Acceptance and expectance: Cultural norms for alcohol use in Denmark.

Alcohol consumption levels in Denmark are high with the risk of increased morbidity and mortality in the population. It is suggested that people's views of "normal" use of alcohol must be the platform for formulating effective alcohol education and prevention strategies. However, little is known about the cultural norms for alcohol use. The aim of this article is to examine the perceptions of cultural norms for alcohol use in Denmark among different age groups and the similarities and differences between the groups, including examining how people construct and negotiate the cultural norms for drinking. Five focus group interviews were conducted with one group per the following age groups: 16-20; 21-34; 35-44; 45-64; and 65-82. These groups consisted of both men and women with five to six participants in each group (a total of 27). Thematic analysis was performed with the aim of developing themes that reflected the cultural norms for alcohol use. The unifying theme of this research was Danish people's acceptance and expectance of social drinking. Alcohol is widely accepted and associated with mutual expectations to drink, leading to identification of cultural influences and facilitation to drink. The social drinking context plays an important role in people's perceptions of the normality of drinking. This includes the selection of particular beverages, and regularly leads to consumption above the recommended levels for low risk to health. This calls for public health attention that promotes low risk drinking in the social context and aims to prevent and reduce serious alcohol-related harm and health problems across the population.

Alcohol use is influenced by a variety of cultural norms that determine where, how and when it is appropriate or not to drink and why (Ahern, Galea, Hubbard, Midanik, & Syme, 2008; Heath, 2000; Wild, 2002). Cultural norms, defined as the rules a particular group uses for appropriate and inappropriate values, beliefs, attitudes and behaviours, are important in understanding people's alcohol use in a society. It has been suggested that what is perceived as “normal” use of alcohol must be the platform from which unhealthy use of alcohol is understood (Rose, 1992). Thus, the perceptions of normality and the cultural norms that influence people's drinking behaviours are essential in considering and establishing public health initiatives aimed at reducing alcohol-related risks to health (Simpura, 1991; Thorogood, 2002). The aim of this article is to examine the perceptions of cultural norms for alcohol use in Denmark among different age groups and the similarities and differences between the groups, including examining how people construct and negotiate the cultural norms for drinking.

Compared with other Scandinavian countries, alcohol consumption levels in Denmark are high (World Advertising Research Center, 2005) with every Dane over the age of 14 drinking 11.3 l of pure alcohol on average annually (Danmarks Statistik, 2011). The proportion of people who drink alcohol above the recommended levels for low risks to health is increasing (Ekholm et al., 2006), and one in five adult Danes are categorized as heavy drinkers (Gottlieb et al., 2011). Most research on norm perception of alcohol use in Denmark has been restricted to perceived high risk groups such as people defined as alcohol dependent or young people, e.g., (Demant & Järvinen, 2011; Gundelach & Järvinen, 2006; Järvinen, 2003; Jørgensen, Curtis, Christensen, & Grønbæk, 2007). The studies on young people revealed a culture where alcohol is perceived essential in collective intoxication, construction of identities, positive experiences and expectations to alcohol and reaffirming friendships. A recent focus group study found that the most important norm to alcohol use concerns the young people's devotion to intensive social drinking. In their party contexts, young people are expected to drink heavily and contribute to the fellowship through drunkenness; thus, heavy social drinking needed no legitimization in the focus groups (Demant & Järvinen, 2011). A study on adolescents and their parents demonstrated that adolescents must learn to master and control the risks associated with heavy alcohol consumption in such a way that consuming rather large amounts of alcohol becomes a pleasant experience. The young people appear to be learning the lessons their parents have taught them about “controlled loss of control” (Østergaard, 2009). A qualitative study on adults revealed that self-control and self-initiative are governing cultural metaphors for normal drinking. While normal drinking is constructed as a spontaneous activity, abnormal drinking is compulsive behaviour over which the individual has lost control (Elmeland, 1996). These studies have provided important insight into the characteristics and norms for drinking among certain groups of Danes. However, there is a dearth of knowledge about the cultural norms and influences of alcohol use across a range of “normal” social drinkers, including how “normal” drinkers construct and negotiate what they believe to be “normal” drinking. Particularly, there is a dearth of knowledge about the cultural norms; the meanings and perceptions of alcohol use in the population older than teenagers and across age groups. Seeing that the supposedly “normal” majority of drinkers need to accept responsibility for deviant alcohol behaviour (Rose, 1992), the cultural perceptions of what is “normal” drinking must undergo continuous investigation if we are to better understand and act to reduce the risks and harms of unsafe drinking.

