^■ Introduction

Reducing alcohol consumption is one of the main objectives of public health policy as alcohol consumption is associated with major preventable risk factors for mortality and disease burden [1, 2]. The World Health Organization (WHO) recommends that countries adopt the WHO “best buys” like increasing the price of alcoholic beverages, limiting the time of alcohol availability, age restrictions and banning alcohol advertising. These measures are cost-effective from the state budget perspective and help reduce alcohol consumption and associated harm [3].

Until 2007, Lithuania was in the process of shaping its alcohol control policy with the Law on Alcohol Control adopted in 1995. The purpose of the Law on Alcohol Control [4] was to reduce overall alcohol availability, particularly to minors.
Furthermore, the Law sought to reduce alcohol abuse and its impact on public health and the economy. It also aimed to establish the legal basis for granting economic entities the right to produce, sell, import and export alcohol pro-ducts [4]. However, that Law has been libera­lised and tightened several times depending on the politi­cal will of the parties ruling during the period 1995-2007 [4]. Since 2008, Lithuania has progressively strengthened its alcohol control measures, making its alcohol policy increasingly restrictive. Ten years later, on 1^st January 2018, the alcohol advertising ban came into effect, completing the implementation of the WHO “best buys” package in Lithuania [5]. This comprehensive package of alcohol control measures was introduced over a relatively short period so it is important to examine whether the declared policy objectives have been achieved.

Integrated alcohol policies had a substantial effect on average consumption. A recent study found that implementation of evidence-based alcohol control measures was associated with reductions of almost 1 litre in adult alcohol per capita consumption [6]. Most studies that analyse alcohol harm in Lithuania have focused on the effects on health and mortality and have informed poli­cymakers and the public. Research showed that rapid increase in male life expectancy was associated mainly with decline in mortality from cardiovascular diseases, external causes of death and alcohol-related causes of death [7]. Furthermore, evidence indicated that the tightening of alcohol control measures in Lithuania contributed to a decrease in mortality from liver cirrhosis [8], cancer [9], cardiovascular diseases [10] and the overall mortality [11]. In addition, studies found that harm to others (beyond the drinker) [12] and incidents of sexual assault also diminished [13].

Supporters of liberal alcohol control policies and alcohol industry representatives often criticise restrictive alcohol control measures. They tend to frame problematic alcohol use in terms of a “small minority of problem drinkers versus the moderate majority who are already aware of the need to drink responsibly” [14: 1579]. Moreover, alcohol industry representatives tend to claim that problem drinkers are not likely to reduce their alcohol consumption and find ways to evade any restrictions [15].

Therefore it is crucial to assess the impact of recent alcohol control measures on changes in alcohol use disorders, so that policy makers and the public are accurately informed about the outcomes of such policies. Public-policy evaluation literature emphasises that the goal-attainment method reduces evaluator subjectivity [16] as it relies solely on indicators before and after the introduction of a specific intervention. The approach does not require in-depth exploration of implementation processes and simply provides clear metrics indicating whether the intended policy objectives are moving in the right direction [16, 17]. While adopting this outcome-oriented approach, we do not deny the utility of process evaluation.

The aim of this study is to examine changes in the prevalence of alcohol use disorders between 2015 and 2020 in the context of strengthened alcohol control policies introduced during this period. The analysis is based on data from the Standardized European Alcohol Survey conducted in 2015 and repeated in 2020. We integrated variables on DSM-IV alcohol abuse and alcohol dependence, comparing the survey results with official statistics on alcohol disorders classified under ICD diagnosis group F10. Before presenting the research method and results, we will briefly review the Lithuanian alcohol control policy measures that were in effect during our analysis period between 2015 and 2020.

Alcohol-control policy and alcohol consumption in Lithuania

Lithuania’s alcohol policy has developed cyclically over the past three decades, with more restrictive measures being replaced by more liberal ones and vice versa. Starting from 2008, the “best buys” package of measures to reduce alcohol consumption recommended by the World Health Organization were gradually implemented [5] with the major comprehensive measures implemented between 2015 and 2020 (Table I). The decrease in affordability, which was achieved by increasing alcohol excise taxes, was consistent from 2015 to 2020 and continues to be pursued. Criminal penalties were introduced for drink-driving in 2017 and extra penalties were introduced in 2019 for refusing to take an alcohol-intoxication breathalyser test on request by a police officer (during 2017-2019, refusal to undergo a breathalyser test was subject to administrative sanctions only).

