Skip to main content
Download PDF
Download ePub

Improving alcohol health literacy and reducing alcohol consumption: recommendations for Germany

Addiction Science & Clinical Practice volume 18, Article number: 28 (2023) Cite this article

Abstract

Background

Although the detrimental health effects of alcohol are well established, consumption levels are high in many high-income countries such as Germany. Improving alcohol health literacy presents an integrated approach to alcohol prevention and an important complement to alcohol policy. Our aim was to identify and prioritize measures to enhance alcohol health literacy and hence to reduce alcohol consumption, using Germany as an example.

Methods

A series of recommendations for improving alcohol health literacy were derived from a review of the literature and subsequently rated by five experts. Recommendations were rated according to their likely impact on enhancing (a) alcohol health literacy and (b) reducing alcohol consumption. Inter-rater agreement was assessed using a two-way intra-class correlation coefficient (ICC).

Results

Eleven recommendations were established for three areas of action: (1) education and information, (2) health care system, and (3) alcohol control policy. Education and information measures were rated high to increase alcohol health literacy but low to their impact on alcohol consumption, while this pattern was reversed for alcohol control policies. The ratings showed good agreement (ICC: 0.85–0.88).

Conclusions

Improving alcohol health literacy and reducing alcohol consumption should be considered complementary and become part of a comprehensive alcohol strategy to curb the health, social, and economic burden of alcohol.

Background

Alcohol consumption is prevalent in most middle- and high-income countries [1] and related to a wide set of health, social and economic consequences [2,3,4]. Several recent modelling studies have suggested that improved alcohol management in primary health care and increased alcohol taxation would have sizeable impacts on consumption and health consequences [5,6,7]. With few exceptions, most countries make little to no progress in reducing alcohol consumption and its consequences, contrasting international goals to lower alcohol consumption [8].

According to the World Health Organization, the availability and affordability of alcoholic beverages are key determinants for alcohol use [9]. Theoretically, lawmakers can restrict these two domains relatively easy but it needs to be acknowledged that the implementation of alcohol control policies require public and political support. A 2015 European survey showed that alcohol control policies which restrict the availability and affordability of alcoholic beverages were found to be more acceptable in countries where such policies are already implemented and among people who abstain from alcohol use [10]. Moreover, knowledge of alcohol use as a risk factor for cancer predicts support for alcohol control policies [11, 12]. Thus, in order to achieve a sustainable reduction of alcohol consumption and attributable harm, it seems prudent to change not only the physical (i.e., availability and affordability), but also the social environment (i.e., norms) as well as the individual risk perception.

Alcohol health literacy (AHL) can serve as a vehicle to consider all relevant determinants for a sustainable reduction of alcohol use. The core attributes of AHL lie in the individual and have been described as the capacity „to obtain, process, and understand knowledge about alcohol content, units, strengths, and harms” [13]. This explicitly covers the knowledge of health risks, but also the understanding of standard drinks, which is a precondition to pour alcoholic drinks according to the desired amounts. Thus, AHL is a specific category of a general health literacy concept, which is commonly defined as “the motivation, knowledge and competencies to access, understand, appraise and apply health information in order to make judgments and take decisions in everyday life” [14].

According to a literature-driven theoretical conceptualization of AHL [13], the core AHL attributes as described above are embedded in social and systemic environments—called antecedents—which determine the individuals’ AHL: social norms (social environment) but also labels on alcoholic beverages, health care and educational systems (systemic environments) can work as facilitators or as barriers for establishing low-risk alcohol use patterns or abstinence. Lastly, AHL explains individuals’ decision to drink or not to drink and predicts health outcomes, which are conceptualized as AHL consequences (see Fig. 1).

Fig. 1
figure 1

Conceptualization of Alcohol Health Literacy, adapted from [13]

Full size image

Given the insufficient progress in reducing alcohol use and consequences and the relevance of AHL to achieving these aims, this contribution aimed to identify and prioritise measures to (a) increase AHL and (thereby) (b) lower alcohol consumption.

We chose Germany as a possible target for these measures given several reasons: First, per capita alcohol consumption in Germany is well above the global as well as European average [1] and the population experiences high levels of alcohol-attributable morbidity [15] and economic burden [16]. Second, Germany has not made any progress in the implementation of alcohol control policies in the past decades. While other European countries have successfully cut alcohol consumption by implementing strict alcohol control policies (see e.g., [17,18,19]), Germany underperforms in several alcohol policy domains, such as availability and marketing [20]. Third, the importance of public support for the sustainability of policies could be observed in the German federal state Baden-Württemberg. Despite achieving the intended effects of reducing hospitalisations among youth, a ban of nighttime sales hours was introduced in 2010 and then lifted in 2017 after a change in the government [21]. Fourth, general health literacy is considered to be low in Germany—in particular among vulnerable groups [22]—but there appears to be little empirical evidence with regards to the manifestation of AHL in the German population.

Methods

To identify measures that improve AHL and/or lower alcohol consumption, the following three areas of action were considered: education, health care and policy. These three areas reflect the determinants for developing AHL, as described in Fig. 1. Specifically, we generalized the four antecedents and derived the three areas of action that are relevant for developing AHL and/or for reducing alcohol consumption.

For each of the three areas, the lead and last author searched for measures that have been empirically linked to either improved awareness of alcohol health risks or decision-making, i.e., changes in alcohol consumption. This involved a brief search on PubMed for systematic reviews and meta-analyses using keywords describing the measure of interest (e.g., availability). Additional studies were identified through input from the experts. In addition to empirically validated measures, we also considered the environment that constitutes a precondition to the success of other measures, for example the resources required to improve health care provision.

