risk perception of alcohol consumption

01 45-6008/98/2207-0277S$03.00/0 ALCOHOLISM: CLINICAL AND EXPERIMENTAL RESEARCH

Vol. 22, No. 7 October Supplement 1998

Risk Perception of Alcohol Consumption Lennart Sjoberg

A review is given of general principles of risk perception, with some historical highlights of the field. It is pointed out that the risk target is of great importance (i.e., that personal risks are almost always perceived as smaller than risks to others). The implications of perceived personal and general risks are different, with general risks being more important for policy attitudes. The concepts needed to inves- tigate risk perception are different, depending on what kind of risk is studied. Alcohol consumption risks give rise to uniquely strong risk denial, closely tied to control notions. Consumption of alcohol is found to be related to personal alcohol risk in a positive manner; the larger the consumption, the larger is the perceived risk. However, no such relationship is found for general risk. At the societal level, alcohol was the most common explanation that people gave for the prevalence of violence.

Key Words: Risk Perception, Alcohol.

LCOHOL CONSUMPTION can be seen as a kind of A risk taking, and such consumption has consequences at many different levels, from individual health to social problems such as violence. The risk aspect is ever present and can be seen in alcohol policies in many countries. Sweden is perhaps one of the more extreme examples, with its strong regulations of distribution of alcohol, but even in a country such as France, alcohol advertising is accompa- nied with warning labels-hence the importance of the risk perspective.

Whenever risk is important, so is perceived or subjective risk. People typically do not respond directly to the real risks, they act on their beliefs or perceptions. Risk perception is a rather new, but vital area of research. Although most of this research has been concerned with more tradi- tional policy problems (e.g., regarding technology or the environment), some of the lessons learned can be more or less directly transferred to problems of alcohol risk. In addition, a small but growing number of investigators have been directly concerned with the perception of alcohol and other lifestyle risks.

The present study is an update of a previous review' written in Swedish and published in 1991. At present, our understanding of general principles of risk perception has improved, and the database is much more extensive, war- ranting a brief review in an international context.

From the Center for Risk Research, Stockholm, Sweden. Reprint requests: Lennart Sjoberg, Ph. D., Professor of Psychology, Center

Copyright 0 I998 by The Research Society on Alcoholism. for Risk Research, Box 6501, 113 83 Stockholm, Sweden.

Alcohol Clin Exp Res, Val 22, No 7, 1998: pp 2778-284s

RISK PERCEPTION RESEARCH: METHODS

Risk perception is basically a subjective phenomenon and must be studied as such (i.e., with psychological methods). The most common approach is that of a survey and questionnaire. The fact that people have been found in many studies to be willing and able to provide the re- searcher with useful quantitative questionnaire ratings is encouraging, and much of modern behavioral science relies on it in one way or another.2

The specific contents of central interest in the present study is that of perceived risk. However, most work has more broadly sampled expectations of alcohol effects, often using the Alcohol Expectation Questionnaire The AEQ is the most commonly used instrument for measuring expectancies. Its psychometric properties have been criticized,' but a recent careful study confirmed at least the tension reduction subscale.6 Cognitive resources (education and self-consciousness) were found to be predictive of more nuanced differentiation of alcohol expectancies.' Swedish' and Norwegian' versions of the AEQ have been published.

Other scales for measuring expectancies are due to Southwick et a1.l' and Critchlow-Leigh." Some of that work has produced results that will be covered in the present review.

Many studies run into a problem of representativeness, because people with a higher education are more likely to respond to questionnaires than are others. This problem could be serious, but luckily enough it usually turns out that there is a very low correlation between level of education and perceived risk (usually negative). Hence, this particular bias, usually the only really obvious one in survey research on risk perception, is not likely to lead to misleading results.