Restrictions on alcohol availability were progressively strengthened during the study period. Alcohol sales at petrol stations were banned in 2016. In 2018, the permitted hours for off-premises alcohol sales were reduced, allowing alcohol to be sold only between 10 a.m. and 8 p.m. from Monday to Saturday and between 10 a.m. and 3 p.m. on Sundays. In 2019, the minimum legal age for purchasing alcohol was increased from 18 to 20 years of age. Furthermore, in 2018, marketing restrictions were introduced, including a near-total ban on advertising. In 2019, a ban on selling non- alcoholic beverages marketed as “child champagne” was introduced alongside other child-protection restrictions (Table I).

The recent decline in alcohol consumption in Lithuania reflects the cumulative impact of comprehensive alcohol control policies, including restrictions on affordability, availability of alcohol as well as the implementation of an advertising ban and other regulatory measures. These interventions have contributed to a sustained downward trend in per capita alcohol consumption, which decreased from 12.4 litres of pure alcohol in 2015 to 9.7 litres in 2020. Furthermore, alcohol consumption continues to decline and has reached 8.8 litres in 2024, with only minor temporary fluctuations related to the COVID-19 pandemic in 2020 and 2021 (Figure 1). Beyond the reduction in overall consumption [6], empirical evidence indicates that these policies have also contributed to decreases in alcohol-related harm. Studies have documented declines in alcohol-attributable mortality [7, 18, 19] and social harm [12] following the implementation of restrictive alcohol policies in Lithuania. These findings highlight the broader public health benefits of a multifaceted alcohol policy framework and suggest that sustained regulatory efforts can gene­rate measurable improvements in both health and social outcomes.

According to data from the Institute of Hygiene in Lithuania, alcohol use disorders (AUDs) based on the F10 diagnosis group also decreased from 8.07 diagnoses per 1,000 inhabitants in 2015 to 6.48 in 2020 [20]. F10-group diagnosis indicators suggest a diminishing number of patients entering the treatment system. However, given that substantial treatment gap between those who suffer from alcohol disorders and those who eventually receive treatment, it is essential to complement these statistics with the data from the Standard European Alcohol Surveys (2015 and 2020). Integrating survey data will enhance the interpretation of official morbidity figures and provide a broader understanding of the effects of recent alcohol policy measures on the dynamics of AUDs. The survey metho­dology and measurement instruments are detailed below. While the survey findings do not represent formal clinical diagnoses, they offer valuable insights into how stricter alcohol-control policies influence change in consumption patterns, including those of heavy or harmful drinking.

^■ Material and methods

Data source and sample

The data came from two cross-sectional surveys conducted in 2015 and 2020. Both surveys were based on the methodology of the Standard European Alcohol Survey (Joint Action on Reducing Alcohol-Related Harm, RARHA SEAS-1) [21].
The first study was conducted in September- October 2015 (N = 1,513) as a part of RARHA SEAS-1 research project. The second one was conducted in August-September 2020 (N = 1,015) as a part of the national project: “Developing Evidence Based Alcohol Policy and Practice from the Standard European Alcohol Survey: The Case of Lithuania”. The second research was financed by the Research Council of Lithuania, grant No. S-MIP20-2. We analysed only Lithuanian data in this study. The data arrays from two studies were merged (N = 2,528) before the analysis.

Measurements

Alcohol use disorders prevalence was calculated using items of the Composite International Diagnostic Interview (CIDI) scale, following Diagnostic and Statistical Manual of Mental Disorders (DSM IV) criteria. The CIDI scale consisted of 16 variables, the first 5 of which were designed to assess whether a person abuses alcohol, and the remaining 11 to assess whether a person is dependent on alcohol (Appendix 1). One or more affirmative answers to questions 1-5 were categorised as indication of DSM-IV alcohol abuse. Three or more affirmative answers to questions 6-16 were categorised as DSM-IV alcohol dependence [21]. We compared changes in prevalence of DSM-IV alcohol abuse and alcohol dependence between 2015 and 2020 by using the Pearson c² test. Differences were interpreted as significant if the p-value was lower than 0.05. Statistical analysis was performed with IBM SPSS 26.0.0.1

Research ethics

Oral informed consent was obtained from all participants prior to data collection. Anonymity and confidentiality were fully ensured. During the interviews, responses were recorded directly into an electronic questionnaire by the interviewer, and the resulting data were stored in a secure database without any personal identifying information or links to respondents’ identities. All study procedures adhered to the ethical standards of Vytautas Magnus University and complied with the current Republic of Lithuania academic ethics regulations.

