Absinthe--Is Its History Relevant for Current Public Health?

Martijn Huisman; Johannes Brug; Johan Mackenbach

Disclosures

Int J Epidemiol. 2007;36(4):738-744. 

In This Article

Is There Something to Be Learned from the Absinthe Case?

What we can learn from the example of absinthe in France (and by later experiences with smoking), is that social inequalities in health as a result of inequalities in health-related behaviours -- especially substance use -- should be prevented when epidemics of such behaviours are identified in their early phases, before they have become fully diffused into the lower social strata. With regard to smoking in many Western European countries we have already missed the boat. But in other countries, a lot of socioeconomic inequalities in smoking, and hence in smoking-related ill health, can still be prevented![20] Also, applying an equity approach in reaction to the obesity epidemic in western countries may prevent increasing inequalities in obesity related ill health in the future.

A related lesson that can be drawn from the absinthe experience is that once such behaviours become fully entrenched in our culture and economy, they become increasingly unlikely to be tackled by short-term, decentralized, approaches aimed at downstream factors. It took massive effort before France was ready to put the ban on absinthe and for this it required the 'help' of the powerful wine industry, the threat of war (absinthe was banned during World War I) in combination with the fear of degeneration of the population, and several decennia of efforts to promote anti-absinthe attitudes and norms. Thus, the ban was as much a result of complex social and political changes as it was the result of targeted efforts by politicians and doctors. Besides, as long as no attention is paid to the underlying stress of being at the bottom of the social hierarchy such apparent successes are likely to be offset by increases in other compensating behaviours that may be equally bad for people's health.

We also want to stress that public health efforts geared towards tobacco use have improved in important respects as compared with similar efforts in the absinthe era. Some of the weapons that were vigorously employed in the anti-absinthe movement in France as well as in the anti-tobacco movement in Nazi Germany were fear appeals and anti-absinthe and anti-tobacco advertising. Examples of anti-absinthe advertising were posters of skulls shouting: 'Absinthe it's death!' (Figure 2), and posters with a bottle of absinthe stating: 'Alcohol, that's the enemy!' (Figure 3). Such forms of advertising were forwarded by the blue cross, the French temperance league movement. It is difficult to assess now what effect these campaigns of the temperance league really had; but we should probably see these anti-absinthe advertisements as being part of a larger, national process of raising awareness of the dangers that were thought to go hand in hand with widespread absinthe use, and promoting more negative social norms against it. Such fear appeals have also been used presently in anti-smoking messages, most notably in the Canadian experience with shocking colour pictures on cigarette packages.[47] But these have been employed in tandem with successful efforts to inform the public about the deleterious effects of smoking,[48,49] and, in reaction to insights from the psychological literature,[50] are also accompanied by messages about where to get help with quitting smoking. This indicates a more humane approach toward improving public health.

Absinthe, it's death!

Alcohol! Behold the enemy

On the other hand, the effectiveness of such approaches have been questioned. And it can be considered surprising that we do not have enough convincing empirical evidence about their effectiveness, even though such types of measures have been employed for decades -- at least since the absinthe era. On the contrary, Proctor[32] indicates that the prevalence of cigarette consumption during Nazi rule kept rising, despite heavy use of anti-tobacco advertising and messages on packages, indicating that at that time they did not have any positive effect on reducing the number of smokers at all. Such measures are nonetheless being advocated as being among the main pillars of the tobacco control effort.

Presently, the successes in tobacco control are attributed to the comprehensive approach combining anti-tobacco health education campaigns, personalized help aimed at smoking cessation, as well as rules and regulations on smoking bans and tobacco taxation.[51] A comprehensive set of measures and social changes has eventually resulted in the reductions in absinthe use, and such an approach is now also advocated to fight the present day obesity epidemic.[52]

Yet, it apparently has not been fully realized that an equity approach is necessary in efforts to reduce smoking, judging from the lack of information about interventions that can help us reduce smoking in lower socioeconomic groups specifically,[53,54] even though we should have been aware of the continuous link between poverty and social disadvantage with public health threats. This can be gathered indirectly too from the recent green paper of the European Commission on policy options related to making Europe 'tobacco free'. The subsection on estimated effects of proposed policy on social equity just contains a very general statement that '[...] an action on smoke-free environments might be expected to bring the biggest benefits to the most deprived groups in society'.[34] Furthermore, while the whole 'green paper' is thoroughly referenced throughout, there is no reference to be found in the subsection on social equity. Attempts to close this gap in the evidence base are among the first steps that should be taken by public health researchers. Not only because these can help us reduce social inequalities in smoking in the near future, but also because they might bear wider relevance, and might be extended to other current (the obesity epidemic) and future socially patterned threats to public health.

Thus, current public health officials and researchers, where possible should focus their attention on preventing the rise of social inequalities in smoking and in obesity, and they should put more emphasis on taking an equity approach in interventions where social inequalities have already arisen. It should be realized that interventions aimed primarily at the proximate will not have lasting public health benefits in the long run, because these do not target underlying social causes. Research can still be much better geared towards providing policy makers with the necessary tools for these purposes, e.g. by rigorous evaluation of measures that currently constitute an important share of policies (such as health-warnings and graphic images on tobacco packages) and by estimation of the effects of designed and implemented intervention studies and policies on different social groups.

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