Methodology

This study was part of a mixed methods study that aimed to create new knowledge and understanding about the culture of alcohol use in Denmark that can be applied to the development of future public health activities. The overall study was informed by a sequential explanatory mixed methods approach (Creswell, 2003; Creswell & Plano Clark, 2011) and involved two partner studies: a quantitative and a qualitative study. The rationale for this approach was grounded in the notion that neither quantitative nor qualitative methods alone were sufficient in capturing or explaining the trends, details and depth of understanding in the area under investigation (Ivankova, Creswell, & Stick, 2006).

The initial quantitative study used national cross-sectional data to describe the different contexts of alcohol use (Grønkjær, Vinther-Larsen, Curtis, Grønbæk, & Nørgaard, 2010). Together with a review of the literature, the quantitative study assisted in informing the focus for the following qualitative study. For example, the quantitative study found that alcohol use (including at heavy levels) is most prevalent in social context such as visiting family and friends. The qualitative partner study thus used focus group interviews to better understand and elaborate on these quantitative findings by exploring further the norms that characterize alcohol use; particularly in social drinking contexts. This article presents essential findings of the focus group study.

Methods

Participants

The focus groups consisted of both men and women who were Danish-born adults with five to six participants in each group (a total of 27). The sample consisted of five groups that were constructed for each of the following age groups: 16–20; 21–34; 35–44; 45–64; and 65–82. This specific age division was chosen because the quantitative study used the same age categories in the initial survey study.

Sampling and recruiting participants

In line with the sequential explanatory strategy (Creswell, 2003), sampling and recruiting for the qualitative study commenced after completion of the quantitative study. The sampling procedure for recruiting participants was informed by a purposive sampling strategy (Polit & Hungler, 1998) and involved a combination of homogeneous and heterogeneous sampling. Participants were purposively sampled through the use of gate keepers who were able to recruit participants with diverse characteristics. They were thoroughly informed about their gate keeper role, including clear inclusion criteria for selection of eligible participants (Danish born, aged 16 years and over, males and females and with variety in educational level, professional background and geographical location). By having impartial persons sampling and recruiting, it was possible to construct focus groups without the researcher being directly involved with the risk of e.g., consciously or unconsciously excluding or recruiting participants who possibly possessed specific features or characteristics. Based on the study aims, gate keepers were informed that the potential participants would be eligible if they considered themselves to be “normal” users of alcohol, i.e., not abstinent or having recognized alcohol-related problems.

The gate keepers identified potential participants and provided them with an information letter. The gate keepers recorded the participants’ names and contact details, and with their permission, handed over this information to the researcher who then made an initial phone call to the potential participants. If the potential participants still expressed interest in the study, they were provided with further information that included details of the focus groups; where and how they would take place.

Focus group interviews

Focus group interviews were chosen because they are appropriate for identifying group norms, sub-cultural and cultural values (Kitzinger, 1994; Kitzinger, 1995; Krueger & Casey, 2000), and because previous Danish alcohol research has used focus groups successfully, particularly in revealing the way people construct their norms for drinking (Demant & Järvinen, 2006). The structure of the focus group interviews was inspired by Morgan (1997) who suggested that a compromise between more structured and less-structured approaches to focus groups are useful. This compromise, the funnel-based interview, is characterized by an initial less structured approach that emphasizes free discussion (based on a broad and open beginning) and then moves towards a more structured discussion of specific themes.

A semi-structured theme guide was developed to ensure that the content of discussions focused on issues that were central to the research aims and objectives. The development of the theme guide was based on the findings of the quantitative study, the extant literature and purpose of the overall study. Participants were initially asked an open-ended question about what they came to think of with regard to alcohol and alcohol use in Denmark. This was followed by a more narrow set of themes: drinking contexts and the legitimacy of drinking alcohol in various contexts; the “normal” use of alcohol; the meaning of alcohol use and public health perspectives in relation to alcohol use. The focus groups were held in a research facility in Aalborg, Denmark. Each group session lasted approximately one and a half hours.

