This thesis consists of three self-contained essays on the economics of alcohol demand. Chapter 2 examines the price elasticity of demand for alcohol across the drinking distribution, using household expenditure data to test whether heavy drinkers respond the same as light drinkers to price increases. Both conditional and unconditional quantile regression are used to compare results generated by the two different methods. The chapter finds that when price increases, heavier drinkers decrease consumption proportionately less than lighter drinkers whilst substituting more towards lower quality beverages. This is an important result since it shows that price-based policies may have little effect in reducing heavy consumption whilst creating large welfare losses for moderate drinkers. Chapter 3 uses several different methods including the Tobit and Double-Hurdle models to estimate the mean price elasticity of demand for alcohol. In doing so, it tests how the price elasticity estimates can differ depending on model choice, even when the same data is used. Household expenditure data contains a large number of households who do not purchase any alcohol, for three distinct reasons: price reasons, non-price reasons, and infrequent purchase. A double-hurdle model is developed which can accommodate all three types of non-purchase. The results suggest that, compared to the double-hurdle model, the frequently-used Tobit model produces larger absolute estimates of the price elasticity of demand for alcohol. The double-hurdle model is the preferred specification since it incorporates all reasons for zeros in alcohol expenditure. Chapter 4 explores changes in alcohol consumption across the lifecourse using a large number of waves of a cross-sectional survey, the General Household Survey, to create synthetic cohorts. Whilst the existing literature looks at how the mean consumption differs across birth cohorts, this chapter instead looks at different quantiles of the drinking distribution to examine whether the changes are consistent across all drinkers, including abstention. This is important because it shows how the alcohol consumption distribution has changed across time, age and birth cohort. It finds that generally, alcohol consumption decreases both as age increases and in older birth cohorts. Alcohol consumption by females has particularly changed; younger birth cohorts drinking much more than their parents’ cohorts did, yet younger birth cohorts are also more likely not to drink at all. Whilst these chapters can be considered stand-alone essays, they are also linked and show how different and cutting edge techniques, applied to the best available data, can be used to show new and interesting results which can aid policymakers and policy decisions.

Theories of family functioning in the context of problem drinking suggest that the family system becomes organised to differing degrees to accommodate an alcohol dependent member, and this organisation influences the expression of addictive behaviour as well as family process. This interconnectivity means that changes in drinking behaviour have consequences that reverberate beyond the individual into the family space. This project focuses on a very specific point in the life cycle of such families – when the alcohol dependent member enters residential treatment. It aims to understand (1) whether the state of family relationships at treatment entry is associated with patient outcome and (2) whether changes occur in family relationships across the rehabilitation process. Two studies addressed these questions. First, a quantitative study of family process across the treatment and follow-up period was conducted. Alcohol inpatients were asked to complete measures of family and individual functioning before, during and after treatment to detect change in key variables and investigate baseline predictors of outcome. Second, a qualitative interview study explored families' own experiences of residential rehabilitation post-discharge. Grounded theory was used to identify common themes and processes. Results from these studies suggest that the family context is indeed a relevant consideration during residential rehabilitation. Patients’ satisfaction with their family relationships was predictive of treatment drop-out, and families themselves experienced considerable change during the transition to sobriety. In consequence, it is proposed that a more systemic view of alcohol dependence and recovery at point of treatment would benefit both patients and their family members.

A conceptual review of the literature highlighted the need to propose a new definition of binge drinking and explore the role of emotional distress, dispositional coping and thought control processes in the maintenance of problem drinking. Binge drinking was redefined as a clinical condition that must satisfy the following three criteria: a) binge drinking is undertaken in discrete periods of time; b) the amount of alcohol consumed is excessive in comparison with the person's usual pattern; and c) the effects of binge drinking cause clinically significant distress or interference with the person's social, occupational or other important areas of functioning. A clinical sample of Binge Drinkers (n=18), Non-Binge Drinkers (n=33) and a sample of Non-Problem Drinkers (n=27) were compared on measures of emotional distress (BDI, Beck, Rush, Shaw & Emery, 1979, BAI, Beck, Epstein, Brown & Steer, 1988), coping (CISS, Endler & Parker, 1990) and thought control (TCQ, Wells & Davies, 1994). The results revealed that Binge Drinkers were significantly less depressed than Non-Binge Drinkers, although both groups were more depressed than Controls. Binge Drinkers did not differ from Non-Binge Drinkers on measures of anxiety or coping. However, both reported higher levels of anxiety and utilized more emotion-focused coping strategies when compared with the Controls. Finally, the Binge Drinkers tended to use fewer social control strategies for controlling their unwanted thoughts. Conversely, the Non-Binge Drinkers tended to adopt distraction strategies for managing their unpleasant thoughts. The clinical and research implications are critically discussed.