For a two-stage survey, we invited five experts (GR, SRH, IS, GS, RS) to (1) review the recommendations and (2) rate the recommendations with regards to the likely impact on (a) improving AHL and (b) reducing alcohol consumption. In the first stage, the experts were not only given the opportunity to refine the recommendations but also to provide additional measures that were not covered in the presented list. In the second stage, the experts were asked to rate the list of recommendations with respect to the expected impact on AHL and alcohol consumption on a scale from 1 (no impact) to 10 (very high impact). The selection of the five experts was driven by the consideration to include persons with long-standing research activities in the field of health literacy and addiction, as well as expertise in prevention and therapy. We also aimed to include both national and international expertise and a balanced gender distribution. No invited expert declined to participate in this exercise.

To evaluate the inter-rater agreement of the five experts for the final list of recommendations, a two-way intra-class correlation coefficient (ICC) was calculated with the ICC function of the ‘psych’ package [23] in R version 4.1.2 [24]. The measure of agreement indicates the proportion of variance in the ratings explained by the variation across raters. We do not assume a generalization of the sampled experts to a larger population of experts, which is why the raters were treated as fixed effect according to the recommendations by Shrout and Fleiss [25].

Results

We identified eleven recommendations to strengthen alcohol health literacy and to reduce alcohol consumption in Germany that are summarized in Fig. 2. They are described below, separately for the three areas of action. For each recommendation, we cite key studies as example and highlight the aspects that need to be taken into account in order to achieve the intended effects.

Fig. 2
figure 2

Overview of the eleven recommendations to strengthen alcohol health literacy and to reduce alcohol consumption, grouped by their area of action. The recommendations partly address different target groups regarding age, indicated by the arrow in the bottom of the visualisation

Full size image

AREA 1: education and information measures

The recommendations concerning measures related to education and information are summarized in Table 1.

Table 1 Summary of recommendations related to education and information
Full size table

#1 Implement effective alcohol prevention programs in schools

School-based alcohol prevention programs can be delivered by teachers or peers and may involve individualized interventions, role plays or internet content [26]. On review of the international literature, the effectiveness could not be established for many programs, but the “Unplugged” program has been singled out as good-practice for Europe, which focusses on knowledge and skills in a series of 12 sessions delivered over 1 year ([26], see also https://www.eudap.net/). Moreover, there are promising effects of web-based programs (although recent technological advances are not yet captured in the literature [27]). A good practice example from Germany is the program “Klar bleiben” (German for “stay clear”). In this intervention, students commit themselves to avoid engaging in heavy episodic drinking for a period of 9 weeks, in addition to discuss alcohol-related topics in four sessions (norms, motives, marketing, expectancies and consequences) [28].

For this recommendation, we refer to programs with established efficacy with regards to knowledge, skills, consumption and/or health outcomes. Such programs often contain modules that demonstrate how health risks depend on the amount of alcohol consumed or modules aiming to build skills for dosing alcohol as desired (e.g., understand how alcohol content and pouring size are related via the concept of standard drinks). Some of these programs also include modules to critically reflect on alcohol advertising (e.g. [28]), which are also called alcohol media literacy trainings [29]. Importantly, the programs need to be tailored to the pupils’ age in order to formulate appropriate aims (foster moderate drinking for older vs delaying onset of use for younger) and methods.

#2 Provide easily-accessible information about alcohol use

Access to accurate information on alcohol use and health implications is a prerequisite for developing AHL but the impact will depend on a number of factors. Public educational campaigns are a key measure here. While effects are generally difficult to establish, two separate campaigns have been related to increased awareness of alcohol as cancer risk factor and elevated support for alcohol control policies [30, 31]. In Germany, the widely known and ongoing campaign “Kenn dein Limit” (German for “Know your Limit”; [32]) informs people about the health risks of alcohol and calls for moderating one’s use mostly via public information materials, short educational videos, and a campaign website.

It should be noted that educational campaigns are very limited in the amount of information they can convey. Accordingly, they need to be diversified in their modalities including interactive formats (e.g., chatbots) to ensure a wide reach and higher engagement and should be accompanied by a resource pool (e.g., on the campaign website) that can be easily accessed by recipients for further information.

#3 Provide information material in simple language as well as in other languages than German, including but not limited to the internet

Currently, there is limited alcohol-related information (health risks, explanation of standard drinks) in simple language, or languages other than German, from official sources. In order to reach disadvantaged populations, e.g., people with low literacy, and populations with a first language other than German, such information should be tailor made to reflect their needs.

#4 Health labels on containers of alcoholic beverages

There are promising outcomes of visible and easy-to-understand warning labels with regards to increasing knowledge of health risks [33] as well as reducing alcohol sales [34]. The impact of health labels on knowledge of the alcohol-cancer link was also found to be linked to elevated support for alcohol control policies [35]. Furthermore, labelling can facilitate the understanding of standard drinks and improve skills for accurate pouring, but should be accompanied by additional educational initiatives to ensure that skills are adequately built (see recommendation #1; [36, 37]). Also, communication of health risks should be accompanied by messages that increase self-efficacy [38], and labels should be tested for acceptability among drinkers prior to being implemented to ensure efficacy (e.g. [39, 40]). Lastly, this recommendation is in line with Europe’s Beating Cancer Plan, through which the European Commission plans to adopt a proposal for health warnings on alcoholic beverages [41].

AREA 2: Health care system measures

The recommendations concerning health care system measures are summarized in Table 2.