Data analysis

The focus group interviews were audio-taped and recorded manually. They were then transcribed ad verbatim and analysed using the Nvivo software. Thematic analysis was performed with the aim of developing themes that reflected the cultural norms for alcohol use. The data analysis was not a linear process, but an iterative and back-and-forth process that involved four different, although highly interconnected, steps: (1) familiarization, (2) identification and coding of themes, including comparisons within case and cross case, (3) categorization and (4) interpretation and understanding (Miles & Huberman, 1994; Rabiee, 2004). This involved reading and re-reading the data with the aim of being immersed in the data and getting a sense of the group discussions before breaking data into parts (Rabiee, 2004). This was followed by the identification of themes and codes that were meaningful and relevant to the study purpose, including noting reflections and other remarks in memos, and sorting the data by identifying similar phrases, relationships between patterns, themes and distinct differences within and between groups. Each case (focus group) was explored, followed by cross-case analysis to identify similarities and differences within the themes across all of the data (Frankland & Bloor, 1999; Miles & Huberman, 1994). The data were then compared and contrasted that allowed similar phrases/quotes to be categorized under the same heading and existing codes to be merged with other categories. The final step involved interpretation and understanding of data, and the identified categories were connected in patterns of major themes including their related sub-themes.

In our analyses, we also considered the interactions between participants by examining the negotiations, agreements, disagreements and accounts that were used in the discussions (Grønkjær, Curtis, de Crespigny, & Delmar, 2011; Silverman, 2006). For this, we used elements of conversation analysis (Silverman, 2006). This approach was chosen because it can assist in gaining access to the construction of meaning and social action in the groups and in analysing how content of norms is negotiated within the participants. We used a fundamental analytical tool from conversation analysis; adjacency pairs. The rationale of adjacency pairs is that many actions in conversation are linked together; they bind conversation together and are considered normative relations. Given this normative relation, adjacency pairs involve preference organization (Potter, 1996). This means that to a particular utterance, there is a preferred response (i.e., acceptance or agreement) or a dispreferred response (i.e., rejection or disagreement). Adjacency pairs involve accounts that are the justifications behind the decisions, opinions and actions that participants express in the groups.

Ethics

Participants received written and oral information about the study and consented to their participation (parental consent was given for participants <18 years of age). Participants were informed about their right to withdraw from the study at any time. Alcohol use is associated with taboo and we therefore considered the potential risks such as participants feeling uncomfortable in the groups. The moderator thoroughly considered the participants’ responses to the discussions, signalled approval and remained open to the interaction by keeping eye contact, nodding and listening. The names cited in the results section are pseudonyms.

Results

The thematic analysis of the focus group data revealed a unifying theme: acceptance and expectance. This theme holds a superior position with regard to the norms that characterize alcohol use in Denmark and includes a number of related themes and a sub-theme that cognate to the superior theme. Fig. 1 illustrates the unifying theme and its superior position, including related themes and sub-theme.

Figure 1

Illustration of the unifying theme and its superior position including related themes and sub-theme.

Our study showed that alcohol use is accepted in many contexts, just as its use is equally expected. Participants described a variety of contexts in which drinking takes place and highlighted that it is non-normal not to drink. This led to the interpretation of alcohol's wide acceptance in Danish society. The wide acceptance of alcohol was evident across all age groups with only few situations defined as inappropriate or unacceptable for drinking (being driving, work and certain sports). Besides being accepted, participants reported that alcohol use is also expected. This is illustrated by an extract for the age group 21–34:

This provides a two-dimensional side of the expectations associated with drinking alcohol: The individual expects oneself to provide something, mostly alcohol as indicated in the quote, just as the group would take notice if alcohol was not served in a setting where it is expected. Thus, the cultural acceptance and expectations to consume alcohol must be viewed both from the individual's and the group's perspective.