^■ Results

The results of the survey show that there was a statistically significant decrease in the proportion of respondents who experienced problems related to alcohol consumption both among men and women between 2015 and 2020. Figure 2 presents the prevalence of DSM-IV alcohol abuse, defined as at least one positive response to CIDI items 1-5, in the general population and by gender in 2015 and 2020. Results indicate a statistically significant decline over time. In the overall sample, the prevalence of DSM-IV alcohol abuse decreased from 18.17% in 2015 to 10.70% in 2020, which implies a decline of over 40%. The prevalence of DSM-IV alcohol abuse declined by 32% among men (from 25.68% to 17.35%) and by 62% among women (from 11.15% to 4.21%), indicating that the relative reduction among men was approximately half that observed among women. In effect male/female ratio in prevalence of DSM-IV alcohol abuse increased from roughly 2 to 4. In 2015, the male/female prevalence ratio of DSM-IV alcohol abuse was approximately 2.3, indicating that males were slightly more than twice as likely as females to report DSM-IV alcohol abuse. By 2020, this ratio increased to about 4.1, reflecting a substantial widening of gender disparities driven by a much steeper decline in prevalence among females than among males.

Figure 3 depicts the prevalence of DSM-IV alcohol dependence, defined as at least three positive responses to CIDI items 6-16. Although the decline is less pronounced compared to DSM-IV alcohol abuse, the trend also shows a statistically significant decrease. In the total sample, DSM-IV alcohol dependence fell from 14.33% in 2015 to 11.49% in 2020. Considerable gender differences remained: in 2015, 21.45% of males and 7.67% of females met the DSM-IV dependence criteria while in 2020, these proportions were 19.70% and 3.49% respectively. The male/female ratio in the prevalence of DSM-IV alcohol dependence increased significantly, from approximately 2.8 in 2015 to about 5.6 in 2020. This widening gap reflects a particularly sharp decline in DSM-IV alcohol dependence among females while prevalence among males decreased only modestly.

As shown in Table II, we found significant reductions in multiple DSM-IV alcohol abuse indicators between 2015 and 2020 (p < 0.05). The proportion of men reporting that drinking inter­fered with work or other responsibilities (CIDI_1) decreased from 13.4% to 7.4%, and among women from 5.2% to 2.3%. Proportion of respondents who reported that drinking caused arguments (CIDI_2) declined from 16.0% to 11.6% in men and from 8.3% to 2.7% in women. Similarly, fewer women continued to drink even though it caused problems (CIDI_3), decreasing from 5.9% to 1.2%. The share of individuals who got hurt under the influence of alcohol (CIDI_4) also fell sharply among men from 11.9% to 4.8% and among women from 3.5% to 1.2%. All these reductions were statistically significant.

Improvements were likewise observed in DSM-IV alcohol dependence indicators. The proportion of respondents who reported a strong desire to drink (CIDI_6) fell from 16.8% to 9.0% among men and from 5.2% to 2.5% among women. Fewer women had to drink a larger amount to get an effect (CIDI_7), declining from 5.9% to 2.5%. Among men, fewer respondents experienced withdrawal symptoms (CIDI_8), with the prevalence dropping from 8.9% to 5.6%. The proportion of respondents who broke a promise not to drink (CIDI_10) declined from 17.1% to 12.2% among men and from 10.0% to 2.3% among women.
Furthermore, drinking more frequently or for more days in a row than intended (CIDI_11) became less common across both genders. Finally, fewer women gave up important activities because of drinking.

^■ Discussion

The aim of our study was to examine changes in the prevalence of alcohol use disorders between 2015 and 2020 within the context of strengthened alcohol-control policies introduced during this period. Our findings demonstrated a notable reduction in DSM-IV alcohol abuse in Lithuania between 2015 and 2020, with the decrease particularly pronounced among women. Declining trends appeared in DSM-IV alcohol dependence; how­ever, only the change for women, among whom prevalence of dependence dropped by half, reached a statistically significant level. Considering both DSM-IV alcohol abuse and dependence, it is noted that the gap between men and women substan­tially increased, which may suggest that women were more sensitive to changes in alcohol control than men. These findings suggest that strengthened alcohol control measures and population-level interventions may have contributed to the substantial decline in AUDs during the study period, particularly among women. One possible explanation for the greater decline observed among women is that women generally express stronger support for restrictive alcohol control policies than men. Previous research has consistently demonstrated higher public support for alcohol control measures among women [22, 23], a finding also reported in the RARHA study. Greater acceptance of alcohol control policies may have contributed to stronger behavioural responses following the implementation of comprehensive alcohol control measures in Lithuania.

The recent study conducted by Rehm et al. [6] examined the impact of alcohol control policies on alcohol consumption and found that two phases of integrated alcohol policies implemented in Lithuania in 2008/2009 and 2017/2018 were associated with average reductions in adult alcohol per capita consumption of almost 0.88 (95% CI: 0.34; 1.43) litre of pure alcohol. Štele­mėkas et al. [11] investigated alcohol consumption indicators, including unrecorded alcohol, and found that total (recorded and unrecorded) alcohol consumption in Lithuania decreased from 15.48 litres of pure alcohol in 2015 to 12.53 litres in 2020 per adult (aged 15 years and over). Therefore Lithuania’s comprehensive alcohol policy measures implemented between 2015 and 2020 appear to have effectively reduced both overall as well as registered alcohol consumption together with the prevalence of mental and behavioural disorders due to alcohol use [23].