Table 2 Summary of recommendations related to the health care system
Full size table

#5 Alcohol screenings and subsequent feedback/ intervention in routine health checks for persons aged 35 years or older (financed by statutory health insurance)

Screening for high-risk alcohol use using short, standardized instruments like the three-item version of the Alcohol Use Disorder Identification Test is recommended by the German Guidelines on Screening, Diagnosis and Treatment of Alcohol Use Disorders (high-risk definition according to guideline: women  ≥ 12 g / men  ≥ 24 g pure alcohol intake per day [42]). While alcohol screening is rarely conducted in German primary health care settings, increased screening activities have the potential to lower population-level alcohol consumption [43]. There is already a routine health checkup for adults aged 35 and older [44] and alcohol should be added to this checkup.

While screening in itself may not foster AHL, it facilitates a conversation on health risks and possibly referral to specialist treatment if screened positive. Interventions subsequent to screening may be based on a continuum of alcohol health risk rather than a binary disease model, to increase problem recognition in patient populations [45]. For patients screened negatively, the treating physician would usually give positive feedback, which could function as reinforcement for low-risk alcohol consumption and further create a supportive environment for AHL.

#6 Alcohol screenings for persons newly admitted to nursing homes/facilities

As above, routine alcohol screening may serve AHL through various pathways. Routine alcohol screening and subsequent brief interventions are feasible in nursing homes and can be conducted by nurses with additional training. Among older adults, high-risk alcohol use is more often unrecognized [46], however, a small minority of older adults who drink heavily may require specialist care that may not be available in the nursing home. Here, sufficient capacities for supporting the patient in achieving abstinence or other treatment goals [47] are required and should be planned ahead, including medications for withdrawal treatment, as well as psychosocial support [42, 48].

#7 Adequate financing/supply of resources for alcohol screenings and brief interventions in primary health care settings

Routine screening for alcohol use and the delivery of subsequent brief interventions requires a substantial level of capacities in primary health care settings. Previous research has demonstrated that lack of financial incentives constitute a main barrier for alcohol screening and brief interventions [49] and withdrawal of adequate financing was related to a reduction of alcohol screenings in England [50]. Improved financing will not impact AHL directly but is a requirement for recommendation #5 and #6.

#8 Training of primary health care professionals for implementing routine alcohol screenings and brief interventions

In Germany but also most other countries, heavy drinking and alcohol use disorders are not commonly managed in primary health care setting [51, 52]. The importance for routine alcohol screening are often neglected by German primary healthcare professionals, while in other countries, stigma-related barriers appear to be more prevalent [53]. Given this, it is not surprising that the training of health care staff can improve alcohol management [54]. Training may not only increase the alcohol-related knowledge and skills of health care workers but also increase their self-efficacy to bring up this topic with patients. As part of training, protocols for management of acute cases, including acute effects of alcohol withdrawal, need to be developed.

As with recommendation #7, training health care staff is not expected to impact on AHL in the general population directly, but it is a prerequisite for recommendation #5 and #6.

AREA 3: alcohol control policy measures

The recommendations concerning alcohol control policy measures are summarized in Table 3. Importantly, alcohol control policy measures may not directly target the core attributes of AHL which lie within the individual, but they can create a supportive environment facilitating AHL. For example, if students are taught that alcohol is harmful and they should not drink and drive but at the same time alcohol is being sold around the clock at gas stations, this could impair a coherent understanding of alcohol-attributable harms.

Table 3 Summary of recommendations related to alcohol control policy
Full size table

#9 Reduction of the (spatial/temporal) availability of alcoholic beverages

Currently, there are no temporal or geographical restrictions to sell alcoholic beverages in most German jurisdictions. However, a natural experiment conducted in one region in south-west Germany showed that banning late-night off-premises alcohol sales is linked to improved health outcomes and reduced crime [21, 55]. Other (quasi-) experimental studies further show that alcohol consumption increases when the number of days on which alcoholic beverages can be sold is expanded [56]. In addition to temporal restrictions, there is solid evidence that a higher density of alcohol outlets is linked to higher crime rates [57].

#10 Raising alcohol taxes

Increasing alcohol taxes also does not directly target the core attributes of AHL. As with reduced availability, increasing retail prices by increasing taxes is expected to result in reduced consumption and improved health [58, 59]. Currently, alcohol taxes in Germany are among the lowest in Europe [60], resulting in alcoholic beverages to be more affordable in Germany than in most other countries [61]. To justify a hike in retail prices driven by tax increases, policymakers would likely refer to the health risks carried by alcoholic beverages—a similar reasoning as employed by the European Commission [41]. A public debate involving alcohol-related health risks may facilitate a supportive environment for developing AHL.

#11 Bans on alcohol advertising

Banning advertising for alcoholic beverages does not directly target the core attributes of AHL. While the evidence is not clear that a ban is directly impacting on alcohol use among adults [62], it can be reasonably assumed that alcohol marketing is facilitating underage alcohol use, e.g. by creating positive social norms regarding alcohol use [63]. In addition to positive effects on consumption, a marketing ban would reduce the need for critical thinking (e.g., deconstructing the marketing intent) resulting in less interference in individuals decision-making process (i.e., more direct transfer of knowledge to behavior).

Expert rating of the recommendations

Each expert rated each of the eleven recommendations with regards to the likely impact on AHL and alcohol consumption on a scale of 1–10. For both AHL (ICC = 0.88; 95% confidence interval: 0.76–0.96) and alcohol consumption (ICC = 0.85; 95% confidence interval: 0.70–0.94), the ratings showed good agreements. The ratings are summarized in Fig. 3.