Being Danish

The participants’ descriptions of the acceptances and expectations to alcohol use revealed the existence of a national predicate or identity with regard to being Danish. In the following extract, the age group 21–34 discusses whether it is possible to have a cosy situation without alcohol:

Besides expanding on the findings above regarding the expectations to drink, this extract also illustrates some of the negotiations that took place in the groups. After clearly indicating that having a good time without alcohol is possible, Troels reconsiders his response, supposedly because he feels the need to explain himself to the other group members and he provides an account where he describes a typical situation where alcohol is not present. Lars obviously disagrees with Troels and questions the possibility of being Danish and having a good time while not drinking. Other participants reported that they were conscious of living up to this predicate by drinking, and that they would experience this for both themselves and for others. Emma (female, 20) used the following example from her experiences when attending an international music festival:

…I think it is a little funny…well I just have the atmosphere from Roskilde [festival]…when I greet people…I am going to have that beer with them because “I have to, hell yes; I am Danish, am I not”?

This quote exemplifies how the cultural norms and expectations for alcohol use can be expressed. The being Danish predicate puts a certain pressure on Emma and it is important for her to indicate this predicate to herself and others to re-inforce her Danish identity. Thus, this is not an example of group pressure as such, but a powerful cultural influence on the individual and groups’ drinking.

Cosiness

When asked about what they came to think of regarding alcohol use and Denmark, participants in all groups highlighted cosiness and social gatherings. Alcohol was expected in most social situations and predominantly associated with positive social experiences. Participants from the group of 65+ gave the following example:

This quote is illustrative of the many instances that were characterized by agreements between the participants’ perceptions of the role and meaning of alcohol. The quote indicates the role alcohol plays when people are gathered; the foundation for a cosy situation. Alcohol contributes to having a good time, just as it is associated with adding something to the social situation. The cosiness of such situations manifests the positive connotations of alcohol. Keeping the unifying theme of acceptance and expectance in mind, this may even suggest that in social gatherings that are not characterized by alcohol, people are deprived of the opportunity of being as cosy as it could have been, had alcohol been introduced. Even though younger participants typically described going-out drinking with the purpose of getting drunk, they too indicated to engage in drinking occasions characterized by cosy drinking. And although most participants in the older age groups indicated that they were drinking for cosy purposes, such situations were at times described as binge drinking at high-risk drinking levels. Thus, a cosy situation does not necessarily mean that it involves low-risk drinking levels.

Following the meaning of alcohol for cosy situations and the positive connotations, the focus groups revealed the existence of a cultural rhetoric on alcohol. Findings suggest that the meaning of alcohol relates to a distinction between drinking and enjoying alcohol. Even though the verb to drink is necessary for an alcoholic beverage to enter the gastric system, to drink was found to be equivalent to problem use and thus not to cosy situations. A sequence from those aged 45 to 64 illustrates this:

Thus, it seems drinking is associated with problem use: even though you indicate to drink more in certain periods (in this case holiday), you don't drink as in having an alcohol problem. Alternatively, the word enjoying had a different connotation. In discussing alcohol problems and politics, Erik (male, 55) said: “I think that we are scared to confront and say: we do not accept that you enjoy alcohol before the age of 17–18”. Connie (female, 65) confirmed this interpretation by saying: “well there is a difference between to drink and to enjoy”. This finding is interesting because even though the groups at this point discussed problem use, their words were centred on something positive; enjoyment. It highlighted that enjoying is a synonym for the actual drinking act, whereas the verb drinking displayed negative connotations closely linked to problem use. It also accentuates the meaning of alcohol in cosy situations; being a matter of enjoying and having a good time.

Being part of a group

The acceptance and expectance involved that alcohol was considered a social necessity among all age groups; an important factor in being able to enter a social setting or gain the sense of being accepted as part of a group. Alcohol was perceived as an admission ticket to the cosiness and a means that glues us together that is important in gaining access to, creating and maintaining relationships. The meaning of the inter-personal relations and drinking socially also revealed connotations of social drinking. Henrik (male, 42) said: “Well I think a word that shines through then, it is very, very often social relations. And the social relation may become less important when it is abuse”. This is a direct statement regarding the perception of what distinguishes normal and problem use; that it all comes down to social relations. This finding suggests that the context of social drinking is normal; thus, drinking socially and having a problem is practically unheard of.