Currently, some researchers are attempting to devise process-oriented models12 for the description of risk perceptions and related beliefs (see, e.g., Refs. 13 and 14), or using associations to key risk concept^.'^ Whereas these studies have led to some interesting findings, the methods are yet in an early stage of development, and they are expensive and cumbersome to use. It is not clear that the simple quantitative risk ratings used in most risk perception work are misleading. On the contrary, they have been found to be fruitful and relatively easy to use. In a meth- odological study of association versus quantitative risk ratings, it was found that risk ratings were more efficient and that associations gave no further useful information.I6

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RISK PERCEPTION MODELS cized.” A high level of explanatory value, in terms of

Risk perception is a research area that has been receiving increased attention since the beginning of the 1970s, fol- lowing the seminal work by Starr.17 Starr showed the exis- tence of widely different risk levels in society, and con- cluded that “acceptance” of a risk was related not only to how large it was, and to the benefits associated with the risk generating activity, but also to such qualitative factors as the degree of voluntariness of the risky activity. Several other researchers followed in his steps, and a model called the psychometric model was proposed in the end of the decade.I8 This model was a compilation of several qualitative factors that had been proposed as important for risk perception and acceptance. The authors showed that two broad dimensions were of paramount importance: new versus old risk and a “dread reaction” to some risks. Later work has led to a somewhat less optimistic conclusion as to the validity of this model” and has pinpointed the need for studying more specific components of risk perception; not all risks are alike or can even be described using the same dimensions.

Be that as it may, some results from the application of the psychometric model are worth mentioning in the present context. The results reported by Fischhoff et a1.I8 show that alcohol risks were perceived as:

old and well-known low in disaster potential low in dread about average in fatality among 30 hazards studied.

It should be noted that these data were for risks without a specified target, hence probably general rather than personal risks.” (See the next section for a full discussion of personal versus general risks.) More recent data collected in Sweden showed alcohol to rank rather highly, in third place, but below smoking.21 Here, again, no target was specified. In this study, benefit ratings were also collected; alcohol was rated as very low in benefit (as was smoking). If people are assumed to act on the basis of cost-benefits (a common economic belief), these data make alcohol consumption incomprehensible. However, positive consequences of drinking alcohol are common,22 and such consequences may simply not be labeled “benefits” by people. Positive expectations do seem to predict consumption level. 10,23,24

There has also been an attempt to analyze risk perception from a cultural point of view, the so-called Cultural Theory of Risk Per~eption.’~ This theory has been em- braced in some quarters as an important explanatory

yet quantitative investigation has shown that it is even weaker than the psychometric It can be noted that some of the claims of validity of the model were based on statistically significant, but weak, correlations. This is unfortunately a common procedure among behavioral researchers, and it has been thoroughly criti-

correlations or some similar statistic, is a necessary condi- tion for model validity (even if it is not sufficient). Statis- tical significance says very little, because it can easily be achieved, even with moderately large samples and very trivial levels of correlation.

Much better explanation of risk perception has been achieved with a model that accounts for it on the basis of attitude, specific fear, and general risk ~ensit ivity.~~ This model has been able to explain some 50 to 60% of the variance of perceived risk. The psychometric model accounts in typical applications for a mere 20%. Cultural theory applications have done considerably worse than the psychometric model and yielded only some 5% explained ~ariance.~’ (They also add very little to the explanatory powers of the other models.)

A factor of some current interest is that of trust and confidence. It has frequently been asserted that trust is a very powerful factor in accounting for risk perception and risk acceptability (see, e.g., Ref. 31). Most of these claims were, however, not based on actual data, but on a general impression that the factor is important. When data are scrutinized, it has been found that trust, in a recent Swedish study, accounted for some 10 to 15% of the variance of perceived risk.32 It is important to note that specific measures of trust (i.e., trust explicitly targeted on a certain area) are likely to give better results (see, e.g., the study by Biel and Dah l~ t r and~~) .

RISK TARGET

The risk target is a very important consideration in any risk perception study. Many studies have shown that perceived personal risk is smaller than the risk perceived to other people: general risk.34,35 This is a phenomenon closely related to what Weinstein has called unrealistic ~ p t i m i s m . ~ ~ - ~ ’ The difference between personal and general risk is not equal for all risks, however. It is almost uniquely large for alcohol consumption and small for such general environmental risks as the depletion of the ozone layer and global warming. Special checks have shown that the difference is not artefactual and that, given the lack of a specified target, respondents probably interpret the instructions as calling for general risk ratings.20

Typical data on general and personal risk are given in Fig. 1, which is based on ratings by a large and representative sample of Swedish respondent^.^^,^' Note that alcohol is perceived as one of the largest general risks, and at the same time as one of the smallest personal risks.

Figure 1 also gives data for risk to family and close friends, and they are, as can be seen, between personal and general risks. In Fig. 2, the difference between general and personal risk is related to perceived control over the risk!2 It is seen that a high level of control is associated with a large difference between personal and general risk. This is

RISK PERCEPTION OF ALCOHOL CONSUMPTION

Mean risk rating

6 -

Fig. 1. Mean risk ratings of 15 hazards: personal, family, and general risks.