Fig. 3
figure 3

Impact of recommended measures on alcohol health literacy (blue bars) and alcohol consumption (red bars), as rated by five experts, by area of action; ASBI Alcohol Screening and Brief Intervention

Full size image

Overall, educational and health care system measures were rated to be most impactful for strengthening AHL. Of all recommendations, the experts highlighted the impact of effective prevention programs in schools (mean: 8.4) as well as the provision of information in simple and other languages than German (mean: 6.8). The three alcohol control policies were rated as least important for strengthening AHL (means between 1.8 and 4.2).

For reducing alcohol consumption, health care system and alcohol control policy measures were prioritized. The most impactful measures were to raise taxes (mean: 8.2) and to reduce the availability of alcoholic beverages (mean: 7.2). A marketing ban and the implementation of alcohol screenings and subsequent interventions in health check-ups for persons aged 35 or older were perceived as equally impactful (mean: 6.0).

Discussion

In this study, we derived 11 recommendations to increase AHL and to decrease alcohol consumption in the German population. Notably, education-based measures, such as (school-based) prevention programs and health labels were judged to be more effective for raising individual competencies regarding alcohol consumption and harm, but less so for impacting on alcohol consumption itself. Conversely, the experts prioritised alcohol control policy measures, with alcohol taxes believed to be the most effective tool to curb consumption, while they are less likely to impact directly on AHL. While these recommendations were developed for Germany, they are likely to be applicable to other countries with cultural and economic similarities, such as most Central and Western European countries.

Interpretation of the findings

The ratings from the experts suggest that strengthening AHL and curbing alcohol consumption may require two different pathways. While a more restrictive environment (marketing ban, decreased availability, increased taxes) would be expected to reduce alcohol consumption in some populations, it might not necessarily improve AHL, e.g., understanding of health risks or the skills to pour the desired amount of alcohol. Conversely, effective prevention programs and health labels on alcoholic beverage containers would be expected to enhance AHL but this may not necessarily be translated into alcohol use behavior.

This pattern could be interpreted as AHL being an entity that is separate from consumption. It appears that the literature supports this assessment: programs aiming to enhance AHL usually focus on psychological concepts, like awareness or skills (e.g., [29, 30]), while the evaluation of alcohol control policies are usually evaluated using sales figures or health outcomes (e.g., [55, 64]). This apparent distinction could be explained by the intervention aims which are determined by stakeholder interest. Arguably, creators of educational programs are sufficiently humble to not expect that their program will have a noticeable short-term impact on consumption, or they are genuinely more interested in psychological concepts that explain behaviour. Conversely, policymakers may not be interested to know whether risk awareness among alcohol users has increased following a price hike. Yet, if the (long-term) effects of educational programs on consumption are not measured and the role of AHL for the success of stricter control policies is ignored, these two areas of action will remain distinct limiting their potential effectiveness.

While we do not provide empirical evidence that these two areas of research need to be combined but the perceived discreteness of educational programs vs. control policies is contrasting the AHL conceptualization. According to the concept proposed by Okan and colleagues [13], the system level is an antecedent for developing AHL attributes. In other words, an environment conveying that alcohol is not an ordinary commodity but comes with certain social and health risks, should facilitate the learning of adequate cognitions and skills, such as risk awareness and pouring skills. Moreover, greater risk awareness can also pave the way for implementing stricter control policies.

Contrasting these theoretical assumptions, we have very limited empirical knowledge of how the alcohol control policies interacts with education-based measures. It could be conceived that raising alcohol taxes at the same time as launching a large-scale educational campaign (e.g., on risky drinking thresholds) may foster the understanding of alcohol-related health risks and thereby produce stronger effects regarding alcohol consumption than either of the two measures on their own. Based on these considerations, it appears reasonable for researchers to explore opportunities for overcoming the discreetness of these two areas of action in order to maximize the intendend effects.

While we have identified several recommendations that appear feasible for improving AHL and reducing consumption for various parts in the population, there is also some caution warranted that becomes apparent when drawing parallels to achievements regarding tobacco use. Unlike alcohol use, smoking has become considerably less prevalent in Germany in the past decades [65]. This progress likely is the result of a combination of several measures including control policies (e.g., price hikes and restrictions in places allowed to smoke) as well as educational measures (e.g., health warning labels [65]). While this strategy was overall successful, smoking behavior has shifted from populations with higher to populations with lower socioeconomic status [65], resulting in a major cause for health disparities [66]. In fact, it has been argued that strong tobacco control policies may result in stigmatizing those who keep smoking, which could introduce a barrier to healthcare access [67].

Learning from these experiences, we should avoid repeating these errors. On one hand, the tobacco experiences suggests that control policies alone may be more effective among people with higher socioeconomic status and can lead to segregation and thus stigmatization of users. On the other hand, development of health literacy is strongly dependent on resources such as educational and financial background [22]. For example, a major German educational campaign regarding alcohol risks is less commonly remembered by youth with migration background and among those not visiting higher educational institutions [68]. Thus, focussing on strengthening AHL alone may also result in widening the disparities with regards to alcohol use and consequences.

Whilst, unlike tobacco use, alcohol use in everyday life is currently well accepted and prevalent in all age, sex, and educational groups [69], alcohol use disorders are among the most stigmatized conditions, on par with schizophrenia [70]; it is assumed that this is one of the causes for the very low treatment rates for this condition [71]. The stigmatization of people with alcohol use disorders prevents those affected and health care providers engaging in honest and unprejudiced conversations on alcohol use.

Learning from the experience in smoking cessation, we propose that any measure aiming to tackling the societal alcohol burden should result in equitable reductions across socioeconomic groups without stigmatizing people who use alcohol or who have developed alcohol use disorders. Importantly, implementing the measures proposed should be monitored in this regard.