Participants reported that they felt comfortable when they were all doing the same in a drinking situation. Alternatively, they reported that they would feel uncomfortable if they refused a drink because it could be viewed by others as their rejection. Accordingly, being part of a group characterized by the same drinking activity influenced the perceptions of those who did not conform. Palle (male, 34) explained this by saying: “If it's a quiet evening with a few glasses of wine and there's one in the company who slips through and consumes more than the others. Then it's a nuisance; then the cosiness disappears”. This highlights the importance of conforming to the norm as well as the meaning of drinking like the rest of the group in obtaining and maintaining a cosy situation. The group aged 21–34 discussed this:

Besides exemplifying the expectance of alcohol and the importance of drinking like the others, this excerpt also illustrates how the participants’ interactions and queries to each other functioned as a catalyst in discussing the topic and influenced the content. Participants argued that as a principle they did not need a reason to refuse a drink, but an excuse would assist them in making their point of saying no to the person offering the drink. The sense of feeling part of a group was perceived as attractive and important by participants, and despite not needing a reason to refuse alcohol, consequences were reported.

Participants of all age groups had experienced some kind of pressure to drink. The following discussion sequence took place in the group aged 45–64:

Participants experienced that they would be questioned if they did not drink in a given context: Other people expect that you are going to drink like them and the individual expect to conform to the others. This elaborates on the concepts of acceptance and expectance of alcohol use; the predicate of being Danish, and that the drinking experience of the individual is to a large extent determined by cultural and contextual factors. The experience of not drinking was interpreted as posing double trouble for the individual: The others are annoying to them because they drink and the others think the individual is annoying because they do not conform. Ellen (female, 72) said: “Well my pet aversion is if you are a little late and the others have started, right. Then they are little annoying until you have had a little to drink yourself”. This suggests a kind of psychological relief that is associated with people taking part in the same drinking activity as others in context.

Refusing a drink in the social context posed a risk of insulting other people or being perceived as being different or boring. Lotte (female, 30) highlighted this by saying: “Well I guess it has to do with being ‘Boring Betty’ if you say no…people almost get really offended that I don't want the damn glass of wine”. It was uncomfortable to say no, as the social group was a powerful external influence on their drinking choices and experiences. After talking about this pressure from others, Lars (male, 33) reflected:

“Well, it might as well have to do with my own self-image that I think I am boring. It doesn't have to be the others that think I am…it might as well be my own feeling of being disappointed that I can't live up to their expectations that I ought to have that beer with my colleagues after work, and I actually don't feel like it”.

In accordance with the unifying theme of acceptance and expectance, this strongly accentuates a cultural pressure; the internal and external expectations to drink. The individual may feel disappointed by not conforming to their group's cultural norms; e.g., his own and other's expectation to drink.

Normality perspectives

On the question of what constitutes normal use of alcohol, the responses were many and varied. In general, participants perceived normal use as being defined by the individual, depending on their age, life stage and drinking context among others. Some reasoned that their perception of normal use conformed to the national recommendations for low risk drinking. The discussions were multi-faceted and Thomas (male, 19) said: “Well I think that it is non-normal not to drink. Because I don't see that very often that someone does not drink…”, indicating that alcohol use is widely accepted and therefore non-drinking was considered abnormal. Or Henrik (male, 43) who said: “Well, for an alcoholic it's probably very normal to drink 30 beers a day…” that highlighted the individually defined perception of what comprises “normal” use of self or others; i.e., some people drink large amounts of alcohol that is normal for them, whereas others drink less that is also normal. The latter is exemplified from the group 65 to 82 years of age:

In this excerpt, the interaction is characterized by disagreement and negotiation about conforming to the recommendations. The sequence reveals a cultural perception that drinking an alcoholic beverage other than wine, such as spirits, is harmful, whereas drinking wine even frequently is not harmful. In this example, the alcohol type was considered more harmful in itself rather than the amount ingested. The connotations of beverage type assisted in influencing people's perceptions of beverage choices as harmful or not. Furthermore, this may even suggest that high risk levels of drinking are normal, if this involves wine. The participants’ acceptance and perceived normality of alcohol use seemed to justify their own use, whereas problematic or what they perceived to be abnormal use concerned others, particularly young people. Participants were generally outraged by the way young people in Denmark use alcohol. participants in the age group 16–20 could be defined as the youth, they indicated their resentment towards those younger than 16. Laura (female, 19) said: “I just can't stand seeing the kids like that…well it is absurd if you see them walking around and drinking beers in the city…they should have enjoyed their childhood”. Participants of all age groups claimed that the youth seemed to be the biggest concern regarding risky drinking; none the less, they came to reflect upon this belief. While discussing this issue, they seemed to suddenly realize that their aversion to youths’ drinking could be viewed differently. After completing the focus group discussion, the recording device had been turned off, Michael (male, 51) said: Thus, it seems that it was easier for people to view and judge other peoples’ drinking rather than their own, and pointing out what comprises normal use vs. problem use. This was a tendency throughout all focus groups: the group of young people talked about drinking among their parents or those younger than themselves; parents talked about young people and the elderly group particularly talked about young people and were scandalized about their drinking behaviour.

