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Alcohol
Written by Eric Single   
Sunday, 21 May 1995 00:00

alt

1995 VOL 6 NO 1

Copyright© IJDP Ltd. The following pages are produced in cooperation and with approval of the International Journal on Drug Policy Ltd.

HARM REDUCTION AND ALCOHOL

Eric Single, Director of Policy Research, Canadian Centre on Substance Abuse y Canada

INTRODUCTION: HARM REDUCTION AND ILLICIT DRUG USE

Harm reduction refers to measures aimed at reducing the harm associated with drug use without necessarily requiring a reduction in consumption (Wodak, 1994). The key feature of harm-reduction programmes which distinguishes them from other approaches is that they attempt to reduce the harmful consequences of drug use while users continue to use. The essence of harm reduction is embodied in the following statement:

'If a person is not willing to give up his or her drug use, we should assist them in reducing harm to himself or herself and others.'

Buning ( 1993)

The following are the three key aspects of harm reduction:

The user's-decision to use drugs is accepted as a fact. This does not imply approval of the decision to use drugs. Harm-reduction measures presume that for the present the user is going to continue his or her drug use, and we must accept that fact.

The user is treated with dignity as a normal human being. By the same token, there is an expectation that the user will behave 'normally', i.e. within the law. Thus, the drug user is responsible for his or her behaviour.

Harm reduction is neutral regarding the long-term goals of intervention. It does not mean that the eventual goal of a harm-reduction approach might not include abstention. Indeed, in many instances, harm-reduction measures are a vital first step towards reduction of, and even cessation of, drug use. By treating the user with dignity rather than as a criminal, harm-reduction programmes have been successful in bringing addicts into treatment programmes. Harm reduction involves a prioritisation of goals, in which immediate and realisable goals take priority when dealing with users who cannot be realistically expected to cease their drug use in the near future, but it does not conflict with an eventual

goal of abstention. It is simply neutral regarding the long term goal of intervention.

Thus, harm reduction does not simply refer to an drug policy or programme which aims at reducing harm, because this is a universal goal of all drug policies and programmes. The term 'harm reduction ' restricted to those policies and programmes the attempt to reduce the harm associated with use without the user giving up his other use at the present time.

HARM REDUCTION AND ALCOHOL

PREVENTION

Harm reduction was developed as an approach t/ deal with problems associated with illicit drug use particularly the spread of HIV infection from the sharing of needles by intravenous drug users. There fore we tend to think of harm reduction in the context of illicit drug use. The central thesis of this article is that the trend towards harm reduction 1r illicit drugs is closely paralleled by a similar trend1r alcohol prevention towards measures aimed at reducing the consequences of drinking.

Although the contrast between harm-reduction approaches for illicit drugs to a 'zero tolerance approach is almost self-evident, the parallel differences between harm-reduction approaches for alcohol and prevailing conceptualisations of alcohol prevention are perhaps less obvious. Until recently, public health advocates in the field of alcohol prevention have tended to focus on alcohol control measures such as the nature and extent of state monopolisation of alcohol trade, the number and location of off-premise sales outlets, licensing regulations, drinking age restrictions, proscriptions against selling to intoxicated people, advertising and sponsorship restrictions, criminal penalties for driving while intoxicated and alcohol taxation. The focus on alcohol availability is based on the well-established relationship between alcohol control measures, levels of alcohol consumption and indicators of alcohol-related health and social problems ,Bruun et al., 1975; Makela et al., 1981; Moore and Jerstein, 1981; Edwards et al., 1994). As stated by 3ruun et al. ( 1975 ), controls over alcohol availability are justified on the grounds of public health:

'. . . our main argument is well substantiated: changes in the overall consumption of alcoholic beverages have a bearing on the health of the people in any society. Alcohol control measures can be used to limit consumption: thus, control of alcohol availability becomes a public health issue.'

  • K. Bruun et al. ( 1975; italics in original)

The focus in preventive education has generally been on the adverse effects of alcohol consumption and the message for all drinkers was generally unequivocal: drinking less is better.

The message in harm-reduction approaches is somewhat different: avoid problems when you drink. This is complementary rather than contradictory to the message that drinking less is better. Indeed, some harm-reduction approaches (e.g. the promotion of low-alcohol content beverages) involve drinking less. But harm reduction differs from prior alcohol prevention approaches in that it focuses on decreasing the risk and severity of adverse consequences arising from alcohol consumption, without necessarily decreasing the level of consumption. It is essentially a practical rather than an idealised approach: the standard of success is not some ideal drinking level or situation (abstention or low-risk levels), but whether or not the chances that adverse consequences have been reduced by the introduction of the prevention measure.

The defining feature of harm-reduction approaches to alcohol is the attempt to reduce the harmful consequences of alcohol consumption in a situation where people will be drinking. That drinking will take place is accepted as a fact, implying neither approval nor disapproval. The drinker is not seen as abnormal in anyway, and he or she is responsible for his or her actions. As with harm approaches or other drugs, harm approaches to alcohol prevention are neutral regarding the long-term goals of intervention, which may or may not include abstention.