Limitations

The recommendations presented in this study are derived from a non-systematic and undocumented search of the literature. While adjusted and extended based on the experts’ input, we cannot rule out a selection bias. Also, it is possible that the choice of experts involved in this study may have influenced the mean ratings. However, there was overall good agreement between the experts recruited from very different backgrounds, minimizing the risk that another group of experts would have come to a substantially different set of ratings.

Conclusions

To achieve a sustainable improvement of AHL and reduction of alcohol consumption, a comprehensive alcohol strategy is required. Using Germany as an example, we have identified 11 recommendations likely to enhance AHL and to reduce alcohol consumption. Both aims—enhancing AHL and reducing consumption—should be considered complementary and not separately.

Availability of data and materials

The reponses of the experts collected and analysed during the current study are available from the corresponding author on request.

References

  1. Manthey J, Shield KD, Rylett M, Hasan OSM, Probst C, Rehm J. Alcohol exposure between 1990 and 2017 and forecasts until 2030: a global modelling study. Lancet. 2019;393(10190):2493–502.

    Article  PubMed  Google Scholar 

  2. Manthey J, Hassan SA, Carr S, Kilian C, Kuitunen-Paul S, Rehm J. What are the economic costs to society attributable to alcohol use? A systematic review and modelling study. PharmacoEcon. 2021;39:809–22.

    Article  Google Scholar 

  3. Shield KD, Manthey J, Rylett M, Probst C, Wettlaufer A, Parry CDH, et al. National, regional, and global burdens of disease from 2000 to 2016 attributable to alcohol use: a comparative risk assessment study. Lancet Public Health. 2020;5(1):e51–61.

    Article  PubMed  Google Scholar 

  4. Kilian C, Manthey J, Rehm J. Gender differences and the role of social inequality in alcohol’s harm to others in Europe. J Stud Alcohol Drugs. 2020;81(6):762–9.

    Article  PubMed  Google Scholar 

  5. Gredner T, Niedermaier T, Brenner H, Mons U. Impact of reducing alcohol consumption through price-based policies on cancer incidence in Germany 2020 to 2050 - a simulation study. Addiction. 2021;116(7):1677–88.

    Article  PubMed  Google Scholar 

  6. Kilian C, Rovira P, Neufeld M, Manthey J, Rehm J. Potenzielle Auswirkungen erhöhter Alkoholsteuern auf die alkoholbedingte Krankheitslast in Deutschland: Eine Modellierungsstudie. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2022;65:668–76.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Manthey J, Solovei A, Anderson P, Carr S, Rehm J. Can alcohol consumption in Germany be reduced by alcohol screening, brief intervention and referral to treatment in primary health care? Results of a simulation study. PLoS ONE. 2021;16(8):e0255843.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Probst C, Manthey J, Neufeld M, Rehm J, Breda J, Rakovac I, et al. Meeting the global NCD Target of at least 10% relative reduction in the harmful use of alcohol: is the WHO European region on track? Int J Environ Res Public Health. 2020;17(10):3423.

    Article  PubMed  PubMed Central  Google Scholar 

  9. World Health Organization. Addressing alcohol consumption and socioeconomic inequalities: how a health promotion approach can help: Geneva. 2021. https://apps.who.int/iris/bitstream/handle/10665/352515/9789240043312-eng.pdf?sequence=1. Accessed 22 Mar 2022.

  10. Kilian C, Manthey J, Moskalewicz J, Sieroslawski J, Rehm J. How attitudes toward alcohol policies differ across European Countries: evidence from the standardized European alcohol survey (SEAS). Int J Environ Res Public Health. 2019;16(22):4461.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Buykx P, Gilligan C, Ward B, Kippen R, Chapman K. Public support for alcohol policies associated with knowledge of cancer risk. Int J Drug Policy. 2015;26(4):371–9.

    Article  PubMed  Google Scholar 

  12. Bates S, Holmes J, Gavens L, de Matos EG, Li J, Ward B, et al. Awareness of alcohol as a risk factor for cancer is associated with public support for alcohol policies. BMC Public Health. 2018;18(1):688.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Okan O, Rowlands G, Sykes S, Wills J. Shaping alcohol health literacy: a systematic concept analysis and review. Health Lit Res Pract. 2020;4(1):e3–20.

    PubMed  PubMed Central  Google Scholar 

  14. Sørensen K, Van den Broucke S, Fullam J, Doyle G, Pelikan J, Slonska Z, et al. Health literacy and public health: a systematic review and integration of definitions and models. BMC Public Health. 2012;12(1):80.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Schelhase T. Statistische Krankenhausdaten: Diagnosedaten der Krankenhauspatienten 2018. In: Klauber J, Wasem J, Beivers A, Mostert C, editors. Krankenhaus-report 2021: Versorgungsketten—Der Patient im Mittelpunkt. Berlin Heidelberg: Springer Berlin Heidelberg; 2021. p. 405–39.

    Chapter  Google Scholar 

  16. Effertz T, Verheyen F, Linder R. The costs of hazardous alcohol consumption in Germany. Eur J Health Econ. 2017;18(6):703–13.

    Article  PubMed  Google Scholar 

  17. Taht T, Kohler K, Ohov E, Menne B, Zambon F, Nemer L. Estonia advances on SDG achievement by tackling high alcohol consumption through a multi-pronged approach. Eur J Public Health. 2020;30:i45–7.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Anderson P, O’Donnell A, Kaner E, Llopis EJ, Manthey J, Rehm J. Impact of minimum unit pricing on alcohol purchases in Scotland and Wales: controlled interrupted time series analyses. Lancet Public Health. 2021;6(8):E557–656.