4 t

2.5 . I 0 1 2 3 4 5 6 7

Possibility of risk protection (control)

Fig. 2. Relationship between risk denial (general minus personal risk) and perceived control.

typical for alcohol consumption risks. It may be related to the finding, in an investigation of college students, that the students believed that they were personally more uncom- fortable with alcohol use than were their peers.43 (This belief was illusory.) On the other hand, RohsenowU found that people expected others to be more affected by alcohol than they would be themselves, with the exception of problem drinkers who expected to experience equally positive and much smaller negative effects than others (see, also

Mean risk rating 7

6

I I I 1

i io alcohol Less than 16 cI 16-20 cI 2137 cI 38-75 CI More than 75 cI

Amount alcohol/week Fig. 3. General and personal alcohol risk as a function of amount of alcohol

consumed per week (men).

l t 01 I I I I 1 1 No alcohol Less than 12 cI 13-20 CI 21 -30 cl 31 -55 cI

Amount alcohol/week Fig. 4. General and personal alcohol risk as a function of amount of alcohol

consumed per week (women).

Ref. 11). Strong denial of serious personal alcohol risks was also reported in Ref. 45.

Many of our studies have given the same result. Alcohol risks are unique in being very strongly underestimated for one's own person. Using different rating formats, other researchers have also reported that there is a clear ten- dency to view the effects of alcohol on others as larger than on one's own person, especially negative effects.46747 Kul- horn4* cited a SIFO poll in Sweden in which nobody said they used to drink "more than they could take."

Expectancies about alcohol effects are partly on the basis of e~perience:~ partly formed before any personal experience, in ~ h i l d h o o d . ~ ~ , ~ ~ Early-developed expectations may predict later heavy drinking.52

personal and general alcohol risks were rated; respondents also gave data on their alcohol consumption. The results for men and women are given in Figs. 3 and 4. The figures show that personal risk was rated as larger, the higher the level of alcohol consumption. No such trend could be discerned for general risk, however.

In a recent Swedish

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General risk was constant over different levels of alcohol consumption.

Self-report data on alcohol use have been found to be reasonably valid53; data cited herein were collected under anonymity.

These data thus show a certain degree of rationality in risk ratings. Of course, perceived personal risk can still be out of line with reality even if it is correlated with the alcohol consumption level. Heavy drinkers usually do not consider their own drinking as abnormal or too In Figs. 3 and 4, personal risks only reached general risk levels for the groups with the highest level of reported consumption. Hence, there was a clear underestimation of personal risk of alcohol. Questions about smoking risk and consumption level showed the same trends. Other studies have shown that the relationship between positive effects of alcohol and level of consumption is even more ~ l e a r . ~ ~ . ~ ~ The everyday life of a heavy consumer of alcohol is hedo- nic,58,59 whereas risk perception appears to be more closely related to instrumental behavior.

It is well-known that health promotion by means of campaigns is usually quite ineffective.60’61 These difficulties may well be related to the lack of insight into personal risk that people frequently reveal.

In a large-scale study in Canada, similar results were found with regard to alcohol and perceived risk: those who consumed more rated the risk as larger.62 Room et a1.62 did not compare personal to general risk, however.

These results are contrary to findings reported by Ag- ostinelli and Miller,63 who found that self-reported alcohol consumption level was negatively related to perceived risk of “risky” behaviors (heavy drinking or drunk driving). The relationship to prevalence ratings of the same risky behaviors was weak. The authors suggested an interpretation of these results in terms of a self-protection m0tive.6~ How- ever, their risk rating instructions do not seem to elicit personal risk and hence they are not comparable with the present data. More heavy drinkers were found to give lower risk ratings in still another

The studies that showed that alcohol consumption was negatively related to risk perception seem to have either failed to specify the risk target or to have specified the risk in relation not to alcohol consumption but to excessive consumption or illegal behavior, such as drunk driving.