An excellent example of a harm-reduction approach to alcohol is provided by the introduction of special early opening hours for a store of the Alberta Liquor Control Board in downtown Edmonton. The objective of the early opening was to reduce the use of potentially lethal non-beverage alcohol by Skid-row inebriates. The measure was not intended to reduce their consumption; indeed, it was expected to increase their consumption of potable alcohol. It was focused exclusively on reducing adverse consequences from drinking things such as shoe polish. Other examples of harm reduction measures for the prevention of alcohol problems include.

  • Measures which reduce the consequences of intoxication: this would include measures not specifically aimed at reducing drinking problems, such as the introduction of airbags into cars (which reduce the number of alcohol-related traffic injuries and fatalities) as well as measures aimed at reducing the consequences of intoxication, such as changes in the physical structuring of drinking establishments which minimise the harm that may result if a fight breaks out (e.g. compartmentalisation of space and padding of furniture). Another example of a measure aimed specifically at reducing the consequence of drinking is the 'Nez Rouge' programme in Quebec, which is a community-based service providing two drivers (one for the drinker and one for his or her car) to anyone who feels that he or she has had too much to drink at a party or a licensed establishment to drive home safely (Single and Storm, 1985).
  • The promotion of low-alcohol beverages: light beers, low-alcohol content wines and even light spirits have been introduced in many countries in recent years. These beverages can reduce ethanol intake without reducing the overall volume of drinking (i.e. liquid intake). Thus, they maintain industry profitability and serve a public health purpose at the same time.
  • Server training programmes: server training represents a harm-reduction measure in several respects. Most programmes involve the development of house policies to promote moderation (e.g. quality upgrading, pricing lower alcohol-content beverages below higher-strength beverages, avoiding Happy Hours, other volume discounts or specials). They may also involve policies (e.g. designated driver programmes) or environmental modifications (e.g. via monitoring of entrances to prevent under-age or intoxicated people entering) to reduce the likelihood that problems will OCCUL Staff are trained to recognise and gradually cease service to intoxicated patrons, offering low-alcohol or non-alcoholic alternatives. To deal with situations when these prevention efforts fail, servers are also trained to manage intoxicated patrons in the appropriate manner, including strategies to provide safe transport home. Thus, server training attempts to reduce the problems associated with drinking without generally restricting drinking by most drinkers or adversely affecting the profitability of licensed establishments. In fact, evaluation studies have generally shown that establishments that have undergone server intervention training tend to attract more customers and be more profitable as a result of the introduction of responsible serving practices.
  • Controlled drinking programmes: the provision of controlled drinking as a treatment alternative for alcohol-dependent people might also be thought of as a harm-reduction measure, although it has been argued that the harm from drinking is not merely reduced but eliminated if drinking is successfully controlled. The often acrimonious debate concerning controlled drinking versus abstinence as a treatment goal for people with alcohol problems parallels in many ways the conflict between harm-reduction and zero tolerance approaches regarding illicit drug use.

REASONS FOR THE TREND TOWARDS HARM REDUCTION IN ALCOHOL PREVENTION

Most of these examples of harm-reduction measures are relatively new. There is a distinct trend towards prevention measures aimed not so much at the reduction of drinking per se, as at a reduction in

harmful consequences of drinking. There are several reasons for this shift in alcohol prevention towards a harm-reduction approach.

There is declining political support for controls over the availability of alcohol, especially in light of declining consumption in many countries and the erosion of international trade barriers. This trend is likely to continue as new evidence regarding the potential benefits of moderate consumption becomes more widely publicised. Increased attention is likely to be given to prevention measures which focus on preventing problems associated with drinking rather than restricting access to alcohol The harm-reduction approach focuses on preventing problems associated with heavy drinking occasions. Rather than attempting to persuade light and moderate drinkers to reduce their level of consumption (e.g. on the grounds that they contribute to overall levels of consumption and may therefore influence someone else to drink excessively), this perspective focuses on environmental controls, such as server intervention and preventive education to convince drinkers at all levels of consumption to avoid drinking to intoxication and to minimise the harm that may result from drinking.

EMPIRICAL SUPPORT FOR THE HARM REDUCTION APPROACH TO ALCOHOL

Furthermore, there is empirical support for the focus on heavy drinking occasions. Analyses of national survey data in Australia (Stockwell et al., 1994), Canada (Single and Wortley, 1993) and the USA (Midanik et al., 1994) all indicate that it may be more efficient to focus on heavy drinking occasions rather than the individual's level of consumption per se. In these analyses, the level of consumption and number of heavy drinking occasions were related to various alcohol problems. It was consistently found that the number of heavy drinking occasions is a stronger predictor of drinking problems than level of consumption.