    Article  PubMed  Google Scholar 

  19. Štelemėkas M, Manthey J, Badaras R, Casswell S, Ferreira-Borges C, Kalėdienė R, et al. Alcohol control policy measures and all-cause mortality in Lithuania: an interrupted time-series analysis. Addiction. 2021;116(10):2673–84.

    Article  PubMed  PubMed Central  Google Scholar 

  20. World Health Organisation. Trends in alcohol consumption 2016—Germany; 2019. https://www.euro.who.int/__data/assets/pdf_file/0003/402186/ACHP_FS_Germany.pdf. Accessed  25 Feb 2021.

  21. Baumann F, Buchwald A, Friehe T, Hottenrott H, Mechtel M. The effect of a ban on late-night off-premise alcohol sales on violent crime: evidence from Germany. Int Rev Law Econ. 2019;60:105850.

    Article  Google Scholar 

  22. Schaeffer D, Berens EM, Vogt D, Gille S, Griese L, Klinger J, et al. Health literacy in Germany—findings of a representative follow-up survey. Deutsches Arzteblatt international. 2021;118(43):723–8.

    PubMed  PubMed Central  Google Scholar 

  23. Revelle W. psych: procedures for personality and psychological research. 2.1.9 ed. Evanston, Illinois, USA: Northwestern University; 2021.

    Google Scholar 

  24. R Core Team. R: A language and environment for statistical computing. 4.1.2 ed. Vienna, Austria: R Foundation for Statistical Computing; 2022.

    Google Scholar 

  25. Shrout PE, Fleiss JL. Intraclass correlations: uses in assessing rater reliability. Psychol Bull. 1979;86(2):420–8.

    Article  CAS  PubMed  Google Scholar 

  26. Agabio R, Trincas G, Floris F, Mura G, Sancassiani F, Angermeyer MC. A systematic review of school-based alcohol and other drug prevention programs. Clin Pract Epidemiol Ment Health. 2015;11:102–12.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Champion KE, Newton NC, Barrett EL, Teesson M. A systematic review of school-based alcohol and other drug prevention programs facilitated by computers or the internet. Drug Alcohol Rev. 2013;32(2):115–23.

    Article  PubMed  Google Scholar 

  28. Hanewinkel R, Tomczyk S, Goecke M, Isensee B. Prävention des Rauschtrinkens im Jugendalter. Dtsch Arztebl International. 2017;114(16):280–7.

    Google Scholar 

  29. Gordon CS, Howard SJ, Jones SC, Kervin LK. Evaluation of an Australian alcohol media literacy program. J Stud Alcohol Drugs. 2016;77(6):950–7.

    Article  PubMed  Google Scholar 

  30. Christensen ASP, Meyer MKH, Dalum P, Krarup AF. Can a mass media campaign raise awareness of alcohol as a risk factor for cancer and public support for alcohol related policies? Prev Med. 2019;126:105722.

    Article  PubMed  Google Scholar 

  31. Martin N, Buykx P, Shevills C, Sullivan C, Clark L, Newbury-Birch D. Population level effects of a mass media alcohol and breast cancer campaign: a cross-sectional pre-intervention and post-intervention evaluation. Alcohol Alcohol. 2017;53(1):31–8.

    Article  Google Scholar 

  32. Schwarz T, Goecke M. National efforts for alcohol prevention by the Federal Center for Health Education (BZgA). Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2021;64(6):671–8.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Hobin E, Weerasinghe A, Vallance K, Hammond D, McGavock J, Greenfield TK, et al. Testing alcohol labels as a tool to communicate cancer risk to drinkers: a real-world quasi-experimental study. J Stud Alcohol Drugs. 2020;81(2):249–61.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Zhao J, Stockwell T, Vallance K, Hobin E. The effects of alcohol warning labels on population alcohol consumption: an interrupted time series analysis of alcohol sales in Yukon, Canada. J Stud Alcohol Drugs. 2020;81(2):225–37.

    Article  PubMed  Google Scholar 

  35. Weerasinghe A, Schoueri-Mychasiw N, Vallance K, Stockwell T, Hammond D, McGavock J, et al. Improving knowledge that alcohol can cause cancer is associated with consumer support for alcohol policies: findings from a real-world alcohol labelling study. Int J Environ Res Public Health. 2020;17(2):398.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Wettlaufer A. Can a label help me drink in moderation? A review of the evidence on standard drink labelling. Subst Use Misuse. 2018;53(4):585–95.

    Article  PubMed  Google Scholar 

  37. Gold N, Egan M, Londakova K, Mottershaw A, Harper H, Burton R, et al. Effect of alcohol label designs with different pictorial representations of alcohol content and health warnings on knowledge and understanding of low-risk drinking guidelines: a randomized controlled trial. Addiction. 2021;116(6):1443–59.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Wright AJ. The impact of perceived risk on risk-reducing behaviours. In: French DP, Kaptein A, Vedhara K, Weinman J, editors. Health Psychol. Oxford: Blackwell; 2010. p. 111–21.

    Google Scholar 

  39. Vallance K, Romanovska I, Stockwell T, Hammond D, Rosella L, Hobin E. “We have a right to know”: exploring consumer opinions on content, design and acceptability of enhanced alcohol labels. Alcohol Alcohol. 2018;53(1):20–5.

    Article  PubMed  Google Scholar 

  40. Hobin E, Vallance K, Zuo F, Stockwell T, Rosella L, Simniceanu A, et al. Testing the efficacy of alcohol labels with standard drink information and national drinking guidelines on consumers’ ability to estimate alcohol consumption. Alcohol Alcohol. 2018;53(1):3–11.