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The negative individual and social impacts of alcohol consumption raise a considerable policy interest surrounding alcohol treatment. Economic evaluations help on the allocation of scarce health care resources, but these have been inadequately conducted in the alcohol field. This thesis builds up a taxonomy of alcohol-related consequences that should be included in economic evaluations of alcohol treatment and uses this taxonomy to critically review the published evidence around the cost effectiveness of alcohol treatments. The review provides a set of recommendations and most of them are pursued throughout the thesis. An economic model for the cost effectiveness of alcohol treatments is developed. The framework provides the means to conduct economic evaluation while bearing the complexity and challenges of decision making in the field of human behaviour. A link between drinking patterns, health consequences and alcohol treatment effectiveness and cost effectiveness is created. This is a probabilistic lifetime model that uses the cohort simulation approach. The model can be applied to any setting and this is exemplified for a UK-scenario. The methods and data for the generation of UK-specific model inputs are described and used in two model applications. A first application of the model extrapolates the results of a short term randomized controlled trial and provides the expected lifetime costs and outcomes of the treatments compared, by age and gender. A second application compares two alcohol treatments delivered in different countries and to populations very different at baseline. Both case-studies show the importance of time and that only a long-term analysis can capture both short-term alcohol consequences, such as injuries, and long-term consequences, such as most forms of alcohol-related chronic diseases. Assumptions and implications of the methods and analyses are discussed and recommendations for future research are presented.

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Regular heavy drinking amongst university students continues to be a current mental health concern (The Royal College of Psychiatrist, 2011). There has been a rise in the number of female undergraduate students consuming dangerous levels of alcohol on a regular basis (Gill, Donaghy, Guise and Warner, 2007). Qualitative research that investigates the drinking behaviour of female undergraduates is limited, especially research that explores the individual's understanding of their harmful drinking. This research discovers how female undergraduates understand and experience their alcohol use within the context of their university life. Three female first year undergraduates who were drinking to harmful levels were recruited and selected via an online drinking behaviour questionnaire. A Free Association Narrative Approach was used (Hollway & Jefferson, 2000) to elicit biographical narratives from participants during face-to-face interviews. Common themes were identified using Free Association Narrative Analysis of the interview transcripts. Female undergraduates were found to understand their drinking behaviours by relating to their previous personal and family experiences and associating their drinking with the challenges of university life. All participants made reference to the positive benefits of social drinking and considered that their drinking was the 'norm' across the student population. Feelings of guilt, shame and embarrassment became apparent in participants' stories where they had recollected engaging in behaviours whilst drunk that they later regretted. All participants used strategies such as minimisation and denial to cope with the negative consequences of their alcohol use. Participants did not regard their drinking as being harmful as they anticipated that their drinking levels would reduce after leaving university due to changing lifestyles. Findings highlight the need for intervention packages to have resonance with female students who are exposing themselves to health and social risks through harmful drinking.

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Excessive alcohol use is a significant public health problem globally. Alcohol use typically begins in adolescence or early adult life, and effective prevention strategies focused on this age group are needed to avoid initiation of harmful drinking. The aims of this PhD are to understand the epidemiology of alcohol use and alcohol use disorders (AUD) in East Africa, to validate self-reported alcohol use among young people in Tanzania, and to use the findings to recommend strategies for the prevention or reduction of harmful alcohol use among young people. Specific objectives include (1) to systematically review the evidence on alcohol use among young people in eastern Africa; (2) to estimate the prevalence of alcohol use, AUD and associated risk factors among different groups of young-people in northern Tanzania; (3) to assess the validity of self-reported alcohol use against the blood biomarker phosphatidylethanol (PEth); and (4) to assess the validity of the Mini International Neuropsychiatric Interview questionnaire (MINI) for the diagnosis of alcohol dependence against PEth, in Mwanza (northern Tanzania). The main findings are a high prevalence of reported alcohol use among diverse groups of young people in eastern Africa, especially among university students and sex workers, but that few studies used standardised alcohol screening questionnaires. In our survey of almost 2000 young people in northern Tanzania, the prevalence of reported alcohol use was higher among males (20-45% for current use) than females (12-47% for current use). Alcohol use was also associated with being in a relationship, greater disposable income, and a higher number of sexual partners. There were significant positive correlations between reported total alcohol intake and PEth concentration in males (Spearman correlation (rs)=0.65 among college students and rs=0.57 among casual labourers; p < 0.001). Self-reported alcohol use in the past month was also a sensitive marker of having a positive PEth result (overall sensitivity 89%, 95%CI 81-94%), and was similar in all groups. The MINI dependence criteria (positive responses to ≥3 questions) were met by 79/202 (39%) casual workers and college students. The high prevalence was mainly due to two non-specific questions (on tolerance and compulsion to drink). Both sensitivity and specificity of the MINI were low when compared to PEth, raising questions about the validity of the tool for this population. This thesis finds that alcohol use is a significant problem among young people in northern Tanzania, and the Timeline Followback calendar (TLFB) and Alcohol Use Disorders Identification Test (AUDIT) are sensitive measures of alcohol use. Most affected groups are college students and casual labourers. These two groups need urgent interventions addressing both individual and societal risks to reduce hazardous/harmful alcohol use.