It suddenly strikes me. When we talked about the young people, it was very different than when we talked about ourselves. You asked about us. It was like an escape. We were escaping by talking about the young people; then we didn't have to talk about ourselves.

A matter of control

The balance between alcohol use being perceived as normal or abnormal was delicate, and often revolved around normal use being perceived as a matter of personal control. This perception was described by all the groups despite age. From the group reflections, it was found that displaying normal use to others involved being in control oneself; that you do not need alcohol and do not want to be perceived as a person who is obviously alcohol dependent. Other focus group sequences revealed that there seems to be an association between cosy situations and people being able to control their use of alcohol: if drinking is controlled and planned, then it is part of a cosy situation and thus normal.

Besides being related to the perceived normality of a drinking situation, being in control was found to influence the perceptions of public health initiatives. Participants were generally against restrictions on alcohol use, with some doubting that giving information about the risks to health was a sensible way of regulating people's alcohol use. Moreover, the discussions on the recommended levels for low risks to health and alcohol politics often led to joking for example about, alcohol legislation. Joking about the recommended levels also occurred in all groups and national recommendations on alcohol were perceived and used as a means to reach the maximum level of consumption rather than the least—as if posing further restrictions or recommendations on alcohol consumption was unthinkable. Often, the discussions centred on making comparisons between alcohol and smoking tobacco. Connie (female, 65) said:”…[with alcohol] we still don't have to stand outside. Well, we are not being chased outside to drink [laughs]”; referring to the fact that smoking has recently been banned from public premises in Denmark. Alcohol restrictions were generally viewed as a threat to their personal freedom; participants found no reasons for further control (i.e., legislation) in that they were able to control their own use (drinking for cosy purposes).

In summary, the unifying theme emerging from this research was cultural acceptance and expectance of social drinking. This theme and the related themes and sub-theme can be summarized as follows: Alcohol use is accepted in many contexts, just as its use is equally expected. It is perceived attractive to be part of a group and drinking like the others. Not drinking has negative consequences such as feeling pressured to drink, or experiencing a double trouble situation in which non-drinkers were annoyed by the group's drinking, as well as feeling excluded. The cultural influence on people accepting and expecting to consume alcohol led to the description of a Danish predicate, in that it is important for Danes to portray their culture through their social drinking behaviours. This suggests cultural pressure to drink in particular situations in Denmark. The perceptions on normal drinking were influenced by alcohol's wide acceptance and non-drinking was therefore considered abnormal. The normality perspectives were further related to being in control of drinking alcohol.

Discussion

The focus of this research was the perceptions of cultural norms for alcohol use particularly among those older than teenagers and across age groups. Strikingly, the study revealed that the norms for alcohol use across age groups are not that very dissimilar to those of Danish teenagers; i.e., that it is considered non-normal not to drink; that participants draw a distinction between drinking and enjoying alcohol; that alcohol consumption is an important factor in being accepted as part of a group; and that it is important for drinkers to present themselves as people who are in control of their drinking (Demant & Järvinen, 2011; Gundelach & Järvinen, 2006; Østergaard, 2009). Although it is known that alcohol consumption, drinking contexts, purposes of drinking and drinking patterns vary with age (Sundhedsstyrelsen, 2011; Grønkjær et al., 2010), and although our study confirmed such age differences (e.g., as going-out drinking vs. cosy drinking), our findings suggest that there are similar features that characterize the use of alcohol in Denmark; despite age group. This is also supported by the way participants discussed drinking norms in the focus groups; the large degree of agreements and preferred responses between participants (on this matter).