Furthermore, there is an interaction effect regarding the joint impact of the number of heavy drinking occasions and level of consumption, with particularly high rates of alcohol problems among low-level drinkers who occasionally drink immoderately. Table 1 presents data from the 1993 General Social Survey in Canada on the joint impact of level of consumption and number of heavy drinking occasions on the likelihood of experiencing a drinking problem (Single et al., 1994). It can be seen that the likelihood of experiencing drinking problems is greater for a moderate level drinker who occasionally drinks immoderately than for a high level consumer who rarely or never drinks immoderately.

This finding may be associated with physical tolerance as well as the tendency for high-volume drinkers to develop social supports and other mechanisms to minimise the adverse consequences of their drinking. Of course, there are limits to which heavy drinkers can control adverse consequences: over time, heavy drinking will greatly elevate the risk of chronic health consequences such as cirrhosis. Nevertheless, for many of the more acute alcohol problems such as impaired driving, alcohol-related family dysfunction or employment problems, relatively low level consumers who occasionally drink immoderately contribute substantially to problem levels.

Table 1: Probability of experiencing a drinking problem by heavy drinking occasions and level of consumption.

Drinks per year No. of drinking occasions (%)*
Drinks per year 0 1 2-6 7+





1-51 2 8 7 17
52-364 2 8 10 21
365+ 7 5 14 35

*Number of times in the last 12 months respondent consumed five or more drinks on one occasion.
Source: Statistics Canada, General Social Survey (1993) (Single et al., 1994).These findings indicate that it may be most efficient to focus specifically on reducing heavy drinking occasions among all drinkers. This is in contrast to focusing on high-volume consumers or on aggregate level of consumption per se. This is not to say that programmes specifically targeted at heavy drinkers, such as early identification and intervention programmes, should not be supported. These would undoubtedly result in reductions in alcohol problems. However, programmes focusing on reducing overall levels of alcohol consumption should not be adopted to the exclusion of approaches that focus instead on heavy drinking occasions. Indeed, the findings above indicate that the most efficient approach may be to target preventive education at the general population (because it is consumers below that associated with alcohol dependence who contribute the most to problem levels), but focus on safe drinking limits and the avoidance of intoxication and other behaviours likely to cause problems rather than on the individual's overall level of consumption. In conclusion, the trend towards harm reduction in illicit drugs is closely paralleled by a similar trend in alcohol prevention towards measures aimed at reducing the consequences of heavy drinking occasions. With the erosion of political support for alcohol control measures and the emergence of new evidence about potential health benefits associates with low-level alcohol consumption, it may be expected that alcohol prevention will increasingly focus on the reduction of harmful consequences of alcohol rather than monitoring individual levels of consumption to avoid dependence.

Eric Single, Director of Policy and Research, Canadian Centre on Substance Abuse, I00 College Street, Suite 207, Toronto, Ontario, Canada M5G 1L5.

REFERENCES

Bruun K, Edwards G, Lumio M, Makela K, Pan L, Popham R al. (1975). Alcohol Control Policies in Public Health Perspective . Helsinki: Finnish Foundation for Alcohol Studies .

Buning E (1993). Presentation to workshop on 'Harm Reduction and Health Promotion', Fifth International Conference on the Reduction of Drug Related Harm, Toronto March

Edwards G, Anderson P, Babor T, Casswell S, Ferrence R, Giesbrecht N et al. (1994). Alcohol Policy and the Public Good.; Oxford: Oxford University Press. lf

Makela K, Room R, Single E, Sulkunen P, Walsh B (1981).) Alcohol, Society and the State l: A Comparative Study of Alcohol Control.Toronto: Addiction Research Foundation. |

MidanikL, TamT, Greenfield T, CaetanoR (1994) . Risk Functions for Alcohol related Problems in a 1988 US National Sam-~ ple. Berkeley, CA: California Pacific Medical ('entec Research Institute, Alcohol Research Group. i

Moore M, Gerstein D (1981) . Alcohol and Public Policy: Beyond the Shadow of Prohibition. Washington DC: N ational Acade my Press.

Single E, Storm T (Eds) (1985). Public Drinking and Public Policy . Toronto: Addiction Research Foundation Books.

Single E, Wortley S (1993). Drinking in various settings: findings from a national survey in Canada. Journal of Studies on Alcohol 54: 59O9.

Single E, Brewster J, Macneil P, Hatcher ), Trainor C (1994). Alcohol and Drug Use: Results from the General Social Survey oi 1993. Ottawa: Canadian Centre on Substance Abuse.

Stockwell T, Hawks D, Lang E, RydonP (1994). Unraveling the Prevention Paradox. Perth, Australia: National Centre for Research into the Prevention of Drug Abuse.

Wodak A (1994) . What is harm reduction. Paper presented at the Conference on Harm Reduction: An Emerging Public Health Perspective, Honolulu, Hawaii, October 20.