The question arises whether risk perception and expectancies are the result of alcohol consumption or its cause. The latter view is common.47 Nagoshi et al. found that the expectation of disinhibitory effects especially was predictive of alcohol use (see, also, Ref. 66). Gustafson’ reported that expectancy and desirability ratings according to the items of the AEQ correlated positively (i.e., the more positive effects were rated as more likely’). He took that as an indi- cation that expectancies have a causal role in drinking, but the inference is made on unclear grounds. Belief-value correlations are commonly found and reflect an ideology

driven way of thinking67; the relationship to overt action or behavior is not obvious, but needs special investigation.

Yet, Gustafson may be right, of course. In a follow-up study of treatment effects, it was found that changes in expectancies paralleled changes in consumption In a group of female college students, alcohol expectancies at the beginning of a school year predicted rather well their subsequent alcohol consumption Corcoran7’ found that both expectancies and a partner’s choice of drinking influenced consumption. Expectancy was an important factor in explaining co-occurrence of problem drinking and depression in a study by Johnson and Gurin71; only some depressed persons expected alcohol to be of help. In still other studies, expectancies were found to be predictive of consumption Family history of alcohol abuse was not predictive of alcohol consumption, but expectancies were.74 In some studies, it has been found that expectancies predict intensity of drinking better than frequency of i n t o x i c a t i ~ n . ~ ~ ~ ~ ~

Using the AEQ,3 Bogart et al.77 found, in a small con- venience sample of female college students, that those who reported that they consumed more alcohol also had more positive expectations of alcohol. Werner et al.’* used a somewhat different instrument in a college sample, called the Comprehensive Effects of Alcohol Q~es t ionna i r e ,~~ and found the level of alcohol consumption to be related positively to both positive and negative expected effects (expectations and evaluations), with the exception of negative expectations, which were weakly negatively related. General expectations were not assessed, only personal.

It is thus quite clear, on the basis of rather extensive work, that expectancies, especially positive ones, do predict alcohol consumption. Their causal role may still be de- bated. however.

RISK PERCEPTION: DEMOGRAPHICS

In many risk studies, it has been found that women and men give different risk ratings. Women tend to give higher ratings, especially of general risks. When it comes to personal risks, there are cases where women give lower risk ratings than men do, often in connection with a realistic assessment of a sex difference (e.g., heart infarct risks). Useful data on demographics and perceived alcohol risk are available in a recent study by Sjoberg42 (see Figs. 5 and 6). The figures show that women rated, on the average, general alcohol risks as higher than men did, but personal alcohol risks as lower. The difference between personal and general risk was dramatic, as shown by a comparison of the two figures.

It has previously been found that women tend to expect more negative effects from alcohol than men d0.4~ These results are probably contingent on the expected consumption level. Women drink less than men, and they know it.

RISK PERCEPTION OF ALCOHOL CONSUMPTION 281s

6 -

t I

0 18-25 26-35 3645 46-55 5665 6575

Age group Fig. 5. General alcohol risk rating as a function of age, for men and women.

6 -

01 ‘ I I I 18-25 26-35 36-45 46-55 56-65 6675

Age group Fig. 6. Personal alcohol risk rating as afunction of age, for men and women.

ALCOHOL RISKS: CONTENTS

Potential alcohol risks include health risks, casualties and accidents, addiction, and social risks.” A large Swedish sample rated a number of possible alcohol-related inju- r i e ~ ~ ~ (see Fig. 7).

Deery and Loves1 approached the special problem of driving and alcohol. They found that expectation factors were of some importance in accounting for impaired driving. High-risk driving was found by Yu and Willifordg2 to be partly caused by sensation-seeking (striving for risk- taking), which in turn seemed to be related to an early onset of drinking habits.

Alcohol is seen to be a major determinant of violence and aggre~sion.~~ This belief is widespread in many countries.83

POLICY IMPLICATIONS

Sweden has a rather restrictive alcohol policy, and sales of alcohol are only permitted in state-operated stores with restricted opening times. The notion of allowing for the

sales of wine in usual supermarkets was investigated in an M.A. thesis in our unit.84 It was found that the general risk rating was clearly more strongly related to the policy notions than the personal one.

It thus seems that people are willing to accept, at least in Sweden, a restrictive alcohol sales policy based on their worries about others’ alcohol consumption, but not their own. It is interesting to speculate that such an attitude might be compatible also with a relaxed view of one’s own illegal actions (e.g. in bringing in too much alcohol from abroad or in producing liquor in one’s own home). Such illegal actions are believed to be becoming more and more common in Sweden.