In line with the study by Elmeland (1996), this study revealed that there seems to be an association between people feeling in control of their drinking (even though it may be at risky levels) and the desired cosiness: if drinking is controlled, it is “normal” and cosy, if not, the signal is different and it is defined as problem use. Being in control was also associated with legislation within the alcohol area. The participants generally viewed alcohol restrictions as threats to their personal freedom. In combination with the wide acceptance and expectance to alcohol, this may suggest serious barriers to public health strategies aimed at preventing alcohol-related harm for this population, keeping in mind the participants’ perceptions about the “normality” of alcohol consumption even at harmful levels that this study revealed. None the less, despite some people's aversion to alcohol legislation, international research shows that the most successful impact on harmful alcohol across the overall population is through price and availability of alcohol (Wagenaar, Salois, & Komro, 2009). This indicates the complexities for those concerned with prevention of risky drinking and alcohol-related harm.

This unifying theme of this research is in accordance with international research where two types of social influences on drinking were identified: active social influences such as explicit invitations or pressures and passive influences such as expectations about the drinking patterns within social groups (Oostveen, Knibbe, & De Vries, 2003; Wild, 2002). Consistent with other Danish research (Gundelach & Järvinen, 2006; Jørgensen et al., 2007; Mandag & Trygfonden, 2008; Mandag & Trygfonden, 2009), this study found that alcohol consumption was generally perceived as positive and attractive, particularly for sociability reasons. Even though the group discussions also concerned problem use, participants’ vocabulary mainly reflected the enjoyment associated with alcohol use. Thus, alcohol was automatically associated with something delightful and pleasurable, with participants focusing more on the positive aspects of drinking rather than any risks to their health or well-being. This elaborates on recent research that found that alcohol is considered a non-issue, being perceived as a means to reduce stress and increase quality of life (Mandag Morgen & Trygfonden, 2009). In this study, problematic use of alcohol concerned other people, particularly young people or individuals who drank alone. Elmeland (1996) reported similar views amongst research participants who avoided personal questions about drinking, and led their conversation towards perspectives on alcohol use of other people.

This research offers new and important perspectives on the cultural norms for alcohol use in Denmark. The study revealed that drinking socially, even above the maximum recommended levels for low risks to health (The National Board of Health, 2005), was perceived as “normal” (and therefore non-harmful) if this involves particular beverage types and social contexts such as cosy gatherings. Moreover, drinking socially plays an important role in people's reflection of their cultural beliefs and belief in their own “normal” use of alcohol. This suggests that social drinking is perceived to be normal and therefore having a problem in this context is practically unheard of. These findings elaborate on the initial quantitative study in which heavy use of alcohol mainly occurred in social contexts amongst Danes (Grønkjær et al., 2010). Moreover, they support international research in which heavy drinkers were found to view their own drinking as normative rather that unusual or deviant (Wild, 2002).

Methodological considerations

The strength of this research is the use of focus groups to gain understanding of cultural norms and contexts of alcohol use in Denmark. Focus groups are useful in identifying group norms and cultural values (Kitzinger, 1995), and the interactions between participants from similar age groups, but with diverse characteristics, allowed the identification of multiple meanings as these emerged, including people's perceptions of what cultural norms exited regarding alcohol use in Denmark. Interaction between group participants is considered the distinct advantage of focus group research because the group dynamics, agreements, disagreements and the way people account for their opinions are essential for the content of the data (Grønkjær et al., 2011). The interactions between participants, however, can be a limitation in that people's views and interactions may negatively influencing others; e.g., being intimidated by another participant or moving the focus of the discussion away from, or towards, a topic that is irrelevant or disturbing. In this study, this may have been a particular disadvantage due to alcohol use possibly being a sensitive topic (Kitzinger, 1994). Also because the findings indicate that people tended to talk about other peoples’ drinking, and focused particularly on young people's use of alcohol instead of their own, there may have been data that were suppressed. This may occur because people have been distracted by being asked to discuss alcohol with people unfamiliar to them, resulting in the focus towards other people's use. None the less, as this issue is understood in alcohol research (Elmeland, 1996), and the group participants openly acknowledged this change of direction during the group discussions, suggests that focus groups were a trustworthy method for this particular research.

