Normalization of non‐drinking and implications for alcohol epidemiology

Normalization of non-drinking may be regarded as a process in which non-drinkers also become a less deviant group, not only in the statistical sense. The implications for alcohol epidemiology are highly important.

There is a growing literature on the declining trend in adolescent drinking in many countries. With their recent article, Caluzzi and colleagues [1] provide an important contribution to this literature by discussing concepts and processes underlying this trend. One key point in their article is that the process of normalization of non-drinking implies that abstinence comes to be seen as a normal and accepted practice. In addition to this, I will argue that normalization of non-drinking may be regarded as a process in which non-drinkers also become a less deviant group, not only in the statistical sense. The implications for alcohol epidemiology are highly important.

In populations where drinking is the norm and only a small minority are non-drinkers, abstainers tend to deviate from their drinking peers by having poorer social network and/or poorer mental health [2-6]. Whether or not this association reflects causality in one direction or another remains unclear. On one hand, it is suggested that those with small social networks and weak ties are less influenced by the drinking norms of the large majority and therefore less likely to drink [7]. In other words, a poor social network may cause non-drinking, due to lack of someone to drink with and lack of social occasions where drinking occurs. On the other hand, it is also suggested that abstinence may lead to a weaker social network and that the cost of being abstinent could be social isolation [8]. In either case, this association seems to reflect the co-occurrence of socially deviant and low-prevalence phenomena, much in line with the idea of individual clustering of problem behaviours [9].

What about populations where non-drinking is normalized and prevalent, which is currently the case for young people in many high-income countries? Here, we may expect that abstainers do not differ from their moderate-drinking peers with regard to social integration and mental health, simply because co-occurrence of marginal phenomena does not apply. There is some empirical evidence to support this expectation. An association between abstinence and loneliness was observed among adults in three countries where abstinence was low prevalence, whereas no such association was found in another country where abstinence was more common [10]. Correspondingly, the association between psychosocial problems and substance use among adolescents was moderated with prevalence of substance use; in populations with low prevalence, the association was stronger than in populations where such use was more widespread [11, 12]. Thus, the substantial increase in non-drinking prevalence among young people may well have been accompanied by a change in psychosocial correlates. However, further examinations into this issue are clearly needed.

This leads us to the important debate in alcohol epidemiology over the J-shaped associations between alcohol consumption and several health outcomes. In short, numerous observational studies reported a lower risk of various health problems among moderate drinkers compared to non-drinkers, even after control for some confounding factors [13]. Most such studies were conducted in affluent societies and in populations where drinking is highly prevalent, and control for social factors, including social network and integration, were apparently often omitted [14]. Notably, poor social network and social isolation are strongly associated with various health outcomes [15, 16] and it therefore seems likely that the observed J-shaped associations to some extent can be attributed to such confounding. Thus, the trend towards normalization of non-drinking in affluent countries could imply availability of population samples with less selection bias and less unobserved confounding of the alcohol–harm associations. If so, this would be of particular importance if the trend continues beyond adolescence and non-drinking also becomes a normal and accepted practice in adult age.

To this end, the question of whether the normalization of non-drinking in adolescence will actually continue into adulthood is still under-researched. However, a few studies [17, 18] found that the decline in adolescent drinking was mainly accompanied by a delayed onset of drinking. Thus, in the current situation, abstinence is not yet a widespread normalized and accepted practice among adults in most affluent societies, which is also where the major bulk of alcohol epidemiology studies are conducted.

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