Even if people accept the status quo, they may be un- willing to accept further strengthening of sales restrictions or price increases, as found in an Australian Fla- herty et al.85 also found that their respondents were op- posed to a more liberal alcohol policy. This topic would be interesting to pursue in further work.

The fact that people are ready to accept restrictions for the sake of others may be related to common-sense notions as to the control of behavior. For example, it was found in a study of attitudes to drug-using pregnant women that punitive measures were endorsed.86

Demand for risk reduction is often believed to follow more or less directly as a function of level of risk: the higher the risk, the more reduction should be demanded. How- ever, risk is a multidimensional concept and refers to both probability and severity of consequences. When these factors are singled out for separate study, a surprising pattern is revealed: risk is tied to probability and demand for risk reduction to severity of consequences.2o These results have by now been replicated many times. In particular, it is quite clear that demand for risk reduction, and also attitudes to ins~rance?~ are driven by the severity of consequences, not by probability as had been previously claimed on the basis of a rather meager basis of data.88989 The matter is of course quite important, because experts, in risk communication with the public, tend to emphasize probabilities. But probabilities are hard to grasp and most often based on more or less tenuous models and theories that may or may not be credible. “Trust the expert,” says Virgil, which is of course rational many times, but not always. Experts may be too quick to discard alarms over environmental risks?’ and the public notes that experts disagree. So, whom should they trust?

SOCIETAL RISK

In a recent study, a large and representative sample of the Swedish population were asked questions about the causes of violence. Clearly, the most common explanation was that of alcohol and drugs, and in that group alcohol was the most important component?2 At the same time, very few respondents indicated that they themselves would be- come violent because of having consumed alcohol. It is

2828

FnNS Injutibs - lmpllrsd judoment -

TmHlc mccldenta - Impaired job pbr(.-

Drownlnp- EmMmlc problems-

MI.urrlaga - Funlly spllt -

~ O l b I l t X - Imp&bd rbhuON-

Llvbr d l n n a - Unbrnploymmt -

Red& memory- R e d u d crMh4ty -

Flrb - Bnln dunagb-

Reduwd wx. caP.CnY - Sleep dlsturbanu -

Qenetk Injury- Hlgh blood p m a -

ObMHy - R b d u d vlslon -

C.nmr- Reduud heating -

Skln dl- -

0 1 2 3 4 5 6

Fig. 7. Mean ratings of various types of alcohol risks.

possible that they saw this type of behavior as prevalent only among quite few persons, accounting for a large share of the violence in society, possibly so-called type I1 alcoholic~.’~ At any rate, the respondents did agree that alcohol was a very important factor in accounting for violence.

The study also posed questions about protection against alcohol risks. The respondents had the opinion that they themselves would be in better control than others in all respects. In problem drinkers, belief in control or its lack can be predictive of drinking habits and treatment outcome.” Negative expectancies were found to predict relapse.93 McMahon and Jones94 suggested that negative expectancies be assessed to measure motivation for change.

CONCLUSIONS

Research on risk perception in general has given some results of considerable importance to the perceived risk of alcohol. It has been found that people distinguish quite clearly between personal and general risk-this target factor must be taken into account in future work on risk perception. The difference between the two kinds of perceived risk is especially pronounced in the case of alcohol. Furthermore, it has been found that perceived control over a risk is a factor related to the difference between personal and general risk: the larger the perceived control, the larger is the difference. Control over the alcohol risk is attributed more to one’s own person than to others. Yet, the more alcohol consumption that is reported by a respondent, the larger is the perceived personal-but not general-risk. There is, thus, an element of rationality in alcohol risk perception, but only an element. The highest level of consumption coincides with reports of a personal risk at the

same level as that of people in general, a clearly overly optimistic judgment. These results were also found in the case of other lifestyle risks, such as smoking.

Gender is one of the most important factors in risk perception. Women usually rate risks as higher than men do. The case of alcohol gives an interesting exception, however. Women ratedpersonal alcohol risks as lower than men did, whereas they rated general risks as higher. Be- cause men indeed tend to have a higher prevalence of problem drinking than women do, these data also illustrate a realistic element of risk perception. It is interesting to note that age groups did not differ with regard to the perceived level of alcohol risk.

Personal and general risk also have different policy attitude implications. The low personal risk of alcohol is weakly related to policy attitude; it is rather the concern about others that seems to drive the attitudes in question.

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