This article presents the sequential findings from mixed methods research that also consisted of an initial quantitative study. It would have been relevant to present the two studies jointly; however, in this article we have emphasized the qualitative data because the words, the dynamics and interactions in the groups are important for understanding the culture of alcohol use, including the constructions and negotiations of the cultural norms for drinking.

Conclusion

In summary, this research revealed people's perceptions about the cultural norms influencing alcohol use in social settings in Denmark. These are potent elements that are influencing risky drinking, and are likely to be serious barriers to public health strategies aimed at reducing alcohol-related risks and harms and promoting health. The cultural norms and peoples’ perceptions of “normal” social drinking must be considered and incorporated into public health initiatives and strategies. Seeing that the proportion of harmful drinkers is increasing in Denmark, this work calls for urgent attention to finding effective ways of promoting low risk drinking. People's acceptance and expectance of risky consumption of alcohol as a way of socially accepted, normal and attractive is the challenge that must be faced.

Lone:	When I think about that we are having friends over on a Friday or Saturday, I could not imagine that I wouldn't serve red wine. Because, that's what you do, right.
Morten:	yes
Moderator:	Do you think they would take notice if you for example served soft drinks?
Lone:	Well I think so. I am sure they would. … I wish I could say the opposite, but I don't think so. I think it would be really weird.

Troels:	Yes, we can [have a cosy time without alcohol]
Morten:	Yes, we can.
Troels:	Or at least I hope so. Well I think I can. We play soccer once a week just for the fun of it. Just the guys from Uni. And we are doing fine without it [alcohol].
Lars:	Well what about those who can't do that? What are they supposed to do? They can't sit and eat bananas … it is completely…it is culture … it is about being Danish.

Per:	And that [alcohol] is the foundation for a cosy gathering isn't it? That you are having a good time with food and drinks. I think that is wonderful.
Knud:	Well it is obvious that there is a sense of feeling close-knit when you sit down and have for example a herring, snaps and a beer. If two people are sitting together, well it adds something – that we are having it [alcohol]
…
Conny:	…it creates a good atmosphere, I think it does
Grethe:	Yes, it wouldn't be nice to live without it.
Conny:	No, I think it is nice that you can sit and enjoy it. It is cosy.

Hanne:	Well, I get that when I am on holiday. Then I get at least five drinks a day, right; without turning a hair.
Michael:	Yes
Hanne:	But I don't drink either. It just belongs [to the holiday], right.

Morten:	…is it possible to sit and talk without a beer in your hand?
Moderator:	Is it?
Morten:	Yes, that is the question. I am not sure.
Lone:	It has consequences somewhere, right: If you are sitting six people together, and you are the only one that doesn't feel like a beer. There is something about the person that is sitting without a beer, am I right?
Troels:	Yes, you feel outside
Lone:	I can't really say what it is, but it seems a little weird to order a coke, right.

Hanne:	I had a colleague who didn't like to drink and she was tired of always explaining herself….so she said: No, I am not going to drink; I take Antabuse. And she didn't, but she just didn't feel like drinking. And no one understands that and they would say: Ah come on you are being silly. So she just said “no, I take Antabuse” and then there were hardly anyone who wanted to speak with her, right.
Erik:	No well…oh my. [Everyone laughs]
Hanne:	She was completely…cut off, right. She said it was so typical to see, right.
Moderator:	It sounds like she had to come up with an excuse?
Hanne:	Well she just didn't feel like it, and she was almost not allowed that. She was left alone because she said she was taking Antabuse…

Moderator:	So you are conscious about the recommendations?
Ellen:	Yes, I am.
Per:	I am not.
Ellen:	I take them into consideration.
Per:	I have a feeling about it, but I never think about it. As I told you…. my wife has an old friend and they were discussing this thing about the 21 drinks a week and he said: Oh god, I am already there by Monday [Everyone laughs]
Connie:	Yes, there are some who drink more than others.
Per:	But conscious about it…I don't think you think about it. I don't think about it. But, you have a feeling of…where…what….there are three….. There are three standard drinks in a bottle of wine [sharing a bottle with his wife each night], and times 7, then you are at 21. And then the rest during the week, right. So then you are up to about 26, 28 per week. I don't think it is harmful when it is wine. I think it is worse when it is strong spirits.
Connie:	Yes, I think so too. Because I think it is rare that we drink strong spirits.