    Article  PubMed  Google Scholar 

  41. European Commission. Europe’s beating cancer plan. Brussels: European Commission; 2022.

    Google Scholar 

  42. Mann K, Batra A, Fauth-Buhler M, Hoch E, the Guideline Group. German guidelines on screening, diagnosis and treatment of alcohol use disorders. Eur Addict Res. 2017;23(1):45–60.

    Article  PubMed  Google Scholar 

  43. Manthey J, Solovei A, Anderson P, Carr S, Rehm J. Can alcohol consumption in Germany be reduced by alcohol screening, brief intervention and referral to treatment in primary health care? Results of a simulation study. PLoS One. 2021;16(8):e0255843.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  44. Bundesministerium für Gesundheit. Gesundheits-Check-up. 2022. https://www.bundesgesundheitsministerium.de/checkup.html. Accessed  17 Feb 2022.

  45. Morris J, Albery IP, Heather N, Moss AC. Continuum beliefs are associated with higher problem recognition than binary beliefs among harmful drinkers without addiction experience. Addict Behav. 2020;105:106292.

    Article  CAS  PubMed  Google Scholar 

  46. Deutsche Hauptstelle für Suchtfragen. Die Versorgung von Menschen mit Suchtproblemen in Deutschland. Hamm2019. https://www.dhs.de/fileadmin/user_upload/pdf/suchthilfe/Versorgungssystem/Die_Versorgung_Suchtkranker_in_Deutschland_Update_2019.pdf. Accessed 1 Oct 2022.

  47. Mann K, Aubin HJ, Witkiewitz K. Reduced drinking in alcohol dependence treatment, what is the evidence? Eur Addict Res. 2017;23(5):219–30.

    Article  PubMed  Google Scholar 

  48. Manthey J, Lindemann C, Kraus L, Reimer J, Verthein U, Schulte B, et al. The potential effects of an extended alcohol withdrawal treatment programme on morbidity and mortality among inpatients in the German city of Bremen: a simulation study. Subst Abuse Treat Prev Policy. 2020;15(1):1.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Buchholz A, Spies M, Härter M, Lindemann C, Schulte B, Kiefer F, et al. Barrieren und Umsetzungsstrategien für die implementierung der S3-Leitlinie screening diagnose und Behandlung alkoholbezogener Störungen aus Sicht von Behandlern und Betroffenen. Suchttherapie. 2022;23(2):66–76. https://doi.org/10.1055/a-1324-5217.

    Article  Google Scholar 

  50. O’Donnell A, Angus C, Hanratty B, Hamilton FL, Petersen I, Kaner E. Impact of the introduction and withdrawal of financial incentives on the delivery of alcohol screening and brief advice in English primary health care: an interrupted time–series analysis. Addiction. 2019;115(1):49–60.

    Article  PubMed  Google Scholar 

  51. Kastaun S, Garnett C, Wilm S, Kotz D. Prevalence and characteristics of hazardous and harmful drinkers receiving general practitioners’ brief advice on and support with alcohol consumption in Germany: results of a population survey. BMJ Open. 2022;12(9):e064268.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Manthey J, Lindemann C, Verthein U, Frischknecht U, Kraus L, Reimer J, et al. Versorgung von Personen mit riskantem Alkoholkonsum und schwerer Alkoholkonsumstörung in Bremen: bedarfsgerecht und leitlinienkonform? Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz. 2020;63(1):122–30.

    Article  PubMed  Google Scholar 

  53. Hanschmidt F, Manthey J, Kraus L, Scafato E, Gual A, Grimm C, et al. Barriers to alcohol screening among hypertensive patients and the role of stigma: lessons for the implementation of screening and brief interventions in european primary care settings. Alcohol Alcohol. 2017;52(5):572–9.

    Article  PubMed  Google Scholar 

  54. Anderson P, Manthey J, Llopis EJ, Rey GN, Bustamante IV, Piazza M, et al. Impact of training and municipal support on primary health care-based measurement of alcohol consumption in three Latin American Countries: 5-month outcome results of the quasi-experimental randomized SCALA trial. J Gen Intern Med. 2021;36:2663–71.

    Article  PubMed  PubMed Central  Google Scholar 

  55. Marcus J, Siedler T. Reducing binge drinking? The effect of a ban on late-night off-premise alcohol sales on alcohol-related hospital stays in Germany. J Public Econ. 2015;123:55–77.

    Article  Google Scholar 

  56. Sherk A, Stockwell T, Chikritzhs T, Andréasson S, Angus C, Gripenberg J, et al. Alcohol consumption and the physical availability of take-away alcohol: systematic reviews and meta-analyses of the days and hours of sale and outlet density. J Stud Alcohol Drugs. 2018;79(1):58–67.

    Article  PubMed  Google Scholar 

  57. Cameron MP. The relationship between alcohol outlets and crime is not an artefact of retail geography. Addiction. 2022;117(8):2215–24. https://doi.org/10.1111/add.15880.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Wagenaar AC, Tobler AL, Komro KA. Effects of alcohol tax and price policies on morbidity and mortality: a systematic review. Am J Public Health. 2010;100(11):2270–8.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Wagenaar AC, Salois MJ, Komro KA. Effects of beverage alcohol price and tax levels on drinking: a meta-analysis of 1003 estimates from 112 studies. Addiction. 2009;104:179–90.

    Article  PubMed  Google Scholar 

  60. Angus C, Holmes J, Meier PS. Comparing alcohol taxation throughout the European Union. Addiction. 2019;114(8):1489–94.

    Article  PubMed  PubMed Central  Google Scholar 

  61. Kilian C, Manthey J, Neufeld M, Rehm J. Affordability of alcoholic beverages in the European Union. Eur Addict Res. 2023;29(1):63–6. https://doi.org/10.1159/000527096.