Beyond differences in public support for alcohol control policies, research on gender differences in alcohol consumption and responses to alcohol control measures suggests that men and women may also react differently to population-level interventions because of social and behavioural factors [24, 25]. Females generally consume less alcohol [21] and experience more negative health consequences at lower levels of consumption [26]. They may also be influenced by stronger social sanctions against heavy drinking, which could make them more responsive to public health messaging and control measures than men [26]. However, systematic reviews note that gender-specific effects of alcohol policies are understudied and often poorly reported, which limits definitive conclusions about differences in effectiveness [24]. Some economic modelling evidence even suggests that certain interventions such as pricing policies might reduce consumption more among men than women, though patterns vary by context and outcome measures [24]. Overall, while existing lite­rature indicates gendered patterns in drinking behaviour and potential responses to interventions, more targeted research is needed to conclusively explain why women might show a stronger decline in alcohol abuse than men.

Our results should be interpreted in the context of persistent heterogeneity in drinking cultures across Europe. The stability of national drinking patterns shown by clustering analyses suggests that long-term cultural factors remain resilient [27]. Moreover, recent work exploring socio-economic profiles of alcohol use in Europe underscores that reductions are not uniformly distributed across social strata: high-risk or disadvantaged groups may still bear disproportionately high burdens [28].
Finally, studies of unrecorded alcohol consumption warn that self-reported survey data may understate total harmful use; unrecorded alcohol still accounts for a nontrivial share of consumption in some countries [29]. These nuances suggest that while our observed decline is promising, targeted interventions remain essential to address persistent inequalities and hidden consumption.

Our study has several limitations that should be considered when interpreting the findings. While the results demonstrate a temporal association between the observed decline in alcohol use disorders and the implementation of alcohol control policy measures, they do not prove a causal relationship. The survey data rely on participants’ subjective self-reports based on standardised screening instruments, which do not equate to formal clinical diagnoses and may therefore differ from the actual prevalence captured in healthcare records. Additionally, changes in prevalence may have been influenced not only by policy interventions but also by broader social, economic, and healthcare system dynamics, the effects of which could not be disen­tangled within the scope of this analysis. How­ever, the relationship between the evidence-based alcohol control policy measures implemented in Lithuania and decrease in alcohol harm indicators were widely studied. There is more than enough of the evidence showing the rapid decrease in alcohol-attributed mortality and morbidity during the reference period in Lithuania [7-11, 30-33].

^■ Conclusions

Although our study has its limitations, it also has advantages as it combines different data sources that reveal the same trends in the impact of alcohol policy. Official indicators of alcohol consumption and diagnoses of mental and behavioural alcohol use disorders constitute an external source of data which confirms trends caught in our analyses. Furthermore, the reliability of our findings is enhanced by the fact that both surveys we conducted using the same methodology and conducted the same research company. Therefore, the comparison of findings from the survey data with the official morbidity indicators and the results of other studies provides sufficient evidence for concluding that population-level alcohol control policy measures might have had a positive impact on reducing alcohol use disorders.

In conclusion, this study demonstrates a significant decline in the prevalence of both self-reported disorders due to alcohol use between 2015 and 2020 in Lithuania, indicating a positive shift in alcohol- related health outcomes. The trends were particularly pronounced among women, whose prevalence data diminish at the much higher pace compared to men. These findings are consistent with broader European evidence showing decreased risky drinking behaviours during recent years [34]. However, persistent disparities across social groups and potential underreporting of harmful consumption remain important concerns. Continued monitoring and targeted public health interventions are necessary to sustain progress and address remaining inequalities in alcohol use-related harm.

Conflict of interest/Konflikt interesów

None declared./Nie występuje.

Financial support/Finansowanie

The Research Council of Lithuania, grant No. S-MIP20-2.

Ethics/Etyka

The work described in this article has been carried out in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki) on medical research involving human subjects, Uniform Requirements for manuscripts submitted to biomedical journals and the ethical principles defined in the Farmington Consensus of 1997.

Treści przedstawione w pracy są zgodne z zasadami Deklaracji Helsińskiej odnoszącymi się do badań z udziałem ludzi, ujednoliconymi wymaganiami dla czasopism biomedycznych oraz z zasadami etycznymi określonymi w Porozumieniu z Farmington w 1997 roku.

References/Piśmiennictwo