweden, and also in the other Nordic countries. It is therefore important that Sweden forms alliances with other countries in order to encourage a development where alcohol policy is taken more seriously within the EU. A step in this direction was taken in October 2004, when all Nordic Health Ministers called for a reduction of the limit for traveller’s alcohol imports and increasing alcohol taxes within the EU. However, experience so far indicates that there is a long way to go before any tangible change in this direction is reached.