    Article  PubMed  Google Scholar 

  62. Siegfried N, Pienaar DC, Ataguba JE, Volmink J, Kredo T, Jere M, et al. 2014 Restricting or banning alcohol advertising to reduce alcohol consumption in adults and adolescents. Cochrane Database Syst Rev. 2014;11:010704.

    Google Scholar 

  63. Sargent JD, Babor TF. The relationship between exposure to alcohol marketing and underage drinking Is causal. J Stud alcohol drugs. 2020;Suppl 19:113–24. https://doi.org/10.15288/jsads.2020.s19.113.

  64. Rossow I. The alcohol advertising ban in Norway: effects on recorded alcohol sales. Drug Alcohol Rev. 2021;40(7):1392–95. https://doi.org/10.1111/dar.13289.

    Article  PubMed  Google Scholar 

  65. Schaller K, Kahnert S, Graen L, Mons U, Ouédraogo N. Tabakatlas Deutschland 2020: Heidelberg: Deutsches Krebsforschungszentrum; 2020.

    Google Scholar 

  66. Stringhini S, Carmeli C, Jokela M, Avendaño M, Muennig P, Guida F, et al. Socioeconomic status and the 25 × 25 risk factors as determinants of premature mortality: a multicohort study and meta-analysis of 1·7 million men and women. Lancet. 2017;389(10075):1229–37.

    Article  PubMed  PubMed Central  Google Scholar 

  67. Bell K, Salmon A, Bowers M, Bell J, Mccullough L. Smoking, stigma and tobacco ‘denormalization’: further reflections on the use of stigma as a public health tool. A commentary on social science & medicine’s stigma, prejudice, discrimination and health special issue (67: 3). Soc Sci Med. 2010;70(6):795–9.

    Article  PubMed  Google Scholar 

  68. Orth B, Merkel C. Der Alkoholkonsum Jugendlicher und junger Erwachsener in Deutschland. Ergebnisse des Alkoholsurveys 2018 und Trends. Köln: Bundeszentrale für gesundheitliche Aufklärung; 2019.

    Google Scholar 

  69. Pabst A, van der Auwera S, Piontek D, Baumeister SE, Kraus L. Decomposing social inequalities in alcohol consumption in Germany 1995–2015: an age-period-cohort analysis. Addiction. 2019;114(8):1359–68. https://doi.org/10.1111/add.14616.

    Article  PubMed  Google Scholar 

  70. Kilian C, Manthey J, Carr S, Hanschmidt F, Rehm J, Speerforck S, et al. Stigmatization of people with alcohol use disorders: an updated systematic review of population studies. Alcohol Clin Exp Res. 2021;45(5):899–911.

    Article  PubMed  Google Scholar 

  71. Mekonen T, Chan GCK, Connor J, Hall W, Hides L, Leung J. Treatment rates for alcohol use disorders: a systematic review and meta-analysis. Addiction. 2021;116(10):2617–34.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

We acknowledge the support of Ms Sinja Klinger in conducting the expert surveys and reviewing the literature.

Funding

Open Access funding enabled and organized by Projekt DEAL.  Further, we acknowledge financial support from the Open Access Publication Fund of UKE – Universitätsklinikum Hamburg-Eppendorf – and DFG – German Research Foundation. This work was supported by the German Ministry of Health (Z36-04814-01/005). GR is funded by the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) North East and North Cumbria (NIHR200173). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

Author information

Authors and Affiliations

  1. Center for Interdisciplinary Addiction Research (ZIS), Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf (UKE), Martinistraße 52, 20246, Hamburg, Germany

    Jakob Manthey & Ingo Schäfer

  2. Department of Psychiatry, Medical Faculty, University of Leipzig, Semmelweisstraße 10, 04103, Leipzig, Germany

    Jakob Manthey & Georg Schomerus

  3. Department of Health Promotion, CAPHRI Care and Public Health Research Institute, Maastricht University, POB 616, 6200 MD, Maastricht, The Netherlands

    Daša Kokole

  4. Public Health Sciences Institute, Campus for Ageing & Vitality, Westgate Rd, Newcastle Upon Tyne, NE4 6BE, UK

    Steffi Riedel-Heller

  5. Institute of Social Medicine, Medical Faculty, Occupational Health and Public Health (ISAP), University of Leipzig, Philipp-Rosenthal-Str. 55, 04103, Leipzig, Germany

    Gill Rowlands

  6. Institute for Psychology, University of Hildesheim, Universitätsplatz 1, 34414, Hildesheim, Germany

    Renate Soellner

  7. Centre for Addiction and Mental Health (CAMH), Institute for Mental Health Policy Research (IMHPR), 33 Ursula Franklin Street, Toronto, ON, M5S 2S1, Canada

    Carolin Kilian

Authors
  1. Jakob Manthey
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Daša Kokole
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Steffi Riedel-Heller
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Gill Rowlands
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Ingo Schäfer
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Georg Schomerus
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Renate Soellner
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Carolin Kilian
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Conceptualization: JM; methodology: JM, CK; software: JM; validation: JM, CK; formal analysis: JM; investigation: all authors; resources: N/A; data curation: N/A; writing—original draft: JM; writing—review & editing: all authors; visualisation: JM, CK; supervision: JM; project administration: JM, CK; funding acquisition: JM, CK. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Jakob Manthey.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Manthey, J., Kokole, D., Riedel-Heller, S. et al. Improving alcohol health literacy and reducing alcohol consumption: recommendations for Germany. Addict Sci Clin Pract 18, 28 (2023). https://doi.org/10.1186/s13722-023-00383-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s13722-023-00383-0

Keywords

Addiction Science & Clinical Practice

ISSN: 1940-0640